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

NEW! CE Credits Quiz

 Volume 13, Number 1 t Februar y 2010 t 1SSN: 2152-2715

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Journal of CyberTherapy
&
rehabiliTaTion

Volume 3, Issue 1, Spring 2010

San Diego, California - Brussels, Belgium

J CR
Journal of
CyberTherapy
& Rehabilitation
ediTor-in-Chief
Brenda K. Wiederhold, Ph.D., MBA,
BCIA
Virtual Reality Medical Institute
Brussels, Belgium
Virtual Reality Medical Center
San Diego, California
managing ediTor
Emily Butcher
Interactive Media Institute
San Diego, California
ediTorial board
Mariano Luis Alcañiz Raya, Ph.D.
Universidad Politécnica de Valencia
Valencia, Spain
Rosa M. Baños, Ph.D.
University of Valencia
Valencia, Spain
A.L. Brooks
Aalborg University
Esbjerg, Denmark
Julian Dooley, Ph.D.
Edith Cowan University
Mount Lawley, Australia
Paul M.G. Emmelkamp, Ph.D.
University of Amsterdam
Amsterdam, Netherlands
Uri Feintuch, Ph.D.
Hadassah-Hebrew University
Medical Center
Jerusalem, Israel
Joshua Fogel, Ph.D.
University of New York
Brooklyn, New York
assoCiaTe ediTors
Cristina Botella, Ph.D.
Jaume I University
Castelló de la Plana, Spain
Stéphane Bouchard, Ph.D.
Université du Québec en Outaouais
Gatineau, Québec, Canada
Tom Furness, Ph.D.
University of Washington
Seattle, Washington
Charles Hughes, Ph.D.
University of Central Florida
Orlando, Florida
Wijnand IJsselsteijn, Ph.D.
Eindhoven University of Technology
Eindhoven, Netherlands
Linda A. Jackson, Ph.D.
Michigan State University
East Lansing, Michigan
Sun. I. Kim, Ph.D.
Hanyang University
Seoul, South Korea
Dragica Kozaric-Kovacic, M.D., Ph.D.
University Hospital Dubrava
Zagreb, Croatia
José Luis Mosso, M.D.
Regional Hospital No. 25 of the
IMSS
Mexico City, Mexico
3
Luciano Gamberini, Ph.D.
University of Padova
Padova, Italy
Giuseppe Riva, Ph.D., M.S., M.A.
Istituto Auxologico Italiano
Verbania, Italy
Paul Pauli, Ph.D.
University of Würzburg
Würzburg, Germany
Heidi Sveistrup, Ph.D.
University of Ottawa
Ottawa, Ontario, Canada
Richard M. Satava, M.D., F.A.C.S.
University of Washington
Seattle, Washington
Mark D. Wiederhold, M.D.,
Ph.D., FACP
Virtual Reality Medical Center
San Diego, California
XiaoXiang Zheng, Ph.D.
Zhejiang University
Hangzhou, P.R. China
 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

JCR
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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
ediTorial
Welcome, readers and researchers, to the Spring 2010
issue of the Journal of CyberTherapy & Rehabilitation
(JCR). Our peer-reviewed quarterly academic journal
continues to explore and support the uses of advanced
technologies for therapy, training, education, preven-
tion and rehabilitation. JCR is unique in the fact that it
focuses on the rapidly expanding worldwide trend of
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porters driven by a similar goal of advancing the use
of technology in the healthcare sector, JCR has re-
ceived positive attention from peers, international in-
stitutions and international conferences. To keep
readers abreast of new developments, within this issue
of JCR we present comprehensive articles submitted
by preeminent scholars in the field, featuring such top-
ics as combining physical activity with learning in an
augmented reality setting, including the sense of ol-
faction more commonly in VR, and how communica-
tion is used in virtual worlds like Second Life.
In the first article Voorhees et al. study the relationship
between attitude and adherence to treatment in adoles-
cents with sub-threshold depression in order to improve
public health strategies to prevent depressive disorders.
Next, Baus and Bouchard address the sense of olfaction
and ways in which it can further and enrich VR any ad-
vocate the growth of the field while discussing possible
applications in virtual environments.
In an attempt to merge learning and physical activity in
the classroom, Hsiao next looks at using augmented re-
ality and VR applications to provide more effective
teaching methods and increase retention, while provid-
ing much-needed exercise to the younger population at
the same time.
In the fourth article, Alquda et al. use Virtual Humans
to look at how race and sex can affect how people inter-
JCR
7
pret others’ pain, pain coping skills, related mood, and
other factors.
Lastly, Park discusses the use of Second Life as an ex-
ample of how activities in virtual worlds might be used
as a communication environment to better understand
each other, with an emphasis in this study on gender.
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– Professor Botella, Professor Bouchard, Professor
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Fogel from the University of New York, and XiaoXiang
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part of this movement and thank you for your continued
support.
Brenda K. Wiederhold, Ph.D., MBA, BCIA
Editor-in-Chief,
Journal of CyberTherapy & Rehabilitation
Virtual Reality Medical Institute
8

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

1
Department of Medicine, The University of Chicago, Chicago, Illinois, USA
2
Department of Economics, Brooklyn College of the City University of New York, Brooklyn, New York, USA
3
Department of Applied Economics, University of Minnesota, Twin Cities, St. Paul, MN, USA
4
Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA
5
Department of Pediatrics, The University of Chicago, Chicago, Illinois, US
10
Pediatricians and family physicians are taking on an ex-
panded role in screening for depressed mood, and also in
identifying and treating adolescents with depressive disor-
ders (Christensen, 2009; Grant, 2009; Kaltenthaler, 2008;
Waller, 2009). The Internet offers a potentially more ac-
ceptable form of intervention in primary care settings for
early intervention or prevention of mental disorders (Gar-
ber et al., 2009; B. Van Voorhees et al., in press). Motivated
adolescents visit self-improvement Web sites to manage
alcohol use, smoking, obesity, sexual risk and HIV/AIDS
related issues, and show positive behavior change as a re-
sult(Kirk et al., 2003; Lou, Zhao, Gao, & Shah, 2006; C.
A. Patten et al., 2006; Ybarra, 2006). For adults, Internet
interventions may be helpful in increasing levels of exer-
cise, adopting a more favorable diet, stopping smoking,
and reducing depressed mood (Van den Berg, Schoones,
& Vliet Vlieland, 2007; Walters, Wright, & Shegog, 2006;
Wantland, Portillo, Holzemer, Slaughter, & McGhee,
2004). However, only 20% of the general population ap-
pears interested in Internet-based lifestyle changes, and as
few as 10% actively visit such Web sites (Evers, 2005; Ver-
heijden, Jans, Hildebrandt, & Hopman-Rock, 2007). The
use of mental health related Web sites by adolescents is
similarly low (G. Clarke et al., 2002; S. B. Patten, 2003;
Santor, Poulin, LeBlanc, & Kusumakar, 2007) Determin-
ing preferences for intervention, and which attitudes and
beliefs are associated with motivation to use a depression-
prevention Web site, could facilitate the development of
more acceptable public health interventions to prevent de-
pression in community settings.
The Competent Adulthood Transition with Cognitive-be-
havioral, Humanistic, Interpersonal Training (CATCH-IT),
(B. W. Van Voorhees et al., 2007) primary care based pre-
ventive intervention was developed to target adolescents
with sub-threshold depressive symptoms and provide an
acceptable, low-cost, and broadly available
intervention/prevention model of depressive disorders
(Garber et al., 2009). This intervention/prevention model
sought to overcome barriers to deployment of preventive
interventions for depression by offering the intervention
within the framework of primary care with an initial en-
gagement interview by the primary care physician (Land-
back, 2009; B. W. Van Voorhees et al., 2007). A
randomized clinical trial was conducted, comparing two
forms of physician engagement (both groups having access
to the Internet site), a motivational interview (MI) versus
brief advice (BA) to determine whether the “patient cen-
tered” MI approach (adolescents develop their own ration-
ale for participation) was superior to the one which relies
Adolescent Internet Depression Prevention
on physician authority of recommendation (BA) (B. W.
Van Voorhees, 2009). In this trial, both groups actively en-
gaged in exploring the Internet site and demonstrated fa-
vorable changes in vulnerability and protective factors for
depressive disorder. However, the MI group demonstrated
higher levels of adherence to the Internet intervention and
fewer depressive episodes (B. W. Van Voorhees, Fogel, J.,
Pomper, B. E., & Domanico, R., 2009; B. W. Van Voorhees
et al., 2008).
A variety of predictors has been identified for adherence
to Internet-based interventions. We know that females,
school-based settings, living in a rural area and lower
pretest anxiety scores predict greater adherence to Internet
based depression interventions in youth (Neil, Batterham,
Christensen, Bennett, & Griffiths, 2009). We also know
that, for older adults, psycho-education is the least pre-
ferred option for preventing depression compared to exer-
cise or vitamin supplementation (Grant, 2009). A few
studies have reported varied levels of acceptability and sat-
isfaction with computer-based cognitive behavioral psy-
chotherapy (Kaltenthaler, 2008), but little is known
regarding the influence of specific attitudinal factors on
adherence (Waller, 2009). In contrast, we do know what
adolescents in primary care think about depression preven-
tion interventions and how such attitudes might influence
motivation and adherence. The use of theoretical models
of behavioral change has been proposed as a method to de-
velop a more systematic understanding of motivation and
adherence to Internet-based mental health interventions
(Christensen, 2009).
Organizing items according to the theory of planned behav-
ior framework has been previously demonstrated to predict
adolescent and emerging perceived need for treatment and
intention in order to accept a physician’s diagnosis of major
depression (B. W. Van Voorhees et al., 2005, 2006). The
Theory of Planned Behavior provides a theoretical frame-
work for understanding motivation, intention and adher-
ence. According to this theory intention is the closest
precedent of behavior, which is directly influenced by atti-
tudes and beliefs toward a behavior (e.g., attitudes toward
intervention), subjective norms (e.g., concerns with regard
to family, peer or employer opinions) and perceived behav-
ioral control (e.g., self-efficacy), as a probability that one
can perform the specific behavior (e.g. adhering to the in-
tervention) (Ajzen, 2002). In these analyses, beliefs and at-
titudes toward the intervention and behavior, rather than
social norms, were the most important predictors of inten-
tion (B. W. Van Voorhees et al., 2005, 2006). Primary care
JCR
Voorhees et al.
physicians, health policy planners, and prevention re-
searchers would benefit from a sound understanding of
preferences for intervention and the attitudinal predictors of
greater motivation for prevention and adherence to a pri-
mary care/Internet-based intervention.
The purpose of this study is to provide an attitudinal de-
scription and to identify predictors of passive and active
adherence within a sample of adolescents with sub-thresh-
old depressed mood enrolled in a randomized clinical trial
of a primary care/Internet-based depression intervention
(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees,
Fogel, J., Pomper, B. E., & Domanico, R., 2009). We focus
on adolescents with sub-threshold depressed mood in pri-
mary care because are the likely targets of preventive in-
terventions for major depression (Garber, 2006; Garber et
al., 2009; Landback, 2009). We provide an attitudinal de-
scription of this sample in the study and explore how spe-
cific attitudes, measured at baseline, within the framework
of the theory of planned behavior may influence motivation
and adherence. Based on the framework of the theory of
planned behavior, we hypothesize that (1) attitudes/beliefs
about intervention effectiveness would be the most impor-
tant predictors of motivation for preventive intervention
and participation in such an intervention in primary care.
We also hypothesize that (2) adolescent primary care pa-
tients with sub-threshold depressive symptoms would ex-
hibit ambivalence toward established traditional
interventions (medications, group and individual counsel-
ing) similar to earlier studies of adolescents and adults with
major depressive disorder (Cooper-Patrick et al., 1997; Jay-
cox et al., 2006).
meThods
sTudy design
This study is based on a survey of adolescents enrolled to
participate in a randomized controlled trial in primary care
of an Internet-based depression intervention and prevention
program (CATCH-IT). We conducted a phase-2 clinical
trial of a primary care/Internet-based depression prevention
intervention for adolescents at 13 U.S. primary care sites
(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees et
al., 2008). Eligible adolescents were assigned randomly to
either a primary care physician (PCP) motivational inter-
view plus the use of a Internet Web site or to PCP brief ad-
vice and use of a Internet Web site. Those eligible and
willing to enroll completed a baseline questionnaire relat-
ing to attitudes and beliefs, as well as motivation for pre-
vention before they received their randomization
assignment. The responses to these questions, together with
JCR
11
the passive and active adherence to the Web site, are the
subject of our analysis. The passive and active adherence
of the intervention was approximated by time spent on the
Web site and number of characters typed in, respectively.
Both measures were obtained by using simple algorithms
in the Web site. The randomized controlled trial methods
have been fully described in prior publications (B. W. Van
Voorhees et al., 2009; B. W. Van Voorhees et al., 2008).
The University of Chicago Institutional Review Board, as
well as those with responsibility for each site ,approved
this study.
sTudy sample and eligibiliTy
Participants were adolescents (N=83) between the age of
14-21, recruited from 13 primary care sites throughout the
Southern and Midwest U.S., and reported at least one core
symptom of depression at both the initial screening and the
at the full eligibility assessment administered one to two
weeks after the initial screening. Potential participants were
identified by completing a two-item screening question-
naire based on the Patient Heath Questionnaire Adolescent
(PHQ-A-2) core depression symptom items in the routine
process of care (all adolescents visiting the clinic) (John-
son, Harris, Spitzer, & Williams, 2002). Adolescents re-
porting any core depressive symptom lasting longer than a
few days in the two weeks prior to the screening were con-
sidered “positive.” Those with “positive” screens and who
consented to be contacted by study staff were called by
phone for eligibility assessment. Inclusion criteria included
aged between 14-21, presence of one core symptom of de-
pression, but below the level of major depression (four or
fewer symptoms, “sub-threshold depressed mood”). Ex-
clusion criteria included meeting criteria (or getting treat-
ment) for minor or major depression, expressing frequent
suicidal thought or intent, bipolar disorder, conduct disor-
der, substance abuse, generalized anxiety disorder, or any
type of eating disorder. Consent from adolescents and par-
ents (if adolescents were under 18 years old) was collected
by study staff at the clinic. A full description and the criteria
of the recruiting method have been previously reported
(Johnson et al., 2002).
demographiCs
Information on age, gender, race/ethnicity, and education
level was recorded. Furthermore, family’s history of de-
pression or any depressive disorder pertaining to the indi-
vidual was assessed by asking, “Have you ever been
treated for depression (via medication or counseling)?” and
“Have any of your family members (mother, father,
sister(s), brother(s)) ever been treated for depression that
12
lasted at least four weeks?” For the participant’s dimen-
sional measures of depressed mood we report Center for
Epidemiologic Studies Depression Scale 10 items
(CESD10), scored as double to create the 60-point scale.
preferenCes for inTerVenTion
Preferences for treatment (get over it naturally, medication,
one-on-one or group counseling) were developed from the
Quality Improvement in Depression study, which showed
that among primary care adult patients viewing treatments
as unacceptable, there is an association with a lower like-
lihood of seeking treatment (Rost, Nutting, Smith, &
Werner, 2000). Responses were recorded in a Likert-type
scale ranging from “1=definitely acceptable” to “4=defi-
nitely not acceptable,” where participants rated statements
such as “I will wait and get over it naturally,” “Use anti-
depressant drugs,” “Seek one-on-one counseling from a
mental health specialist,” and “Seek group counseling…
led by a mental health specialist.” We added several options
that were not included in the original scale, represented by
statements such as “Talking with primary care physician
(PCP) about what you can do to prevent depression,”
“Talking with PCP and agreeing to set up a regular sched-
ule,” “Talking with PCP about your feelings and situation,”
“Talking with PCP and agreeing to complete an e-pro-
gram,” “Talking to a counselor through the phone about
your feelings,” “Complete a questionnaire with your PCP,”
“Complete a questionnaire Online,” “Start an exercise pro-
gram with thirty minutes of aerobic activity, individually,”
“Start an exercise program with thirty minutes of aerobic
activity with a group,” “Participate in a religious youth
group,” “Take a health class to learn about feelings and
coping skills,” and “Group meeting with 6-10 peers from
your school.” All items were scaled in accordance to the
original scale, as mentioned above.
depression preVenTion iTems based upon Theory of
planned behaVior
We adapted the items from a previous questionnaire, which
was modified based on the preventive health model (Myers
et al., 1996; B. W. Van Voorhees et al., 2006). The original
instrument, developed for prostate cancer, was adapted to
primary care based depression prevention. The reliability
(Cronbach alpha =0.89) and validity of the instrument was
evaluated during a pilot study of the CATCH-IT interven-
tion in 2004. Validity is supported by several items demon-
strating a trend toward predicting intervention performance
(predictive validity) and post-study qualitative interviews
suggested that the concerns/themes identified were consis-
tent with items on the scale (face validity). The participants
Adolescent Internet Depression Prevention
indicated a level of agreement based on a Likert-type scale
ranging from “1=strongly disagree” to “5=strongly agree.”
Beliefs about the intervention were defined by such state-
ments as “depression intervention makes sense to me,”
“protecting yourself from depression through interven-
tion,” “participating in intervention is important,” “if de-
pression is found early it can be prevented,” “depression
intervention could prevent further depression,” “depression
intervention will help me to get healthy,” and “would be
better off without the intervention.” Attitudes toward the
behavioral intervention were measured by the statements
“going through depression intervention is too much trou-
ble,” “the benefits of the prevention outweigh any diffi-
culty,” and “going through a depression intervention is too
embarrassing.” Subjective social norms were measured by
such statements as “members of my family support me
going through intervention,” “I want to please family,” “I
want to do what the doctors want me to do about depres-
sion,” “I think physicians want me to do a depression in-
tervention,” “my close friends support my going through
a depression intervention,” and “I want to please my close
friends.” Perceived behavioral control was measured by
self-efficacy and had items of “going through this depres-
sion intervention would be easy” and “arranging the sched-
ule for the intervention will be easy.” We had previously
administered this questionnaire in a pilot study and found
it acceptable and easily understood.
moTiVaTion ToWard preVenTiVe inTerVenTion
These items were adapted from Miller and Rollnick’s
three-item assessment of motivation (Miller & Rollnick,
1991). The measures of motivation toward treatment or in-
tervention were constructed from the responses to the fol-
lowing statements measured with a Likert-type scale
ranging from “1=not important” to “10=very important”:
“rate your ability to learn coping skills to reduce your risk
of clinical depression,” “rate your readiness to reduce your
risk of clinical depression by learning coping skills,” and
“rate the importance of preventing an episode of clinical
depression over the next year.”
ouTCome Variables
BEhavioral iNtENtioN
Behavioral intention was measured by the stage of chang-
ing ways to deal with problems in order to prevent depres-
sion. It was measured by the response to the question,
“Please indicate which statement best fits your current po-
sition with regard to changing the way you think about and
solve everyday problems to reduce your risk of developing
clinical depression.” Participants indicated their responses
JCR
Voorhees et al.
using a Likert-type scale, consisting of “1=I have not given
any thought to changing...”, “2=I am giving some thought
to changing...”, “3=I am preparing to change...”, “4=I have
decided to change...but do not have a plan...” and “5=I have
decided to change...and I have a plan...” where higher
scores indicate a more active adherence towards changing
the behavior.
PassivE adhErENcE
We measured passive adherence on the Web site by calcu-
lating the total amount of time participants spent online
throughout the intervention. This variable was constructed
by a simple algorithm, which subtracted the first page load
timestamp from the last page load timestamp in a given
session. The length of time for each session was capped at
seven minutes, since that is the approximate maximum
amount of time required to review the materials on each
page. In cases when sessions lasted more then seven min-
utes, we assumed the participant was not reviewing mate-
rial and the page was still loading. The length of all sessions
was then added together to generate the total amount of
time spent online. We chose to calculate time spent on the
Web site because this is a broad measure of willingness to
at least review material related to depression prevention
and its ease of measurement (B. W. Van Voorhees et al.,
2009). Visitation of the Internet Web site was done entirely
at the adolescents’ discretion and occurred completely sep-
arate from the physician encounter.
activE adhErENcE
Active adherence was measured by a proxy measure of the
total number of characters typed throughout the interven-
tion. The variable was constructed by counting the total
number of characters typed by each participant as a part of
completing exercises and writing notes at the end of each
module, and then adding the characters together across all
modules to generate the total number of characters typed.
This outcome variable was used to measure the active be-
havior of the participants. It was selected because of its
ease of measurement and its relationship to choosing to ac-
tively participate in a behavior change process (B. W. Van
Voorhees et al., 2009). This is similar to “homework” in
cognitive behavioral psychotherapy.
statistical aNalysEs
Descriptive statistics were calculated for the demographic
variables, preferences for treatment variables, and depres-
sion prevention items based upon the theory of planned be-
havior. Separate linear regression analyses were performed
for the three outcome variables of intention, passive adher-
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13
ence, and active adherence. As passive adherence and ac-
tive adherence were both skewed data, they were logarith-
mically transformed to allow for a normal distribution.
There were four models for each analysis. Model 1 was a
univariate analysis. Model 2 adjusted for age, race/ethnic-
ity (white/non-white), and gender. Model 3 adjusted for the
items from the same category/block. Model 4 simultane-
ously adjusted for all items that were significant or ap-
proached significance for each outcome (p-value<0.10) in
model 3 in order to understand the strongest correlates from
the category/block in a multivariate framework. Motivation
items were added as predictors to the passive adherence
and active adherence outcome analyses. They were not in-
cluded for the intention outcome analysis, as the theory of
planned behavior does not typically include motivation as
a predictor for the intention outcome. STATA 10 was used
to conduct the analyses ("Stata Statistical Software: Re-
lease 10," 2009).
resulTs
demographiCs
The total number of participants screened reporting at least
one core depressive symptom in the two weeks prior to the
screening comprised 21% (N=293) of the entire sample,
with participants aged from 14-21 years. One hundred and
sixty-two participants were contacted to participate in the
full assessment, (N=131 were not able to be contacted). Of
the 162 participants, 71.6% (N=116) agreed to a full assess-
ment and 13 were ruled ineligible (i.e., due to major depres-
sion, conduct disorder, or suicide intent). The remaining 103
participants were found eligible and 80.6% (N=83) en-
rolled. Fifty-seven percent were females (N=47). Race/eth-
nicity varied and included, 61% (N=49) whites and 24%
African American (N=19), followed by 6% Asians (N=5),
5% Hispanics (N=4), and 4% of other racial composition
(N=3). Average age was 17.5 years old (SD=2.04). Twenty-
seven percent of the adolescents (N=20) sampled were cur-
rently attending college, with one individual who had
already completed college, while over half of the teens had
finished at least 10 years of education (N=43) and 14%
(N=10) had completed 12 years of education. The mean
household income of the sample measured by zip code in-
formation obtained from the U.S. Census 2000 was $40,249
(SD=$14,500). More than half of the screened adolescents
in the sample had a family history of depression (N=43),
while 31% (N=21) of the adolescents had received prior
counseling, and 18% (N=13) had been previously treated
with medication. The demographic profile of this sample
has been reported in greater detail in the primary clinical
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

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Voorhees et al.
dividual aerobic exercise program for thirty minutes a day,
talking with PCP about feelings and situation, completing
Internet questionnaires, seeking one-on-one counseling
from a mental health specialist, starting a group aerobic ex-
ercise program for thirty minutes a day, and completing
questionnaires with a PCP. The least preferred preferences
for treatment that were endorsed by less than 40% included
talking to a counselor by phone about their feelings, and a
Table 2
Depression Prevention Based on Theory of Planned Behavior
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15
group meeting with 6-10 peers from your school. Almost
three-fifths endorsed “waiting and getting over it naturally”
(i.e., no treatment) as acceptable.
depression preVenTion iTems based upon Theory of
planned behaVior
As shown in Table 2, most adolescents endorsed favorable
beliefs toward a primary care Internet-based depression
16 Adolescent Internet Depression Prevention

Table 2 cont.

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Voorhees et al.
Table 2 cont.
prevention intervention program, indicating that it makes
sense to them (68%, N=53 chose strongly agree and agree)
and believing it will help them be healthy (70%, N=53
chose strongly agree and agree). Additional beliefs favored
by more than 64% (N=50) included beliefs that depression,
if detected early, can be prevented, prevention intervention
could prevent further depression (65% N=51), and strongly
disagree/disagree with being better off without a depression
prevention intervention (68% N=54). For the attitude
items, 60% (N=46) favored that the benefits of a depression
prevention program outweigh any difficulty. Similarly,
adolescents (62.83% N=49) generally disagreed with the
concept that the intervention was “too much trouble” but
only a minority reported favorable social norms toward the
intervention. In terms of self-efficacy, while most felt it
would be easy to arrange their schedule to participate (59%
N=45) only less than half the adolescents in the sample felt
that completing such an intervention would be “easy”
(42% N=32).
prediCTors of inTenTions
As shown in Table 3, with regard to beliefs, the belief of
“participating in an intervention like this is important” sig-
nificantly predicted intentions for changing ways to deal
with problems in order to prevent depression for Models 1
and 3 and approached significance in Model 2. Also, the
belief of “a depression prevention intervention could pre-
vent further depression” was significant in Model 1 and ap-
proached significance in Model 2. None of the attitudes
significantly predicted intentions. Social norms had signif-
icance in Model 3 for the family item of “I want to please
my family,” the physician item of “I want to do what the
physicians want me to do about depression prevention” in
Model 1 and Model 3, and approached significance for
friends for the item of “My close friends support my going
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17
through a depression prevention program” in Models 1 and
3. No self-efficacy items were significant. The demograph-
ics item of male gender significantly predicted lower inten-
tion in Model 1 and 3, but depressed mood (CES-D score)
did not predict intentions. In Model 4, only the social norms
item of family was significantly associated with intentions.
prediCTors of passiVe adherenCe
As shown in Table 4 with regards to beliefs, the belief of
“participating in an intervention like this is important” and
“a depression prevention intervention could prevent further
depression” all significantly predicted total time spent on-
line as a measure of passive adherence to prevent depression
for Models 1 and Model 2. Also, there was a significant
negative association with “being better off without a depres-
sion prevention intervention” and total time spent online in
Models 1, 2, and 3. The attitude item of “the benefits of a
depression prevention intervention outweigh any difficulty”
significantly predicted total time spent online in Models 1
and 2. None of the perceived social norms significantly pre-
dicted total time spent online. The perceived behavioral
control item of “arranging my schedule for depression pre-
vention intervention will be easy” significantly predicted
total time spent online in Model 3. Motivation item of “rate
your ability to learn coping skills to reduce your risk of clin-
ical depression” significantly predicted total time spent on-
line for both Models 1 and 2 and the motivation item of
“readiness” approached significance in Model 1 and was
significant in Model 2. The motivation item of “preventing
an episode” approached significance in Model 2. Depressed
mood did not predict total time spent online in any of the
models with which it was included. In Model 4, only the
belief about “being better off without a depression preven-
tion intervention” was significant with a negative associa-
tion with total time spent online.
18
prediCTors of aCTiVe adherenCe
As shown in Table 5 with regards to beliefs, the beliefs of
“protecting myself from depression through a depression
prevention intervention,” “participating in an intervention
like this is important,” and “when depression is found early
it can be prevented” all significantly predicted the total
Table 3
Predictors of Intention
Adolescent Internet Depression Prevention
numbers of characters typed, as a measure of active adher-
ence in preventing depression in Models 1 and 2. The belief
of “depression prevention intervention could prevent fur-
ther depression” for Models 1 and 2, and also “depression
prevention intervention will help me to be healthy” for
Model 1, all approached significance. With regard to atti-
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Voorhees et al.
Table 3 cont.
tudes, the item of “the benefits of a depression prevention
intervention outweigh any difficulty” significantly pre-
dicted number of characters typed in Models 1, 2, and 3.
The social norm item of “I want to do what the physicians
want me to do about depression prevention” significantly
predicted the dependent variable only in Models 1 and 2
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19
and approached significance in Model 3. Also, there was a
negative association of “immediate family support” for sig-
nificantly predicting number of characters typed in Model
3. None of the perceived behavioral control items were
significant predictors. Male gender approached signifi-
cance for a negative association with number of characters
20
Table 3 cont.
Self efficacy
Demographics
typed in Model 3. The motivation item of “readiness” sig-
nificantly predicted the total number of characters typed in
Models 1, 2, and 3. Depressed mood did not predict num-
ber of characters typed in any of the models with which it
was included. In Model 4, only the belief item of “protect-
ing myself from depression through a depression preven-
tion intervention” significantly predicted total numbers of
characters typed.
missing daTa ConCerns
Participants and those eligible to participate did not differ
based on PHQ-A -2 scores. Similarly, participants did not
vary based on PHQ-A-2 scores from those we identified
in screening but whom we either did not reach or did not
consent to a phone interview. We examined reasons for
non-participation in the phone assessment (N=177). Of
those who did not participate in the initial phone assess-
Adolescent Internet Depression Prevention
ment, 46 answered the phone for the follow-up study. Of
those who answered the phone, the most common reason
for declining an interview was that they were not interested
(50.0%, N=23), followed by being too young (21.7%,
N=10). There was no significant difference in the level of
depressed mood between those who participated in the
study and those who chose not to participate.
disCussion
Adolescents endorsed favorable attitudes and prefer-
ences toward primary care Internet-based interventions
and more ambivalent attitudes toward more traditional
delivery forms such a group counseling program. While
the majority of the sample participants found conven-
tional approaches to depression prevention, such as talk-
ing to their primary care doctors about depression
prevention and feelings and setting up a regular schedule
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Voorhees et al.
with their family practitioners acceptable, a great number
of the adolescents found novel forms of intervention ac-
ceptable, such as completing an Internet questionnaire
and starting an individual exercise program. Further-
more, most of the adolescents we assessed agreed that
intervention programs were important and relevant and
more than half believed that an intervention program
Table 4
Predictors of Passive Adherence
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21
could help prevent further depression. The most impor-
tant predictors were family social norms for intentions,
disagreeing with the belief about “being better off with-
out a depression prevention intervention” for passive ad-
herence, and the belief of “protecting myself from
depression through a depression prevention intervention”
for active adherence.
22
Table 4 cont.
preferenCes for inTerVenTion
This is the first study to consider preferences for interven-
tion of adolescents with sub-threshold symptoms. As hy-
pothesized, (hypothesis 2) we found that adolescents with
sub-threshold symptoms in primary care preferred novel
approaches such as personal exercise or completing Inter-
net questionnaires. The preference for primary care and In-
ternet-based approaches might be congruent to the
preference reported for an autonomous-supportive envi-
ronment from patients’ health practitioners (Sheldon, 2003;
Vansteenkiste & Sheldon, 2006; Wisdom, Clarke, &
Green, 2006) and methods under personal control such as
exercise or vitamin supplementation (Grant, 2009). The
findings that a majority of adolescents preferred no treat-
ment (57%) (“Waiting and getting over in naturally”) and
preferred individual counseling (79%) to group counseling
Adolescent Internet Depression Prevention
(43%) are new and important. The most effective preven-
tive intervention to date have used the group counseling
approach (G. N. H. Clarke, M., Lynch, F., et al., 2001; Gar-
ber et al., 2009). This is consistent with preference ex-
pressed by older adults for less psychologically-oriented
approaches such as those including exercise and vitamins
(Grant, 2009). In contrast, Jaycox and colleagues demon-
strated that most adolescents in primary care settings diag-
nosed with major depressive disorder preferred active
treatment (72%) with face-to-face counseling or anti-de-
pressants, rather than watchful waiting (28%) (Jaycox et
al., 2006). This difference might be explained by the find-
ings that symptom severity substantially predicts perceived
need for intervention and willingness to accept treatment
(B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et
al., 2005, 2006) and in our study participants had low levels
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Voorhees et al.
Table 4 cont.
of depression symptom severity. Our study findings in an
adolescent sample may differ due to the greater concern of
adolescents with regard to opinions of peers compared to
adults.
aTTiTudes ToWard depression preVenTion
Prior studies have assessed the influence that attitudes and
beliefs of adolescents with varying levels of symptoms
have on their intent to seek treatment (B. W. Van Voorhees
et al., 2007; B. W. Van Voorhees et al., 2006) or preferences
for treatment (Jaycox et al., 2006). However, to our knowl-
edge this is the first study that reports specific attitudes and
beliefs towards depression prevention on adolescents with
sub-threshold depressive symptoms (Christensen, 2009;
Neil et al., 2009). Our study also departs from the previous
studies in that it assesses perceived behavioral control in
accordance with the theory of planned behavior framework
(Ajzen, 2002). The participants appeared to endorse pri-
mary care/Internet-based prevention, which is consistent
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23
with prior work demonstrating that the lay public and ado-
lescents view primary care physicians as their first source
for care (Highet, Hickie, & Davenport, 2002; Joffe, Radius,
& Gall, 1988) and that they desire psychosocial interven-
tions despite the reported growing acceptance of the “bio-
logical model” for treating depression (Blumner & Marcus,
2009).
prediCTors of inTenTions
The significant relationship for both beliefs about the in-
tervention and perceived social norms with the intentions
outcome is a new finding consistent with prior work that
shows attitudes/beliefs toward an intervention predict both
intention and service use (Jaycox et al., 2006; Leaf et al.,
1987; Lin & Parikh, 1999; B. W. Van Voorhees et al., 2003;
B. W. Van Voorhees et al., 2005, 2006). However, the rel-
atively greater importance of social norms for predicting
intention to prevention surprised us because our prior work
with predicting treatment suggested that beliefs toward the
24 Adolescent Internet Depression Prevention

Table 5
Predictors of Active Adherence

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Voorhees et al.
Table 5 cont.
intervention demonstrated a primacy in decision-making
(B. W. Van Voorhees et al., 2005, 2006). Similarly, self-ef-
ficacy and/or attitudes toward the behavior did not predict
intention or use as it has in other studies (Leaf et al., 1988;
B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al.,
2005, 2006). Perhaps for new or novel preventive inter-
ventions such as our Internet-based intervention and also
JCR
25
when the perceived need for treatment is low since these
individuals had sub-threshold depressive symptoms, an
adolescent turns to family, such as parents, and friends for
guidance (DeBar, 2009). The inverse relationship between
males and intention is consistent with prior work demon-
strating greater use by females of the Internet-based pro-
grams (Christensen, 2009; Neil et al., 2009).
26
Table 5 cont.
prediCTors of passiVe and aCTiVe adherenCe
The findings that beliefs about the intervention, attitudes
toward behavior, self-efficacy and motivation predict pas-
sive and active adherence for the prevention intervention
is a new finding. Conversely, demographic factors such as
age, gender, depressed mood severity or non-white ethnic-
ity, did not influence adherence as has been noted in prior
studies (Christensen, 2009; Neil et al., 2009). The findings
that beliefs concerning the intervention were the most im-
portant predictors support our first hypothesis that beliefs
about intervention effectiveness would be the most impor-
tant predictors of motivation for preventive intervention.
These findings are consistent with an extensive amount of
literature linking attitudes to help seeking and/or intentions
(Jaycox et al., 2006; Leaf et al., 1987; Lin & Parikh, 1999;
B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al.,
2005, 2006). These findings are also consistent with the
theoretical models of the Theory of Planned Behavior
(Hagger, Chatzisarantis, Biddle, & Chatzisarantis, 2002)
and Transtheoretical Model of Change (Miller & Rollnick,
1991). Similarly, we have previously established that mo-
Adolescent Internet Depression Prevention
tivational interviewing before Web site use increases both
time on the Web site and also number of characters typed
(B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Doman-
ico, R., 2009). Neil and his team have previously demon-
strated that symptom severity influences adherence (Neil
et al., 2009). We were surprised that symptom severity did
not influence adherence in our study. This may reflect that
the perceived need for “intervention” was deliberately con-
structed around a “prevention and resiliency model” rather
than an illness model (B. Van Voorhees et al., in press). Per-
haps the adolescents discounted their current symptoms
when determining whether or not to engage in the Internet
Web site activities (B. Van Voorhees et al., in press; B. W.
Van Voorhees et al., 2007).
limiTaTions
The primary strength of this study was the recruitment of
a sample of adolescents in varied primary care settings in
two U.S. regions, which resulted in a diverse sample (40%
ethnic minority). Limitations of this study include the
small sample size and possible selection bias toward ado-
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Voorhees et al.
lescents who may be more favorably disposed toward pri-
mary care, Internet-based interventions and possibly all
mental health interventions than adolescents who chose not
to respond to the study after the initial screening identified
them as “at risk.” Similarly, we omitted individuals who
did not visit the Internet site from the adherence analyses
in order to convert the outcome variable to a natural log
and attain a normal distribution. Also, the small sample size
limited the capacity to complete multivariate analyses and
consequently may have underestimated the number of po-
tentially significant relationships in the multivariate mod-
els. Conversely, the adolescent participants that consented
to a relatively “low burden” study and were found eligible
to participate in the study were not originally “seeking”
treatment for depression or any other mental-health related
disease. As such, they might have represented a “snap shot”
of primary care attendees in these practices. Given the lim-
itations of the sample size, we must characterize these find-
ings as exploratory in nature.
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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
brain, the olfactory system is the most ancient and perhaps
the least understood” (Ratey, 2001, p. 62). The sense of
smell is believed to have been a major catalyst in the evo-
lution of the primitive brain, and it is suspected that the
entire limbic system actually evolved from its original
function of interpreting odorants and emitting pheromones
(Ratey, 2001). Its significance for animals is readily rec-
ognized (Ache & Young, 2005). It plays a role in their
search for food, navigation and orientation, reproductive
behavior, and social organization (Albrecht & Wiesmann,
2006). Although many of these aspects also apply to hu-
mans (Albrecht & Wiesmann, 2006), many tend to con-
sider olfaction of minor importance (Shepherd, 2006).
The relatively minor interest in the olfactory sense is also
reflected in the field of virtual reality (VR), and various
factors may contribute to the underutilization of olfactory
stimuli in virtual environments (VE). According to Sad-
owski (1999), these factors include the perception that in-
corporating olfaction stimuli would neither enhance the
virtual experience, nor be useful in concrete applications.
Most importantly, the primary obstacle to a generalized
integration of olfactory stimuli in VEs may be the diffi-
culty in dispensing and controlling the odorants in the en-
vironment (Sadowski, 1999).
To date, relaxation techniques (Kawai & Noro, 1996),
posttraumatic stress disorder (PTSD) treatment (Gerardi,
Rothbaum, Ressler, Heekin, & Rizzo, 2008), and drug ad-
diction research (Bordnick et al., 2008; Ryan, Kreiner,
Chapman, & Stark-Wroblewski, 2009) belong to the rare
applications integrating olfactory cues in clinically perti-
nent VR scenarios. More specifically, Kawai and Noro
(1996) coordinated olfactory cues with the content of
stereoscopic 3-D images, for example, using the fragrance
of a forest with 3-D images of a green forest, in order to
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: stephane.bouchard@uqo.ca.

1
University of Ottawa, Ottawa, Ontario, Canada
2
Université du Québec en Outaouais, Gatineau, Quebec, Canada
3
Laboratory of Cyberpsychology, Gatineau, Quebec, Canada
32
tions. The results of this experiment suggest that such as-
sociations can lead to a psychological effect as measured
in three psychological factors–depressive mood, anxious
mood, as well as tension and excitement–that differs ac-
cording to the type of fragrance (forest, marine, or laven-
der). In the field of PTSD treatment in VR, Gerardi and
colleagues' (2008) protocol calls for exposure to visual,
auditory, tactile (i.e., vibration), and olfactory stimuli
(burning rubber, diesel fuel, weapons fire and spices).
During treatment, the patient is exposed to multi-sensory
combat zone stimuli while driving a Humvee in either
urban or non-urban "Iraq-like" scenes. The intensity of
these stimuli increases gradually across sessions. The re-
sults of this brief, single case VR exposure treatment in-
cluded clinically and statistically significant changes in
scores on the Clinician Administered PTSD Scale (Blake
et al., 1990) and the PTSD Symptom Scale Self-Report
(Foa, Riggs, Dancu, & Rothbaum, 1993), thereby suggest-
ing preliminary promise for this type of intervention (Ger-
ardi et al., 2008). In the field of substance abuse and
addictions, Bordnick and colleagues' (2008) VR alcohol
cue reactivity assessment system incorporated visual, au-
ditory and olfactory stimuli. These stimuli included the
scents of vanilla, pizza, coffee, the preferred drink of the
participant (such as whiskey, beer, brandy, tequila, gin,
scotch, red wine or white wine), beer, cigarette smoke, and
pine trees. During trials involving non-treatment seeking
individuals with alcohol use disorders, the exposure of the
subjects to multi-sensory alcohol related cues generated
higher subjective alcohol cravings than when these cues
were absent. Furthermore, the multi-modal VE appears to
be associated with high levels of presence in VR (Bord-
nick et al., 2008). In an interesting variation on the previ-
ous experience, Ryan et al. (2009) found that, when
exposed to multi-sensory alcohol related cues, binge
drinking college students reported significantly higher
cravings for, and thoughts of, alcohol than non-binge
drinkers.
Yet, considering that the sense of smell plays a significant
role in everyday human life (Drummond, Douglas, &
Olver, 2007), and that its loss or impairment has signifi-
cant chances of adversely affecting an individual’s quality
of living and emotional experience (Pollatos et al., 2007),
it would seem that the successful integration of olfactory
stimuli in VEs should be pursued more actively. Thus, the
purpose of this paper is to provide VR researchers an
overview of the olfactory system, and its involvement in
psychological reactions, in the hope that this information
may contribute to an increased use of olfactory cues in VR
The Sense of Olfaction
clinical applications. To this end, the information is struc-
tured into six sections, the first of which briefly addresses
the neuroanatomy of the olfactory system. The next two
sections cover the capabilities of the olfactory sense, and
the characteristics of odors. Next, the potential interactions
involving the olfactory sense are covered. The fourth sec-
tion presents various factors that influence olfactory pro-
cessing and the fifth section presents some of the
influences of odors on physiological state, perception and
mental processes. Lastly, the present status of the research
involving the sense of olfaction, and the use of olfactory
stimuli in VEs will be discussed. This discussion will in-
troduce some of the present, and some of the potential, ap-
plications of exposure to olfactory stimuli in VEs.
neuroanaTomy of The olfaCTory sysTem
Olfaction is the “sensation of odors that results from the
detection of odorous substances aerosolized in the envi-
ronment” (Simpson & Sweazy, 2006, p.377), and thus, it
is categorized as a chemical sense, as in the sense of taste.
In addressing olfaction, it is important to distinguish be-
tween the terms “odor” and “odorant” (e.g., Hudson, 2000;
Hudson & Distel, 2002a,b). While an odorant, or olfactory
stimulus, is a physicochemical entity of molecules in the
environment (Hudson & Distel, 2003), an odor is the per-
cept created by a subject’s nervous system, in reaction to
the contact between the olfactory receptors and the mole-
cule patterns of the odorant (Hudson & Distel, 2003).
An odorant commences its transformation into an odor ei-
ther from the outside (orthonasal) or from the inside
(retronasal) of the subject’s body. Whereas orthonasal
stimulation results from sniffing the ambient air, retronasal
stimulation results when the odorants of ingested food
travel up from the back of the oral cavity and through the
nasopharynx into the nasal cavity (Shepherd, 2006). In ei-
ther case, the odorant ends up in the olfactory mucosa, it-
self located in the superior and posterior part of the nasal
cavity (Mackay-Sim & Royet, 2006). There, the odorant,
which must be hydrophilic or lipophilic in order to dis-
solve in the mucus (Stockhorst & Pietrowsky, 2004),
comes into contact with the olfactory receptors of the ol-
factory epithelium (Ratey, 2001). The axons of the sensory
neurons fasciculate to form the fila olfactoria (Mackay-
Sim & Royet, 2006), which traverses the skull base
through the cribriform plate, to then enter the olfactory
bulb. The left and right olfactory bulbs are interconnected
via the anterior commissure (Mackay-Sim & Royet,
2006), and axons leave the olfactory bulb via the olfactory
tract, to then project onto a group of structures collectively
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Baus and Bouchard
referred to as the primary olfactory cortex (Mackay-Sim
& Royet, 2006). These structures include the amygdala
which seems to play critical roles in odor processing
(Jones-Gotman & Zatorre, 1993; Zald & Pardo, 2000),
conditioned fear and attention (Bremner et al., 1999), as
well as aversive and negative emotional states (Hamann
& Mao, 2002). There exist important differences in neu-
roanatomical connections between the olfactory sense and
other senses. The various connections of the olfactory sys-
tem are illustrated at Fig.1. While other senses go through
a series of cortical relays before reaching the limbic sys-
tem, the olfactory bulb projects uncrossed (Ratey, 2001),
and without being mediated by the thalamus (Simpson &
Sweazy, 2006), onto the amygdala. There seems, however,
to exist an additional indirect and less prominent link be-
tween the primary olfactory cortex and the secondary ol-
factory area via the thalamus, (Djordjevic &
Jones-Gotman, 2006). In addition, the connection to the
orbitofrontal cortex provides olfaction with the “fastest
route between perception and action” (Malaspina et al.,
2006, p. 222).
In summary, an odor is the result of complex interactions
between the molecular pattern of an odorant, the olfactory
receptors, the olfactory bulb, the primary olfactory cortex
and the secondary olfactory area. Most importantly, when
compared to the other senses, the sense of olfaction enjoys
a more direct, and thus, faster and less filtered, uncrossed
connection with the amygdala. It is this privileged relation
with the limbic system, as well as that with the or-
bitofrontal cortex, that speak in favor of the use of olfac-
tory cues in VR. Indeed, many of these brain regions are
involved in the processing of virtual stimuli used in clin-
ical applications, including anxiety disorders (Phillips,
Drevets, Rauch, & Lane, 2003), addictions (Everitt &
Robbins, 2005) and eating disorders (Beckman, Shi,
Levine, & Billington, 2009).
CapabiliTies of The olfaCTory sense
Differentiable behavior and physiological changes ex-
pressed by newborn in reaction to odorants suggest that,
unlike the visual system, the olfactory system is remark-
ably mature at birth (Schaal, Marlier, & Soussignan, 1998,
2000). However, other than “an aversion to decaying, pu-
trid or bitter things” (Morean, 2007, p. 157), the only in-
born olfactory preference seems to be that for the mother’s
amniotic fluid (Schaal, Marlier, & Soussignan, 1998). It
seems that the right hemisphere is involved in the elabo-
ration of odors (Zatorre, Jones-Gotman, Evans, & Meyer,
1992; Zucco & Tressoldi, 1989), and that they are acquired
JCR
33
as a whole entity (Zucco, 2007). Unlike vision or hearing,
olfaction needs to be activated (Köster, 2002), and its ol-
factory bulb-produced “images” are subconscious (Shep-
herd, 2006). This latter point is supported by the absence
of a significant relay in the thalamus (Shepherd, 2006).
Furthermore, it seems impossible for a subject to conjure
up an olfactory image (Moeran, 2007). Concerning this dif-
ference form the other senses, Zucco (2003) offers the ex-
planation that, unlike olfactory representations, visual and
verbal representations are conceptual, and thus, can give
rise to conscious representations. Alike the other sensory
modalities, the olfactory system habituates to a prevailing
stimulus (Morean, 2007). This phenomenon is observable
through a rapid decline in the pyriform cortex activation
during constant exposure to a particular olfactory stimulus
(Poellinger et al., 2001; Sobel et al., 2000).
In humans, the development of different cognitive
processes for socialization seems to have led to loss of
function mutations in the olfactory receptor genes
(Rouquier, Blancher, & Giorgi, 2000), and the human’s ol-
factory acuity is inferior to that of most animal species
(Malaspina et al., 2006). A person’s ability to localize the
source of an odorant–based on olfaction alone–is relatively
poor (Kobal, Van Toller, & Hummel, 1989), and humans
are anomic to certain odorants (Albrecht & Wiesmann,
2006). Nevertheless, an individual can detect up to 10,000
odorants (Albrecht & Wiesmann, 2006) with less than
10,000 receptors (Ratey, 2001). Hudson and Distel (2003)
propose three ways the olfactory system is able to meet this
challenge: the combination of wide spectrum receptors and
neurons, the ability to learn, and the ability to adjust the
sensitivity of the receptors according to the environment,
the individual experience and the situation. However, de-
spite its still impressive detection spectrum, the human is
only able to discriminate between up to four separate com-
ponents of an odorant (Laing & Francis, 1989). Further-
more, unless it is exposed to certain odorants early in
development, the olfactory system may never develop the
ability to recognize them. Conversely, one’s olfactory sense
can be improved through training (Ratey, 2001).
An odor incorporates a potentially great number of
odorants into a single percept, for example, about 800
in the case of coffee (Deibler, Acree, & Lavin, 1998).
According to Albrecht and Wiesman (2006), each indi-
vidual is equipped with a different set up of receptors,
and they qualify one’s olfactory world to be as individ-
ual as a fingerprint. It also appears that individual sub-
jects encode one same odorant differently during
34
Figure 1. Major projections of the olfactory cortex (Simpson & Sweazy, 2006).
consecutive presentations (Engen, 1983). In addition, it
seems that the individuality of one’s olfactory world is
further defined by contextual contributions. Indeed,
Hudson and Distel (2003) suggest that individuals shar-
ing the same sensory-chemical niche–the home, the
neighbourhood, the city, etc.–will respond to an olfac-
tory stimulus in a more similar manner than those not
sharing that same olfactory niche. In support of this sug-
gestion, Stockhorst and Pietrowsky (2004) found that
the perceived intensity of an olfactory stimulus de-
pended on its concentration, as well as on the level of
everyday experience with the odorant. Hence, an odor
is a subjective percept produced by the combination of
an olfactory stimulus and a context, it is modulated via
the nervous system (Hudson & Distel, 2003), its mean-
ing is probably acquired by individual experience (Hud-
son, 1999), its perceived intensity depends on
interpretation and cognitive appraisal, and therefore, it
can be modified through learning (Stockhorst &
Pietrowsky, 2004).
In summary, the olfactory sense is remarkably mature
at birth. It can detect up to 10,000 odorants, but the non-
exposure to some odorants in early development may
lead to an inability to detect them. Olfaction must be ac-
tivated, habituates to prevailing stimulus, and it is im-
possible for a subject to conjure up an olfactory image.
An odorant may be encoded differently during consec-
The Sense of Olfaction
utive presentations, and its resulting odor is influenced
by a variety of contextual contributions and personal ex-
periences. Of particular interest to the integration of ol-
factory cues in VEs is the finding that the localization
of the source of an odorant, based on olfaction alone (i.e.
without the support of the other senses), is relatively
poor. For the purpose of integrating odors in a VE, the
implication of this characteristic could be three-fold. For
one, it allows, within certain limits, the use of a single
remote source to release the olfactory cues (instead of
using multiple sources and activating one, or the other,
depending on the position and/or orientation of the
user). The second implication may be that, in order to
trigger the user's association between the odor and the
intended virtual source of that odor, the visual (and po-
tentially auditory as well as haptic) details need to "sup-
port" the intended odor. For example, the odor of a
lemon should be matched with a virtual object that looks
and, if applicable, feels like a lemon. Lastly, the syn-
chronization between the user's virtual position and the
timing of the releases of the olfactory cues need to con-
trolled precisely, perhaps through a three dimensional
model creating an increasing odorant intensity as one
approaches the intended virtual source.
CharaCTerisTiCs of odors
dimensions of an odor
Hedonicity, or the measure of pleasantness, familiarity and
JCR
Baus and Bouchard
intensity are the dimensions mostly used to qualify an
odor, and they are not totally independent of another
(Delplanque et al., 2008). Hedonicity, also referred to as
valence (Schiffman, 1974), is the most salient (Engen &
McBurney, 1964; Harper, Land, Griffiths, & Bate-smith,
1966) of these dimensions. Hedonicity is not quantified
via a continuum of pleasantness, but via two opposing
clusters of pleasantness and unpleasantness (Godinot,
Sicard, & Dubois, 1995; Schiffman, 1974), and the effect
of a pleasant olfactory stimulus seems to be more persist-
ent than that of an unpleasant one (Weber & Heuberger,
2008). As proposed by the mere exposure effect (Cain &
Johnson, 1978; Sulmont, Issanchou, & Köster, 2002),
pleasantness and familiarity of odors seem to be positively
correlated (Engen and Ross, 1973; Bensafi, et al., 2002).
While Henion (1971) had suggested that, generally, an in-
crease in intensity leads to decreased pleasantness,
Moskowitz, Dravnieks, and Kiarman (1976) later sug-
gested that, depending on the odorant used, the correlation
could be positive, negative, complex or nonexistent. It has
also been suggested that the path for neutral or pleasant
odors is slower, and cognitively more complex, than that
for unpleasant odors (Rouby & Bensafi, 2002). As the for-
mer would be associated with higher order associations,
it may also be more influenced by familiarity (Royet et
al., 1999; Larsson, 2002). As proposed by Delplanque and
colleagues (2008), the existence of two distinct paths for
pleasant and unpleasant odors is in line with models sug-
gesting the existence of different evaluative channels for
the processing of positive and negative stimuli (Cacioppo,
Garner, & Bernston, 1999; Sander, Koenig, Georgieff,
Terra, & Franck, 2005). Furthermore, the existence of
these two distinct paths is supported by neuroimaging
(Fulbright et al., 1998; Zald & Pardo, 1997) and electro-
physiological (Hummel & Kobal, 1992) results of cerebral
activations during odor processing.
The dimensions qualifying an odor are hedonicity, famil-
iarity and intensity and certain correlations seem to exist
between these dimensions. In order to improve the VR ex-
perience, it may be useful to consider each of these three
dimensions. For example, it is conceivable that the hedo-
nicity of an odor could contribute to the determination of
its intended virtual source (e.g., during immersion, the de-
tection of a pleasant but non-specific odor, while the user
is positioned equidistantly from an overflowing garbage
can and a bouquet of flowers, is likely to result in an as-
sociation between the pleasant odor and the flowers). Fur-
thermore, the level of familiarity is likely to lead to a more
rapid, and stronger, association with the cues presented
JCR
35
via other modalities. For example, the level of presence in
a virtual kitchen may differ between users, depending on
their familiarity with the type of food odorant use, which
in turn, may be associated with cultural background. Fi-
nally, varying odorant intensities may be useful in cueing
the user about the position, and rate of position change,
relative to the intended virtual source of that odor.
faCTors influenCing olfaCTory proCessing
gender
Herz (2004) reports that women are more sensitive to ol-
factory stimuli than men, and although the results are not
unequivocal, consistent replications suggest that women
outperform men in olfactory tests (Good & Kopala, 2006;
Pause, Sojka, Krauel, Fehm-Wolfsdorf, & Ferstl, 1996).
These differences appear at an early age (Dorries,
Schmidt, Beauchamp, & Wysocki, 1989), and apply more
specifically to discrimination, recognition and identifica-
tion abilities (Doty, 1997; Wysocki & Gilbert, 1989), as
well as the accuracy of higher order olfactory processing,
such as naming or memory tasks (Good & Kopala, 2006).
The effect size of this difference increases with age (Ship
and Weiffenbach, 1993), and is consistent across cultures
(Barber, 1997; Doty et al., 1985). Although women detect
pleasant and unpleasant odors faster than neutral ones, this
is not the case for men (Pollatos et al., 2007). Neither Chen
and Dalton (2005), nor Pollatos et al. (2007) found a dif-
ference in perceived pleasantness and arousal between
men and women. In general, women are more sensitive to
biologically relevant olfactory stimuli, such as the
pheromone androsterone (Wysocki & Gilbert, 1989). This
last point, when combined with women’s peak sensitivity
to olfactory stimuli during the pre-ovulatory period (Good
& Kopala, 2006), and the passive communication of mate
quality through body odor (Sergeant, Davies, Dickins, &
Griffiths, 2005), supports the biological relevance of the
superior sensitivity of the woman’s olfactory system.
emoTional sTaTes
Current emotional states also seem to influence olfactory
processing (Pollatos et al., 2007). While an individual’s
current emotional state does not seem to affect olfactory
discrimination, it seems that across both sexes, negative
emotional states are associated with an increase in judged
odor intensity. For men, this increase in judged odor in-
tensity is observed across all emotional conditions (Chen
& Dalton, 2005; Pollatos et al., 2007). Viewing pleasant
and unpleasant pictures, respectively, increases and de-
creases the pleasantness ratings of a neutral suprathreshold
odor judged according to intensity and pleasantness (Pol-
36
latos et al., 2007). The viewing of unpleasant pictures is
followed by significantly reduced olfactory sensitivity
(Pollatos et al., 2007). This result is congruent with the ef-
fect of negative emotional states on the ”primary sensory
level of stimulus processing as measured by threshold
tasks” (Pollatos et al., 2007, p. 587-588), as previously
demonstrated with depressive patients (Serby, Larson, &
Kalkstein, 1990; Pause et al., 2003). Song and Leonard
(2005) suggest that, considering the projection of the ol-
factory system onto the limbic system (in particular, the
orbitofrontal cortex and the amygdala), there could be a
link between the dysfunction of a depressed patient’s lim-
bic system and the reduced olfactory sensitivity. Interest-
ingly, Vasterling, Braily, and Sutker (2000) found that
patients with PTSD suffered from olfactory identification
deficits–an observation which Doop, Mohr, Folley,
Brewer, and Park (2006) report as consistent with PTSD
related dysfunction of the fronto-limbic system. These
findings could be considered contradictory to the use of
olfactory cues in the treatment of PTSD. This apparent
contradiction will be addressed in the next section.
Visual sTimuli
Multisensory integration is a “process by which inputs
from one sensory modality influences processing of infor-
mation from another modality and leads to either en-
hanced or dampened neural responses depending on the
variety of factors, such as context and temporal or spatial
concordance” (Small, 2004, p. 120). This process implies
that “when two or more sensory cues occur at the same
time and in approximate spatial correspondence, the firing
rate of a multisensory neuron to a stimulus in one modality
can be measurably altered by the presence of a second
stimulus in another modality” (Österbauer et al., 2005, p.
3434). Anatomical and physiological evidence suggests
that the multisensory integration of olfactory and visual
stimuli involves the orbitofrontal cortex and the amygdala
(Thesen et al., 2004). There seem to exist compelling
color-smell associations (Österbauer et al., 2005). Indeed,
color not only facilitates odorant identification, but it can
also influence judgments of odor intensity and pleasant-
ness (Zellner, Bartoli, & Eckard, 1991). The mere pres-
ence of color in an odorant-less solution increases the
likelihood that subjects will report an odor (Engen, 1972),
and a seemingly impossible color-smell combination
(such as red colored white wine) can create perceptual ol-
factory illusions (DuBose, Cardello, & Maller, 1980; Mor-
rot, Brochet, & Dubourdieu, 2001). So far, however, the
literature offers little evidence whether odors can, in turn,
influence visual perception (Thesen et al., 2004).
The Sense of Olfaction
In summary, women’s olfactory processing seems more
sensitive than that of men, and negative emotional states
are associated with an increase in judged odor. Although
the gender-related difference in olfactory processing may
not necessarily warrant the development of gender-spe-
cific olfactory environments, it may need to be taken into
consideration during the analysis of the effect of odorants
during immersion. Most importantly for the integration of
olfactory cues in VEs, visual stimuli seem to influence and
enhance olfactory processing.
The influenCe of odors on
perCepTion and menTal proCesses
A variety of studies demonstrate that olfactory cues can
exert a cross-modal influence on the judgement of a vari-
ety of non-olfactory stimulus attributes or qualities (De-
mattè, Österbauer, & Spence, 2007).
odors, emoTions, and arousal
Pleasant and unpleasant odor cues have the power to lead
to, respectively, positive and negative affective states
(Ehrlichman & Halpern, 1988) and moods (Alaoui-Ismaïli
et al., 1997; Goel & Grasso, 2004). Specifically, it has
been demonstrated that pleasant odors decrease arousal,
whereas unpleasant odors have the opposite effect
(Knasko, 1992; Alaoui-Ismaïli et al., 1997). Furthermore,
arousal seems to be positively correlated with the strength
of an odor (Royet et al., 2003; Heuberger, Hongratana-
worakit, & Buchbauer, 2006).
odors and pain
Odors seem to have the potential to increase and decrease
perceived pain. Familiar odors, such as maternal milk
odorant (Mellier, Bézard, & Caston, 1997; Rattaz, Gou-
bet, & Bullinger, 2001), can soothe up to moderate pain
in infants, thereby limiting or even preventing crying and
thus, limit the energy expended during somewhat painful
medical procedures (Goubet, Rattaz, Pierrat, Bullinger,
& Lequien, 2003). Conversely, in the presence of already
existing pain, certain odors seem to superimpose addi-
tional pain, and slowly increase the level of background
pain (Villemure, Wassimi, Bennett, Shir, & Bushnell,
2006). Neurophysiologically, the intensification in per-
ceived pain can be observed by increased neural activa-
tion in several areas associated with pain (Villemure et
al., 2006). However, although the unpleasantness of the
odor predicts the increase in pain intensity and unpleas-
antness, it is the changes in mood evoked by the odors
that correlates best with the perceived level of pain (Ville-
mure et al., 2006).
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Baus and Bouchard
odors and soCial inTeraCTion
The perceived masculinity/femininity of photographed
faces can be influenced by the presence of human sex hor-
mone-like chemicals (Kovács et al., 2004). These findings
are in line with results suggesting the influence of human
pheromones on people’s judgements of the written de-
scriptions of others (Cowley, Johnson, & Brooksbank,
1977), and on the ratings of the sexual attractiveness of
pictures of women (Kirk-Smith, Booth, Carroll, & Davies,
1978; Kirk-Smith & Booth, 1990). Pheromones, which
humans emit in all body fluids (Ratey, 2001), are also
processed via the olfactory system (Stockhorst &
Pietrowsky, 2004). Even though they may carry no con-
sciously perceptible odor, they can cause measurable
changes in the autonomic nervous system and, depending
on the pheromone, they can induce mild impressions of
contentment or uneasiness (Ratey, 2001). Evidence sug-
gests that pheromones affect human sexual behavior, not
through sexual activity per se (Stockhorst & Pietrowsky,
2004), but through the modification of socio-sexual mat-
ing preference, attractiveness and mood (Cutler, Fried-
mann, & McCoy, 1998). More specifically, they “facilitate
the perception of species members for reproduction (Cow-
ley & Booksbank, 1991; Wyatt, 2003), they lead to an en-
trainment of the menstrual cycle (Stern & McClintock,
1998), change the physical attraction of possible sexual
partners (Kohl, Atzmüller, Fink, & Grammer, 2001;
Grammer, 1993) and mood (Jacob & McClintock, 2000),
and they are correlated to physical attractiveness
(Rikowsky & Grammer, 1999)” (Stockhorst &
Pietrowsky, 2004, p.5).
Research results also suggest a tendency to rate other peo-
ple more positively when in the presence of a pleasant fra-
grance (Kirk-Smith & Booth 1990). In turn, there is a
significant positive correlation between the rated sexiness
of a man’s body odor and his facial attractiveness to fe-
males (Rikowski & Grammer,1999). However, Demattè
et al. (2007) suggest that odors do not affect the actual per-
ception of the visual characteristics of a subject, but that
instead, they change the affective reaction to them.
odors, learning, and CondiTioning
Indicators supporting the role of learning in olfaction in-
clude an improving ability to discriminate between two
previously unfamiliar odorants with exposure (Rabin,
1988; Jehl, Royet, & Holley, 1995), and the ability to ac-
quire the qualities used to describe an odor (Stevenson,
2001). Olfactory learning appears to take place as early as
the olfactory bulb and the pyriform cortex (Brennan &
JCR
37
Keverne, 1997; Haberly, 2001). This process permits the
fine tuning, amplification and storage of the particularly
important odors, thus allowing the subject to distinguish
them from the multitude of olfactory stimuli in the envi-
ronment (Hudson & Distel, 2003). Learning greatly affects
the perception and processing of odors, and it allows an
organism to associate a specific situation with a particular
smell (Stockhorst & Pietrowsky, 2004). It may be the
processes of amplification and storage of odors (identified
as particularly important through "learning" during a trau-
matic event) that, despite the previously mentioned find-
ings of olfactory identification deficits in PTSD patients,
make the use of trauma-related odorants pertinent in the
treatment of this category of clientele. As demonstrated
by one trial exploring aversions to smells and tastes asso-
ciated with nausea-inducing substances, olfactory learning
can take place in the form of one classical conditioning
trial (Stockhorst & Pietrowsky, 2004).
Olfactory conditioning appears to first have been demon-
strated on humans by Kirk-Smith, Dodd and Van Toller
(1983), and by Marinkovic, Schell, and Dawson (1989),
as well as by Moore and Murphy (1999). Respectively,
these researchers successfully paired an odorant with an
elevated level of anxiety, physiological arousal, and an
eye-blink response. Olfactory stimuli may also, by virtue
of an association with unconditioned drug stimuli, elicit
conditioned responses in the form of increased craving,
skin responses and heart rate changes (Bordnick et al.,
2008). Olfactory conditioning seems to contribute to the
phenomena of sick building syndrome and multiple chem-
ical sensitivities (Magnavita, 2001). Various investigations
(Van den Bergh et al., 1999) suggest that the somatic neg-
ative symptoms in reaction to certain chemicals are most
likely linked to conditioned increases in olfactory sensi-
tivity to those same chemicals (Chu, 2008), potentially
leading to reactions such as pre-chemotherapy nausea
(Siegel, 1999). Olfactory conditioning has also emerged
as an influence in drug administration (Stockhorst et al.
1999) and cigarette smoking behavior (Lazev, Herzog, &
Brandon, 1999).
Herz, Schlanker, and Beland (2004) have suggested that
ambient odorants, initially paired with seemingly easy but
actually impossible to complete tasks, could have an in-
fluence on behavior. In one of their experiments, they ex-
posed their participants to an unfamiliar ambient odorant
during a frustration mood induction. When the participants
later worked on puzzle tests in a room scented with either
the same odorant, a different odorant, or no odorant, par-
38
ticipants in the same odorant condition spent significantly
less time working on the tests than participants in the other
conditions. Herz, Schlanker et al. (2004) suggest the ex-
istence of an emotional conditioning mechanism–the re-
duction in the time spent on the task in the presence of the
conditioned odor is the result of a reduced motivation, it-
self resulting from the odor-triggered re-emergence of the
negative emotional reaction initially experienced during
the failure to complete seemingly easy tasks. But the op-
posite also seems to be true. Indeed, Chu (2008) demon-
strated that, by classically conditioning an odorant with
positive task-related experiences, subsequent perform-
ances of underachieving schoolchildren could be manip-
ulated to significantly improve on subsequent tasks. An
olfactory stimulus can also act as a conditioned stimulus
in fear conditioning (Engen, 1973), and Chu (2008) sug-
gests that stronger emotions increase the likelihood of ef-
fective olfactory associative links.
odor and memory
Lehrner et al. (1999) report evidence supporting the exis-
tence of a discrete olfactory memory system branching
into component subsystems. Olfactory memory is inde-
pendent of, and different from, other modalities of mem-
ory (Vermetten & Bremner, 2003). Common and complex
odorants are encoded and remembered as poorly as ab-
stract meaningless geometrical shapes (Lawless, 1978);
Lawless (1978) and Engen (1991) suppose that the lack
of structural information in olfactory stimuli could con-
tribute to the poor immediate recognition of odors (in
comparison to visual and verbal stimuli). Odor memory
seems strongly affected by proactive interference (Engen,
1987; Lawless & Engen, 1977), barely affected by the ef-
fect of learning strategies (Zucco, 2007), and very resistant
to retroactive interference (Lawless & Engen, 1977; Zucco
2007). As such, it may well be the absence of attributes
that contributes to its resistance to interference (Schab,
1991). Although Engen and Ross (1973) had proposed that
odors are encoded in relation to perception and independ-
ent of semantic networks, Royet et al. (1999) found that
semantic and perceptual subsystems interacted during
odor processing (Doop et al., 2006).
According to Engen and Ross (1973), there seems to be
no difference between the recognition rates of intention-
ally and incidentally learned odor. In addition, the memory
of an odor seems unaffected by higher order abilities
(Danthiir, Roberts, Pallier, & Stankov, 2001). Although
Engen and Ross (1973), as well as Lawless and Cain
(1975), had found no link between familiarity and odor
The Sense of Olfaction
memory, more recent sources have suggested that familiar
odors are easier to remember and discriminate than unfa-
miliar ones (Savic & Berglund, 2000; Schab & Crowder,
1995). Royet et al.’s (1999) finding that odor familiarity
strongly predicted odor naming further supports the link
between familiarity and odor memory. Anatomical support
to this result includes the observation that the judgement
of odor familiarity involves the left inferior frontal gyrus
(Royet et al., 1999), an area normally linked to semantic
association (Ricci et al., 1999; Vandenberghe et al., 1996).
Thus, familiar and unfamiliar odors may be mediated by
separate neuronal circuits (Savic & Berglund, 2004). Fur-
thermore, if familiarity and pleasantness are indeed cor-
related (as suggested by Bensafi et al., 2002; Sulmont et
al., 2002), then odor pleasantness may also affect odor
memory.
While the memorization of a new odor seems more diffi-
cult than that of visual and auditory stimuli, if it is suc-
cessfully stored, the memory of that odor is particularly
persistent (Herz & Engen, 1996; White, 1998). During
recognition tasks immediately after exposure to stimuli,
visual and auditory stimuli are recognized at a rate of 90%
(Zucco, 2007), while olfactory stimuli are recognized at a
rate of only 70% (Herz & Engen 1996; Zucco 2003,
2005). However, over an entire year, unlike the case for
verbal and visual stimuli, the forgetting curve of an ac-
quired odor is relatively flat (Engen & Ross, 1973; Nick-
erson & Adams 1979). In fact, Engen and Ross (1973)
observed that after one year, over and above the 30%
recognition rate lost during initial memorization, the
recognition rate of odorants only decreases by an addi-
tional 5%.
Odor memory is excellent for odors associated with
significant autobiographical experiences (Engen, 1973).
This is supported by the ability of certain adults to name
odors they had not smelled since childhood (Goldman &
Seamon, 1992), and may be influenced by the aforemen-
tioned strong resistance to retroactive interference. Auto-
biographical memories are “episodic memories:
recollected events that belong to an individual’s past. The
events that are recalled as autobiographical memories are
typically multimodal (involving vision, hearing, smell,
taste, touch, and body sense or kinesthesis); they vary in
spatial, temporal, emotional, and narrative content and
context; they have personal relevance” (Rubin, 2005), and
they are usually encoded passively (Chu & Downes,
2000a). Thus, the systems that play a role in autobiograph-
ical memory are the individual senses, a multi-modal spa-
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Baus and Bouchard
tial system that notes the location of people and objects,
emotion, language, a non language narrative system which
tracks causal relations (Rubin, Schrauf, & Greenberg,
2003; Schrauf & Rubin, 2000), and “an explicit memory
system that coordinates or binds information from the
other systems” (Rubin, 2005, p. 79). When autobiograph-
ical and semantic memory retrievals are compared, the
amygdala, the hippocampus and the right inferior frontal
gyrus were found to be more active (Rubin, 2005), and
working more closely together (Greenberg et al., 2005)
during the former.
Autobiographical memory retrieval is enhanced by expo-
sure to events associated with odors (Doop et al., 2006).
In an autobiographical memory recall task, twice as many
memories were recalled when accompanied with the ap-
propriate odorant than without (Maylor, Carter, & Hallett,
2002). Odor-evoked memories seem different from other
memory experiences (Willander & Larsson, 2006). Al-
though they are no more accurate than those evoked by
other senses (Herz, 2004), odorant-triggered memories are
rated as more pleasant, and recalled less frequently
(Rubin, Groth, & Goldsmith, 1984). Odor representations
can be recalled after longer periods of time than verbal or
visual ones. While visually and verbally-triggered mem-
ories generate a reminiscence bump between the ages of
10 and 30 years at event (Conway & Haque, 1999; Rubin,
Rahhal, & Poon, 1998), olfactory-triggered memories
have been localized to the first decade of life (Chu &
Downes, 2000b; Willander & Larsson, 2006). These re-
sults are in agreement with research suggesting that asso-
ciative olfactory learning begins very early in life (Schaal,
Marlier, & Soussignan, 2000; Van Toller & Kendal-Reed,
1995), and earlier than the formation of autobiographical
memories consisting of verbal or visual information (Wil-
lander & Larsson, 2006). The strength of the relationship
between the olfactory cue and the autobiographical mem-
ory is directly correlated to the emotional charge and sig-
nificance of the remembered event (Vermetten &
Bremner, 2003). The remarkable ability of olfactory stim-
uli to evoke very old autobiographical memories may be
attributed to weak retroactive interference (Lawless &
Engen, 1977), strong proactive interference and, when
compared to visual or auditory stimuli, a low probability
of subsequent exposure interference (Herz, 2004). Conse-
quently, the first odor/event association is very hard to un-
learn, a subsequent association to the same odor is difficult
to form (Herz, 2004), and hence, exposure to event-con-
gruent olfactory information can give access to very old
personal experiences (Willander & Larsson, 2006).
JCR
39
In addition to being more potent autobiographical memory
cues than stimuli presented to other senses (Chu &
Downes, 2000), research suggests that olfactory-triggered
memories generate a stronger feeling of being brought
back in time than verbally or visually-triggered ones
(Herz, 2004; Willander & Larsson, 2006). Indeed, cross-
modal laboratory and autobiographical studies of episodic
memory have shown that olfactory-triggered memories
are more vivid than memories evoked by corresponding
words (Chu & Downes, 2002), and more emotional than
those triggered by alternate sensory variants, including au-
ditory stimuli (Royet et al., 2000) of the same item (Herz,
2004; Herz, Eliassen, Beland, & Souza, 2004). In fact,
specific trauma-related olfactory cues can lead to anxiety,
fear-related memories, flashbacks (Vermetten & Bremner,
2003) and panic attacks (Hinton, et al., 2004) in PTSD pa-
tients. These reactions may, in turn, lead to avoidance be-
havior. In the case of PTSD, the conditioned responses
rooted in the autobiographical memory do not extinguish
with time (Vermetten & Bremner, 2003). These observa-
tions are congruent with the direct synapsing from the ol-
factory area to the amygdala-hippocampal complex– the
neural substrate of emotional memory (Cahill, Babinsky,
Markowitsch, & McGaugh, 1995; Herz, Eliassen, et al.,
2004)–and the greater activation in the amygdala-hip-
pocampal complex in reaction to personally relevant odors
(Herz, Eliassen, et al, 2004).
effeCT of sub-ConsCiously proCessed odors
The research presented above suggests that olfactory
processed signals can affect organisms, but it is important
to recognize that these signals need not be consciously
processed to create an effect. Indeed, subliminal odors, as
little as seven ppt, (Shepherd, 2004) can influence implicit
odor memory (Degel & Köster, 1999; Köster, Degel, &
Piper, 2002), social likeability judgements, and autonomic
responses in a valence-consistent manner (Li, Moallem,
Paller, & Gottfried, 2007). In fact, contrary to autonomic
responses which are independent of the level of awareness
of an odor, the effects on social likeability emerge best when
the odor is subliminal (Li et al., 2007). As bottom-up sen-
sory input often induces top-down regulation, thereby re-
sulting in synthesized processes (Schneider & Chein, 2003),
it has been suggested that it is the absence of the conscious
awareness of the odor, and thus, the absence of a top-down
regulation, that allows the subliminal odor to exert a greater
effect than supraliminal odors (Li et al, 2007).
In summary, the presence of an odorant is associated with
numerous effects, and some of the ways these effects
40
could be exploited in VEs will be addressed in the discus-
sion section. While pleasant odors seem to lead to positive
affects and decrease arousal, unpleasant ones seem to in-
crease arousal and lead to negative affects. Furthermore,
arousal is inversely related to pleasantness, but positively
related to odor strength. The presence of odors can in-
crease or decrease the pain perceived by an individual. The
indications that an odor can influence how another person
is perceived are of particular interest to social presence in
a VE. These results seem to speak in favor of assigning
individual olfactory signatures to each virtual human in a
particular VE. Olfactory learning enables the discrimina-
tion of odorants in the environment, and this ability can
be improved through exposure. Olfactory conditioning–
the association between an olfactory stimulus and a par-
ticular situation–can not only elicit physiological and
physical responses, but it can also affect performance. The
olfactory system seems to have its own memory system,
and although the establishment of the memory of an odor
is more difficult than that of a visual stimulus, if it is suc-
cessfully established, it becomes particularly persistent.
There seems to be no difference between the recognition
rates of intentionally and incidentally learned odors, and
the memory of an odor seems unaffected by higher order
abilities. Odor memory is excellent for odors associated
with significant autobiographic experiences, and the re-
trieval of an autobiographical memory is enhanced by ex-
posure to event-associated odors. The strong resistance to
retroactive interference allows olfactory cues to trigger
memories originating in the first 10 years of life. These
memories are vivid, and result in a strong feeling of being
brought back in time. The conscious awareness of the odor
is not necessarily required to enable its potential effects.
disCussion
The sense of olfaction is used constantly and often subcon-
sciously (Drummond et al., 2007). It contributes to per-
sonal safety by helping to test the quality of the air
(Drummond et al., 2007), detect the presence of food and
individuals (Drummond et al., 2007), determine the edibil-
ity of food (Holland, Hendriks, & Aarts, 2005), sense the
flavors of food (Ratey, 2001; Shepherd, 2006), to the pleas-
ures of eating (Simpson & Sweazy, 2006), and thus, it also
influences future consumption. The olfactory sense’s sig-
nificant role in human social behavior is supported by the
observation that, contrary to congenitally blind, mute or
deaf people, individuals with congenital anosmia do not
have intact reproductive–social behavior (Naftolin, Harris,
& Bobrow, 1971). The olfactory sense contributes to the
identification of, not only an individual, but also his/her
The Sense of Olfaction
gender (Russel, 1976), as well as certain emotional states
(Stockhorst & Pietrowsky, 2004). Subconsciously, it affects
mating behavior (Herz & Inzlicht, 2002; Sergeant et al.,
2005). Specifically, it influences attraction and sexual part-
nering by affecting mood states (Jacob & McClintock,
2001), detecting immune system characteristics (Jacob,
McClintock, Zelano, & Ober, 2002; Thornhill & Ganges-
tad, 1999), genetic similarities (Eggert, Müller-Ruchholtz,
& Ferstl, 1999), and female fertility (Poran, 1995). As pre-
sented earlier in this document, research results suggest
that through the association of an olfactory cue with an
emotion (the more intense the emotion, the stronger the as-
sociation), that same olfactory cue can later evoke the con-
ditioned emotion, thereby affecting the abilities and
behavior of the subject. Thus, it could be expected that the
use of olfactory cues would be common in experimental
as well as in clinical psychology–yet, it isn’t so.
Several factors may have contributed to this situation. First
and foremost, as olfaction often acts subliminally, its im-
portance in day-to-day life may be underestimated (Al-
brecht & Wiesmann, 2006). Secondly, due to their
complex composition and transient character, controlled
exposure to olfactory stimuli is more complex than that to
visual or acoustical stimuli (Stockhorst & Pietrowsky,
2004) and it is still impossible, from one exposure to an-
other, to stimulate the exact same combination of olfactory
receptors (Hudson & Distel, 2003). Thirdly, the odor per-
ceived by each subject is highly subjective, and thus, gen-
eralization involving one particular odorant is likely to be
difficult. These factors may have contributed to the knowl-
edge gap between olfaction and the more researched
senses such as vision and audition. This knowledge gap
also applies to the technology behind devices reproducing
and dispensing olfactory stimuli.
More recently, however, due to the potential of this rela-
tively neglected sense and, in particular, its ability to evoke
vivid memories, this trend has begun to change (Chu &
Downes, 2000a). Today, in the field of scent machines,
dispensing and controlling odorants in VEs (previously
identified, as the primary obstacle to a generalized inte-
gration of olfactory stimuli in VEs; Sadowski, 1999) are
being addressed by a variety odor delivery systems, such
as the SDS100 by Biopac Systems Inc., the Scent Collar
by the Institute for Creative Technologies in collaboration
with AnthroTronix Inc., and the Scent Projector by ATR
Media Information Science Laboratories. These systems
allow exposure to a variety of orthonasally-delivered ol-
factory stimuli. In the field of applied research, the interest
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Baus and Bouchard
in aromachology, the study of the influence of odors on
behavior, now grows annually, and the topics covered by
this research include the effect of odorants on emotions,
physiology, cognitive abilities and behavior (Chu &
Downes, 2000a). It has been suggested that a jasmine
scent can enhance individuals' performance on problem-
solving tasks, as well as lead to higher levels of interest
and motivation to a task (Rottman, 1989), and that the
scents of rose and mustard seed differentially modulate at-
tention to brightness (Michael, Jacquot, Millot, & Brand,
2003). A stimulating peppermint fragrance seems to con-
tribute to increased pain tolerance (Raudenbush, Koon,
Meyer, & Flower, 2002), to enhance athletic performance
(Raudenbush, Meyer, & Eppich, 2002; Raudenbush, Cor-
ley, & Eppich, 2001), to induce physiological arousal
(Raudenbush, Koon, et al., 2002), and to enhance attention
to visual stimuli. The latter also seems true for muguet
(Warm, Dember, & Parasuraman, 1991). Finally, a rose-
mary scent seems to contribute to, at the cost of slower
performance, increased memory recall accuracy (Moss,
Cook, Wesnes, & Duckett, 2003), while a cinnamon scent
seems to contribute to enhanced cognitive performances
such as attention processes, virtual recognition memory,
working memory, and visual-motor response speed (Zo-
ladz & Raudenbush, 2005). Some of the physiological
changes resulting from pleasant ambient scents may, in
turn, contribute to behaviors such as increased gambling
in casinos (Hirsch, 1995), increased time spent on a deci-
sion task (Bone & Ellen,1999; Mitchell, Kahn, & Knasko,
1995), and intentions to visit a store (Spangenberg, Crow-
ley, & Henderson, 1996). At the opposite end of the spec-
trum, the persistent scents of air pollution seem to
contribute to aggression in school-aged children (Ratey,
2001). Other results indicate that odors can impair the
memory for faces that are presented simultaneously with
an odorant (Walla et al., 2003), and that when an odor is
semantically (Platek, Thomson, & Gallup, 2004) or hedo-
nically (Ehrlichman & Halpern, 1988) congruent with a
picture or a word, it facilitates the detection of that picture,
or the production of that word. Furthermore, stimulating
odorants seem to have the ability to increase alertness
(Goel & Lao, 2006; Weber & Heuberger, 2008).
In clinical applications, aromatherapy aims to capitalize
on the ability of olfactory stimuli to elicit specific emo-
tional responses. It relies on the hypothesis that, due to the
rapid connection between the olfactory system and the
limbic system, the appropriate olfactory stimulus could
calm or stimulate an individual, assist sleep, influence eat-
ing habits, reduce pain (via the release of enkephalins), or
JCR
41
heighten sexual arousal (via the release of endorphins)
(Ratey, 2001). For example, the natural scent of blooming
plants seems to be able to increase calmness, alertness,
and mood (Weber & Heuberger, 2008), while a lemon
scent seems to lead to fewer reports of health symptoms
(Knasko, 1992).
Whether in clinical or experimental research, VEs have,
so far, failed to fully integrate the potential of olfactory
stimulation, but there are exceptions. In clinical scenarios,
some interesting VR research utilizing olfactory stimuli
is being pursued in the field of behavioral and physiolog-
ical reactivity to drug and alcohol triggers/cues (Bordnick
et al., 2008). In such scenarios, the power of combining
visual and olfactory cues to induce drug cravings and un-
desired behavior can be employed as a tool for behavior
modification. Clinical scenarios for treating PTSD utilize
the tendency of prevailing olfactory cues to become
strongly associated to a highly emotional event occurring
at the same time, such the odor of burning human flesh
during a Rocket Propelled Grenade attack on a convoy.
In these virtual world scenarios, olfactory cues, along
with visual and acoustic ones, are meant to ease access
to, and thus facilitate the processing of, traumatic mem-
ories (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo,
2008).
However, the use of olfactory cues in VEs is more often
the exception than the rule, and more extensive applica-
tions of olfactory cues seem possible. For example, VEs
are presently used for pain distraction (Hoffman, Patter-
son, & Carrougher, 2000), and odors seem to have the po-
tential to decrease perceived pain. It would be interesting
to verify the effect of integrating them in these types of
applications. Furthermore, Kawai and Noro (1996) have
suggested that odorants, combined with stereoscopic 3-
D images may, through their ability to affect arousal and
emotions, be useful in relaxation procedures. It seems
that, as an extension of this application, the investigation
of the use of olfactory cues as an element of treating
mood disorders in VEs would also be pertinent. In train-
ing scenarios, VR olfactory conditioning could turn out
to be useful in triggering more appropriate responses to
emergency situations–for example, the use of the smell
of smoke during the practice of a fire drill in a VE may
lead to more appropriate behavior, including better con-
trol of emotions, in the presence of this stimulus during
an actual fire. Olfactory cues in a VE may also turn out
to be useful to establish an association between a distinct
odorant and “virtually-evoked” positive emotions. Such
42
an association may possibly find use in relaxation train-
ing, or the treatment of certain mood and anxiety disor-
ders. Furthermore, the ability of a VE to expose a great
number of users to a complex, yet perfectly identical sce-
nario, would seem to make it a good tool for investigating
the fundamental interactions between olfactory cues, per-
ception, cognition, emotion, and behavior. The results of
such investigations are of major interest, because they
could reveal whether the integration of olfactory stimuli
in training devices, such as combat simulators, would en-
hance the virtual experience, and if so, how and to what
degree.
In sum, research has demonstrated the importance of ol-
factory stimuli in the human experience, and the results
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The writing of this paper was supported by scholarships
from the Fonds de la Recherche en Santé du Québec
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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
physical activity not only for physical and mental health,
but such studies have also indicated a potential positive
impact on intelligence (Chomitz et al., 2009; Hillman, Er-
ickson, & Kramer, 2008), and cognitive development
(Neubauer, 2008; Sibley & Etnier, 2003). Further, physical
activity was even proven to positively correlate to stu-
dents’ academic performance (Hillman, Erickson, &
Kramer, 2008; Castelli et al., 2007; Coe et al., 2006). Re-
cent research done on fourth-eighth grade students re-
vealed that both mathematics and English test scores
increased as the passed number of fitness tests increased
(Chomitz et al., 2009). Other research conducted on third
and fifth grade students (Castelli et al., 2007), found that
"aerobic fitness" was positively associated with total aca-
demic achievement, including reading and mathematics.
tively associated with their total academic achievement.
Therefore, Chomitz et al. pointed out that “promoting fit-
ness by increasing opportunities for physical activity dur-
ing Physical Education (PE), recess, and out of school
time may support academic achievement” (Chomitz et al.,
2009).
While the importance placed on standardized testing is in-
creasing, many schools in the United States have tried to
diminish or even eliminate PE programs, although no em-
pirical evidence suggests that this elimination could result
in higher academic performance (Hillman, Erickson, &
Kramer, 2008). A similar situation is also apparent in Tai-
wan. Contrary to the "Health Related Physical Fitness" poli-
cies of the Ministry of Education in Taiwan (Ministry of
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: kfhsiao@mail.mcu.edu.tw

1
Department of Information Management, Ming-Chuan University, Taiwan
52
non-academic programs in order to maximize the time for
academic programs in order to meet parents’ expectations.
In Taiwan, most parents expect their children to spend most
of their time on academic programs instead of other non-
academic endeavors, though, as mentioned above, spending
more time on academic programs does not guarantee higher
scores. Nonetheless, many Chinese parents are profoundly
influenced by the Chinese philosophy that says, “Regardless
of the result, just throw all your endeavors into studying”
(Hsiao, 2005). Because of their parent’s high expectations
with respect to studying, students may feel it is inappropri-
ate to spend time on physical activity instead of studying
academic subjects. This old Chinese philosophy has trig-
gered the innovative idea of "learning while exercising" that
will be discussed in this study.
One of the main research objectives of this study was to
develop a learning system that can facilitate students'
"learning while exercising." A new information technol-
ogy termed "Augmented Reality" (AR) was employed to
achieve this objective. Most previous studies involving
AR learning systems used 3-D features to assist students
to learn in a way that is more realistic than 2-D instruc-
tional tools (Yee, Ning, & Lipson, 2009; Chen & Wang,
2008). Kaufmann reported that AR is a variation of Virtual
Reality (VR) (Kaufmann, 2002). Recent research provided
fruitful results by using VR, MR or AR to help sufferers
of mental (Mühlberger et al., 2008; Manzoni et al., 2008)
or physical health disorders. Regarding mental healthcare,
a recent study reported exciting results using VR applica-
tions for patients with schizophrenia (Kim et al., 2008).
Concerning physical health, Schaik et al. reported that par-
ticipants strongly preferred virtual augmented physical ac-
tivity over traditional physical exercise and the adherence
rate was 100% (Schaik et al., 2008). Wiederhold and
Wiederhold pointed out that VR has made a significant
impact on behavioral healthcare with its multiple effective
uses over the past decade (Wiederhold & Wiederhold,
2008). In addition to healthcare by the applications of VR,
MR or AR, Schaik et al. also found that fitness level was
not associated with the performance of solving simple
puzzles and hitting targets in the game. Further, the corre-
lation of preference for type of games with performance
in the game was not significant. In this study, a new ap-
proach was taken by creating an AR system for educa-
tional purposes using the current-day curriculum, not only
for simple puzzles or simple arithmetic puzzles, together
with three types of physical activity. Moreover, the poten-
tial of AR environments would be explored for adolescent
high school students.
Learning with AR Physical Activity
In addition to creating an AR learning system including
exercise, another objective of this study was to compare
the academic performance and learning attitude towards
science between high school-age groups using CARLS
and a group using KMCAI. In terms of assessment for ed-
ucational objectives, Bloom classified six categories of
cognitive domains–Knowledge, Comprehension, Appli-
cation, Analysis, Synthesis and Evaluation (Bloom et al.,
2009). Among these six categories, "Knowledge" was de-
fined as “recalling or remembering something without
necessarily understanding, using, or changing it.” The re-
vised taxonomy of the cognitive domains by Anderson and
Krathwohl included Remembering, Understanding, Ap-
plying, Analyzing, Evaluating and Creating (Pickard,
2007; Anderson & Krathwohl, 2001). The subject special-
ists involved in the research divided the assessment for the
unit of chemistry in high school science into two cate-
gories–memorized type and non-memorized type. The
memorized type referred to the content, which students
only needed to recall or remember without necessarily un-
derstanding. The memorized type corresponded with the
basic level "Knowledge" in Bloom’s classification of cog-
nitive skills and "Remembering" in Anderson’s & Krath-
wohl’s Revised Bloom’s Taxonomy (RBT). For the rest
of the assessment, the non-memorized type was identified
with the other five categories of cognition domains except
remembering knowledge. Our final goal in this study was
to compare the impact of the three types of physical ac-
tivity in CARLS on the memorized type and non-memo-
rized type of knowledge in high school science.
meThods
subJeCTs
In this study, the participants consisted of 687 seventh and
eighth grade students, aged between 13-14 years old, from
22 classes in five high schools located in Northern Taiwan
during the spring term of 2009. Approximately half of the
participants were male and the other half were female. A
total of 673 valid data samples were collected. All students
were divided into four groups–Group AR-Jump, Group
AR-Stretch, Group AR-Box and Group KMCAI. In these
four groups, only the first three groups used the AR learn-
ing system. Each group used a different type of AR phys-
ical activity. Group AR-Jump practiced aerobic fitness,
Group AR-Stretch practiced flexibility fitness and Group
AR-Box practiced muscle strength. The reference Group
KMCAI used a keyboard and a mouse to operate the com-
puter. The gender distribution ratios, male versus female,
among the above-mentioned four groups are 84 (53.5%)
versus 73 (46.5%), 77 (48.4%) versus 82 (51.6%), 79
JCR
Hsiao 53

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

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

JCR
54
ward learning about science. Afterwards, all students in
the four groups received one 50-minute lesson for con-
ventional instruction using textbooks and CAI materials
and the other 50-minute lesson for the second part, "prac-
tice," by using four different approaches in the following
three weeks. After the completion of learning the unit of
Elements and Compounds, all students in the four groups
spent 20 minutes for the post-test and 15 minutes for the
post-attitude test toward learning about science. The post-
test and post-attitude test were applied a week after fin-
ishing all activity with AR in order to examine students’
learning retention. Thus, in addition to a four-week inter-
vention with AR, the fifth week was used for the exam
and the questionnaire.
In order to avoid anxiety and resistance towards the new
AR technology from parents and teachers, the four-week
intervention using AR technology and one week for the
exam and questionnaire in this study were authorized by
the schools. Relating to the intervention time of this study,
the following realistic and practical problems did exist at
the beginning stage of designing the experiment: (1) AR
is new to most schools in Taiwan so there are a great num-
ber of doubts and resistance towards new technology. (2)
This study involves a large sample of students (n= 673)
from 22 classes in five high schools. To avoid uncertain
academic results for students, most schools would not
allow the long-term experiment to be conducted on their
students, particularly for the pioneer or exploratory study.
To examine the differences in students’ academic achieve-
ment including both memorized and non-memorized
types, as well as students’ attitude change towards learn-
ing, a series of statistical analyses was conducted among
Figure 1. Equipment setup and user’s location in CARLS.
Learning with AR Physical Activity
the five groups. Since the group means differed both pre-
test and post-test in academic achievement and learning
attitude, covariance analysis was applied to the following
statistical analyses. Furthermore, in order to explore a
richer, in-depth context of students’ learning with AR, ex-
tensive interviews and observations were also carried out
in this study.
ChemisTry ar learning sysTem (Carls)
In this study, AR technology was employed to facilitate
students "learning by exercising." By modifying the con-
tent of chemistry for seventh and eighth grade high school
students, CARLS was developed as an assisted tool for
students’ science learning. Thus, CARLS can be viewed
as another type of a Computer Assisted Instruction (CAI)
tool, but differentiated from conventional KMCAI.
In terms of AR technology, the most well-known defini-
tion of AR was provided by Milgram and Kishino, who
defined it as “a continuum of real to virtual environments
in which AR is one area within the general area of Mixed
Reality (MR)” (Milgram et al., 1994). In Azuma’s work,
AR was defined as a system with three characteristics: (1)
a combination of real and virtual environments; (2) inter-
active in real time; and (3) registered in 3-D (Azuma,
1997). However, Malik et al. argued that AR uses virtual
objects, including text, 2-D images or 3-D models, to en-
hance users' insight into the real world (Malik, Roth, &
McDonald, 2002). Kaufmann reported that AR is a varia-
tion of VR (Kaufmann, 2002). VR immerses a user in a
virtual environment but, in contrast, AR allows a user to
see the real world combined with virtual objects in the
same space at the same time.
JCR
Hsiao
In this study, CARLS adopted a webcam to capture stu-
dents’ gestures and body movements from the real world
and combined them with designed virtual images to create
an interactive image. These virtual interactions were dis-
played onto a screen by a projector (see Figure 1, previous
page). In CARLS, when students touch the "answer area"
in the virtual environment, their positions and gestures can
be captured by the webcam and CARLS will generate re-
Figure 2. AR Physical activity including jumping, boxing and stretching in CARLS.
JCR
55
actions according to the students’ intended answers. The
results and feedback from CARLS will be displayed on a
large screen-wall in the real world.
CARLS combined learning with three types of physical
activity–aerobic fitness or jumping (see Figure 2a), flexi-
bility fitness or stretching (see Figure 2b) and muscle
strength or boxing (Figure 2c).
56 Learning with AR Physical Activity

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

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

group -0.029
ar-stretch

group 0.049 0.078

ar-box

group 0.451** 0.480** 0.403**

KmCai

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

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

JCR
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
ar-Jump

group -0.382
ar-stretch

group -0.014 0.368

ar-box

group -0.616** -0.234 -0.602**

KmCai

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
ar-Jump

group 0.115
ar-stretch

group -0.041 -0.155

ar-box

group 0.143 0.028 0.184*

KmCai

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

JCR
Hsiao
disCussion
This study developed an AR learning system, CARLS, to
facilitate students learning about science by including
three types of physical activity–aerobic fitness, flexibility
fitness and muscle strength–at the same time. Further, the
performance in academic achievement in science, includ-
ing both memorized and non-memorized types of knowl-
edge and learning attitude change toward science between
the four groups, Group AR-Jump, Group AR-Stretch,
Group AR-Box and Group KMCAI, have been com-
pared.
In comparison to the previous research which reported
that "aerobic fitness" was positively associated with total
academic achievement, including reading and mathemat-
ics (Castelli et al., 2007), the findings derived from this
study support the notion that students combining all three
types of physical activity in CARLS obtained signifi-
cantly higher scores of the non-memorized type knowl-
edge of science than those in the control group KMCAI.
The findings concur with those revealed by previous
studies that there was no negative link between distrac-
tion from physical exercise and performance of cognitive
activity (Schaik et al., 2008). This study also found evi-
dence for the benefits of AR physical activity with cog-
nitive activity, irrespective of physical activity type.
Meanwhile, the students in the control group KMCAI
tended to attain significantly better performances on the
memorized type of knowledge than those in Group AR-
Jump and Group AR-Box. These results imply that both
conventional KMCAI and our new AR technology ap-
proach were both helpful to students’ learning, but in dif-
ferent types of knowledge. In terms of memorized
knowledge, based on the revised taxonomy of the cog-
nitive domain by Anderson and Krathwohl (Anderson &
Krathwohl, 2001), "remembering" is the basic level of
cognitive domain where students "do not need to under-
stand, use or change" knowledge. However, non-memo-
rized knowledge includes other cognitive domains such
as understanding, applying, analyzing, evaluating or cre-
ating. All of these could be seen as very essential abilities
in the field of science.
In addition to quantitative evidence on academic achieve-
ment, qualitative interviews and observations were car-
ried out to obtain a better picture of the educational setting
and learning process. Relating to higher-level learning be-
yond memorizing of the concepts of chemistry, especially
the unit dealing with elements and compounds, students
from all three types of physical activity in CARLS ex-
JCR
59
pressed their personal experiences about the new ap-
proach using AR:
“After learning with the use of CARLS, I know the fun-
damental concepts of Elements and Compounds better
now.” (Interviews, June 2009, opinions from Student 2-
81020-C).
“After learning with the use of CARLS, I could clearly un-
derstand the differences between Elements and Com-
pounds and the characteristics of Elements and
Compounds.” (Interviews, June 2009, opinions from Stu-
dent 2-81035-A, 3-80332-A, 4-71001-A,2-80215-B, 2-
80426-B, 2-80609-B, 2-81013-C, and 2-80235-C).
In terms of the change in attitude toward learning about
science, this study revealed that the students in Group AR-
Box using the "muscle strength" physical activity obtained
a significantly more positive attitude change than those in
the control group KMCAI. Thygerson and Larson (Thyger-
son & Larson, 2006) suggested that muscle fitness could
improve the peoples' ability to manage and function well
under pressure or anxiety. Further, it also promoted peo-
ple’s intention and willingness to carry out their tasks. The
findings of Thygerson and Larson imply that muscle fitness
might improve peoples' attitude toward certain objects or
situations since Loyd and Loyd suggested that attitude in-
cludes four components–anxiety, confidence, liking and
usefulness (Loyd & Loyd, 1985). Moreover, Gibson et al.
defined attitude as the positive or negative mental state to-
ward objects or situations (Gibson, Ivancevich, & Don-
nelly, 1991). Thus, the findings in this study corresponded
with previous studies and also explained why the students
in the muscle fitness exercise group had the highest posi-
tive learning attitude change toward science.
In addition to quantitative evidence on learning attitude,
the qualitative interviews also provided some clues.
Among three groups with AR physical activity, the stu-
dents in both Group AR-Box and Group AR-Jump ob-
tained higher scores in learning attitude change than
Group AR-Stretch, though only the students in Group AR-
Box obtained significant results in comparison with those
in the control group KMCAI. Based on the analysis of col-
lected data between the quantitative survey and qualitative
interviews, we provide outlines to explain this situation.
Firstly, the design of three types of physical activity in
CARLS might cause students to progress less concerning
learning attitude. The physical activity design for both AR-
Box and AR-Jump is quite "simple" and "straightforward."
60
The students only need to jump a certain height to touch
the answer, or to box the answer there is only a "short"
distance between their hands and the answer. However,
the physical activity design for AR-Stretch is slightly more
complicated than the other two. Students have to move the
correct answer from location A to location B carefully and
stretch their body in a difficult manner. The students from
Group AR-Stretch which resulted in less progress regard-
ing positive attitude change towards learning stated:
“It is a bit difficult to move the answer to the target loca-
tion. Even though I know the answer, I am not able to move
the answer to reach the assigned location.” (Interviews,
June 2009, opinions from Student 2-81003-B, 3-80322-
B, and 3-80419-B)
“The system should be improved to be easier for user and
the route for moving should be re-designed.” (Interviews,
June 2009, opinions from Student 2-80831-B and 3-
80110-B)
However, in order to reach the aim of the "stretch" exer-
cise, the route between location A and location B was de-
liberately designed to be longer and more winding in
comparison with the other two types of physical activity.
Future research may look more closely at the relationship
between the precise functions of exercise and the effect
on learning.
ConClusions
This study provides a new approach to increasing students’
physical activity without diminishing students’ academic
performance since many schools have tried to decrease
PE programs in many countries due to a variety of reasons.
In addition, better academic achievement in non-memo-
rized knowledge of science and a more positive attitude
toward learning about science were also promoted by
using CARLS. In this study we have shown that by using
CARLS it is possible to promote better academic achieve-
ment in non-memorized knowledge in science, and a more
positive attitude toward science while students also par-
ticipated in extra physical fitness exercises while learning.
In spite of the above findings, as the exploratory study that
pioneers in combining learning with AR and physical ac-
tivity, some suggestions and research constraints are
needed for future researchers and teachers adopting new
AR technology in the classroom. First, the content used
Learning with AR Physical Activity
in the AR learning system was taken from a certain unit
in high school science so that the findings could not be
generalized to other fields or subjects. Moreover, the stu-
dents who were involved in this study only used the
CARLS system to specially learn the unit dealing with el-
ements and compounds for a relatively short period of
time. One week of training was used to provide familiarity
with the AR system and three weeks were spent learning
with CARLS. There may possibly have been a novelty ef-
fect effecting students’ performances or behaviors, which
is partially in response to increased interest in, or attention
to, the AR technology, instead of the curriculum. The find-
ings might vary when CARLS is used in learning for a
longer period of time. Therefore, instead of drawing too
much attention to the novelty of the new technology, fu-
ture researchers and teachers should be encouraged to em-
phasize more valuable characteristics of AR, i.e. exploring
learning material through the combinations of the real and
virtual objects in the 3-D space so that it would help to
display more concrete demonstrations to learners. Further-
more, students obtain more physical activity while learn-
ing compared to the sedentary learning style. Finally,
although this study revealed that the students participating
in all three types of physical activity in CARLS obtained
higher scores on the non-memorized science knowledge,
this study did not directly prove that any specific physical
activity in CARLS promoted any specific students’ abili-
ties in the above-mentioned five non-memorized cognitive
domains. Future studies might prove fruitful in providing
more details of the likely causes of the results by utilizing
more sophisticated medical equipment.
For teachers adopting the new AR technology in the class-
room, we suggest that they pay close attention to the safety
of students since physical activity typically takes place in
the classroom. Further, the amount of physical activity
should be individualized for different students’ health con-
ditions. Physical activity should ideally take place within
a normal school schedule, however, if student exercise has
been limited by school budgets or any variety of reasons
as has happened in different countries, an AR learning sys-
tem with physical activity functions, like CARLS, might
provide an alternative solution.
Acknowledgements
This research work has benefitted from the technical sup-
port by Professor SY Huang and an AR work team in
Ming-Chuan University, Taiwan.
JCR
Hsiao
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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
differences in pain (Dao & LeResche, 2000; Ellemeier
& Westphal, 1995; Frot, Feine, & Bushnell, 2004;
Hawthorn & Redmond, 2000; Robinson, Riley, Myers,
Papas, Wise, Waxenberg et al., 2001; Robinson & Wise,
2003; Robinson & Wise, 2004; Unruh, 1996; Vallerand
& Polomano, 2000). Some studies have shown that fe-
males perceive and express higher levels of pain than
males in clinical settings (Hawthorn & Redmond,
2000). Sex-related differences in pain perception have
also been found in experimental pain settings (Frot, et
al., 2004). These sex differences extend to the observa-
tion of pain in others, with one study finding that par-
pain intensity in an experimental pain task compared to
males (Robinson & Wise, 2004).
Sex-specific relationships between pain and negative
affect have been reported in both community and clin-
ical samples (Riley, Robinson, Wade, Myers, & Price,
2001). In the National Health and Nutrition Examina-
tion Survey, pain and depression were more prevalent
in females than in males (Magni, Caldieron, Rigatti-Lu-
chini, & Merksey, 1990). In clinical pain samples, the
prevalence of depression and anxiety is typically higher
for females (Unruh, 1996). Although little is known
about the differences between males and females in
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

1
University of Jordan, Department of Psychology, Amman, Jordan
2
University of Washington, Department of Rehabilitation Medicine, Seattle, Washington, U.S.A.
3
University of Florida, Department of Clinical and Health Psychology, Gainesville, Florida, U.S.A.
64
found that females use a wider range of coping strate-
gies than men do. However, Keogh & Herdenfeldt
(2002) suggested that the use of a wider range of strate-
gies could reflect the failure of coping strategies to ef-
fectively reduce pain.
A number of studies have also suggested that there are
racial differences in pain perception, pain-related neg-
ative affect, and pain coping. In one study, African
Americans with rheumatoid arthritis reported signifi-
cantly higher use of distraction and praying/hoping as
coping strategies, whereas, Caucasians reported greater
use of ignoring pain and coping statements (Jordan,
Lumley, & Liesen, 1998). Campbell, Edwards, & Fill-
ingim (2005) examined racial differences in responses
to multiple experimental pain stimuli, including heat
pain, cold pressor pain, and ischemic pain and found
that African Americans reported greater use of passive
pain coping. Moreover, research on pain-related mood
has shown that African Americans with chronic pain
had higher pain-related depression and disability when
compared to Caucasians (Carmen, Green, Ndao-Brum-
blay, Nagrant, Baker, & Rothman, 2004). Riley, Wade,
Myers, Sheffield, Papas, & Price (2002) also found that
African Americans experience greater emotional suf-
fering compared to Caucasians with similar levels of
pain intensity.
Most research studies investigating sex and race differ-
ences in pain perception and evaluation focused on how
both sexes and different races perceive and evaluate
their own pain. The current study focuses on the differ-
ences in perceiving and evaluating others’ pain. Fur-
thermore, studies investigating differences in
perceiving and evaluating pain in others relied mainly
on recorded videos and still pictures of actual pain pa-
tients expressing pain. This methodology, however, is
not sensitive to the possible variance that might already
exist amongst video-taped pain patients. The current
study controls this possible variance through a novel
computerized technology which reduces the variance
to almost zero. The purpose of this study was to employ
a novel computer-generated virtual human (VH) tech-
nology to investigate sex and racial differences in the
observation of pain, pain coping, pain-related negative
affect, and recommendations to seek treatment. The use
of a VH technology allows for the standardization of
the amount of pain expression independent of the sex
and race characteristics that are of interest as dependent
variables. This level of experimental control is not pos-
Sex and Race Differences in Rating Pain
sible with traditional research methodologies, such as
those that involve historical chart reviews. It was hy-
pothesized that a VH stimulus would elicit the same sex
and race differences previously published in traditional
self-report and observational studies.
meThods
parTiCipanTs
Seventy-five University of Florida undergraduate stu-
dents (53 females, 22 males) were recruited through
fliers and posters requesting volunteers to participate
in this study. The participant sample was 83% Cau-
casian and 17% African American.
inClusion/exClusion CriTeria
Eligibility requirements for participation were being at
least 18 years old, English speaking, and of African
American or Caucasian background. Participation was
also contingent upon ability to give consent.
proCedure
Each participant was asked to read a description of the
study including the time required to complete the study
and a reminder that the study is voluntary. After reading
the study description, all participants read and signed a
computerized consent form acknowledging that the
study procedures were explained and that they could
withdraw, without prejudice, from the study at any
time. Next, they completed a brief demographic ques-
tionnaire that collected participants’ age, race, and sex.
Participants then read a set of instructions that provided
information on how to approach the task and how to
use Visual Analogue Scales (VASs) to give ratings.
A series of 16 vignettes were produced using comput-
erized VH technology via a commercially available
software package (People Puttytm). A novel feature of
this approach was the ability to standardize the amount
of pain expressed in the VH face across different sexes
and races of VHs. This was accomplished by employ-
ing the Facial Action Coding System (FACS). The
FACS is based on an anatomic analysis of facial muscle
movements and distinguishes 44 different action units
(AUs). An abbreviated version of the FACS was used
in this study focusing on the four primary action units
that are involved in the facial expression of pain and
produced validated facial expressions showing pain–
brow lowering, tightening of the orbital muscles sur-
rounding the eye, nose wrinkling/upper lip raising, and
eye closure.
JCR
Alqudah et al.
Each stimulus the participants observed consisted of a
vignette and a VH patient. Each VH contained three
cues–sex (two levels: male or female), race (two levels:
Caucasian or African American), and pain (two levels:
low amount or high amount of pain) which was re-
flected on the VHs facial expressions.
Participants were instructed to completely respond to
VHs in the order presented, complete the ratings for one
VH before going on to the next, and they were not al-
lowed to revisit a previously viewed VH. For each VH,
participants used computerized VASs to rate the level
of pain intensity observed, the level of pain unpleasant-
ness observed, the level of pain-related negative mood
observed, how well the observed VH was coping with
the pain experience, and the extent to which they would
recommend the observed VH to seek pain-related med-
ical help. Participants also completed a computerized
version of the Gender Role Expectations of Pain ques-
tionnaire (GREP) (see appendix A) using computerized
VASs to assess the degree to which gender role expec-
tations of pain may contribute to their ratings.
The Gender Role Expectations of Pain questionnaire
(GREP) consists of visual analog scales to assess par-
ticipants’ view of the typical male and female regarding
pain sensitivity, pain endurance, and willingness to re-
port pain. It also assesses the participants’ personal at-
tribution of his/her pain sensitivity, pain endurance, and
willingness to report pain relative to the typical male
and female. The psychometric properties of the GREP
factor structure are close to the theoretical formulation
of the scales, accounting for 76% of the variance in
scores. The questionnaire has good test–retest reliability
with individual item correlations ranging from 0.53 to
0.93. The sex differences in the endorsement of items
on the GREP were large, with the largest differences
(46% of variance) shown for willingness to report pain
items. Wise, Price, Myers, Heft and Robinson found
that the GREP was a significant predictor of experimen-
tal pain ratings in undergraduate males and females, and
that a significant proportion of sex differences in pain
report was accounted for by gender role expectations.
Task duration for the current study was approximately
one hour. Following the completion of the task, partic-
ipants were asked to respond, in writing, to a task valid-
ity probe, in which they were asked to guess the study
hypotheses. Then, participants were briefed regarding
the variables of interest and the study hypotheses.
JCR
65
analysis
All data analyses were performed using SPSS for Win-
dows (Version 15). Mixed model ANOVA analyses
were performed where sex and race of participants and
VHs served as independent variables, and ratings of
pain intensity, pain unpleasantness, pain-related nega-
tive mood, pain coping, and the extent to which the
VHs were recommended to seek medical help for their
pain served as dependent variables. We had no a priori
hypotheses regarding a number of the interaction terms
(e.g. sex of participant, by race of participant, by sex
of video, by race of video), therefore, we approached
the analyses by looking at only the main effects and
specified two-way interactions for which a priori hy-
potheses were available.
Willingness to report pain and pain endurance, taken
from the GREP, were investigated to determine whether
they met the criteria to serve as covariates in the analy-
ses involving participants’ ratings of pain intensity and
pain unpleasantness.
resulTs
CoVarianCe analysis
Willingness to report pain and pain endurance are two
factors of the GREP that were considered for inclusion
in the models as covariates. Correlation analyses were
conducted on these two factors as well as male and fe-
male participants’ ratings of pain intensity and pain un-
pleasantness for male and female VHs. Results of the
correlation analyses were not significant, thereby indi-
cating that the two GREP factors did not meet the as-
sumptions of covariance analysis. Therefore,
willingness to report pain and pain endurance were not
included in the following models.
assoCiaTions among The dependenT Variables
A correlation analysis was conducted between the de-
pendent variables. All dependent variables in this study
(ratings of pain intensity, pain unpleasantness, pain-re-
lated negative mood, pain coping, and recommending
medical help) were significantly correlated. The mag-
nitude of the correlations ranged from 0.35 (pain coping
and recommending medical help) to 0.87 (pain intensity
and pain unpleasantness.) See Table 1 below.
analysis of pain inTensiTy raTings
sEx EffEcts
Both male and female participants rated pain intensity
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 – – –
unpleasantness

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

JCR
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

JCR
68
analysis of reCommending mediCal help raTings
sEx EffEcts
A main effect for sex of VHs on sex of participants was
found. Both male and female participants’ ratings for rec-
ommending medical help were significantly higher for fe-
male VHs than that for male VHs, F (1, 73) = 5.98, p <
0.05. The sex of participants was also found as a main ef-
fect, indicating that male participants’ ratings for recom-
mending medical help (M=52.86, SE=4.31) were
significantly higher than female participants’ ratings
(M=42.50, SE=2.78), F (1, 73) = 4.02, p < 0.05. Race of
the participant did not have an effect on ratings of recom-
mending medical help.
racE EffEcts
Male participants’ ratings for both Caucasian and African
American VHs (M=52.86, SE=4.31) were significantly
higher than that of female participants (M=42.50,
SE=2.78), F (1, 73) = 4.06, p < 0.05. Table 6 below sum-
marizes the results of recommending medical help ratings.
Table 6
Means and standard deviations of recommending med-
ical help ratings
recommending
Vh
medical help
male 44.05* (21.16)
female 47.15* (20.94)
Caucasian 45.80 (21.35)
african american 45.28 (20.71)
* < .05 significant difference between participants on
recommending medical help ratings
summary of resulTs
In summary, male and female participants both rated fe-
male VHs’ pain intensity, pain unpleasantness, pain-re-
lated negative mood, and poorer pain coping, as higher
than male VHs. Male and female participants were also
more likely to recommend that female VHs seek medical
help than male VHs. However, Caucasian and African
Sex and Race Differences in Rating Pain
American participants’ ratings for female VHs were higher
than that for male VHs only on pain intensity and pain un-
pleasantness. Caucasian VHs were viewed as having
higher pain-related negative mood and as coping more
poorly with their pain than African American VHs.
African American VHs’ pain intensity was rated higher
only by African American participants. Ratings made by
male participants tended to be higher than ratings made
by female participants.
disCussion
Although pain levels–as expressed by the faces of the
VHs–were digitally controlled to be equivalent across dif-
ferent sexes and races, results indicated that participants
of both sexes and races still viewed female VHs’ pain,
both the sensory (intensity) and affective (unpleasantness)
components, as significantly higher than that for male
VHs. This is consistent with other research findings. In a
study of experimentally-induced pain, Robinson et al.
found that viewers rated females’ pain as higher than
males’. One explanation for why female VHs were viewed
as having higher pain is the difference in pain expecta-
tions. Females are expected to report higher levels of pain
than males in general. Although willingness to report pain
and pain endurance (as measured by the GREP) did not
correlate significantly with pain ratings in this study, a siz-
able literature shows that both males and females expect
females to experience greater amounts of pain (Robinson
et al., 2001; Unruh, 1996). Additional research is needed
to determine whether such expectations are also elicited
by computer-generated VH characters.
The International Association for the Study of Pain’s def-
inition of pain highlights the importance of understanding
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-
trolled to be similar for males and females in this study,
female VHs’ pain-related negative mood was rated as sig-
nificantly higher than that for male VHs’ by participants
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
Nutrition Examination Survey, where pain and depressive
symptoms were more evident in females than in males
(Magni et al.,1990).
Caucasian VHs were rated by both African American and
Caucasian participants as experiencing greater pain-re-
lated negative moods. These results suggest that assess-
JCR
Alqudah et al.
ment of the pain-related negative mood is, at least, partly
determined by the race of the individual experiencing pain.
Consistent with the pain-related negative mood results,
participants of both sexes rated female VHs as coping
more poorly with their pain, and participants of both races
rated Caucasian VHs as coping more poorlywith their
pain. These results mirror those for pain-related negative
mood, and suggest that when females and Caucasians are
viewed as having higher pain than males and African
Americans, respectively, they are also more likely to be
viewed as experiencing higher levels of pain-related neg-
ative mood and poorer pain-related coping.
When an individual’s pain level, pain-related negative
mood, and maladaptive pain coping is rated as high, it is
expected that he/she is more likely to be recommended to
seek medical help for his/her pain. In this study, female
VHs were rated higher on all these variables than male
VHs. They were also recommended to seek medical help
for their pain significantly more often than male VHs.
However, it was not expected for male participants’ rec-
ommendations to be higher than female participants’.
Male participants recommended that VHs of both sexes
and races should seek medical help for their pain signifi-
cantly more than female participants. This is consistent
with studies showing sex differences in health-seeking be-
haviors. Males have been found to request more drugs
than females after surgery when given access to patient
controlled analgesia (Macintyre & Jarvis, 1995). Burns,
Hodsman, McLintock, Gillies, Kenny, & McArdle (1989)
and Stinshoff, Lang, Berbaum, Lutgendorf, Logan &
Berbaum (2004) also found that males tend to seek more
medication for their pain compared to females. Based on
the current findings, it also appears that males are more
likely to recommend that others seek care for their own
pain complaints. Several other interpretations are possible.
For example, perhaps males consider themselves to be less
equipped than females to help others with their medical
concerns. Males may also be less tolerant of expressions
of distress from others, which results in them being more
likely than females to encourage that medical care be
sought. These speculations could be investigated in future
studies.
The ratings of pain intensity, pain unpleasantness, pain-
related negative mood, pain coping, and recommending
JCR
69
medical help showed significant intercorrelations. Rela-
tionships between these dependent variables have a pattern
that might add to the explanation of some of the current
results. For example, the high correlation between pain in-
tensity, pain unpleasantness, pain-related negative mood,
and pain coping might add to the explanation of why fe-
male virtual videos were rated higher on all variables, if
pain ratings influenced the other ratings.
The results of this study have several implications that are
worth noting. First, the use of computerized VHs with dig-
itally controlled facial expressions of pain across sexes
and races is an innovative technique that enabled greater
standardization of pain expression than real humans would
allow. This standardization allows for greater confidence
in interpreting the results as being determined by the sex
and race biases that participants brought to the ratings.
Furthermore, the VH technology used in this study has the
potential to be an educational assessment and intervention
tool. Students, healthcare providers, and other individuals
can use this technology to assess their own biases in in-
terpreting pain or other emotions expressed by others. This
technology can also be accessible to almost anyone in the
world via the Internet.
This study did have some limitations, however. First, there
was only one African American male participant in the
sample. Future investigations with more diverse samples
would be necessary to provide additional evidence of the
sex and race findings of the present study. Second, the par-
ticipants in this study were undergraduate students and it
would be important to replicate these findings in other
populations. Finally, the VH characters only showed the
head region and, thus, did not address the many other non-
verbal expressions of pain that are communicated through-
out the entire body. Future work could examine whether
the sex and race effects observed herein are also found
when full body characters are used and other nonverbal
expressions are manipulated.
Acknowledgement
The present work was supported by grants from the Na-
tional Institute of Dental and Craniofacial Research
(R01DE013208), National Institute of Neurological Dis-
orders and Stroke (F31NS049675), and National Center
for Rehabilitation Research (T32HD007424).
70
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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-
tion. In this new period, entrenched stereotypes and prej-
udices may yield to a more balanced sense of social values
based on rationality and dignity. This will be a direct result
of empowering the individual, without the distinction of
sexual, ethnic, or class discrimination. Talented individu-
als who may otherwise be stifled will have a better chance
to be realize their own potential and become socially rec-
ognized.
Jonassen et al. (1999) argues that technologies can be ap-
plications of human knowledge to solve real-world prob-
lems. Such technological tools can support human needs
and expand the individual’s functional capacities. This
knowledge can be constructive, aid in informational re-
source management, and requires producing communica-
tion connectivity. In the same context, Second Life is a
social virtual environment tool and new media for explor-
ing communication environments may improve mutual
understanding between men and women concerning gen-
der roles. Virtual worlds continue to grow as a significant
component of many children’s and adults’ leisure time.
They are being used in education worldwide, and they
whole.
Different societies reflect cultural values that vary, alter
and evolve with given social, political and environmental
locations. Male and female gender roles, and the interac-
tion between the two, have long been a key determinant
of social-cultural values. In other words, expectations of
male and female behavior are set according to gender dif-
ferences and variance. However, such expectant interpre-
tive analysis is within accordance to age modification
variants. A gender role is set within a particular social, po-
litical, and environmental context shared between male
and female subjects. However, such expectant interpretive
analysis is within accordance to age modification variants.
This is social science and humanity’s framework for the
desired analysis. Gender is the primary component of the
gender system in human society, which refers to the set of
arrangements by which a society transforms biological
sexuality into products of human activity, and in which
these transformed needs are satisfied (Reiter, 1975).
Thorne (1999) classified four kinds of meaning for gender
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: hyungsung@gmail.com

1
Kyonggi University, Republic of Korea, San 94-6 Iui-dong, Paldal-gu, Suwon-si, Gyeonggi-do, 443-760, Republic of Korea
72
is community activity through role playing with gender
classifications, gender identities, and gender areas. He ar-
gued that gender role playing is an important activity to
understand one's own gender identity and to understand
the opposite gender role. It has been determined that gen-
der roles are decided by social and cultural factors more
than biological factors. This makes online communities
an interesting site to explore how gender is perceived in
virtual spaces. The online player community serves the
function of interaction and socialization for many players,
and one virtual world in particular, is the so-called Second
Life. This Second Life is rich in scenery with players in-
teracting with other characters through text-based chat,
virtual environment and social activities.
Virtual Reality (VR) is an emerging computer interface
that strives to make simulations believable and realistic.
Highly realistic and believable simulations are accom-
plished using high-speed supercomputers and three-di-
mensional graphic accelerators (Ken & Teixeira, 1995).
The important distinguishing features of VR is that it is
highly immersive, interactive, colorful and visually ori-
ented, fun and generally exciting. VR technology is in-
creasingly being recognized as a potential tool for the
assessment and rehabilitation of cognitive and functional
processes in humans (Foreman et al, 1997; Pugnetti et al,
1995; Rizzo & Buckwalter, 1997; Rose, 1996). Virtual en-
vironments (VE) allow the creation of dynamic stimulus
environments in which all responding behaviors can ver-
ifiably be recorded. Such advanced technology could po-
tentially offer testing and training options that are
unavailable with the use of conventional neuropsycholog-
ical methods. It is proposed that computer-generated in-
teractive simulated environments can be used to assess
and rehabilitate cognitive abilities, much like an aircraft
simulator tests and trains piloting abilities.
Second Life is a social virtual environment entirely built
and owned by its residents. Since opening to the public in
2003, it has grown explosively, and today over 12 million
unique accounts have been created world-wide (Sec-
ondlife.com, 2008). Second Life has the capacity to con-
tain game content, but it is not a game, rather, it is a social
virtual world within itself. It is also a representation of the
first generation of this type of free open source technology.
Unlike games, it is a VE without a back story and educa-
tors. Also, users have the opportunity to write their own
narratives in a social virtual world. Through the willing
suspension of disbelief, users initially enter the virtual
world and experience it as visually appealing in a passive
Communication in Virtual Worlds
sense. However, through continued participation, the user
transitions from feeling like an outsider or a viewer into
an active “resident” who is “living” in the virtual world,
performing social positions and role play.
The purpose of this study is to explore the possibilities of-
fered by virtual worlds such as Second Life as a tool for
understanding gender roles. Virtual worlds have many
uses for testing users’ experiences about and understand-
ing of other people, recognition of gender roles, and how
their experiences in these virtual worlds may change the
way they think about men and women. Through these ac-
tivities, we believe that users will develop positive values
concerning gender identification and respect for other peo-
ple. At the same time, we can explore the broader possi-
bilities of using virtual worlds for education.
seCond life as a CommuniCaTion enVironmenT To
undersTand opposiTe gender roles
All societies and cultures have unique expectations and
rules about men and women. Because of sociocultural fac-
tors, the performance of gender roles has a tremendous in-
fluence on an individual's life. Gender roles are
internalized through the socialization process, many times
unconsciously. Gender roles also determine many social
expectations of men and women, such as family and oc-
cupation roles, political roles, self-efficacy, and psycho-
logical factors. As social customs have changed,
present-day gender roles require a deeper understanding
about men and women. In modern times, the meaning of
gender roles has been shown to be far more independent
of physiological and anatomical differences than previ-
ously believed. This permits individuals to utilize interac-
tive social technology within a controlled environment to
explore the complicated patterns of behavior that modern
society has adapted in response to both men and women’s
traditional gender roles.
According to psychologists (Chodorow, 1978; Dinnerstein,
1977; Johnson, 1988), gender identity results from distin-
guishing gender identity differences between males and fe-
males since birth. Also, Whiting and Edward (1988) stated
that gender identity is a result of biological difference.
Nood and Attema (2006) said that Second Life is a VE
where one can interact with the environment, made up of
a realistic graphic representation of our physical world.
The first thing a new visitor sees is a modifiable puppet,
called an "avatar" that enables the user to move through
the virtual world. With this avatar, the user can fly, tele-
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port, or walk to practically any place within Second Life.
Moreover, the user can meet others, create objects, go to
parties, buy kitchens, and, through the introduction of
commerce, earn money in a currency called the "Linden
Dollar"(L$), and perform many other activities.
Virtual worlds can supplement education, modeling ideas
that are abstract and making them interesting, relevant,
and concrete (Williamson & Facer, 2004). Virtual worlds
might also provide safe places where children can interact
and socialize, without worrying about unknown dangers
in an educational context (Alvarez, 2006). However, they
still include some physical dangers, predator behavior, re-
sulting negative emotions and so on. Another main appeal
of Second Life is that new activities can be tried in an al-
most risk-free environment. This can encourage experi-
mentation in a way that is not possible in the real world.
There can be some very real, human aspects to this, such
as people with social disorders practicing talking to others
behind the safety of a computer screen (Johnson, 2007).
We need to change our teaching methods to enhance the
skills that future citizens will need in a digital society.
Children and young people are introduced to virtual
worlds via video games, and the ways that they interact
with technology may change methods of learning, and the
accumulation of knowledge (Gros, 2007).
At the same time, Garau (2003) commented about the role
of virtual worlds that recent works of cyber fiction have
depicted, in a not-so-distant future where the Internet has
developed into a fully three-dimensional and immersive
data-scope, simultaneously accessible by millions of net-
work users. This virtual world is described as having spa-
tial properties similar to the physical world and its virtual
cities are populated by digital proxies of people.
Slater et al. (2000) argues that practical applications of VR
are normally in the realms of engineering, product design,
and skill rehearsal. Users can enter into a VE such as Sec-
ond Life in order to learn something new about a real sit-
uation, to which the simulation corresponds, or to improve
or learn a new skill. Participants can create their avatar
and explore, meet other people, own land, play games or
sports, have discussions, dance, create, run a business, en-
hance their education and so on, through a VR such as
Second Life. Users can perform actions in real life as well
as something that is impossible in real life. In fact, the cul-
ture in Second Life is characterized by its combination of
real actions as well as virtual life representations and ac-
tivities.
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73
researCh meThods
researCh QuesTions
For this research, we had to consider the following ques-
tions:
-Do virtual worlds provide a learning environment for role
playing to understand the opposite gender?
-Do users change their recognition of gender roles via vir-
tual worlds?
The research questions are formed to reflect the main ob-
jectives of this research and they are statistically tested in
this study.
parTiCipanTs of The sTudy
The sample for this study was drawn from university stu-
dents consisting of one hundred twenty female students in
the author's three classes titled, "Instruction Method and
Technology." The the sample consisted of thirty partici-
pants. Most of the students are women, with just three
male students. The men were excluded in this research to
avoid biases. The students’ ages ranged from 21-23 years
old. Participants did not meet prior to the experiment to
avoid the possibility of any first impressions influencing
their thoughts on gender in the conversation of the virtual
world. The experiment took place for twelve weeks to give
participants ample opportunity to develop an awareness
of gender roles in the virtual environment.
design
The study took place at the school of the participants. The
instructional interventions were divided into three main
phases–pre-testing, treatment, and post-testing. Treat-
ments were carried out over three months based on the
3rd-4th grade female students since a pre-service teacher
was taking "Instruction method and Technology" at the
university. Participants experienced their gender role for
two hours per day in a controlled environment within Sec-
ond Life. Assessment methods were the same for all stu-
dents who participated in the three groups. The first group
served as a control group, performing a female gender role
in the real world. The other groups performed in the virtual
world of Second life as male and female roles, respec-
tively. Gender roles were set as dependent variables. In
order to answer the research questions, we calculated
ANOVA to examine the statistical effect.
researCh proCedure and aCTiViTy
During the sessions, four experimental tasks were em-
ployed in order to evaluate the degree of gender role ex-
perienced by the participants as they engaged in the virtual
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

Masculine
Adjectives
SD .75 .73 .72

M 4.82 4.80 4.76

Feminine
Adjectives
SD .60 .76 .72

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

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Table 2
Analysis of variance

measure ss df Ms f p

Between Group .123 2 .062 .115 .892

Masculine
Adjectives Within Group 44.674 83 .538

Total 44.798 85

Between Group .048 2 .024 .050 .951

Feminine
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

Masculine
Adjectives
SD .68 .89 .82

M 4.51 4.58 3.89

Feminine
Adjectives
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

Masculine
Adjectives Within Group 52.786 83 .636

Total 60.825 85

Between Group 7.830 2 3.915 5.773 .004

Feminine
Adjectives Within Group 56.286 83 .678

Total 64.115 85

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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.

ConClusion
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

Women-Women
Masculine *
Adjectives
Women-Women
**
Women-Men
* **
Women-Women
Feminine *
Adjectives
Women-Women
**
Women-Men
* **
Result of post hoc multiple comparisons by Tukey

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Park
that can offer significant support for education. There are
several ways in which VR technology is expected to fa-
cilitate learning. One of its unique capabilities is the ability
to allow students to visit environments and to interact in
events that real-life distance, time, or safety factors make
unavailable. The type of activities supported by this capa-
bility facilitate current educational thinking that students
are better able to master, retain, and generalize new knowl-
edge when they are actively involved in constructing
knowledge through learning by doing.
Learners are represented in the virtual world by their char-
acters, called an “avatar.” In graphic-based virtual world
environments, like Second Life, it is possible for a user to
choose an avatar that is the opposite gender from their real
life gender. Thus, this opens up many possibilities for re-
search and exploration. Indeed, the way gender shapes
basic human interaction in virtual worlds is often noticed
and reflected upon, and has been studied in game-based
virtual worlds. According to Svatos (2007), during game
play a user’s character gains experience points through ac-
tivities he or she does in the virtual world, and these ex-
perience points drive the character’s evolution and
external form. Though Second Life is not a game, there
are many similarities between these virtual worlds and
video games, just as a video game character gains “expe-
rience” that changes their avatar’s evolution and form. It
may be possible for learners to gain “experiences” about
gender in virtual worlds in ways that can change their per-
ceptions of gender in the real world.
referenCes
Alvarez, M. (2006). Second Life and School: The Use of
Virtual Worlds in High School Education. Re-
trieved June 13, 2008, from http://www.trin-
ity.edu/adelwich/worlds/articles/trinity.manny.a
lvarez.pdf.
Bem, S. L. (1981). Bem Sex Role Inventory: Professional
Manual. Palo Alto, CA: Consulting Psycholo-
gists Press.
Bem, S. L. (2007). Sex role inventory test. Retrieved Au-
gust 9, 2007, from http://www.okcupid.com
/tests/take?testid=9417365772332679709.
Chodorow, N. (1978). The reproduction of mother-
ing. Berkeley: University of California
Press.
JCR
77
The analytical statistical results of this study indicate that
virtual world environments offer the possibility of a clear
understanding of gender roles and their placement and
functionality within the context of a social environment.
This in itself further provides opportune foundational cri-
teria for such information to become the building blocks
of further educational processing analyses. This research
analysis provides concrete and useful data pertaining to
the functionality of gender roles' impact and variation
when it comes to formal educational values, strategies,
methods, measurable results and treatments. This research
provides a measure of gender recognition, and shows that
such target placement can be variable with a users’ variant
activity experience within the context of a virtual world
in an educational context. Furthermore, it demonstrates
the capability and capacity for educational virtual worlds
to be accurate means of promoting practical and theoreti-
cal data which is key to understanding the time-worn, in-
finite complexities of male/female social relations and
educational placement within a given social context.
This study has the limitation that can also reflect the char-
acteristics of gender role in the real world–during the ses-
sion, females in the real world had to have a male or
female avatar in a virtual world such as Second Life. To
reduce this point, we explained to the participants that they
had to focus on understanding the opposite gender. Also,
given the topic for discussion, they had to come up with a
solution through rational decision making and positive
thinking activities during the session.
Foreman, N., Wilson, P., & Stanton, D. (1997). VR and
spatial awareness in disabled children. Commu-
nications of the ACM, 40(8), 76-77.
Garau, M. (2003). The Impact of Avatar Fidelity on Social
Interaction in Virtual Environments. Ph D the-
sis, University College London.
Gros, B. (2007). Digital Games in Education: The Design
of Games-Based Learning Environments. Jour-
nal of Research on Technology in Education,
40(1), pp. 23-38.
Johnson, M. (1988). Strong mothers, weak wives. Berke-
ley: University of California Press.
Johnson, N. (2006). The educational potential of Second
Life. Ohio State University. Digital Union.
78
Jonassen, D. H., Peck, K. L., & Wilson, B. G. (1999).
Learning with technology: A constructivist per-
spective. NJ: Phoenix Color Corp.
Ken, P., & Teixeira, K. (1995). Virtual Reality: Through
the New Looking Glass, second edition, Wind-
crest Books.
Nood, D., & Attema, J. (2006). The Second Life of Virtual
Reality. EPN REPORT. Retrieved June 24,
2008, from https://docs.rice.edu/confluence/
download/attachments/5111868/EPN-RE-
PORT-The_Second_Life_of_VR1.pdf?ver-
sion=1.
Pugnetti, L., Mendozzi, L., Motta, A., Cattaneo, A., Barbi-
eri, E., & Brancotti, B. (1995), Evaluation and
retraining of adults’ cognitive impairments:
Which role for virtual reality technology?, Com-
puters in Biology and Medicine, 25(2), 213- 227.
Reiter, R. (1975) ed. Toward and Anthropology of Women.
Monthly Review Press: New York.
Rizzo, A. A., Buckwalter, J. G., & Neumann, U. (1997).
Virtual reality and cognitive rehabilitation: A
brief review of the future. The Journal of Head
Trauma Rehabilitation, 12(6), 1-15.
Rose, F. D. (1996). Virtual reality in rehabilitation follow-
ing traumatic brain injury. Proceedings of the
European Conference on Disability, Virtual Re-
ality and Associated Technology (pp. 5-12).
Cognitive, Clinical, and Methodological Issues
Communication in Virtual Worlds
in Assessment and Rehabilitation (G. Riva,
Ed.), IOS Press, Amsterdam, 123-146.
Savtos, O. (2007). The Potential of Online Virtual Worlds.
Retrieved Oct. 9, 2007, from http://almorea.
com/papers/PotentialofVW.pdf.
Singh, K., & Agrawal, P. (2007). Perceived Sex Role and
Fear of Success: A Study on Urban Working
Women. Journal of Social Sciences, 15(1), 65-
69.
Slater, M., Howell, J., Steed, A., Pertaub, D-P., Garau, M.,
& Springel, S. (2000). Acting in Virtual Reality.
Proceeding of the Third International Confer-
ence on Collaborative Virtual Environments,
San Francisco, U.S.A.
Terdiman, D. (2003). SL Intrudes On First One. Retrieved
March 9, 2008, from http://www.wired.
com/news/games/0,2101,59675,00.html.
Thorne, B. (1999). Gender play: Girls and boys in school
(6th ed.). New Brunswick: Rutgers University
Press.
Whiting, B., & Edward, C. (1988). Children of difference
worlds. Cambridge: Harvard University Press.
Williamson, B., & Facer, K. (2004). More than ‘just a
game’: the implications for schools of chil-
dren’s computer games communities. Educa-
tion, Communication & Information, 4,
255-270.
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CyberproJeCTs
IN THIS FEATURE, we will try to describe the char-
acteristics of current cyberpsychology and rehabilitation
research. In particular, CyberProjects aims at describing
the leading research groups and projects, actually run-
ning around the world, with a special focus on European
research.
geTTing families and friends
TogeTher again–VirTually
A fireside chat, sharing photos with granddad, a family
get-together to play Monopoly on a Sunday afternoon…
Digital media designed for the individual has hastened
the demise of collective social events, but it could also
enable their revival.
By marrying state-of-the-art video and audio communi-
cations technology with digital media, interactive de-
vices and ambient intelligence, a team of European
researchers hopes to give people of all ages the opportu-
nity to get together, play games, share experiences and
generally communicate, interact and have fun together,
even if they are thousands of kilometers apart. Their goal
is to break down the barriers between people – techno-
logical and social.
“E-mail, the Internet, cellphones, Internet video calls…
they are all designed for one person using one machine.
They are not designed to support families or groups of
people communicating,” suggests Nikolaus Färber, a re-
searcher at the Fraunhofer Institute for Integrated Cir-
cuits IIS in Germany. “People have become isolated by
technology,” he adds.
Coupled with people moving and traveling more fre-
quently for work and study, it is a situation that has led
families and friends to spend less time together. Even in
the same home many people now tend to entertain and
educate themselves alone, whether it is the teenager play-
ing computer games in her room, the father listening to
music on his MP3 player in the lounge or the mother
studying on her laptop in the kitchen. Technology has
encouraged this isolation, but advances in that same tech-
nology could now reverse this trend.
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83
TelepresenCe and more
Working in the EU-funded TA2 (Together anywhere, to-
gether anytime) project, Färber and a team of researchers
from seven European countries are aiming to turn the ta-
bles on technology by simply and affordably bringing
telepresence into normal households. Their vision con-
sists of groups of friends and family members seeing
each other on their TVs, hearing each other through their
stereo systems, sharing photos and videos and playing
games almost as naturally as if they were in the same
room.
“My brother lives in Switzerland and we have kids about
the same age, but they only get to see each other twice a
year. With the system we are developing they would be
able to play together whenever they wanted to without
having to leave their homes,” Färber notes.
To make that possible, the TA2 researchers are develop-
ing the components necessary to build an affordable and
easy to install in-home telepresence system. The compo-
nents can then be used to build complete telepresence
systems without the need for special rooms or big
screens to bring people together virtually. A television
set, sound system, cameras and microphones placed in a
living room suffice to create a sufficiently interactive and
immersive experience, while state-of-the-art software,
which is transparent to the end user, manages the com-
munications backbone.
“Audio and video quality is of essence… it needs to be
sharp and responsive,” Färber says. “At the same time,
TA2 is aware that high audiovisual quality is not the only
thing that matters. Applications like games, photo shar-
ing, or virtual pin boards are necessary to frame and trig-
ger the communication.”
Fraunhofer IIS has developed an Audio Communication
Engine to provide low-delay, hi-fi quality sound that
vastly improves upon current shaky and echo-prone In-
ternet calls. Other project partners, among them Philips,
BT and Alcatel-Lucent, are working on enhancing video
communications, linking interactive devices together and
implementing ambient intelligence.
84
Two or more families playing a board game, for exam-
ple, would be able to see and hear each other over their
TV sets, with artificial intelligence used to focus in-home
cameras on the person speaking or whoever's turn it is.
A touch screen embedded in a table might serve as a
board game interface, while ambient intelligence from
in-home sensors will let the system and other players
know where participants are and what they are doing.
“Ambient intelligence could also improve communica-
tions by letting friends and family know when someone
is available for a call or if they are busy, depending of
course on how much information the person wants to dis-
close,” Färber says.
Children and the elderly, who often find themselves more
isolated than other social groups in the modern world,
could particularly benefit from the technology. One sce-
nario, which will be used as a demonstration to highlight
the project results, envisions a grandparent and grand-
child playing a picture-matching game called "pairs" in
which old photos could be used to trigger conversations
and pass stories down through generations.
“At IFA in Berlin (the world’s largest consumer electron-
ics fair) we set up a demonstration consisting of two
rooms, two TV screens and two tables with integrated
touch screens on which people could play games. People
CyberProjects
were playing with each other as if they were really to-
gether in the same room… Many people were interested
in the system, particularly those with families and friends
in different parts of the world,” notes Matthias Rose, the
head of marketing communications for audio and multi-
media at Fraunhofer IIS.
Fraunhofer is already working on integrating its audio
technology into commercial products, and commercial
applications are also likely to stem from other areas of
research in the TA2 project, which is being funded by
the EU’s Seventh Framework Programme.
“Obviously, once the project ends, it would be interesting
to find investors and partners to create a commercial
product out of the whole system that would allow every-
one to incorporate telepresence into their homes and
bring families and friends closer together,” Färber says.
For more information visit http://www.ta2-project.eu/.
Compiled by Giuseppe Riva, Ph.D. and
Simona Raspelli, Ph.D.
Istituto Auxologico Italiano
Data provided by ICT Results
(http://cordis.europa.eu/ictresults).
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CyberfoCus

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

The CyberFocus column welcomes your contributions. To supply relevant information for this feature, please send
an e-mail to: office@vrphobia.eu.

Cyberpsychology & CyberTherapy 15

June 13 - 15, 2010
Seoul, Korea
www.interactivemediainstitute.com

The Journal of CyberTherapy & Rehabilitation is the official journal of the CyberTherapy Conference. The 15th An-
nual International CyberTherapy Conference (CT15) brings together researchers, clinicians, policy makers and 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
www.raveconference.com

-----------------------------------------------------------------------------------------------------------------------------------------

The World of health iT Conference & exhibition

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

-----------------------------------------------------------------------------------------------------------------------------------------

ieee Vr 2010
March 20 - 24
Waltham, Massachusetts, USA
http://conferences.computer.org/vr/2010/

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applied psychophysiology & biofeedback 2010

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

-----------------------------------------------------------------------------------------------------------------------------------------

2010 haptics symposium

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

-----------------------------------------------------------------------------------------------------------------------------------------

spie defense, security, and sensing

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

-----------------------------------------------------------------------------------------------------------------------------------------

society of behavioral medicine: 2010

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

-----------------------------------------------------------------------------------------------------------------------------------------

laval Virtual 2010: 12th Virtual reality international Conference

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

-----------------------------------------------------------------------------------------------------------------------------------------

The 7th annual World health Care Congress

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

-----------------------------------------------------------------------------------------------------------------------------------------

med-e-Tel
April 14 - 16
Luxembourg
http://www.medetel.lu/index.php

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-----------------------------------------------------------------------------------------------------------------------------------------

19th international World Wide Web Conference: WWW2010

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

-----------------------------------------------------------------------------------------------------------------------------------------

human systems interaction Conference

May 13-15
Poland
http://hsi.wsiz.rzeszow.pl/

-----------------------------------------------------------------------------------------------------------------------------------------

american Telemedicine association 2010: 15th annual international meeting and exposition
May 16 - 18
San Antonio, Texas, USA
http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3629

-----------------------------------------------------------------------------------------------------------------------------------------

The 6th annual World health Care Congress – europe

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

-----------------------------------------------------------------------------------------------------------------------------------------

The xii symposium on Virtual and augmented reality – sVr 2010

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

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WCbCT 2010-World Congress of behavioral and Cognitive Therapies

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

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Cyberpsychology & CyberTherapy 15

June 13 - 15
Seoul, Korea
www.e-therapy2010.org

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siggraph 2010
July 25 - 29
Los Angeles, California, USA
http://www.siggraph.org/s2010/

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

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

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2010 american psychological association Conference

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

-----------------------------------------------------------------------------------------------------------------------------------------

8th iCdVraT with artabilitation

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

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The 5th international Conference on interactive mobile and Computer aided learning
September 16 - 17
Hasselt University, Belgium
http://www.imcl-conference.org/

-----------------------------------------------------------------------------------------------------------------------------------------

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

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

-----------------------------------------------------------------------------------------------------------------------------------------

40th european association for behavioural and Cognitive Therapies annual Conference
October 7 - 10
Milan, Italy
http://www.eabct2010-milan.it/

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-----------------------------------------------------------------------------------------------------------------------------------------

association for behavioral and Cognitive Therapies (abCT 2010)

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

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92
for auThors
To submiT
Please submit electronic copies of your manuscript
by visiting www.vrphobia.eu and clicking on the
“Submit Paper” link on the right.
manusCripT sTyle. The language of the journal is
American English. Submissions should follow Ameri-
can Psychological Association (APA) format. Format
questions not addressed in the checklist below can be
sent to the Managing Editor at office@vrphobia.eu.
CopyrighT. Submission of a manuscript will be held
to imply that it contains original unpublished work and
is not being submitted for publication elsewhere at the
same time. If selected for publication, authors must
sign and return a Copyright Transfer Form (available
on the Web site or from the Publisher.) Submitted ma-
manusCripT submissions
formaT. The original manuscript should be double-
spaced and formatted for A4 paper (.27in. x 11.69 in.;
21cm. x 29.7cm.) with adequate and consistent mar-
gins on all pages.
The title page, abstract, references, appendixes, author
note, content footnotes, tables, figure captions, and figures
must be on separate pages (with only one table or figure
per page.) They should be ordered in sequence, with the
text pages between the abstract and the references.
terial will not be returned to the author, unless specif-
ically requested.
reVieW. Papers will be evaluated anonymously by
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reviewed based on scientific merit, originality, read-
ability, and interest to the readership.
furTher informaTion. Typeset proofs will be sent to
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duction process. Prompt return of the corrected proofs,
preferably within 48 hours of receipt, will minimize
the risk of the paper being held over to a later issue.
Two complimentary copies of the issue will be pro-
vided to the corresponding author, unless otherwise in-
dicated. Further copies of the journal may be ordered.
Is the author note typed on the title page, which is re-
moved by the journal editor before review? Are all other
pages free of author identification? Does each page have
the paper title at the top?
All pages (except figure pages) should be numbered in
sequence, starting with the title page.
CoVer leTTer. A cover letter must be included with
the manuscript. The letter should include the author's
JCR
93
postal address, e-mail address, telephone number, and
fax number for future correspondence and a statement
that the manuscript is original, not previously pub-
lished, and not under concurrent consideration else-
where.
This letter needs to inform the journal editor of the ex-
istence of any similar published manuscripts written
by the author.
TiTle page and absTraCT. The title should be 10 to
12 words in length. The byline should reflect the insti-
tution or institutions where the work was conducted.
The abstract must be between 100-150 words and up
to five keywords may be included after the abstract.
headings. The levels of headings should accurately
reflect the organization of the paper, and all headings
of the same level must appear in the same format.
a bbreViaTions . Any unnecessary abbreviations
should be eliminated and any necessary ones must be
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Abbreviations in tables and figures need to be ex-
plained in the table notes and figure captions or leg-
end.
r eferenCes . References must follow APA format.
Please be sure references are cited both in text and in
the reference list.
Text citations and reference list entries should agree
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reference list must be spelled out fully.References
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erence list) are to be ordered alphabetically by the au-
thors' surnames.
Inclusive page numbers for all articles or chapters in
books must be provided in the reference list.
JCR
noTes and fooTnoTes. The departmental affiliation
should be given for each author in the author note. The
author note includes both the author's current affiliation
if it is different from the byline affiliation and a current
address for correspondence.
The author note must disclose special circumstances
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sented at a meeting, whether a student paper was
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ceived as a conflict of interest.
Footnotes should be avoided unless absolutely neces-
sary. Check to make sure essential footnotes are indi-
cated by superscript figures in the text and
explanations are collected on a separate sheet at the
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Tables and figures. Every table column must have a
heading. Make sure the elements in the figures are large
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duced to no larger than 11 cm.
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Minimum file resolution (dots per inch) for printing:
• line art (graphs, drawings) = 1,200 dpi
• halftones (photos) = 300 dpi
• combo line/halftone = 600 dpi
CopyrighT and QuoTaTions
Written permission to use previously published text, tests
or portions of tests, tables, or figures must be enclosed with
the manuscript.
Page or paragraph numbers need to be provided in text
for all quotations.
 94

general informaTion
Journal of CyberTherapy & Rehabilitation
ISSN: 1784-9934
GTIN-13 (EAN): 9771784993017
Journal of CyberTherapy & Rehabilitation is published
quarterly by the Virtual Reality Medical Institute, Rue
de la Loi, 28/7, B-1040 Brussels, Belgium. The journal
explores the uses of advanced technologies for therapy,
training, education, prevention, and rehabilitation. Areas
of interest include, but are not limited to, psychiatry, psy-
chology, physical medicine and rehabilitation, neurology,
occupational therapy, physical therapy, cognitive reha-
bilitation, neurorehabilitation, oncology, obesity, eating
disorders, and autism, among many others.
publishing house
Virtual Reality Medical Institute
Rue de la Loi, 28/7
B-1040 Brussels, Belgium
Telephone: +32 2 286 8505
Fax: +32/2/286 8508
E-mail: office@vrphobia.eu
Website: www.vrphobia.eu
publisher
Brenda K. Wiederhold, Ph.D., MBA, BCIA
adVerTising
For advertising information, rates, and specifications
please contact Virtual Reality Medical Institute, Rue de
la Loi, 28/7, B-1040 Brussels, Belgium, Telephone: +32
2 286 8505; Fax: +32/2/286 8508; E-mail: office@vr-
phobia.eu.
reprinTs
Individual article reprints are available from correspon-
ding authors. Please contact the publisher for rates on
special orders of 100 or more.
manusCripTs
Please submit electronic copies of your manuscript
by visiting www.vrphobia.eu and clicking on the
“Submit Paper” link on the right. Information about
manuscript submission requirements and formatting
can be found at the back of each issue or on the Web
site.
CopyrighT
Copyright © 2010 by Virtual Reality Medical Institute.
All rights reserved. Journal of CyberTherapy & Reha-
bilitation is owned by Virtual Reality Medical Institute
BVBA and published by the Virtual Reality Medical In-
stitute BVBA. Printed in Hungary.

subsCripTion informaTion With the exception of fair dealing for the purposes of
Rates for subscription are for a volume of four issues. research or private study, or criticism or review, no part
Print of this publication may be reproduced, stored, or trans-
Europe: €115 mitted in any form or by any means without prior per-
International: €145 mission in writing from the copyright holder.

Online and Print For permission to photocopy an article for internal pur-
Europe: €135 poses, please request permission and pay the appropri-
International: €165 ate fee by contacting office@vrphobia.eu.

Online Only The accuracy of contents in Journal of CyberTherapy

All locations: €75
Subscriptions begin with the first issue of the current vol-
ume. No cancellations or refunds are available after the
volume’s first issue is published. There are also no re-
funds on single issue purchases.
& Rehabilitation are the responsibility of the author(s)
and do not constitute opinions, findings, conclusions,
or recommendations of the Publisher or editorial staff.
In addition, the Publisher is not responsible for the ac-
curacy of claims or information presented in advertis-
ing portions of this publication.

The Journal of CyberTherapy & Rehabilitation is indexed in PsycINFO, Gale and EBSCO, and
is currently under review with SCOPUS, EMBASE and Medline.

JCR
95

insTruCTions for ConTinuing eduCaTion Quiz
The quiz is an open-book exam. Clearly mark answers
by circling the correct letter. You may photocopy the
exam or work directly on the journal page. Mail the
completed exam and appropriate payment (see fees,
next page) to Interactive Media Institute, 6155 Corner-
stone Court East, Suite 210, San Diego, California
92121, U.S.A. If you wish to receive a receipt of pay-
ment or a copy of the correct quiz answer, please in-
clude a self-addressed, stamped envelope.

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

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

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

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

Name________________________________________

Address______________________________________

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

Country______________________________________

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

Signed_________________________________________________________Date_____________

For iACToR members and personal subscribers, payment is US $20. For others, payment is US $40.

Check ____ Visa ____ MasterCard ____ Card # _______________________________________Exp.___________

Signed________________________________________

JCR
96
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-
est in VR applications because:
a)the incorporation of olfaction stimuli in the VR expe-
rience would not enhance it
b)the odor perceived by each subject is highly subjec-
tive, and thus, generalization involving one particular
odorant is likely to be difficult
c)due to their complex composition and transient char-
acter, controlled exposure to olfactory stimuli is more
complex than that to visual or acoustic stimuli
d)all of the above
2. Up to date, the rare VR applications that include
some forms of olfaction stimulation regard:
a) the treatment of specific phobias
b) the treatment of eating disorders
c) drug addiction research
d) the treatment of psychotic disorders
3. When exposed to multi-sensory alcohol related cues
presented in virtual environments, individuals with al-
cohol use disorders:
a) increase their level of presence
b) become more relaxed
c) report significantly higher cravings for alcohol than
non-binge drinkers
d) both A and C
4. One of the differences between the olfactory system
and the other senses is that:
a) the olfactory bulb projects without being mediated
by the thalamus onto the amygdala
b) the olfactory bulb projects crossed onto the amyg-
dala
c) the olfactory bulb goes through a series of cortical
relays before reaching the limbic system
d) none of the above
5. Which of the following cerebral structures are in-
volved in the olfactory system:
a) the olfactory bulb
b) the amygdala
c) the orbitrofrontal cortex
d) all of the above
6. Compared to other animals, humans:
a) have a poor ability to localize the source of an odor-
ant
b) have an olfactory acuity inferior to that of most ani-
mal species
c) use olfaction for socialization
d) none of the above
7. In order to be effective, the presentation of an odor
in a virtual environment should be:
a) provided using many remote sources to release the
olfactory cues
b) supported by a visual cue related to the odor
c) randomly provided
d) none of the above
8. In a VR experience including odor stimulation:
a) the hedonicity of an odor contributes to the determi-
nation of its intended virtual source
b) the level of familiarity leads to a more rapid associa-
tion with the cues presented via other modalities
c) varying odorant intensities may be useful in cueing
the user about the position, and rate of position change,
relative to the intended virtual source of that odor
d) all of the above
JCR

9. The presence of an odorant in the environment can
be associated with:
a) positive affects and increased arousal, if the odor is
pleasant
b) an alteration in the level of pain perceived by an in-
dividual
c) negative affects and decreased arousal if the odor is
unpleasant
d) the pleasantness of the experience
10. Contrary to congenitally blind, mute or deaf peo-
ple, individuals with congenital anosmia:
a) experience less pain
b) are more prone to illness
c) do not have intact reproductive–social behavior
d) all of the above
ConTinuing eduCaTion CrediTs
To qualify for CE credits, readers will need to do the
following:
• After reading an article, answer the questions above.
• Send the completed answer sheet, along with pay-
ment, to Interactive Media Institute, 6155 Corner-
stone Court East, Suite 210 San Diego, CA 92121,
U.S.A.
JCR
97
11. Clinical scenarios for treating PTSD utilize odors to:
a) make the virtual experience more fascinating
b) make the experience more realistic
c) facilitate the processing of traumatic memories
d) none of the above
12. In training scenarios, olfactory stimulation could
be useful to:
a) trigger appropriate responses to emergency situa-
tions
b) establish an association between a distinct odorant
and “virtually-evoked” positive emotions
c) enhance the virtual experience
d) all of the above
• If you wish to receive a receipt of payment or a copy
of the correct quiz answer, please include a self-ad-
dressed, stamped envelope.
• The fee is $20 for iACToR members or subscribers and
$40 for non-subscribers.
• All CE exams are open-book.
• Credits assigned are based on the length of time re-
quired to read each article.
 JCR The Journal of
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& Rehabilitation

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