2023 8th International Conference on Business and Industrial Research 18 - 19 May 2023
(ICBIR2023) Bangkok, Thailand
The Effect of the Gaze Visualization Interface
on the Learning Performance of Virtual
Reality Medical Education
Haram Choi
Dept. of Culture and Technology
Changwon National University
2023 8th International Conference on Business and Industrial Research (ICBIR) | 979-8-3503-9964-6/23/$31.00 ©2023 IEEE | DOI: 10.1109/ICBIR57571.2023.10147557
Changwon, Republic of Korea
20227578@gs.cwnu.ac.kr
Abstract—Here we propose a virtual reality
education system that applies an eye-tracking-based
gaze visualization interface to prevent the user from
experiencing cognitive overload, which may occur in
existing virtual reality educational environments. Two
gaze visualization interface types, Circle Marker and
Highlight, are first used by the instructor to produce
virtual reality medical educational content. An
experiment is then conducted to analyze the difference
in learning performance between these two interface
types, with the degrees of concentration and learning
flow selected as the learning performance indicators to
be evaluated. The learning concentration is evaluated
using the dwell time, and the learning flow is evaluated
using a survey. A correlation analysis between the
degrees of concentration and learning flow is
performed, with a positive correlation determined for
these two learning performance indicators. An
independent samples t-test confirms that there is a
statistically significant difference between the degrees
of concentration and learning flow based on the type of
gaze visualization interface, with the results obtained
using the Circle Marker type having a more positive
effect on both learning concentration and flow.
Keywords—Concentration, Eye-tracking, Learning
Flow, Gaze Visualization, Virtual Reality
I. INTRODUCTION
Virtual Reality (VR) technology can provide users
with both a sense of immersion and the ability to
interact in a virtual environment that is similar to
reality [1,2]. VR technology is therefore being
utilized to improve educational outcomes [3]. The
advantage of implementing VR in education is that it
can enhance student creativity and imagination,
thereby motivating them to learn [4–8]. VR
technology is being used across the education sector,
spanning the sciences, engineering, humanities, and
social science [9].
VR technology is becoming widely used in
medical education. This is because VR technology in
medical education is safer and more repeatable than
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Sanghun Nam
Dept. of Culture and Technology
Changwon National University
Changwon, Republic of Korea
Corresponding author: sanghunnam@changwon.ac.kr
traditional education methods, and can positively
impact learning [10–14].
VR education can deliver more visual information
than traditional education methods since it is based on
a 360° virtual environment [15]. However, cognitive
overload can occur if lots of visual information is
delivered to the learner at the same time, resulting in a
lack of focus in learning the presented information,
which may degrade learning performance [16–18].
Gaze visualization signals based on eye-tracking
technology can reduce distractions, and help learners
focus on specific information in a three-dimensional
environment with lots of visual information [19].
Learning flow means that the learner is immersed
in a specific task. Flow state, a concept proposed by
Csikszentmihalyi, means a good feeling and optimal
experience as motivation in daily life such as work,
sports, and artistic activities [20]. Jackson and Marsh
proposed a Flow State Scale (FSS) developed based
on Csikszentmihalyi’s nine characteristics of flow
[21]. FSS is a scale that can measure learning flow,
and has been used in various fields, with recent
applications in virtual reality and augmented reality
[20].
Various methods, such as surveys and interviews,
are often employed during learning performance
analysis to collect the learners’ recalled information
after learning, but the results can be difficult to
accurately analyze because the learners’ memories are
distorted. Eye-tracking technology, which records
human eye movements as objective data, is also used
for learning performance analysis [22], with these
real-time observations making it easy to measure the
learners’ cognitive processes in a multimedia learning
environment [23]. Among the eye-tracking metrics,
the dwell time, which refers to the cumulative time
spent by a user gazing at an Area of Interest (AOI),
may indicate the level of interest in the AOI. The
degree of concentration can be measured through the
dwell time, with a long dwell time meaning that the
level of interest in a specific area increases, which is
indicative of concentrating, and vice versa [24].
 2023 8th International Conference on Business and Industrial Research 18 - 19 May 2023
(ICBIR2023) Bangkok, Thailand

Here VR medical education content with a gaze
visualization interface was developed using eye-
tracking technology to prevent the cognitive overload
issues that may occur in existing A research
hypothesis was derived that there would be
differences in learning performance depending on the
type of gaze visualization interface. Two gaze
visualization interface types, Circle Marker and
Highlight, were applied to the developed VR medical
education content. To prove the research hypothesis,
an experiment was conducted to analyze the
difference in learning performance between the two
gaze visualization interface types. A mixture of
quantitative and qualitative data was used for
effective evaluation and analysis of learning
performance. Therefore, based on previous studies,
learning performance indicators were derived for
learning concentration evaluated with eye tracking
data and learning flow evaluated with surveys.
Learning concentration was evaluated as
quantitative data using dwell time among eye tracking
metrics [25]. In this study, it was evaluated that the
higher the dwell time, the better the concentration of
learning. Learning flow was evaluated with
qualitative data using the FSS questionnaire. The FSS
questionnaire proposed by Jackson and Marsh was
adapted for the study and evaluated on a 5-point
Likert scale [21]. It was evaluated that the higher the
FSS score, the better the learning flow.
Correlation analysis was conducted to analyze the
correlation between quantitative data (concentration
by eye-tracking data) and qualitative data (flow by
questionnaire data). As a result of the correlation
analysis, it was found that there was a significant
correlation between learning concentration and
learning flow. An independent samples t-test was
conducted to determine if there was a significant
difference in learning performance based on the gaze
visualization interface type. The t-test results
confirmed that there was a statistically significant
difference between the degrees of concentration and
learning flow based on the gaze visualization
interface type, with the Circle Marker type having a
more positive effect on both learning concentration
and flow.
II. DEVELOPMENT OF VIRTUAL REALITY
MEDICAL EDUCATION CONTENT WITH A GAZE
VISUALIZATION INTERFACE
VR medical education content with a gaze
visualization interface was developed to prevent the
cognitive load that may occur in existing VR
education and improve concentration. The VR
medical education content was developed using the
Unity game engine, and consisted of educational
scenarios to prevent patient safety accidents that may
occur during surgery. The educational environment
and content were reviewed by current medical
professionals to increase the objectivity of the
medical education content development. Ten Areas of
Interest (AOIs) were selected as objects that learners
should focus on when viewing the medical education
content based on the reviewer feedback, and are listed
in Table 1.
TABLE I. AOI CLASSIFICATION
AOI Number AOI Name
AOI 1 Patient Band
AOI 2 Confirmation Form of Operation
AOI 3 Surgical Site
AOI 4 Anesthesia Machine
AOI 5 Anesthesia
AOI 6 Stethoscope
AOI 7 Defibrillator
AOI 8 Monitor
AOI 9 Surgical Count
AOI 10 Specimen
An instructor’s gaze visualization interface was
created to assist the learners in learning the medical
education content more effectively, with Circle
Marker and Highlight gaze visualization interfaces
produced and tested for this experiment. Tobii XR
SDK was used to visualize the instructor’s gaze. The
Circle Marker gaze visualization interface is shown in
Fig. 1, and is executed when presenting the VR
medical education content as follows. While the
instructor wears a head-mounted display (HMD) with
an eye-tracking function and views the VR education
content, a ray is created in the direction of the
instructor’s gaze, with the visualized material
rendered in front of the object to create a gaze
visualization object. This gaze visualization object
appears as an object with a sprite texture, with the
sprite shader render queue appearing first in the Unity
scene. This causes the gaze visualization object to
appear first, even if there are other objects behind it.
Fig. 1. Circle Marker Interface.
The Highlight gaze visualization interface is
shown in Fig. 2, and is executed when presenting the
VR medical education content as follows. When the
instructor’s gaze falls upon an object that has a
collider applied to it, that object is highlighted in a
color that is set by the instructor. The object then
returns to its original color after the instructor’s gaze
shifts away from that object.

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 2023 8th International Conference on Business and Industrial Research
(ICBIR2023)
Fig. 2. Highlight Interface.
A function to measure the learner’s concentration
was developed to analyze how well the learner
followed the educational content and focused on the
learning objects based on the two gaze visualization
interface types. The G2OM algorithm in Tobii XR
SDK was used to develop a function to measure the
dwell time from the eye-tracking data. When the
learner views the VR educational content, the names
of the objects (AOIs) that are gazed by the learner and
their associated dwell time is measured in real-time
from the eye-tracking data, as shown in Fig. 3-(a).
The dwell time is measured as the time from when the
learner’s gaze focuses on an AOI that has a collider
applied to it to the time the learner’s gaze moves from
that object. The dwell time for each AOI is saved as a
comma-separated values (CSV) file after the learner
views all of the VR medical education content, as
shown in Fig. 3-(b). These data are then analyzed to
determine the degree of concentration.
Fig. 3. Dwell time Measurements.
III. ANALYSIS OF THE DIFFERENCE IN LEARNING
CONCENTRATION AND FLOW BASED ON THE TYPE OF
GAZE VISUALIZATION INTERFACE
An experiment was conducted to analyze whether
there was a difference in learning concentration and
flow based on the instructor’s gaze visualization
interface type in a given set of VR medical education
content. Fig. 4 shows the experimental environment,
where 56 undergraduate and graduate students in
Korea viewed the VR medical education content. The
subjects were divided into two experimental groups
based on the gaze visualization interface type used in
the VR medical education content, The Circle Marker
type was used for the Group A subjects, and the
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18 - 19 May 2023
Bangkok, Thailand
Highlight type was used for the Group B subjects,
with 28 participants in each group.
Fig. 4. Experiment Environment.
The process of the experiment is shown in Fig. 5.
In the experiment, the Vive Pro Eye HMD was used
to track the subject’s gaze tracking data. Vive Pro Eye
has Tobii's eye-tracking sensor built-in, and the eye-
tracking specifications are as follows. Gaze data
output frequency = 120Hz, Accuracy = 0.5°–1.1°
(within FOV 20°), Trackable field of view = 110°.
Each subject was first seated and given a HMD, and
an eye calibration was performed. The experimenter
then briefly explained the guidelines and precautions
of the experiment. The subject then viewed the VR
medical education content, with the subject’s dwell
time data being measured in real-time; these data
were saved as a CSV file after the content was viewed.
The subject then completed a FSS questionnaire after
viewing the VR medical educational content.
Fig. 5. Experiment Procedure.
The eye-tracking data and surveys were used in
parallel as learning performance evaluation methods.
Each subject’s degree of concentration was evaluated
using the dwell time, which was derived from the
eye-tracking data. We determined the average dwell
time for all of the AOIs for each group (A and B) to
determine if there was a significant difference
between their average dwell time. The higher the
average dwell time between groups, the higher the
learning concentration of the group was evaluated.
The FSS questionnaire was used to evaluate the
learning flow. The FSS items included attention
questionnaire items, which were evaluated on a 5-
point Likert scale. The higher the average FSS score
between groups, the higher the learning flow of the
group was evaluated.
A correlation analysis was first conducted to
analyze whether there was a correlation between the
degree of concentration, which was evaluated using
the eye-tracking data (dwell time), and the degree of
learning flow, which was evaluated using the
questionnaire, with the results shown in Table 2.
There was a significant correlation between the
degrees of concentration and learning flow within the
95% confidence interval. The Pearson Coefficient (r)
between the degrees of concentration and learning
 2023 8th International Conference on Business and Industrial Research
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flow was found to be r = 0.303, which indicates a
positive correlation. A positive correlation between
learning concentration and flow therefore existed
based on the correlation coefficient standard, with this
correlation highlighting that learning concentration
would improve (degrade) as the learning flow
improved (degraded).
TABLE II. CORRELATION ANALYSIS RESULTS
Concentration
Pearson 1 0.303*
Correlation (r)
Concentration Sigma
(2-tailed)
N 56
Pearson 0.303*
Correlation (r)
Flow Sigma 0.23
(2-tailed)
N 56
*Correlation is significant at the 0.05 level (2-tailed).
An independent samples t-test was also conducted
to analyze whether there was a significant difference
between the degrees of concentration and learning
flow based on the type of gaze visualization interface.
The t-test results for analyzing the difference in
the degree of concentration based on the type of gaze
visualization interface are shown in Table 3. The
results yielded t = 5.219 and p = 0.000, which
highlighted that the difference in learning
concentration between the two gaze visualization
interface types was statistically significant, such that
there was a difference in the degree of concentration
depending on the type of gaze visualization interface.
The average concentration time was 4.01 s for group
A, which had the Circle Marker type applied, whereas
the average was only 2.07 s for group B, which had
the Highlight type applied.
TABLE III. INDEPENDENT SAMPLES T-TEST RESULTS
(CONCENTRATION)
Group N Mean SD t p
A 28 4.01 1.17
5.219
B 28 2.07 1.57
*p < 0.05, **p < 0.01, ***p < 0.001.
Table 4 lists the t-test results for analyzing the
difference in the degree of learning flow based on the
type of gaze visualization interface. The results
yielded t = 2.589 and p = 0.012, which highlighted
that the difference in learning concentration between
the two gaze visualization interface types was
statistically significant, such that there was a
difference in learning flow depending on the type of
gaze visualization interface. The average learning
flow was 4.23 points for group A, which had the
Circle Marker type applied, whereas the average was
3.64 points for group B, which had the Highlight type
applied.
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Bangkok, Thailand
TABLE IV. INDEPENDENT SAMPLES T-TEST RESULTS
(LEARNING FLOW)
Group N Mean SD t p
A 28 4.23 0.91
2.589 0.012*
B 28 3.64 0.78
*p < 0.05, **p < 0.01, ***p < 0.001.
Flow The independent samples t-test results therefore
indicated that the Circle Marker type of gaze
visualization interface had a more positive effect on
0.23
the both the learning concentration and flow. This
56 means that the Circle Marker type can be more
1 effective than the Highlight type in increasing
learners’ concentration and learning flow in VR
education.
56
IV. CONCLUSION
Here VR medical education content with a gaze
visualization interface was created and analyzed to
prevent the cognitive overload that may occur when
using existing VR medical education content. Two
gaze visualization interface types were produced,
Circle Marker and Highlight, and an experiment was
conducted to analyze the difference in the degrees of
concentration and learning flow between the two gaze
visualization interface types. A correlation analysis of
the experimental results was conducted, with a
positive correlation between the degree of
concentration, which was derived from the eye-
tracking data, and the degree of learning flow, which
was derived from the survey score, obtained.
Furthermore, an independent samples t-test was
conducted to analyze whether there was a difference
in learning concentration and flow based on the type
of gaze visualization interface, with a significant
difference between the Circle Marker and Highlight
gaze visualization interfaces in both learning
concentration and flow. It was concluded that the
Circle Marker gaze visualization interface had a more
positive effect on learning concentration and flow of
the VR medical education content.
The two gaze visualization interfaces developed in
0.000*** this study are not restricted to VR medical education
content, and can therefore be applied in other
educations fields to analyze the applicability and
effectiveness of these gaze visualization interfaces in
enhancing the uptake of VR education content.
Furthermore, this study only measured the degrees of
concentration and learning flow of the learners; the
range of learning performance indicators will be
expanded to increase the objectivity of the research
results in future studies.
ACKNOWLEDGMENT
This research was supported by the Institute of
Information and Communications Technology
Planning and Evaluation (IITP) grant funded by the
Korean government (MSIT) (No.2021-0-00986,
Development of Interaction Technology to Maximize
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(ICBIR2023) Bangkok, Thailand

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