Rehabilitation Psychology 2005, Vol. 50, No.

3, 285291

Copyright 2005 by the Educational Publishing Foundation 0090-5550/05/$12.00 DOI: 10.1037/0090-5550.50.3.285

Evaluation of a Computer-Assisted, 2-D Virtual Reality System for Training People With Intellectual Disabilities on How to Shop
Sing-Fai Tam, David Wai-Kwong Man, Yuk-Piu Chan, Pan-Ching Sze, and Chi-Ming Wong
The Hong Kong Polytechnic University
Objective: To evaluate the effectiveness of a 2-D virtual reality (VR) program for training people with intellectual disabilities to shop. Study Design: Pretest and posttest quasi-experimental design. Participants: Sixteen persons with intellectual disabilities (age 1723 years; IQ 40 54). Intervention: A VR program or a conventional program training them in supermarket-shopping skills. Main Outcome Measure: Checklist for supermarket-shopping skills. Results: Participants in both training groups showed signicant improvement. There was no signicant difference in effectiveness between the two methods. Conclusions: The VR program appears effective in training people with intellectual disabilities in an important community living skill.

Keywords: computer-assisted system, virtual reality, shopping skills

In the past few decades, computers have developed rapidly in power and sophistication. The computer can be used as a tool for assessment and even treatment, including applications in cognitive rehabilitation (e.g., Armstrong, 1989; Burda, Starkey, Dominguez, & Vera, 1994; Gontkovsky, Nicholas, Clark, & Ruwe, 2002; Green, Green, Harrison, & Kutner, 1994; Johnson & Gravie, 1985; McGuire, 1990; Smart, 1988; Waters & Ellis, 1996). This is despite the fact that methodological shortcomings have been observed in some studies on the subject (Skilbeck, 1991), as compared with traditional methods of cognitive rehabilitation (Hall & Cope, 1995). Applications of an advanced form of computer technology, virtual reality (VR), and evaluations of its efcacy have begun to appear in studies on the assessment, treatment, and functional outcomes of persons with cognitive impairments (Christiansen et al., 1998; Cunningham & Krishack, 1999; Elkind, 1998; Lengenfelder, Schultheis, Al-Shihabi, Mourant, & DeLuca, 2002; Moffat, Hampson, & Hatzipantelis, 1998; Myers & Bierig, 2000; Riva, 1998; Riva, Bacchetta, Baruf, Rinaldi, & Molinari, 1999; Rizzo et al., 2000; Rizzo, Buckwalter, & Neumann, 1997; Schultheis & Rizzo, 2001). VR can create the illusion that a person is in, and is interacting with, an articial world (Burdea, Richard, & Coiffet,

Sing-Fai Tam, David Wai-Kwong Man, Yuk-Piu Chan, Pan-Ching Sze, and Chi-Ming Wong, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. We would like to express our gratitude to the ParknShop supermarket, the Hong Chi Association, the Society of Homes for the Handicapped, the Mental Health Association of Hong Kong, and Dick Chi Day Activity Center and Hostel Christian family service center for their contribution and efforts in collecting the data. Finally, we sincerely thank all of the participants in this project. Correspondence concerning this article should be addressed to SingFai Tam, PhD, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. E-mail: rsalan@polyu.edu.hk 285

1996; Popescu, Burdea, & Trefftz, 2002). VR can simulate reallife situations and may enhance the learning and transfer of skills to everyday circumstances. There have been preliminary ndings that there is a clear, positive transfer effect from virtual and real training, as well as suggestions that the elements of cognitive strategy and cognitive loads of the training are broadly equivalent (Rose et al., 2000). Rose et al. (1999) found that active participation is crucial to the effectiveness of VR training. The effectiveness was related to the activity of the nervous system (Pugnetti et al., 1998) and to neuroplastic changes in the cerebral cortex (Rose et al., 1998) and was further evidenced by neuroimaging and psychophysiological studies (McComas & Jayne, 1998). However, there are disadvantages to using VR in some cases. VR can be of two types: immersive and nonimmersive (Christiansen et al., 1998; Psotka, 1995; Rizzo et al., 1997). An immersive VR application might lead to some side effects (e.g., nausea, vomiting, eyestrain, disorientation, ataxia, and vertigo). These are believed to occur when there is a conict between perceptions in different modalities of sense, for example, auditory, visual, vestibular, or proprioceptive (Galimberti, Ignazi, Vercesi, & Riva, 2001; Rizzo et al., 1997). To accommodate participants of various abilities and to prevent possible side effects of using the immersive method, many studies have applied a nonimmersive, 2-D atscreen approach, as did the present study. Nonimmersive VR is still providing valuable information for VR applications, including cognitive rehabilitation (Brooks et al., 1999; Riva, 1997; Rizzo, Wiederhold, & Buckwalter, 1998; Ruddle, Payne, & Jones, 1997; Wiederhold & Wiederhold, 2000). VR environments have also been used to train functional skills. Underwood (1997), for example, developed and applied a VR simulated shopping software system to study the effects of visual package information on the shopping attitudes and behavior of customers. Moreover, Browne, Evans, Sales, and Aleksander (1997) studied learned state space representations of knowledge, examining how participants explored and named objects in a virtual environment called a kitchen world. The efcacy of using a virtual kitchen for vocational

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TAM, MAN, CHAN, SZE, AND WONG dividing the shopping process into a series of tasks that required participants to use their judgment. Choices were provided for the participants at crucial points. They could proceed and get immediate visual and auditory reinforcement only if they had chosen the right way to proceed. The 2-D VR program was presented using an interactive Smartboard, an extrawide touch-screen monitor. Psychoeducational training package. A psychoeducational training package with identical training contents was developed for comparison. The package adopted a teachinglearning process that included demonstration, role-play, and verbal feedback (Goldstein, Gershaw, & Sprafkin, 1979).

training has also been demonstrated for people with learning disabilities (Brooks, Rose, Alltree, & Elliot, 2002). There has been increasing interest in studying whether people with learning disabilities are capable of using a virtual environment (and would be motivated to do so) and whether they would benet from using this method of training (Rose, Brooks, & Attree, 2002). The present study was thus developed to compare the effectiveness of a nonimmersive, at-screen VR method with a conventional psychoeducational method in training people with intellectual disabilities in supermarket-shopping skills. We hypothesized that (a) VR would be an effective modality for training people with intellectual disabilities to shop in a local supermarket and (b) there would be a signicant difference in the effectiveness of VR-based and conventional psychoeducational strategies in training these individuals in supermarket-shopping skills.

Measure: Checklist for Supermarket-Shopping Skills

We developed a behavioral checklist of skills required in typical supermarket shopping. The items, developed with reference to a checklist created by Westling, Floyd, and Carr (1990; see the Appendix), assessed what participants wanted to buy, gave them a sufcient amount of money, and then told them to go shopping for the item(s). Each participant went through the same assessment procedures in the real setting before and after the respective training programs (see the Appendix). Their behavior in the process was also observed. Their remarks and general comments were noted both during and after training.

Method Participants
By convenience sampling, 16 participants with upper functioning, moderate-grade mental disability (with a StanfordBinet IQ of 40 to 54) were recruited from four local organizations (Hong Kong Government, 1995, 1997). The participants were trainees of a vocational skills training center. Per the selection criteria for this study, individuals needed to (a) be age 16 or above; (b) be emotionally and medically stable; (c) have no history of psychiatric problems or autism; (d) be independent in basic self-care activities; (e) be able to follow simple verbal instructions; (f) be able to grasp simple concepts about money; (g) have real shopping needs; and (h) have given their consent to participate in the study.

Procedures
Before the start of training, a plan for completing the task was explained to the trainees. This plan allowed both trainer and trainees to recognize the appropriate action and the role of that action in completing the task of shopping. In 2-D VR training, each trainee participated in a two-session VR-based program in training in supermarket-shopping skills. The rst session lasted 45 min. During the rst 15 min, participants were briefed on the VR-based instructional strategy and on the contents of the training. A trainer demonstrated how participants could orient and navigate in the program and the steps involved in buying a designated type of food. The second session lasted 30 min, during which participants navigated themselves with the software to practice and learn the shopping skills. Retraining occurred on an individual basis, involving two trainers who gave instructions to the participants. There were two training sessions. In the rst session, in addition to being introduced to the shopping process, participants also received help in familiarizing themselves with navigating in the virtual environment. The second session, on revising and practicing the shopping skills, lasted 30 min (see Figure 1). During the training, the trainers physically collaborated with the trainees, interacting and communicating in nonverbal ways to help the trainees learn supermarket shopping skills. The trainers also tracked the trainees visual attention and physical movements in interacting with the 2-D VR environment (e.g., by examining the position and orientation of their hands). In the conventional, psychoeducational group, each participant participated in a two-session psychoeducational tutorial and role-play. Each session lasted 30 min, during which participants received consistent instructions from a trainer that were complemented with audiovisual demonstrations. The two sessions had the same contents as the VR sessions, focusing on supermarket-shopping skills (see Figure 1). Using informationbased and simulated methods, the trainer introduced the basic concepts and skills required in supermarket shopping. The trainees would role-play these skills before they interacted with the actual task in the actual environment. In this regard, a trainee might have difculty generalizing his or her learning in the group session to perform the real task in a real environment.

Study Design
In the present study, a pretest and posttest quasi-experimental design was used to compare the intervention group and the control group. The participants were randomly assigned into groups. Eight participants, 4 men and 4 women, ranging in age from 18 to 23 (M 18.21, SD 2.30), received training in shopping skills using a newly developed, 2-D VR-based computer program. In this program, participants received guidance in learning basic shopping skills through interaction within an interactive virtual environment. Another 8 participants, 4 men and 4 women, ranging in age from 17 to 23 (M 17.92, SD 2.52), received training in shopping skills using a conventional strategy (a psychoeducational package using demonstration, role-play, and immediate feedback with verbal reinforcement).

Instrumentation
A 2-D VR-based training program in shopping skills and a corresponding psychoeducational package were developed for the present study. The structure and contents of the programs were similar, consisting of an introduction to the training objectives, training in supermarket-shopping skills, practice in shopping skills, and a revision of the shopping skills (see Figure 1). 2-D, nonimmersive, at-screen VR-based training program in shopping skills. Because we considered that the use of a fully immersive headmounted display might not be feasible or necessary for participants with cognitive decits, a 2-D, nonimmersive, at-screen VR training software was designed instead. The program is interactive in nature, enabling the user to exercise direct control over a video-based virtual environment. It allows the user to navigate, explore, and interact with videos that make up a virtual supermarket environment. We designed the training program by

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Figure 1. Training programs of the 2-D virtual reality (VR) system and the control psychoeducational groups.

Statistical Analysis
We used the nonparametric MannWhitney U test to evaluate the between-groups difference in preassessment scores, postassessment scores, and improvements in scores in supermarket-shopping skills of both training groups, respectively. The Wilcoxon signed-ranks test was used to evaluate the within-group difference between the pre- and postassessment scores in the shopping skills of each training group.

difference between the pre- and postassessment scores of both the 2-D VR training group and the conventional training group (p .05; see Table 1).

Comparing Training Outcomes Between the VR and Conventional Groups

Although participants were randomly assigned to treatment groups, their baseline levels were slightly different. The mean preassessment score of the 2-D VR training group was slightly higher than that of the conventional training group (see Table 1), although this difference was not statistically signicant (p .05; see Table 1). The mean postassessment score of the 2-D VR

Results Within-Group Comparisons

Participants in both programs showed improved shopping skills after receiving their respective training. There was a signicant

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Table 1 Mean Scores (and Standard Deviations) of the Two Treatment Groups Before and After Training
Comparison Within groupa 2-D VR training group (n 8) Conventional training group (n 8) Between groupsb Pre Post Diff Pre 55.00 (3.16) 50.90 (8.39) Post 63.60 (3.25) 57.60 (6.61) Diff 8.65 (1.77) (15.72%) 6.75 (3.92) (11.72%) Z 2.53 2.53 1.16 1.91 0.74 p .012 .011 .28 .06 .51

Note. Pre preassessment score; Post postassessment score; Diff difference between pre- and postassessment scores; VR virtual reality system. a Wilcoxon. b MannWhitney U.

training group was higher than that of the conventional group. Also, the mean improvement in score of the 2-D VR training group (15.72%) was larger than that of the conventional training group (11.72%). This suggests that the 2-D VR training group may have had a clinically signicant increase, although not a statistically signicant one (see Table 1). Members of the 2-D VR training group had pre- to posttreatment improvements ranging from 6 to 11; for the conventional group, the improvements ranged from 1 to 11 (see Figure 2), suggesting that the training effect of the VR program was more consistent than the effect of the conventional method. The effect size of 4% (15.72% minus 11.72%) falls in the null hypothesis range. Thus, VR can achieve the same level of improvement as conventional intervention.

Discussion
This study compared the relative effectiveness of the newly developed 2-D VR training program and conventional strategies in teaching shopping skills. The results showed that although both methods were effective, there was no signicant difference between the two programs in level of improvement. The mean values

Figure 2. Box plots showing (VR) range of score improvement of the two training groups. Group 1 2-D virtual reality (VR) training group (n 8); Group 2 conventional training group (n 8). Error bars indicate standard errors of the mean.

of improvement, however, suggest that the 2-D VR program had a slightly greater effect. Because our sample was small, we see the need to conduct a large-scale study to conrm this nding. The participants who improved by receiving conventional training showed more varied learning outcomes than those who were trained using the VR method. This might be due to the fact that the VR method provides a more focused learning framework that is more consistent and motivating. Practice is a critical factor that affects outcomes in the learning of skills. In the 2-D VR program, participants practiced their shopping skills in a relatively realistic virtual environment. In contrast, participants in the conventional training group practiced shopping skills through simulated role-plays. The results also supported ndings of previous studies (e.g., Brooks et al., 1999; Rizzo et al., 1997) that learning in a virtual training environment can be effectively transferred to an actual environment. Effective feedback facilitates learning. Participants in the VR program were able to obtain their immediate objective and receive consistent feedback from the virtual environment (Vockell & Schwartz, 1992), whereas those in the conventional training group received feedback from the trainer that they may not have considered to be objective and consistent. Demonstration and modeling can facilitate the process of learning. Participants in the 2-D VR training program received in vivo demonstrations in a virtual environment. However, participants receiving conventional training received less realistic demonstrations by the trainer, because the shopping process and skills were presented by simulated role-play and verbal instructions only. Because VR creates an articial multisensory experience of an environment, including space and events that are experienced as reality, Cromby et al. (1996) opined, VR may be a more effective educational and training medium to expand care in the community for people with learning disabilities. However, in the present study, we observed that the trainees impaired learning ability could limit their ability to navigate within the virtual environment and thus participate in VR training. Wickens and Baker (1995) suggested that cognitive issues in virtual reality (e.g., knowing about and understanding the virtual environment) should be considered in the designing of a VR system. Therapists should prepare their clients by helping them to be aware of the short-term knowledge provided by VR (e.g., Where am I in the environment?

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What do I see? Where do I go, and how do I get there?) and also the long-term knowledge (e.g., What can and do I learn about the environment as I see and explore it?). Although it is believed that most people can easily master the modes of VR navigation, VR navigation may present problems to a person with a cognitive decit (Rizzo et al., 1997).

Conclusion
The present study provided evidence of the efcacy of a newly developed, 2-D, nonimmersive VR system in training people with cognitive decits in supermarket-shopping skills. Although in its present stage of development, the VR method is not a substitute for a conventional community-living skills-training program, it can be a workable and worthwhile complement. Besides training in shopping skills, the present 2-D VR strategy can be used to assess and train people in various skills of community survival, such as transport skills, road safety, wheelchair accessibility, and so forth. The virtual reality environment can be a very powerful tool in rehabilitation, and we recommend further research to realize its full potential.

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Received March 8, 2004 Revision received August 25, 2004 Accepted September 8, 2004