Promoting health in a virtual world: Impressions of health communication messages delivered in Second Life
First Monday

Promoting health in a virtual world: Impressions of health communication messages delivered in Second Life by Joan E. Cowdery, Jeannette Kindred, Anna Michalakis, and L. Suzanne Suggs

The purpose of this exploratory study was to examine the use of the online virtual world Second Life (SL) for the delivery of health communication messages designed to encourage individuals to make healthy lifestyle choices regarding physical activity and nutrition. Research questions addressed participants’ impressions of the usefulness and relevance of health information received via an online virtual world and participants’ overall impressions of an online health education intervention program. Forty individuals participated in a health education intervention and completed a post–test survey. Four focus groups were also held, one in real life and three in Second Life and included a total of 28 participants. Overall, participants rated the health intervention positively, found the information useful in helping them think about changing their health behaviors, and reported finding the information easy to understand and personally relevant. Participants were also consistent in reporting they found the use of Second Life to be a unique and novel approach for the delivery of health information.


Literature review




Computer–based health promotion interventions targeting many behaviors, including diet and physical activity and smoking cessation, have been delivered online for years with a plethora of research substantiating their varying degrees of effectiveness (Anderson, et al., 2001; Bock, et al., 2008; Brug, et al., 1999; Fox, 2008; Boulos and Wheeler, 2007; Kreuter, et al., 2000; Parlove, et al., 2004; Smeets, et al., 2008; Strecher, et al., 2008; Webb, et al., 2010). Technology and computer based approaches continue to provide the means needed to adapt solutions to target populations, to be able to deliver appropriate volumes of information, and to increase access to health messages (Suggs, 2006). To date however, little research exists on health promotion interventions directed toward individuals participating in virtual world experiences. The purpose of this exploratory study, then, was to examine the use of the online virtual world Second Life (SL, for the delivery of health communication messages designed to encourage individuals to make healthy lifestyle choices regarding physical activity and nutrition.



Literature review

Virtual worlds and Second Life

While the initial application of virtual worlds was in the gaming realm, the current generation of virtual worlds consist of millions of simultaneous users and has moved beyond the realm of gaming to a user–generated, three–dimensional place for social networking (Au, 2008). Relative to Web 1.0, the virtual worlds that are now possible with Web 2.0 technologies have many distinct characteristics. According to Ondrejka (2008), one of the defining characteristics of virtual worlds is that they generate simultaneously shared spaces. This is in contrast to the early Web, which was built around sequential, solo access to content. Web 1.0 is typically characterized by traditional Internet applications, such as Web pages, which are created and published by a Web developer with the intent of providing static content to users (Hanson, et al., 2008). Web 1.0 provided a tremendous opportunity for health educators to both deliver and acquire health information. Several recent estimates show that upwards of 60 percent of American adults access the Internet with between 75 percent and 80 percent of Internet users having looked online for health information (Fox, 2008).

In contrast to Web 1.0, Web 2.0 is often referred to as the social Web because much of the content is now user generated (Boulos and Wheeler, 2007). This increase in social interaction takes place through the use of wikis, blogs, podcasts, and social networking sites such as MySpace ( and Facebook ( While these technologies have provided the mechanisms for increased social interactivity on the Web, they are inherently limited in that they are only able to process bits of information consecutively. So although many users may read a blog or post to a discussion board, these posts are made sequentially which is not analogous to having a real world discussion. Even with real–time communication, such as instant messaging, there is a lack of a sense of physical presence in the communication exchange. Not only do virtual worlds foster real–time social interaction, they allow users to inhabit a physical space through the creation of graphical 3–D self–representations called avatars. Estimates have predicted that 80 percent of active Internet users will have a presence in a virtual world by 2011 (Gartner, 2007).

Although several different virtual worlds are now available for Web users to inhabit, one of the most popular and widely used is Second Life. Second Life is a 3–D virtual world entirely built and owned by its residents. Originally developed in 2003, it is now inhabited by over 20 million residents from around the globe. Given this explosive growth and popularity, various real–world institutions have begun to create a presence in Second Life for a myriad of purposes including online education, and marketing and advertising.

To experience and participate in a virtual world such as Second Life, an in–world representation of the self must be created. This typically consists of participants creating a 3–dimensional graphic avatar as their Second Life persona. In Second Life for example, residents can develop avatars to look like anything from humans, to animals, robots, or abstract art, although anecdotal evidence suggests that 70–80 percent of Second Life residents exist as human avatars (Au, 2008).

In its roughly eight years of existence, Second Life has evolved from primarily a social networking platform to a vehicle for educating students in a wide variety of disciplines. The use of Second Life for educational purposes ranges from anthropology, sociology, architecture, and business (Fang and Lee, 2009). Subsequently, the expansion of the application of Second Life in various disciplines has resulted in the generation and publication of research examining the effectiveness of these approaches. To date, the bulk of the published research has focused on the use of Second Life in education including secondary, higher education, and professional training (Cheong, 2010; Mayrath, et al., 2011; O’Connor, 2010; Petrakou, 2010; Warburton, 2009).

Medical training

Increasingly virtual worlds, including Second Life, are being used in the training of health and medical professionals. Wiecha, et al. (2010) evaluated the use of Second Life for delivering continuing medical education (CME) for physicians and found significant increases in treatment and diagnosis outcomes. Furthermore, physicians in the Wiecha, et al. study not only unanimously rated the virtual world approach to CME as superior to other methods of online CME but also thought that the Second Life approach to CME could potentially be superior to face–to–face CME (Wiecha, et al. 2010). Nurse educators have found application for the use of SL in educating nursing students in the areas of therapeutic communication, patient and family interaction, role playing, and patient care simulations and predict that the use of Second Life in educating nurses will continue to expand (Ahern and Wink, 2010; Trangenstein, et al., 2010).

Patient and consumer health education

Although the use of virtual worlds in medical education has begun to expand, by far the largest health related application of SL is in patient and consumer health education. In a comprehensive survey of health related sites in SL, Beard, et al. (2009) found that of the 68 sites identified, 34 were primarily designed to provide health information. Additionally 14 sites were identified as providing patient or peer support for specific illness conditions (Beard, et al., 2009). Specific applications such as group visits and behavior modification for patients with Diabetes have been documented (Watson, et al., 2008). Because of the unique features present in virtual worlds, such as a greater feeling of presence, the ability to communicate in real time through voice and text, and the elimination of many physical and psychological barriers to participation, the potential for use in psychological interventions has been explored (Gorini, et al., 2008). Studies have shown effectiveness for the treatment of various psychological disorders, particularly specific phobias (Gorini, et al., 2008). Perhaps most uniquely, virtual worlds offer an opportunity for individuals with physical disabilities to access education, support, and entertainment activities that would not be otherwise available or accessible (Stewart, et al., 2010). Although Second Life itself is not yet fully Web accessible per Web content accessibility guidelines (WCAG), there are multiple examples of user generated resources for individuals with a variety of disability issues (Stewart, et al., 2010).

Although the Internet has increasingly been used to promote health behavior change, little empirical evidence exists with regards to the specific use of virtual worlds for impacting individual health and health behavior (Webb, et al., 2010). Woodruff, et al. (2008) explored the use of a virtual chat room space used in conjunction with motivational interviewing to promote smoking cessation in adolescents. In this study, participants were represented by avatars in a virtual world chat room where they could move around and have real–time discussions with each other and with a smoking cessation counselor. Initial results were positive in that program participants were more likely than controls to have abstained from smoking in the past week, smoked fewer days in the past week, and smoked fewer cigarettes in the past week (Woodruff, et al., 2008). One of the limits to generalizeability with this study is that the virtual world that was used employed proprietary software in a controlled research setting. Given the explosive growth in popularity of widely available virtual worlds, it is imperative that we begin to explore their utility in health education and promotion efforts.

There are multiple examples of health related communication and education efforts within Second Life in particular. Boulos, et al. (2007) provide a detailed description of the most extensive health related locations in Second Life. This includes Healthinfo Island, which is funded by a U.S. National Library of Medicine grant. Among other things, Healthinfo Island consists of a medical and consumer library, HIV/AIDS center, and a path of support, which contains information and links to 60 different health related support groups. Many of these groups are affiliated with national organizations while others are user created groups to facilitate the sharing of knowledge and interests. Although to date the health information available at these locations is provided by objects rather than avatars, much of it is interactive and consists of streaming audio, video, and links to relevant online resources.

Conclusions and research questions

Given the recent emergence and novelty of virtual worlds, this research aimed to explore the use of Second Life to deliver health messages to college students regarding physical activity and nutrition. These two health behaviors were chosen given their relevance for the majority of the target audience. The following research questions guided this study:

  1. What are participants’ impressions of the usefulness and relevance of information regarding physical activity and nutrition received via an online virtual world?
  2. What are participants’ impressions of a health education intervention program delivered by a health educator avatar via an online virtual world?




In order to examine participant reported impressions of the impact of health messages delivered via the online virtual world of Second Life, we combined survey data with focus group interviews. All processes and procedures were approved by the University’s human subjects review committee.

Participant recruitment and procedures

Participants were actively recruited from undergraduate communication classes at a mid–size Midwestern university and through posting of fliers in areas common to students. Inclusion in the study required only that participants be at least 18 years of age. Both students who had prior experience with Second Life and those who did not were encouraged to participate; however, none of the actual study participants had any previous experience in any virtual world, including Second Life. As a result, all participants were required to attend an orientation session. During this session the research procedures were explained, informed consent was obtained, and assistance in creating their Second Life account and choosing their avatar was provided.

Approximately one week later participants participated in a brief health promotion intervention at a pre–determined location in Second Life. Prior to the intervention demographic data was collected from all participants. Following the brief health promotion intervention, participants were then immediately asked to complete a post–test survey and given the opportunity to participate in a focus group interview. All of the intervention sessions were held in an on–campus computer lab. Upon completion of all data collection, participants were provided a monetary incentive for their participation. All recruitment and data collection for the study was completed over a five–month period during the spring and summer of 2008.


The geography of Second Life is set up as various islands and parcels of land. There are numerous islands dedicated to education and education institutions where many Universities have purchased their own parcels. This Intervention was conducted in a common area on a teaching parcel where this University had a virtual presence. The setting is a traditional open air amphitheatre with a stage, podium, and overhead signage in addition to multiple rows of bench seats (see Figure 1).


Figure 1: Amphitheatre
Figure 1: Amphitheatre.


Participants were sent the link to this location ( upon logging in to Second Life. Using this, they could then teleport themselves to the amphitheatre. The intervention was designed to mimic a traditional classroom with a health educator avatar speaking from the stage to the participants sitting in the audience (see Figure 2).


Figure 2: Health education intervention
Figure 2: Health education intervention.


The health educator avatar was intentionally designed to present a conservative and somewhat older and more authoritarian image than the participants and was an actual trained health educator in real life (see Figure 3). The participants were not told the health educator’s real identity, nor were they given any background information as to the person’s qualifications. The intervention consisted of approximately 15 minutes of information regarding physical activity and nutrition with 10 minutes of question and answer at the completion of the information session. The intervention was developed by trained health educators and consisted of age appropriate recommendations and established guidelines for physical activity and dietary behaviors as well as increasing awareness of on and off–campus resources. Health information was communicated via a variety of methods. The health educator and participants could speak using the chat feature in Second Life. Interactive signs and note cards were also developed that allowed participants to click on them to receive specific information which could then either be stored into their Second Life inventories or to be directed to pre–selected Web sites, such as, to get more information. Because the signs were not permanent given the shared nature of the space, storing the information in their personal inventories allowed participants to go back to the information anytime they logged in to Second Life in the future.


Figure 3: Health educator avatar
Figure 3: Health educator avatar.


Data collection

Data collection included both quantitative and qualitative measures. Quantitative assessment included the use of a print survey that collected demographic data such as age, gender, race, ethnicity, and height and weight as well as level of experience with Second Life. Upon completion of the brief intervention, data was collected that assessed overall program rating and intention to utilize Second Life in the future as well as usability and participant satisfaction.

Four focus group interviews (FGI) were also held, one in real life and the remaining three in Second Life (SL). There were a total of 28 participants, 10 men and 18 women, all of whom had participated in the intervention. The first FGI was conducted face–to–face approximately one week after the initial health interventions. Although nine participants who participated in those interventions committed to attend the real life FGI, only four participants ended up participating, two men and two women. This FGI lasted approximately 45 minutes and was digitally recorded.

The first focus group was held in person in order to not only discuss the health intervention program the participants experienced in Second Life, but also to gain insight into other aspects related to Second Life (for example, participants general impressions of the SL world or perceptions of using SL for education). Since all FGI participants were new users of SL, we wanted at least one discussion where all verbal and non–verbal cues would be available and feedback would be immediate. This setting was the best way to gather new insights we could ask later groups. This group then helped solidify and confirm the questions we would ask in the later FGIs, which all took place in–world.

To maximize participation, we conducted the remaining three FGIs in Second Life and held them immediately following one of the scheduled health promotion interventions. Those who had previously signed up could attend, but it also provided the opportunity to recruit participants immediately. Participation did improve. The first in–world FGI consisted of seven participants (two men and five women); the second in–world FGI consisted of eight participants (three men and five women); and, the third in–world FGI consisted of nine participants (three men and six women). Each of these FGIs lasted about 45 minutes and was held in an open air pavilion (see Figure 4). Questions focused on two key areas: participants’ reactions to the health campaign they experienced in Second Life and participants’ reactions to Second Life in general.


Figure 4: In-world focus group
Figure 4: In–world focus group.


Data analysis

Quantitative analysis was conducted using SPSS 16.0 for Windows and included descriptive analyses of the post–intervention survey. Focus group interview transcripts were analyzed using the constant comparative method (Strauss and Corbin, 1998). The constant comparative method is a grounded theory methodology whereby data is broken down and conceptualized into key ideas and themes. One researcher and a research assistant examined each transcript separately, noting key ideas and themes. They then met and compared their findings, resulting in 100 percent final agreement on the key themes identified in the interviews. To protect subjects’ anonymity, numbers were assigned to each focus group participant.




Survey results

Forty participants completed the post test survey and participated in the intervention (see Table 1). Of those 40, 15 (37.5 percent) were male and 25 female (62.5 percent). Ages ranged between 18 and 31 years with a mean of 22 years. 32.5 percent of participants were African American, 57.5 percent Caucasian, and 10 percent self–identified as Asian, American Indian, or multiracial. Self–reported measures of height and weight were collected for the purposes of calculating Body Mass Index (BMI). Fifteen percent of participants were overweight by BMI standards with 25 percent categorized as obese (see Table 1).


Table 1: Demographic characteristics of program participants.
African American32.513
Hispanic or Latino2.51
American Indian/Alaska Native2.51
More than one race5.02
Body Mass Index 
Members of Second Life 
0–3 months100.040
Age (years)X=22.0 (18–31 yrs.) 


All participants reported having been a member of Second Life for less than three months. Participant satisfaction and receptivity to the delivery of health messages within Second Life were assessed with a series of items related to the program itself. Overall participants rated the intervention positively with 60 percent of participants rating the program as excellent or very good (see Table 2). Eighty percent found the information useful in helping them think about changing their health behaviors while 92.5 percent found the information easy to understand and to be personally relevant. Eighty–seven and a half percent (n=35) of participants agreed the Second Life program was easy to use with 45 percent (n= 18) strongly agreeing. Furthermore, 82.5 percent of participants stated they would be interested in experiencing other health related programs in Second Life (see Table 3). Intention was measured using a six–point Likert scale ranging from extremely unlikely to extremely likely.

Post–tests results show a high level of intent to continue to utilize Web–based resources for health information with 62.5 percent (n=25) of participants stating they intend to search for health–related information using the Internet, and to continue to explore Second Life, while 52.5 percent (n=21) intend to search for health information within Second Life (see Table 2).


Table 2: Program rating and intention to seek health information.
Overall rating of program 
Very Good37.515
Intend to continue to explore SL 
Extremely unlikely7.53
Very unlikely10.04
Somewhat unlikely20.08
Somewhat likely27.511
Very likely22.59
Extremely likely12.55
Intend to search for health info in SL 
Extremely unlikely10.04
Very unlikely17.57
Somewhat unlikely20.08
Somewhat likely35.014
Very likely17.57
Intend to search for Internet health info 
Extremely unlikely5.02
Very unlikely2.51
Somewhat unlikely30.012
Somewhat likely27.511
Very likely22.59
Extremely likely12.55


When asked to describe the appearance of the avatar they created to represent themselves in world, 52.5 percent (n=21) reported they designed their avatar to look like themselves. Five percent of participants stated they sometimes appear in SL as the opposite gender and only 2.5 percent reported sometimes appearing as an animal. When asked to rate how much they agreed that they thought about the health information they received as it applies to their real life habits, 90 percent (n=36) reported agreeing with regards to physical activity with 32.5 percent (n=13) strongly agreeing. Regarding nutrition, 87.5 percent (n=35) agreed that they thought about the nutrition information as it applies to their real life eating habits with 45 percent (n=14) strongly agreeing (see Table 3).


Table 3: Usability and participant satisfaction.
 Strongly/somewhat disagreeDisagreeSomewhat/strongly agree
Found information useful5.0215.0680.032
Found information easy to understand2.515.0292.537
Information personally relevant2.515.0292.537
Found program easy to use0012.5587.535
Thought about physical activity information as it applies to real life0010.0490.036
Thought about nutrition information as it applies to real life2.5110.0487.535


Focus group results

Several key themes were identified in all four focus groups. Participants overwhelmingly thought the health information presented was useful and informative, which would then cause them to rethink their current health behaviors. Many remarked, however, it was information they already knew and while they might think about their health behaviors, they will not necessarily make any specific behavioral changes. In addition, they thought the health intervention conducted in Second Life was creative, they appreciated the anonymity of the format, and they judged Ms. Howlett (the health educator) as informative, credible, and personable. Student comments (using participant numbers to protect students’ anonymity) are highlighted below to illustrate each theme found.

While participants thought the health information was useful in general, many commented it was information they already knew. The information they particularly noted as useful was the statistics. Many also commented on the usefulness of the links and note cards: Below are some sample participant comments:

P1: I thought it was interesting. I didn’t know you could go on campus to have your BMI done.

P2: It was ok, but not anything new. The links were useful if you wanted more information.

P3: The statistics were pretty cool.

P4: I knew everything already about what was said.

Even though the information was largely seen as common knowledge, many participants indicated the presentation would encourage them to think about their healthy behaviors:

P5: It made me realize that although I have a busy schedule, somehow I can incorporate exercise in it somewhere.

P6: I liked the information that was given, it really made me stop and think about all the bad things I eat.

While they seemed interested in thinking about their health behaviors, very few noted the Second Life health intervention would promote actual behavior changes. Participants noted several reasons here: they indicated it would be difficult as busy college students to make changes, or they indicated they are already healthy and therefore do not need to make any changes:

P6: I can’t change overnight.

P7: I am so very hard wired into my unhealthy way of life.

P8: I just feel that our generation, we know what we should be doing, we are just lazy.

Several participants also pointed out the irony of learning about health information online. I just thought it was ironic that we were learning about health information via computer/Internet/online gaming. This quote by P9 also points out the perception many of the participants had of Second Life. Because all participants were new to Second Life, many had the first thought that it was a game or an environment to be used only for leisure or fun. This may be a key reason why although participants thought the health information was useful, it was not in the end reported to be very influential.

Next we asked the participants about their impressions of the format (lecture followed by group discussion in Second Life), and their impressions of the health educator, Ms. Howlett. Participants in each of the focus groups commented that being exposed to the health information in Second Life was different. P3 thought it was a creative and innovative way to present information. P10 said it was fun and interactive and can be helpful to those who learn from seeing things instead of hearing. P9 noted it was nice to be in a setting different from the typical classroom environment.

Another frequently mentioned theme was the anonymity of communicating in Second Life. While some participants did know each other, many thought the anonymity might encourage more people to ask questions about issues related to health. Talking about health issues in Second Life made it easier for you to express yourself P11 noted, adding you weren’t really concerned about what others would think of your answers.

While participants enjoyed the experience and appreciated the anonymity, participants in two of the four focus groups reported feeling overwhelmed and distracted during the health intervention. Below are some sample comments:

P12: I couldn’t read all the comments because there were too many people talking.

P13: I held back from commenting because I was nervous about missing something.

P14: Some stuff that people were saying was ridiculous.

Participants in the last two focus groups all participated in the same health intervention. They experienced the intervention in a large group of 17, versus the other participants who experienced the intervention in much smaller groups. In addition, participants in this large intervention knew each other, which was not the case with the earlier interventions. The large number of participants made for too much conversation to follow and since participants were new to Second Life, viewed it as a game, and knew each other from class, there were many comments made during the intervention and focus group that were unrelated to the topic. For example, P15 kept making comments about eating pineapples both in the intervention and later in the focus group.

Despite some of the above frustrations, Ms. Howlett, our health educator, was viewed very favorably across all four focus groups. Overwhelmingly, participants thought she was informative and very credible. P7 said she was helpful and I really appreciated the links she provided. Others commented on her credibility. P14 had several comments: She seemed healthy. She looked professional. Her body physique showed that she was physically active. Ms. Howlett’s avatar was specifically designed to look professional and physically fit and participants noticed.




Results of this exploratory study of the use of Second Life to deliver health messages are encouraging. While no one method of health communication or health education will meet all of our needs it is essential that health educators use a variety of means to reach target audiences. This study illustrates that the use of virtual worlds to communicate information regarding nutrition and physical activity has potential.

Although the scope of this intervention limited our ability to see significant changes in health behavior, participants were consistently receptive to receiving the health information in a virtual setting. Evidence supporting the efficacy and effectiveness of internet based health behavior change interventions continues to grow (Strecher, 2007; Webb, et al., 2010). Previous research, particularly in the use of tailored messaging, has provided evidence that engagement with the material is the essential first step toward behavior change (Strecher, et al., 2008). Furthermore, in a meta–analysis of the effectiveness of behavior change interventions based on mode of delivery, the effect size for interventions that included a communicative function (i.e., access to an adviser) was larger than for automated follow–up messaging (Webb, et al., 2010).

In this current study, both survey and focus group results indicated the participants found the information to be useful and informative; however, interview data revealed very few participants felt motivated to make actual health behavior changes. This finding could be due to the widely known information presented (nutrition and physical activity), and the brevity of the program. Interactive technologies have the ability to persuade “by increasing a person’s abilities, providing users with an experience, or by leveraging the power of social relationships” [1]. Second Life, as an interactive technology, should then be effective in promoting health behavior change. The evidence of effectiveness of existing e–health interventions, particularly those with a solid theoretical foundation indicates potential for this approach (Strecher, et al., 2008; Webb, et al., 2010).

Participants in this study were also consistent in reporting they found the use of Second Life to be a unique and novel approach to the delivery of health information. One interesting finding was that although the uniqueness of the delivery medium was seen as a positive characteristic of the program, participants also liked the somewhat traditional and conservative approach to the delivery of the intervention which used a traditional lecture type setting and an educator avatar with a fairly conservative image. The avatar “Ms. Howlett” was viewed as a credible provider of health information; participants seemed to enjoy interacting with her while also appreciating the anonymity of the format. It may be that virtual worlds such as Second Life can offer the feeling of obtaining personalized health information, but in a way that provides for confidentiality and anonymity. Although this was a new experience for all of the participants, the majority were receptive enough to it to report they would continue to explore Second Life and would welcome the opportunity to participate in additional health promotion programs delivered in–world.

One of the most pressing questions regarding the use of alternate personas to experience virtual worlds is how information and experiences are processed. Groundbreaking research that examines how the alteration of digital self–representations changes how the users make those self–representations behave (Yee and Bailenson, 2007) has been termed the “Proteus effect.” In a series of experiments, Yee and Bailenson concluded that avatar appearance does shape avatar behavior in that attractive avatars displayed shorter interpersonal distances and disclosed more pieces of information than did unattractive avatars. Furthermore, in a study to examine negotiation patterns related to the splitting of a hypothetical pool of $100, participants with tall avatars were significantly more likely to negotiate an unfair split than participants of normal or short height while participants with short avatars were significantly more likely to accept an unfair split than either normal or tall avatars (Yee and Bailenson, 2007).

One of the concerns regarding the delivery of health information in a virtual world is whether or not the information is perceived and processed as our real world selves or as our in–world personas as represented by our avatars. Before user modifications, the default human avatars in Second Life tend to be attractive and typically normal to underweight. Based on the aforementioned studies, we are beginning to understand how avatar appearance influences avatar behavior but little is known about how avatar appearance shapes real–life behavior. Our study begins to explore that question by examining how the participants processed, received, and applied the health information as their real–life selves. Both survey and focus group data from this study show that by and large participants received and processed the information delivered through Second Life as themselves and not as their avatars, although we were limited in our analysis of the adoption of online personas given the short duration during which the participants had experienced Second Life. It is possible with longer use and more immersion as an avatar in a virtual world that the distinction between real–life selves and in–world selves would become less distinct which may impact the reception and processing of information.


This study was limited due to the reliance on a convenience sample that represented a fairly limited age range and was restricted to individuals currently enrolled at a University and with access to computer technologies. Furthermore the content regarding nutrition and physical activity was generic and widely available both on the Internet and through other communication sources. The intervention itself was very brief with follow up occurring immediately upon completion of the intervention. This did not allow for changes in behavior to be measured.

The difficulty in securing experienced Second Life “residents” was another limitation. All student participants were new users of Second Life and needed training before they could experience the health intervention. They were not experienced with communicating via an avatar, and many of the students saw Second Life as a game instead of a shared community space. Finally, the interventions were held in a computer lab where students could see and interact with each other in the physical as well as the virtual world. At times, students were communicating with each other in real life and not paying full attention to what was going on in Second Life.




Overall participants were receptive to receiving health information in a virtual world setting. This was not entirely surprising as our participants were all college students, and college students tend to be early or mainstream adopters of new technologies (Caruso and Salaway, 2007). Caruso and Salaway (2007) found over half of college students surveyed like to learn using technology, particularly learning via the Internet and through online games and simulations. In addition, Second Life is an enhanced type of online social network; even though Second Life was new to all the students, the concept of social networking was not. Since college students report spending up to five hours a week on social networking sites like Facebook and Myspace (Higher Education Research Institute, 2008), they were most likely comfortable communicating about health information in this virtual environment.

Although students were very receptive to the new technology, at the same time they seemed to prefer a more traditional (i.e., classroom–based) health intervention method with a message source that is deemed credible. This was evident in the focus group feedback regarding the perceived credibility of the health educator avatar, which was designed to project a more traditional image. This finding points to the potential to deliver health related information within virtual worlds, to targeted groups, if done in a structured and credible manner. This would include messages delivered at familiar sites from credible and known sources, as well as established real–time interventions (lectures, classes, focus groups, etc.).

The applications of this research both to the practice of health education and to continuing research in this area are vast. Evidence shows more and more people are turning to the Internet for health information and many personal decisions about how to treat an illness or condition are significantly impacted by these searches (Fox, 2008). In addition to information seeking, Web 2.0 technologies are increasing the opportunities for patients and caregivers to share information and support. The anonymity of Web–based interaction including Second Life, can contribute to the engagement of hard to reach populations particularly when dealing with sensitive subjects such as drug use and sexual behavior as has been demonstrated in the creation of a Second Life portal, by Spanish health authorities, through which real doctors can offer advice to anonymous patients (Keeley, 2008). The potential target audiences for this type of communication strategy therefore include not only current virtual world participants, but those interested in and receptive to new technologies, as well as individuals with geographic or mobility limitations. Although the target audience for this type of approach to health education and communication is increasing, it is imperative that health educators be mindful of the limitations regarding access to technology particularly within marginalized populations. Given these types of applications, it is imperative that researchers continue to explore new strategies for delivering health information while simultaneously evaluating the effectiveness of these strategies. Future research should include longitudinal analyses of the effectiveness of health behavior change interventions delivered within virtual worlds. In addition, while previous research documented the effectiveness of the use of virtual worlds in addressing health behaviors in an adolescent population (Woodruff, et al., 2008) and this study explored the usefulness of this approach in a college age population, further research needs to examine the effectiveness of virtual world technology in the delivery of health messages across a wide range of ages.

The use of virtual worlds for health education presents unique challenges particularly because of the nature of the participant interaction with the setting. The creation and use of avatars presents a unique dynamic for exploration regarding the receptivity to health messages and whether they are processed relative to the avatar persona or as our real selves. Future research should also include the examination of how our experiences in virtual worlds change with long term participation. As with the emergences of past approaches to health education and behavior change, it is not likely that the use of virtual worlds will replace current approaches, but will most likely add to the tools available to health educators.

Although this initial study has identified some user trends and impressions, it is imperative we continue to monitor and evaluate how users choose to create and participate in virtual worlds. Health promotion efforts will only realize their potential if strategies are created that work within this user–defined culture. End of article


About the authors

Joan Cowdery is an Associate Professor of Health Education in the School of Health Promotion & Human Performance at Eastern Michigan University. Her research interests are in the use of innovative health communication and behavior change strategies, including tailoring and the use of virtual worlds in health education and health promotion

Jeannette Kindred is Associate Professor in the Department of Communication, Media and Theatre Arts at Eastern Michigan University. Her research interests are in computer–mediated communication and the scholarship of teaching and learning.
Direct comments to Jeannette Kindred: jkindred [at] emich [dot] edu

Anna Michalakis recently received her master’s degree in health education from Eastern Michigan University and is currently serving as an adjunct lecturer in the School of Health Promotion and Human Performance.

L. Suzanne Suggs is an Assistant Professor in the Institute of Communication and Health, at the Università della Svizzera italiana, Lugano, Switzerland. Her research focuses on the use of communication technologies and messaging strategies (tailoring and targeting) to improve health status, health outcomes, and facilitate behavior and social change.



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Editorial history

Received 19 February 2010; revised 18 June 2011; revised 12 July 2011; accepted 17 August 2011.

Copyright © 2011, First Monday.
Copyright © 2011, Joan E. Cowdery, Jeannette Kindred, Anna Michalakis, and L. Suzanne Suggs.

Promoting health in a virtual world: Impressions of health communication messages delivered in Second Life
by Joan E. Cowdery, Jeannette Kindred, Anna Michalakis, and L. Suzanne Suggs.
First Monday, Volume 16, Number 9 - 5 September 2011

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