Living in 3D social virtual worlds and the influence of health literacy, health behaviour and wellbeing

Background:
Health literacy refers to the ability to access, appraise, understand and use health information to make health decisions in everyday life. Literacy and health literacy surveys in high and low income countries have highlighted the independent association between low health literacy and poor health outcomes. Recent global health policies and reports recommend the use of new technology and innovative methods to engage the public and ensure access to health information. One such technology recently used to deliver health information, peer support and health interventions to the public, includes avatar-based social virtual worlds (VWs). However, to date there is little evidence to understand how VWs can help users to access, appraise, understand and use health information within these environments and how this impacts upon their physical world behaviour. The ability to stay socially connected and access social resources, such as relationships, work or education are considered important to health and wellbeing, particularly for people who are socially isolated, have long term conditions or disability. However, little is known about how engagement in VW communities and social activities influences the ability to live or cope with long term conditions in the physical world.

Aims:
The first study in this thesis explores the health literacy skills and practices undertaken by people who have accessed health information in a 3D social VW and the influence on their physical world health behaviour. The second study presented explores how mechanisms, such as being part of virtual communities, networks and virtual friendships, influence people’s ability to cope with and manage their long term condition(s) in the physical world.

Methods:
The first study employed in-depth interviews in a sample of 25 people who accessed health information in a VW: 12 females and 13 males. The second study was a longitudinal multiple method case study design with four participants: three females and one male, who were proficient long term users of the VW and had one or more long term conditions (LTC) in the physical world. The methods of data collection included: interviews, social network questionnaire and diary data. Thematic analysis was used to analyse the data.

Findings:
The findings from these studies make an important contribution to existing knowledge about how VWs can influence and enhance physical world health and wellbeing. In particular, the studies highlighted the importance of immersion in the VW environment, mastering VW skills, and embodiment and identity of the avatar to integration into social networks and feeling social presence with others in the VW. These findings are important to understanding the mechanisms of action and features which explain how VW participation can influence changes to health literacy and physical world behaviour, health and wellbeing, and living and coping with long term conditions in the physical world. The importance of place and people which emerged in both studies illustrated how the VW environment, VW social networks, social activities and social resources, can contribute to, and shape, improvements in health literacy and access to positive health resources and assets such as, social capital and resilience factors. Additionally, the findings highlighted the importance of the design of, and signposting to, health related areas within VWs and the influence that interaction with health information had on users’ health literacy skills and practices.

Conclusion:
The social skills and cultural literacy competencies evidenced in this thesis demonstrate how the collective knowledge and skills of communities in VW environments can influence improvements in individual and community health literacy. As such, the findings offer support for a move away from health literacy as set of skills which reside within an individual to a sociocultural and community model of health literacy. In the context within this thesis, that is, online social VWs, this model makes a unique contribution to enhancing understanding of the literacies required in modern online social environments to promote, support and sustain physical world health behaviour change. Additionally, the access to VW positive health resources, assets and resilience factors evidenced in this thesis can contribute to people’s ability to self-manage their long term conditions.