THE Concept: Behavior Change Virtual Worlds: Taking Health Promotion to New Levels Lucy Annang, PhD, MPH; Jessica L. Muilenburg, PhD, MPH; Sheryl M. Strasser, PhD, MPH, MSW INTRODUCTION Traditionally, health promotion practice has relied on print and popular media for information dissemination. However, technology sprawl has challenged this tradition, and progressive health promotion professionals are integrat- ing email, text messaging. Web sites, and online support groups into their repertoire.' A less familiar, yet attractive, platform for health promotion specialists is the virtual world. An online virtual world is "an interactive computer simula- tion which allows participants to see, hear, use, and modify simulated objects in a computer-created world."^*P '''^' Virtual worlds can be designed for single participants; simultaneous participants; or multiple groups of users, referred to as a virtual community.• '' We explore the possibilities of using virtual worlds to broaden the reach and scope for health promotion. Use of Technology in Health Promotion The Internet is a demonstrably effective, vast channel for health programming implementation. Successful Web-based interventions include tutorials designed to increase knowl- edge and change attitudes,• *• * counseling designed to aid behavior change,'''" and personalized disease management offered to help control health conditions.'^ A meta-analysis of a variety of Web-based and non-Web-based behavior change Lucy Annang, PhD, MPH, is an Assistant Professor at University of South Carolina, Arnold School of Public Health, Department of Health Promotion, Education, and Behavior, Columbia, South Carolina; Jessica L. Muilenburg, PhD, MPH, is an Assistant Professor, University of Georgia, Department of Health Promotion and Behavior, Athens, Ceorgia. Sheryl M. Strasser, PhD, MPH, MSW, is an Assistant Professor, Georgia State University, Institute of Public Health, Atlanta, Georgia. Send reprint requests to Lucy Annang, PhD, MPH, University of South Carolina, Arnold School of Public Health, Department of Health Promotion, Education, and Behavior, 800 Sumter Street, Suite 320B, Columbia, SC 29208; lannang@gwm.sc.edu. This manuscript was submitted April 22, 2008; revisions were requested August 19, November ¡3, and December 20, 2008; the manuscript was accepted for publication December 24, 2008. Copyright © 2010 by American Journal of Health Promotion, Inc. 0890-1171/10/$5.00-hO DOI: l0.4278/ajhp.08042236 interventions showed improved knowledge increases, inter- mediate and main behavioral outcomes, and long-term behavioral maintenance from Web-based interventions.* These Web-based interventions have been effective in changing behaviors, primarily through interactive messaging and information dissemination. However, the use of virtual worlds provides a platform for expanding the horizons of health promotion even more. Examples of Online Virtual Worlds Several current instances of virtual world use are relevant to public health and are presented here on the basis of their public health applicability and/or content. The River City Project (http://muve.gse.harvard.edu/rivercityproject/ index.html), funded by the National Science Foundation, invites middle-school science students to address emerging health problems of a simulated 19th century town. Students use the interface, which closely resembles a video game, to study illnesses of River City inhabitants, to create experiments to test hypotheses about the nature of these illnesses, and to make recommendations on the basis of their research findings.^ Students who have used River City in their classroom have experienced changes in self-efficacy and learning processes, which suggests that increased use of such platforms may be beneficial to young people.'" Whyville (http://www.whyville.net), a virtual world for pre- teens and teens, allows citizens to learn about science, journalism, civics, economics, and public health." The Centers for Disease Control and Prevention (CDC) has used Whyville to expose youth to real-world health lessons about vaccinations for whypox and whyflu.'^'"' This interactive community has been lauded for increasing awareness, improving education, and generating real-world discussion by youth about health issues with their peers and family members.''' A third example. Second Life (http://secondlife.com), is a virtual world designed for recreation.''' With more than 13 million users. Second Life offers a variety of venues to reach massive audiences at once. It has been recognized for fostering explorative interaction and communication for users to build social networks.''"' Several illustrations of Second Life use include academic courses offered exclusively in Second Life; educational tool warehouses created by non- profit organizations for inhabitants; and a virtual office established by the CDC that is complete with evolving event 344 American Journal of Health Promotion