In the metaverse, users will actively engage with 3D content using extended reality (XR). Such XR platforms can stimulate a revolution in health communication, moving from information-based to experience-based content. We outline three major application domains and describe how the XR affordances (presence, agency and embodiment) can improve healthy behaviour by targeting the users’ threat and coping appraisal. We discuss how health communication via XR can help to address long-standing health challenges.
The predicted arrival of the metaverse has given rise to heated public debate. Critics of the metaverse argue that companies’ economic self-interest is primarily responsible for the hype surrounding the metaverse and that such a platform would be difficult to regulate. Some critics argue that the metaverse poses a ‘terrifying danger to humanity’1, potentially leading to a surge in harassment and manipulation2. However, others contend that the metaverse could ‘unleash amazing creativity and open up new frontiers and horizons’3, providing a platform for new tools to learn, socialise and collaborate in cyberspace.
Adding to the debate, we focus on the tremendous potential of the metaverse to revolutionise health communication. Public access to the Internet marked the first revolution in health communication by diminishing the role of the general practitioner as the sole authority and source of health-related information. The metaverse can stimulate a second revolution, allowing users to engage actively with tailored health-related information from an interactive first-person perspective. In other words, we will witness a transformation from information- to experience-based health communication. We argue that by creating theory-driven and evidence-based health communication content using immersive technologies, the metaverse can significantly promote individual and public health. In addition, we outline how future efforts in this domain can address long-standing challenges to public health and point to new challenges arising from this transformation.
What is the metaverse?
The term metaverse was used for the first time by Neal Stephenson in his novel Snow Crash4, where he describes people using avatars to interact with each other in virtual worlds. This vision resembles virtual worlds that we already know, such as Second Life, Fortnite or VRChat. The metaverse adds extensive use of 3D graphics to this, allowing users to permanently access online content using extended reality (XR)5. XR technologies encompass a wide spectrum of immersive technologies, from augmented reality (AR) to mixed reality (MR) to virtual reality (VR). These technologies differ in how much of the outside world is included in the experience, with VR at the end of the immersive spectrum, providing users with a virtual experience that almost completely shuts out the external environment. Although XR technologies have been available for many decades, the metaverse would allow us to bring them together and make them accessible to everybody anywhere, all the time.
How does XR in the metaverse facilitate effective health communication?
There is abundant evidence indicating that XR, in particular VR, can create realistic experiences that produce genuine emotional, cognitive, social and behavioural reactions6,7. The content presented and experienced in XR can be modified in such a way that it is particularly useful for effective health communication, with three main application domains (Fig. 1). First, XR allows people to experience phenomena that they could not experience in the real world (e.g., visualising how otherwise unobservable viruses or bacteria spread)8. Second, XR can overcome limitations of space and time by communicating the negative consequences of unhealthy behaviours that are temporarily distant from the present behaviour, such as obesity or smoker’s lungs9,10. Third, XR makes it possible to experience the world from other perspectives, including those of vulnerable individuals, thereby eliciting empathy and compassion11.
According to Protection Motivation Theory (PMT)12, a prominent and widely adopted theoretical framework for disease prevention and health promotion, successful health communication requires improving threat appraisal and coping appraisal. Threat appraisal encompasses two aspects: threat severity (i.e., perceived level of severity of the threat to health) and vulnerability (i.e., perceived level of susceptibility to the threat). Coping appraisal encompasses response efficacy and self-efficacy. Response efficacy refers to an individual’s belief as to whether a recommended coping behaviour will effectively reduce a health-related threat; self-efficacy describes the confidence that the individual has in his/her ability to perform the recommended behaviour. Compared to cyberspace and social media accessed using standard media (i.e., computers or mobile devices), which already play a crucial role in health communication13, immersive XR has specific affordances of presence, agency and embodiment14. These affordances can be addressed in health communication via the metaverse, for instance, by providing immersive environments for patient support groups, expert-moderated health communities13 or health-aware pre-programmed agents and immersive health messages to facilitate health-related behaviour change more effectively than standard media (Fig. 1)15. Although these XR affordances are empirically related16, each affordance can conceptually be linked to specific health-related perceptions, that is, threat and coping appraisal, which we discuss below.
According to PMT, low threat appraisal of temporally distant consequences of current unhealthy behaviours frequently explains people’s reluctance to adopt health-protective behaviours. This idea is supported by construal level theory17, which states that events, including threats, that are temporally, spatially or socially distant, are perceived as abstract and therefore as less relevant. As compared to the standard text, image or video interventions, XR technology can elicit higher presence, a feeling of being ‘there’ in the simulated environment18. Presence is comprised of three sub-dimensions: physical presence (i.e., place illusion), self-presence (i.e., perceived authenticity of our self-representation in the virtual environment) and social presence (i.e., perceived realness of virtual others)19. Being highly present in the virtual environment makes scenarios, such as experiencing the consequences of unhealthy behaviours9, feel more imminent and therefore increases threat appraisal20. Experiencing the consequences of behaviours is also crucial for coping appraisal, particularly response efficacy, as it allows the individual to vividly experience the impacts of such behaviours from a first-person perspective instead of reading about them.
Furthermore, as we are social creatures, and others largely influence our behaviour, high social presence, which results in increased social influence21, plays an important role in behavioural change. In health communication, avatars are often used to exemplify health consequences and influence our decisions. We can be affected by the presence of others via social norms and conformity22, such as the presence of ‘health-aware’ programmed agents (e.g., interacting with an agent who engages in exercising and healthy eating could influence the user to do the same). In a similar vein, self-efficacy, which plays a major role in adopting new behaviour and closing knowledge-behaviour gaps23, can be enhanced not only by our past experience but also by observing others similar to ourselves succeeding in the desired action24.
According to Bandura, personal experience of success is the most influential source of self-efficacy24. As compared to immersive videos or more fixed scenarios that do not allow users to take their own courses of action, a highly interactive XR environment elicits the feeling of being in control of one’s actions (i.e., a sense of agency). Agency provides the user with a first-person interactive experience of success, i.e., mastery experience14,24, and is crucial for promoting self-efficacy and, in turn, the intention to adopt healthy behaviour. For example, Fox et al. showed that individuals who experienced positive effects of their own physical exercise on their virtual selves in an XR environment undertook more exercise in real life25.
Although PMT and similar theories focus on the protection of the actors themselves, the health behaviours of individuals can provide social externalities to others, for example, by indirectly protecting others by increasing herd immunity via vaccination26. The XR affordance embodiment refers to the illusion of ownership of the virtual body14. The embodiment allows users to experience the world from someone else’s perspective, including someone of a different gender, race or species, and, in turn, influences our attitudes towards them27. The successful embodiment can promote positive health-related decisions by making the experience more personal, increasing the user’s perceived own vulnerability but also the vulnerability of others. For example, being embodied as a vulnerable person and therefore experiencing health threats from that person’s perspective, as well as the impact of others’ behaviour on the person’s health, can affect other-directed threat and coping appraisal, motivating the user to engage in behaviours that benefit not only their own health but that of others8. Due to such an embodied vivid perspective-taking experience, XR, particularly VR, has been labelled the ultimate ‘empathy machine’11. In line with this perspective, studies have shown that embodying users in the body of a person who is vulnerable to COVID-19 increases their collective responsibility to get vaccinated and, in turn, vaccination intention8,28.
How can the metaverse address long-standing challenges in health communication?
Public health is plagued by several challenges, intensively discussed in the literature, that are difficult to overcome with standard health communication methods. Here, we outline how these challenges could be tackled by combining XR affordances with social aspects and the future accessibility of the metaverse.
Health inequity, which leads to unequal health outcomes and arises from economic, societal and environmental barriers, is one such challenge29. Two crucial factors contribute to health inequity: systematic differences in accessibility to evidence-based health information and the ability to process such information (health literacy)29,30. The metaverse could help address both of these factors. First, with the increasing accessibility and affordability of XR devices, individuals worldwide, including those in developing countries, could participate in the metaverse in the next decade. Second, as noted above, the metaverse represents a shift from information- to experience-based health communication. XR affordances provide visceral experiences that are easy to interpret and intuitively understandable. Therefore, XR can assist in the information processing of abstract health concepts. For instance, instead of processing complex scientific evidence about the relationship between (un)healthy eating, obesity and cardiovascular disease, users can be embodied in an avatar that allows the first-hand experience of this nexus. Such experience-based learning can overcome health inequity related to poor health literacy, something that has been shown to undermine the effectiveness of standard health communication methods30.
Another challenge in health communication is that current health campaigns targeting the general public typically have weak effects on actual health behaviours because people perceive them as unrelated and unengaging31. In contrast, there is increasing evidence that health interventions that are tailored specifically to a recipient’s characteristics and needs are more effective than generic messages32. Standard interventions usually allow customisation based only on broad characteristics, such as gender, race or age. In the metaverse, it would be possible to tailor health interventions based on multisensory health-related data, including body movements or health measures within or outside the metaverse, for instance, by linking virtual experiences to data from trackers or wearables. Such ‘dynamic tailoring’ of interventions rather than ‘static tailoring’ would allow interventions to be created and adapted specifically for individual users. Furthermore, it could improve threat and coping appraisal among population groups (e.g., young males) that are usually less responsive to standard health communication32.
Conclusions and outlook
It is predicted that the metaverse will have a major influence on how we behave and interact, with 25% of us spending at least 1 h a day in the metaverse by 202633. Despite the challenges arising from the potentially massive impact of the metaverse on our lives, it offers great potential for a paradigm shift in health communication. Indeed, current evidence from ‘lab-in-the-field’ experiments shows the promise of XR health communication in effectively improving healthy behaviour, even when self-administered28 or when administered in a non-laboratory environment, such as in public parks8 or afterschool34 or community settings35. Ultimately, the metaverse could revolutionise health communication by providing novel solutions to long-standing and pressing challenges in the field of public health.
By utilising the metaverse in health communication, new challenges arise. For instance, collecting and linking data within and outside the metaverse creates issues with data privacy. There is a need to find solutions to address these issues and develop guidelines and legislation on what and how information is used, including the problem of misinformation36. Lessons learned from classic social media are important and useful in this regard13. We also need to reach an agreement on ethical issues relating to the exploitation of the technological potential of the metaverse and our interactions within the metaverse. A useful step in this direction is the GuestXR project37. As part of this project, VR experts from academia and the private sector apply machine learning in XR to create virtual agents that can mediate information and social exchange in the metaverse and therefore limit harassment and conflicts in the metaverse.
Only when we find solutions to how health communication can be adapted to XR environments in ways that are both evidence-based and ethically responsible can XR platforms, such as the metaverse, truly have a positive impact on individual and public health.
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
This research does not report on novel original data.
This research does not rely on any code.
Hale, T. Facebook’s metaverse is “dystopian” and poses “terrifying danger” to humanity, say critics. IFLScience https://www.iflscience.com/facebooks-metaverse-is-dystopian-and-poses-terrifying-danger-to-humanity-say-critics-61535 (2021).
MacDonald, K. I’ve seen the metaverse—and I don’t want it. The Guardian https://www.theguardian.com/games/2022/jan/25/ive-seen-the-metaverse-and-i-dont-want-it (2022).
Hackl, C. The metaverse is coming and it’s a very big deal. Forbes Magazine https://www.forbes.com/sites/cathyhackl/2020/07/05/the-metaverse-is-coming--its-a-very-big-deal/?sh=113cb9c9440f (2020).
Stephenson, N. Snow Crash: A Novel (Random House Publishing Group, 1992).
Pimentel, D. et al. An Introduction to Learning in the Metaverse. Meridian Treehouse. (2022).
Llobera, J., Spanlang, B., Ruffini, G. & Slater, M. Proxemics with multiple dynamic characters in an immersive virtual environment. ACM Trans. Appl. Percept. 8, 1–12 (2010).
Bailenson, J. N., Blascovich, J., Beall, A. C. & Loomis, J. M. Interpersonal distance in immersive virtual environments. Pers. Soc. Psychol. Bull. 29, 819–833 (2003).
Vandeweerdt, C. et al. Virtual reality reduces COVID-19 vaccine hesitancy in the wild: a randomized trial. Sci. Rep. 12, 4593 (2022).
Ahn, S. J. Incorporating immersive virtual environments in health promotion campaigns: a construal level theory approach. Health Commun. 30, 545–556 (2015).
Jung, S., Lee, J., Biocca, F. & Kim, J. W. Augmented reality in the health domain: projecting spatial augmented reality visualizations on a perceiver’s body for health communication effects. Cyberpsychol. Behav. Soc. Netw. 22, 142–150 (2019).
Herrera, F., Bailenson, J., Weisz, E., Ogle, E. & Zaki, J. Building long-term empathy: a large-scale comparison of traditional and virtual reality perspective-taking. PLoS ONE 13, e0204494 (2018).
Rogers, R. W. A protection motivation theory of fear appeals and attitude change1. J. Psychol. 91, 93–114 (1975).
Gunasekeran, D. V. et al. The impact and applications of social media platforms for public health responses before and during the COVID-19 pandemic: systematic literature review. J. Med. Internet Res. 24, e33680 (2022).
Makransky, G. & Petersen, G. B. The cognitive affective model of immersive learning (CAMIL): a theoretical research-based model of learning in immersive virtual reality. Educ. Psychol. Rev. https://doi.org/10.1007/s10648-020-09586-2 (2021).
Riva, G., Baños, R. M., Botella, C., Mantovani, F. & Gaggioli, A. Transforming experience: the potential of augmented reality and virtual reality for enhancing personal and clinical change. Front. Psychiatry 7, 164 (2016).
Nowak, K. L. & Biocca, F. The effect of the agency and anthropomorphism on users’ sense of telepresence, copresence, and social presence in virtual environments. Presence 12, 481–494 (2003).
Trope, Y. & Liberman, N. Construal-level theory of psychological distance. Psychol. Rev. 117, 440–463 (2010).
Cummings, J. J. & Bailenson, J. N. How immersive is enough? A Meta-Anal. Eff. Immersive Technol. Use. Presence 19, 1–38 (2015).
Lee, K. M. Presence, explicated. Commun. Theory 14, 27–50 (2004).
Breves, P. & Schramm, H. Bridging psychological distance: The impact of immersive media on distant and proximal environmental issues. Comput. Hum. Behav. 115, 106606 (2021).
Fox, J. et al. Avatars versus agents: a meta-analysis quantifying the effect of agency on social influence. Hum. Comput. Interact. https://doi.org/10.1080/07370024.2014.921494 (2015).
Ajzen, I. The theory of planned behavior. Organ. Behav. Hum. Decis. Process. 50, 179–211 (1991).
Rimal, R. N. Closing the knowledge-behavior gap in health promotion: the mediating role of self-efficacy. Health Commun. 12, 219–237 (2000).
Bandura, A. Self-efficacy: toward a unifying theory of behavioral change. Psychol. Rev. 84, 191–215 (1977).
Fox, J. & Bailenson, J. N. Virtual self-modeling: the effects of vicarious reinforcement and identification on exercise behaviors. Media Psychol. 12, 1–25 (2009).
Fine, P., Eames, K. & Heymann, D. L. “Herd immunity”: a rough guide. Clin. Infect. Dis. 52, 911–916 (2011).
Peck, T. C., Seinfeld, S., Aglioti, S. M. & Slater, M. Putting yourself in the skin of a black avatar reduces implicit racial bias. Conscious. Cogn. 22, 779–787 (2013).
Mottelson, A. et al. A self-administered virtual reality intervention increases COVID-19 vaccination intention. Vaccine 39, 6746–6753 (2021).
Starfield, B. The hidden inequity in health care. Int. J. Equity Health 10, 15 (2011).
Nutbeam, D. & Lloyd, J. E. Understanding and responding to health literacy as a social determinant of health. Annu. Rev. Public Health 42, 159–173 (2021).
Keller, P. A. & Lehmann, D. R. Designing effective health communications: a meta-analysis. J. Public Policy Mark. 27, 117–130 (2008).
Krebs, P., Prochaska, J. O. & Rossi, J. S. A meta-analysis of computer-tailored interventions for health behavior change. Prev. Med. 51, 214–221 (2010).
Gartner predicts 25% of people will spend at least one hour per day in the metaverse by 2026. Gartner https://www.gartner.com/en/newsroom/press-releases/2022-02-07-gartner-predicts-25-percent-of-people-will-spend-at-least-one-hour-per-day-in-the-metaverse-by-2026 (2022).
Ball, C. et al. Scaling the virtual fitness buddy ecosystem as a school-based physical activity intervention for children. IEEE Comput. Graph. Appl. 42, 105–115 (2022).
Chan, J. Y. C. et al. Effects of virtual reality on moods in community older adults. A multicenter randomized controlled trial. Int. J. Geriatr. Psychiatry 35, 926–933 (2020).
Park, S.-M. & Kim, Y.-G. A metaverse: taxonomy, components, applications, and open challenges. IEEE Access 10, 4209–4251 (2022).
GuestXR—Machine learning agent for social harmony in extended reality. guestxr https://guestxr.eu/ (2020).
The authors received no financial support for the research, authorship and/or publication of this article.
The authors declare no competing financial interests but the following competing non-financial interests: R.B. is a member of the Technical Advisory Group on Behavioural and Cultural Insights of the World Health Organization/Regional Office for Europe.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Plechatá, A., Makransky, G. & Böhm, R. Can extended reality in the metaverse revolutionise health communication?. npj Digit. Med. 5, 132 (2022). https://doi.org/10.1038/s41746-022-00682-x