Received: 9 November 2020 | Revised: 21 September 2021 | Accepted: 23 October 2021

DOI: 10.1002/ase.2146

RESEARCH REPORT

The role of spatial ability in mixed reality learning with the

HoloLens

Simon Ho1 | Pu Liu2 | Daniela J. Palombo1 | Todd C. Handy1 | Claudia Krebs2

1
Department of Psychology, University
of British Columbia, Vancouver, British Abstract
Columbia, Canada
The use of mixed reality in science education has been increasing and as such it has
2
Department of Cellular and Physiological
Sciences, University of British Columbia,
become more important to understand how information is learned in these virtual
Vancouver, British Columbia, Canada environments. Spatial ability is important in many learning contexts, but especially

Correspondence
in neuroanatomy education where learning the locations and spatial relationships
Dr. Simon Ho, Department of Psychology, between brain regions is paramount. It is currently unclear what role spatial ability
University of British Columbia, 2136 West
Mall, Vancouver, BC V6T 1Z4, Canada.
plays in mixed reality learning environments, and whether it is different compared to
Email: simonho213@gmail.com traditional physical environments. To test this, a learning experiment was conducted

Funding information
Mitacs, Grant/Award Number: F18-­02840
where students learned neuroanatomy using both mixed reality and a physical plastic
model of a brain (N = 27). Spatial ability was assessed and analyzed to determine its
effect on performance across the two learning modalities. The results showed that
spatial ability facilitated learning in mixed reality (β = 0.21, P = 0.003), but not when
using a plastic model (β = 0.08, P = 0.318). A non-­significant difference was observed
between the modalities in terms of knowledge test performance (d = 0.39, P = 0.052);
however, mixed reality was more engaging (d = 0.59, P = 0.005) and learners were
more confident in the information they learned compared to using a physical model
(d = 0.56, P = 0.007). Overall, these findings suggest that spatial ability is more rel-
evant in virtual learning environments, where the ability to manipulate and interact
with an object is diminished or abstracted through a virtual user interface.

KEYWORDS
cognition, learning, mental rotation, mixed reality, neuroanatomy education, neuroscience,
spatial ability

I NTRO D U C TI O N can lead to improvements in both skill and knowledge-­based learn-

A wide range of new technologies, including virtual reality and mixed
reality, have been adopted in science education across a number of
topic domains (Tolentino et al., 2009; Cheng & Tsai, 2013), and their
use has been increasing over the past decade (Martin et al., 2011;
Akçayır & Akçayır, 2017). This increased adoption is likely due to
increased immersion and interactivity afforded by the technology
(Martin et al., 2011; Erolin et al., 2019), and has generally been shown
to improve student learning performance (Hacket & Proctor, 2016,
2018). For example, virtual reality has been shown to have learning
benefits over traditional teaching methods (Kyaw et al., 2019) and
ing (Lee & Wong, 2014; Merchant et al., 2014; Kurul et al., 2020).
Moreover, student motivation and engagement are also increased as
a result of virtual reality learning (Pan et al., 2006; Fairén González
et al., 2017; Marks et al., 2017).
Technological advances have also led to the rise of mixed re-
ality learning, which introduces multimodal methods, such as
cross-­
section training and interactive exercises (McJunkin et al.,
2018; Maniam et al., 2020). Like virtual reality, mixed reality pro-
vides a novel and engaging experience (Gnanasegaram et al., 2020;
Duncan-­Vaidya & Stevenson, 2021). It has also been shown to be
useful for learning in cases such as digital pathology due to the ease

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HO et al.
with which it allows learners to manipulate spatial data (Hanna et al.,
2018). The learning benefit of mixed reality, however, is not entirely
clear as some studies have shown that it yields the same student
performance as traditional teaching methods (Moro et al., 2017;
Gnanasegaram et al., 2020; Henssen et al., 2020). It could even be
detrimental to performance: for example, in some studies, learning
pelvic anatomy in mixed reality led to poorer knowledge retention
compared to the use of a physical model (Khot et al., 2013; Wainman
et al., 2018, 2020). This has been attributed to the lack of stere-
opsis in many mixed reality platforms, which can lead to impaired
depth perception, whereas stereo vision is retained when using true
physical models (Wainman et al., 2018, 2020). Overall, mixed reality
learners expect the technology to be more helpful than it actually
is in practice, and current implementations are not fully effective
replacements for traditional techniques (Zafar & Zachar, 2020). This
raises the question of why mixed reality leads to inconsistent effects
on learning, and whether individual characteristics of the learners
themselves might be affecting the relationship (Lee et al., 2009;
Cheng & Tsai, 2013). One candidate for a learner characteristic that
might moderate learning benefits is spatial ability, as it has been
shown to correlate with learning performance across a number of
domains (Khot et al., 2013; Lee & Wong, 2014). Of particular interest
in the present study is how spatial ability might affect learning in
mixed reality environments, specifically in the context of neuroana-
tomical learning.
Spatial knowledge can be represented using different frames of
reference, for example, egocentric and allocentric (Easton & Sholl,
1995; Mou & McNamara, 2002). Object locations in an egocentric
representation are stored relative to the observer (e.g., “where is the
coffee shop from my current location?”), whereas allocentric repre-
sentations are coded with respect to other objects in the environ-
ment (e.g., “where is the coffee shop in relation to the hospital?”).
Allocentric representations are particularly important in the case
of neuroanatomical learning as learners are required to encode the
relative spatial locations and orientations of different brain regions.
As it is concerned with object-­to-­object relations and transforma-
tions, the allocentric system is highly related to mental rotation abil-
ity, which is the ability to mentally rotate an internal representation
of a two-­dimensional (2D) or three-­dimensional (3D) object (Wraga
et al., 1999; Zacks & Michelon, 2005; Voyer et al., 2017). Findings
in the educational literature converge on the idea that mental rota-
tion ability is highly beneficial for performance on spatial learning
tasks. For example, mental rotation ability has been found to cor-
relate positively with spatial learning performance across different
learning modalities (e.g., mixed reality, virtual reality, and computer
screen), and can be a stronger predictor of overall performance than
the learning modality itself (Khot et al., 2013; Wainman et al., 2018,
2020). These findings have also been observed in anatomical learn-
ing (Garg et al., 2001; Guillot et al., 2007; Lee & Wong, 2014), and
participation in mental rotation training can lead to improvement on
tests of anatomy (Hoyek et al., 2009).
The literature is more divided, however, with respect to the role
of spatial ability in virtual environments. Some studies show that 3D
|
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1075
virtual models only improve learning in individuals with high spa-
tial ability. This is known as the ability-­as-­enhancer hypothesis and
suggests that high spatial ability allows the learner to devote more
cognitive resources to building a mental representation of the object
(Huk, 2006; Lee et al., 2009). However, studies have also shown the
opposite effect and support the ability-­as-­compensator hypothesis,
where the presence of a virtual model can compensate for lower
spatial ability of the learner (Lee & Wong, 2014). A confound in these
studies is that the virtual model is not true virtual reality, and instead
displayed on a computer screen, which removes the possibility of
stereopsis. A recent study showed that stereopsis can interact with
spatial ability, improving performance of individuals with low base-
line spatial ability (Bogomolova et al., 2020). Additionally, immersive
virtual or mixed reality (i.e., using a head-­mounted display) allows for
increased interactivity and direct manipulation of the model, which
has also been shown to interact with spatial ability (Sjölie et al., 2010;
Jang et al., 2017). These features are potentially more important in
the context of neuroanatomical learning due to the higher level of
visual occlusion compared to, for example, pelvic anatomy. In fact, it
could be argued that the need for spatial ability is minimized when
learning pelvic anatomy due to how capacious the region is (Khot
et al., 2013; Wainman et al., 2018, 2020). Currently, it is unclear how
spatial ability affects learning in an immersive environment when
high levels of visual occlusion are involved.
The present study addresses two main questions. First, does
mixed reality confer any additional benefit over traditional physical
model learning? Second, to what extent does spatial ability affect
performance in each of the two learning modalities? To test the
validity of the ability-­as-­enhancer and ability-­as-­compensator hy-
potheses, a learning experiment was conducted using a mixed real-
ity head-­mounted display (displaying a virtual brain) and a physical
plastic brain model. It was hypothesized that spatial ability would
have a differential effect in each of these modalities. As mental
rotation involves similar cognitive processes to physical object ro-
tation (Gardony et al., 2014), it was predicted that spatial ability
would be unrelated to learning performance when physical rotation
of the model is possible (i.e., learning from a physical model). This
is supported by studies that show no relationship between spatial
ability and academic course performance, where the course was
taught using traditional methods like physical models (Sweeney
et al., 2014). However, when physical rotation is unavailable and ab-
stracted through a user interface, it was predicted that higher levels
of spatial ability would be required for effective learning.
M ATE R I A L S A N D M E TH O D S
Participants
A two-­tail power analysis was conducted to determine minimum
sample size for the study. In terms of effect size, previous studies
have shown that the relationship between mixed reality learning
and test performance ranges from 0.38 to 1.99 (Enyedy et al., 2012;
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1076
Albrecht et al., 2013; Merchant et al., 2014); however, pilot stud-
ies in the laboratory showed that the effect size could be as low as
0.08 when learning neuroanatomy. Across these studies, the aver-
age effect size was 0.64, which was used for the power analysis.
The analysis indicated that a minimum of 22 participants would be
needed to achieve 80% power when using a within-­subjects design.
A total of 31 participants were recruited from the University of
British Columbia and received $30.00 CAD for their time. In terms of
inclusion criteria and eligibility for the study, participants had to be
current undergraduate or graduate students with no prior participa-
tion in any neuroanatomy courses. Four participants were excluded
due to computer problems that prevented data collection. The
final sample consisted of 27 participants (mean age = 20.93 years,
SD ±3.46, 10 males, 16 females, 1 other).
HoloLens and HoloBrain
The experiment used a Microsoft HoloLens (Microsoft Corp.,
Redmond, WA) as the presentation device as it offers full stereopsis.
For the neuroanatomy content, the research team developed an ap-
plication called HoloBrain (Holman et al., 2018), which is an educa-
tional tool designed to teach neuroanatomy by projecting a virtual
interactive brain in front of the user. The brain could be locked in
place and allowed for full exploration across all three spatial axes.
Additionally, the user could also reposition, resize, and rotate the
virtual brain using a series of menu options and voice commands. All
F I G U R E 1 Screen captures of the HoloBrain application. (A) HoloBrain main menu system; (B) HoloBrain MRI room
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HO et al.
of these user interactions, as well as the position of the HoloLens
itself, were recorded to a log file on the device.
HoloBrain consisted of two primary learning modes: education
room and magnetic resonance imaging (MRI) room. The purpose of
the education room was to teach the locations of different brain re-
gions in 3D space (Figure 1A). For the limbic system, HoloBrain con-
tained only the thalamus, amygdala, hippocampus, fornix, mammillary
bodies, and the mammillothalamic tract. For the basal ganglia regions,
HoloBrain contained only the caudate nucleus, putamen, globus
pallidus, thalamus, substantia nigra, and the subthalamic nuclei. The
names of the six brain regions were shown using pop-­up labels that
would appear whenever the user looked at a region. The education
room offered an “isolate” mode, where the user could choose the spe-
cific brain regions they wanted to view. Upon selecting a region, an
audio recording was played that spoke the region name. An “expand”
mode increased the spacing between selected brain regions, which al-
lowed for easier visualization of the shape of the individual structures.
The second learning mode was MRI room, which was designed
to teach locations in 2D space (i.e., an MRI scan). Upon entering the
MRI room, 2D MRI scans were displayed in a side panel (in a two-­
by-­t wo grid) next to the brain, and each scan had colored outlines
to indicate the different brain regions of interest (Figure 1B). The
side panel was the primary method by which 2D information was
learned. Additionally, each scan was also shown intersecting the 3D
brain model to show the location at which that scan was taken. The
combination of side panel images and intersecting images was de-
signed to provide a link between 2D and 3D spatial understanding.

HO et al.
Plastic model
The overall design goal of the plastic model modality was to ensure
that participants had access to the same information, and that it
was presented in a similar fashion, to HoloBrain. Some concessions
had to be made, however, as the two learning platforms are fun-
damentally different (e.g., there are no buttons and menu systems
in reality, physical disassembly of the brain is not possible in mixed
reality, etc.). Participants were asked to learn region locations using
a physical plastic model of the brain (BS 25; SOMSO® MODELLE
GmbH, Coburg, Germany), which could be assembled and disassem-
bled by the user (Figure 2). The model was color coded, and partici-
pants were provided with a separate sheet that showed the names
and locations of the specific regions they were asked to learn. To
minimize differences between learning modalities, the plastic model
only contained labels for the six regions presented in the HoloBrain
condition. Thus, the learning requirements were the same: to learn
the spatial locations of the same six basal ganglia regions or six limbic
system regions that were described in the previous section.
In addition to the 3D model, participants were also provided with
a sheet of MRI images that was used to teach 2D spatial information.
To ensure plastic model learning was as similar to HoloBrain as pos-
sible, the paper-­based scans were the same as the ones used in the
HoloBrain application and were also organized in an identical two-­
by-­t wo grid. HoloBrain also contained scans that intersected the 3D
brain to signify the location at which the scan was taken. To create
an analogous demonstration on paper, a small brain diagram was dis-
played, next to each MRI scan, that contained an intersecting line to
show the location from which that scan was taken.
Spatial ability
The present study focused only on allocentric spatial ability as the
research question was about learning the spatial relationships of ob-
jects to each other, rather than in relation to the observer. This is a
F I G U R E 2 Disassembled plastic model of the inner brain regions
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1077
fundamentally allocentric reference frame as the occipital lobe, for
example, will be posterior to the parietal lobe regardless of where the
observer is standing. Although some egocentric ability is likely to be
involved given the use of mixed reality (for example, HoloBrain users
need awareness of where their hand is in relation to the virtual brain
in order to interact with it), this is beyond the scope of the current
research question.
To assess allocentric spatial ability, each participant completed a
computerized version of the mental rotations task (MRT; Shepard &
Metzler, 1971; Vandenberg & Kuse, 1978; Peters et al., 1995). During
each trial of the task, a target image, consisting of a geometric shape,
was presented along with four options. Two of the (correct) options
were identical to the target but rotated around one of the axes. The
remaining two (incorrect) options were similar looking shapes but
slightly modified such that they could never be rotated to match the
target. Participants were asked to select the two options that could
be correctly rotated to match the target. A single point was given for
the trial if both shapes could be identified, and no point was awarded
if only one correct answer was chosen. There were a total of 24 trials,
split into two halves of 12, and participants had a total of 6 minutes
for the task (3 minutes per half). Each participant received a score out
of 24 for this task. The version of the task used was identical to the
MRT (Peters et al., 1995) in terms of stimuli, task timings, and scoring
method, thus preserving the psychometric properties of the assess-
ment. The full set of task stimuli can be found in Peters et al. (1995).
Knowledge test and survey
A 40-­item multiple choice knowledge test was designed to assess
retention of the learned material. Furthermore, the test showed
new/unseen images and contained novel application questions as
participants were expected to generalize their learning to unfamiliar
contexts; this was made clear to them at the beginning of the study.
In terms of Bloom's taxonomy, the questions were designed to as-
sess the first three levels of the cognitive domain: (1) remember the
names and locations of brain regions, (2) understand their spatial re-
lationships with regards to the ventricular system and other learned
regions, and (3) apply that information to new images and unfamiliar
contexts (Anderson & Krathwohl, 2001). All knowledge test scores
were converted to percentages for ease of comparison.
The test itself consisted of 20 questions about the limbic system
and 20 questions about the basal ganglia. Half of the questions asked
about general 3D spatial understanding (e.g., “the posterior aspect
of the thalamus is <blank> to the hippocampus”), and the other half
tested the ability to translate those 3D relationships to 2D slices
through the brain (e.g., “if the brain was sliced at the line indicated
below, which one of these structures would you expect to see?”). For
each question, participants were also asked to state how confident
they were in their answer on an ordinal scale from 1 to 10, with 10
being the highest level of confidence. The full list of knowledge test
questions, along with a breakdown of basal ganglia/limbic system and
2D/3D understanding, can be found in the Supporting Information.
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1078
After the knowledge test, participants completed a quick survey
containing a couple of demographic questions designed to be used
as covariates in the analyses: (1) what is your level of proficiency with
English? (1 to 6, with 6 being native level), and (2) have you used a
virtual reality device before? (Yes/No). Participants were also asked
to provide their general opinions on the HoloBrain learning method
(“what did you like/dislike about the HoloBrain learning method?”).
Finally, they were asked to state their level of agreement with spe-
cific attitude questions: “I found the <method> engaging” and “the
<method> helped me learn the concepts” (method was replaced by
both “HoloLens” and “plastic model” to create a total of four differ-
ent question combinations). These questions were measured using a
6-­point Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Somewhat
disagree, 4 = Somewhat agree, 5 = Agree, 6 = Strongly agree).
Experimental procedure
The experiment was spread across three consecutive days, with each
session lasting a maximum of one hour (Figure 3). On day one, the
experimenter explained the study and acquired written informed
consent from the participant. The four main learning objectives were
then explained: (1) learn the correct anatomical orientation terms
to describe locations (e.g., anterior, superior, and lateral), (2) learn
the locations of brain regions in three dimensions, (3) learn the lo-
cations of brain regions in two dimensions from MRI scans, and (4)
learn the locations of these structures relative to the ventricular sys-
tem. These objectives, along with a diagram explaining anatomical
orientation, were displayed on a screen during days one and two.
Participants then watched a short introductory video about the
F I G U R E 3 Overview of the experimental procedure
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HO et al.
central nervous system (Rothman, 2014) to provide everybody with
a basic familiarity with the content they will be asked to learn. The
remainder of day one was spent teaching participants how to work
with the plastic model and how to use the various functions available
in the HoloBrain application. The practice and training sessions were
essential; otherwise, the novelty of both learning methods quickly
became daunting and overwhelming.
Day two was the main learning day. Participants were explicitly
informed that none of the images from the learning day would be
shown as-­is on the knowledge test, but rather they were expected
to generalize their learning to unfamiliar contexts. For each learn-
ing method, participants were provided with a list of six different
brain regions to be learned and 20 minutes to complete the task.
The learning was entirely self-­guided, and participants were re-
minded to focus on the four main learning objectives. Both learning
method and brain regions were counterbalanced across partici-
pants to reduce the possibility of order and practice effects. For
example, one participant started by using the plastic model to learn
the basal ganglia, followed by HoloBrain for the limbic system. The
presentation order was then switched for the next participant (i.e.,
plastic model for limbic system and HoloBrain for the basal gan-
glia). Finally, participants were instructed not to review the material
at home to ensure learning was limited to the session itself.
Day three was spent on the computer task, knowledge test, and
survey. Participants started with the MRT followed by the 40-­item
knowledge test. The questions on the knowledge test assessed un-
derstanding of both the limbic system and basal ganglia, and presen-
tation order of all questions was randomized for each participant.
Knowledge test scores were calculated as percentages for each
learning method separately and used as the primary outcomes in the

HO et al.
analyses. At the end of the session, participants were debriefed on
the purpose of the study and paid for their time.
Statistical analysis
The knowledge test was first validated for use by assessing reliabil-
ity; this was achieved using Cronbach's alpha as a way to determine
the degree to which the test items measured the same underlying
construct. A confirmatory factor analysis approach would be pre-
ferred as test items may be measuring different constructs, and
ideally multiple models would be tested for different latent factor
structures. However, that approach was not possible due to having
(1) a large number of knowledge test items and (2) a small sample
size, the combination of which would pose problems with model
estimation due to limited degrees of freedom. Following validation
of the measurement instrument, a few manipulation checks were
conducted to ensure that question difficulty was balanced between
different sets of questions (e.g., basal ganglia questions were at the
same difficulty as limbic system questions). These were checked by
calculating the mean test performance for each set of questions and
conducting a paired-­samples t-­test to ensure equality. A paired test
was chosen due to the within-­subjects experimental design, where
each participant was exposed to all learning manipulations.
Next, to address the first research question regarding differences
between mixed reality and plastic model learning, a paired t-­test was
again used to test for mean difference between groups. This was
conducted on both knowledge test performance and knowledge test
confidence. As test performance is not the only important factor in
an educational setting, paired t-­tests were also conducted on the
Likert scale survey items asking about the helpfulness and engage-
ment of each learning modality.
To address the main research question regarding the role of
spatial ability, linear regressions were conducted due to spatial
ability being a participant-­level construct without a direct exper-
imental manipulation. It was important to first establish whether
spatial ability was related to knowledge test performance at an
overall level. English language proficiency was used as a covari-
ate to ensure it was not confounding the results. Specifically, total
knowledge test score was predicted from MRT performance and
English proficiency:
Knowledge test = 𝛽 0 + 𝛽 1 MRT + 𝛽 2 English.
The degree to which spatial ability was related to both mixed
reality performance and plastic model performance was then as-
sessed. A combined model was constructed where MRT perfor-
mance was predicted from mixed reality performance, plastic model
performance, and English language level. Additionally, prior expe-
rience with virtual/mixed reality and total travel distance of the
HoloLens during the learning session (as an analog for physical per-
spective taking) were added to the model as they likely covary with
performance on the mixed reality portion of the knowledge test:
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1079
MRT = 𝛽 0 + 𝛽 1 Mixed reality + 𝛽 2 Plastic model
+ 𝛽 3 English + 𝛽 4 Experience + 𝛽 5 Travel.
Statistical assumptions in each of the above models were
checked by visual inspection of quantile-­
quantile and normality
plots. Furthermore, due to potential issues with collinear predictors,
variance inflation factor was checked for all predictors.
Finally, a thematic analysis was conducted on the qualitative
responses to assess how learners felt about the HoloBrain applica-
tion. A research assistant, who was blind to the research hypothe-
sis, assigned codes to relevant fragments of each participant's text
response. These individual codes were then collated into potential
themes. The themes were assigned appropriate names, and propor-
tions were calculated to communicate the frequency of each theme
within the collected data (Braun & Clarke, 2006).
R E S U LT S
Knowledge test validation
The knowledge test was assessed for reliability using Cronbach's
alpha. Overall, the instrument was found to be reliable and contained
a wide range of question difficulty. Across the set of knowledge test
items, alpha was calculated to be 0.59, 95% CI [0.38, 0.80]. Reliability
values of this magnitude are deemed to be sufficient, especially when
the measurement instrument is not strictly unidimensional (Taber,
2018). Each test item was also examined separately in terms of the
percentage of participants that correctly answered the question. In
terms of usability of knowledge test scores as an outcome variable,
the set of questions needed to have a wide range of difficulty, and it
was desirable to avoid floor and ceiling effects (questions that were
answered incorrectly by all participants, or correctly by all partici-
pants) to maximize response variation. This was achieved, as the mini-
mum and maximum of percentage correct responses were 18.52%
and 92.59%, respectively, with mean of 48.24% (SD = 17.98). An item-­
level breakdown can be seen in the Supporting Information.
It was also important that knowledge test performance between
different question sets was equal to ensure that a difficulty imbalance
would not bias later statistical analyses. Overall, question difficulty
on the knowledge test was balanced across the different sets and
unlikely to confound the main analyses. Mean performance between
the basal ganglia and limbic system questions was not found to be sig-
nificantly different, t(26) = 0.34, P = 0.737, d = 0.07. Additionally, no
performance difference was found between the 2D and 3D question
types, t(26) = 1.13, P = 0.267, d = 0.22. Descriptive statistics for each
question set can be seen in the knowledge test section of Table 1.
Mixed reality versus plastic model
Next, learning outcomes between the two modalities were tested.
The results showed no statistical difference between mixed reality
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1080 HO et al.

TA B L E 1 Mean and standard deviation (±SD) of participant

was not. The regression estimates for each predictor can be seen in
knowledge test score percentage, confidence and attitude ratings,
the Model 1 section of Table 2. Next, the degree to which mixed re-
and spatial ability task performance
ality and plastic model test performance were independently related
Question set Mean (±SD) to spatial ability was assessed. The results showed that mixed reality
Knowledge test % performance was positively associated with spatial ability, whereas
Total 48.24 (±11.54) plastic model learning was not (Figure 5). Additionally, English lan-
Basal Ganglia 48.89 (±13.03) guage proficiency, experience with virtual reality, and HoloLens

Limbic system 47.59 (±17.12) travel distance were not significantly related to spatial ability. The
regression estimates for each predictor can be seen in the Model 2
2Da 50.19 (±16.49)
section of Table 2. Overall, these results suggest that spatial ability
3Db 46.30 (±12.37)
played a bigger role in a mixed reality environment than a real physi-
Mixed reality 51.85 (±15.82)
cal environment.
Plastic model 44.63 (±13.65)
Confidence ratings
Mixed reality 5.96 (±1.25) Qualitative responses
Plastic model 5.42 (±1.33)
Attitudes For the question regarding what participants liked about the
Mixed reality helpful 5.48 (±0.70) HoloBrain learning method, the thematic analysis revealed three
Mixed reality engaging 5.56 (±0.80) main themes: (1) facilitation of learning objectives, (2) effectiveness
Plastic model helpful 4.85 (±0.99) of the technology, and (3) enjoyable user experience. The most com-
Plastic model engaging 4.74 (±1.10) mon theme was facilitation of learning objectives, which made up

Spatial ability
Mental rotations task 11.78 (±5.74)
N = 27 for all measures.
a
Two-­dimensional test items.
b
Three-­dimensional test items.
and plastic model test performance, t(26) = 2.03, P = 0.052, d = 0.39.
All of the participants performed at, or above, chance levels as can
be seen in Figure 4 (top left). Four participants in the mixed reality
condition, and five in the plastic model condition, achieved a chance-­
level score on their test (25%), which is akin to guessing. However,
this is not too surprising given participants only had 20 minutes to
learn the material, and some low scores would be expected. Despite
observing a non-­significant difference in test performance, partici-
pants were more confident when answering mixed reality-­learned
questions than plastic model questions, t(26) = 2.92, P = 0.007,
d = 0.56 (Figure 4, top right). Descriptive statistics for mixed reality
and plastic model conditions can be seen in Table 1.
In terms of attitudes and perceptions, participants found the
HoloLens to be a more engaging and helpful method of learning.
Participants found mixed reality to be significantly more engaging
than the plastic model, t(26) = 3.05, P = 0.005, d = 0.59 (Figure 4,
bottom left), and significantly more helpful, t(26) = 2.51, P = 0.019, d
= 0.48 (Figure 4, bottom right). Descriptive statistics for each of the
above attitude ratings can be seen in the attitudes section of Table 1.
50% of the coded responses. This theme was primarily composed of
response codes related to ease of manipulation of individual brain
regions, which promoted easier memorization of the areas:
I enjoyed being able to make certain areas of the brain
disappear or reappear, in order to form an accurate
visual picture of where these areas are and how they
fit into the grander scheme of brain anatomy.
The next most common theme was effectiveness of the technol-
ogy (making up 30% of coded responses), where participants com-
plimented the novelty and ease of use of the HoloBrain application.
Finally, the theme of enjoyable user experience made up 20% of codes,
where participants reported the HoloBrain as an interactive and en-
gaging learning method. In general, these findings are in line with the
quantitative results reported previously, where participants found the
mixed reality method to be significantly more engaging and helpful
than the plastic model.
With regard to disliked aspects of the HoloBrain application,
three main themes emerged in the thematic analysis: (1) technologi-
cal bugs, (2) not user-­friendly, and (3) physical discomfort. The most
common theme was technological bugs, which made up 45% of the
response codes. Participants reported many visual glitches in the
software and inaccuracies in hand gesture input, which disrupted
their learning experience:

The image can be unstable, especially at close range

Spatial ability
The relationship between spatial ability and learning performance
was then tested, and it was found that spatial ability was positively as-
sociated with overall test performance, whereas English proficiency
to the brain. There were sometimes issues with the
menu buttons not working as expected.
Participants also reported aspects of HoloBrain as being not
user-­friendly (25% of response codes), due to the steep learning
 |

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HO et al. 1081

F I G U R E 4 Box plots and distributions of (A) knowledge test score; (B) confidence; (C) engagement, and (D) helpfulness ratings (N = 27).
Mixed reality learning showed higher mean values across all four measures; however, only confidence, engagement, and helpfulness were
statistically significant

curve of the application and the tedious/repetitive nature of menu

interactions. The hardware also caused physical discomfort (17.5%
of codes), citing the headset as being uncomfortable to wear and
inducing motion sickness and/or headaches. Two minor themes

TA B L E 2 Inferential statistics from regression models assessing

the impact of spatial ability on knowledge test performance (%)

Model β 95% CI t-­value P-­value

Model 1 (df = 24)

MRT 1.24 [0.57, 1.91] 3.83 0.0008a
English −2.53 [−9.33, 4.27] −0.77 0.450
Model 2 (df = 21)
Mixed reality 0.21 [0.08, 0.34] 3.39 0.003b F I G U R E 5 Spatial ability and knowledge test scores for each
Plastic model 0.08 [−0.08, 0.23] 1.02 0.318 learning modality (N = 27). Lines indicate the estimated regression
coefficient (β) and standard error of the mean. Spatial ability was
English 1.30 [−2.30, 4.89] 0.75 0.462
significantly related to knowledge test score, but only in the mixed
Experience 0.45 [−3.63, 4.53] 0.23 0.821 reality learning condition
Travel 0.01 [−0.04, 0.06] 0.23 0.822

Note: Mental rotation test was a significant predictor of total knowledge

test performance (Model 1). This was primarily driven by the mixed also emerged, with participants reporting that the application did
reality modality, which was the only significant predictor of MRT
not replicate reality in an engaging way (5% of codes), and in some
performance in Model 2.
cases compromised learning objectives (7.5% of codes). Generally,
Abbreviations: β, regression coefficient; CI, confidence interval; df,
degrees of freedom; MRT, mental rotations task. these disliked qualities can mostly be attributed to software and
a
P < 0.001 hardware limitations, rather than to the nature of mixed reality
b
P < 0.01. learning itself.
 |
1082
DISCUSSION
Overall, the study revealed three key findings: (1) there was no dif-
ference in knowledge test performance between the two learning
modalities, (2) mixed reality was found to be more helpful and en-
gaging than the plastic model, and (3) spatial ability facilitated per-
formance during mixed reality learning, but not during plastic model
learning.
In terms of differences in learning outcome between modalities,
the results showed that mean mixed reality performance was mar-
ginally better than the plastic model; however, this difference was
not statistically significant. Mixed reality learners tend to expect the
technology to aid their learning (Zafar & Zachar, 2020), and although
this benefit is often seen in the case of virtual reality (Hackett &
Proctor, 2016; Kyaw et al., 2019), the benefit in a mixed reality envi-
ronment is less clear. For example, studies have shown that mixed re-
ality confers no learning advantage over traditional methods, or even
other digital methods like tablets (Moro et al., 2017; Duncan-­Vaidya
& Stevenson, 2021). In some cases, traditional 2D cross-­sectional
learning has been shown to be more effective than mixed reality
methods (Henssen et al., 2020). There could be a couple of rea-
sons for similar performance between the two learning modalities.
First, learners have reported that mixed reality confers no additional
benefit over traditional methods when learning factual content, so
mixed reality benefits may depend on the type of material being
learned (Gnanasegaram et al., 2020). Second, stereopsis has been
shown to be critical for learning in both physical and mixed reality
environments (Hackett & Proctor, 2018; Wainman et al., 2018, 2020;
Anderson et al., 2019). The HoloLens used in the present study of-
fered stereoscopic mixed reality, meaning stereopsis was available in
both learning modalities. The availability of stereopsis across both
the mixed reality and plastic model modalities may have reduced the
magnitude of the potential difference between conditions, thus mak-
ing it more difficult to detect a statistically significant effect. Overall,
this first result is in line with much of the literature on mixed reality
benefits, or lack thereof, rendering mixed reality as a good supple-
mental method, but not currently a full replacement for traditional
learning (Henssen et al., 2020; Zafar & Zachar, 2020).
It is important to note that knowledge test performance is not
the only indicator of successful learning, however, as the study re-
sults also showed that mixed reality can lead to increased confidence
in answering test questions. This is currently an understudied area,
but studies have shown that general 3D visualization technologies
(e.g., monoscopic displays and augmented reality displays) can result
in increased learner confidence in anatomical education (Hackett &
Proctor, 2016). A systematic review has shown that mixed reality
specifically can lead to increased confidence of the learned material
(Akçayır & Akçayır, 2017). One study, using a HoloLens to teach den-
tistry, asked learners to rate whether the technology increased their
confidence in anatomy skills (Zafar & Zachar, 2020). Their results
showed that 39% of learners experienced increased confidence,
compared to 36.5% that did not. The benefit trends in favor of mixed
reality, but it is important to note that the study used a 5-­point Likert
19359780, 2022, 6, Downloaded from https://anatomypubs.onlinelibrary.wiley.com/doi/10.1002/ase.2146 by Air University, Wiley Online Library on [01/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HO et al.
scale, where 24.7% of learners responded with a neutral option. It
would be interesting to see which way the neutral responders would
lean under a forced-­choice paradigm. Overall, the finding that mixed
reality can increase learner confidence is in line with the current
literature on the topic, but this is an area that would benefit from
further research.
In terms of participant attitudes and perceptions, the study re-
sults showed that mixed reality learning was both more helpful and
more engaging than learning with the plastic model. Although a few
studies suggest that learners believe mixed reality offers little addi-
tional value over traditional methods (Zafar & Zachar, 2020), and that
its level of engagement is the same as other digital technologies like
tablets (Moro et al., 2017), the general consensus in the literature is
that mixed reality offers a richer and more engaging learning expe-
rience. For example, virtual learning methods have been shown to
be more helpful than traditional printed images (Hackett & Proctor,
2018), and almost half of learners believe mixed reality improved
their anatomical understanding (Zafar & Zachar, 2020). Mixed reality
has also been shown to be a more engaging way to learn compared to
traditional methods like lectures (Gnanasegaram et al., 2020; Zafar &
Zachar, 2020; Duncan-­Vaidya & Stevenson, 2021). Additionally, it can
also increase motivation (Akçayır & Akçayır, 2017) and imposes less
cognitive load while learning (Henssen et al., 2020). It has been sug-
gested that a large part of the reason for why virtual learning meth-
ods are more engaging is because of their novelty (Fairén González
et al., 2017; Marks et al., 2017). It is interesting to note, then, that
the present study was designed with a familiarization and practice
session during Day 1, which would have presumably reduced some
of the novelty of using the HoloLens. That an engagement effect was
still observed two days later suggests that the benefit of mixed real-
ity for learner engagement is a somewhat robust effect.
Finally, the results showed that increased spatial ability was as-
sociated with better overall knowledge test performance; however,
the effect was driven primarily by the mixed reality learning method.
In other words, spatial ability was associated with performance in
mixed reality, but not when learning using a physical model. This
finding represents a novel contribution to the literature, as very few
studies have been conducted on the impact of spatial ability across
different learning modalities. The overall spatial ability benefit is well
supported in the literature, where higher MRT scores are predictive
of improved anatomical learning performance (Garg et al., 2001,
Guillot et al., 2007; Khot et al., 2013; Lee & Wong, 2014). However,
there is little work examining how this effect might differ between
physical and mixed reality learning modalities. Learners subjectively
report that mixed reality is more effective than traditional methods
for teaching spatial information, implying a link between spatial abil-
ity and virtual learning environments (Gnanasegaram et al., 2020).
Additionally, one study found that spatial ability was unrelated to
performance in anatomy courses, which were taught using tradi-
tional methods such as physical models and images (Sweeney et al.,
2014). Together, these studies provide tentative support for the
finding that spatial ability is important for mixed reality learning, but
less so for physical model learning.

HO et al.
One possible reason for the disparity between modalities is that
when using a physical model, the ability to mentally rotate the ob-
ject is not required because the model can be rotated physically.
However, in mixed reality, object rotation can only happen through
interactions with the user interface, which potentially increases the
need to mentally rotate the object. Therefore, it is not necessarily
surprising that in a virtual mixed reality environment, individuals tend
to learn more if they have higher levels of spatial ability. This result
provides partial support for the ability-­as-­enhancer hypothesis (Huk,
2006; Lee et al., 2009) as spatial ability appeared to facilitate per-
formance; however, the distinction between the ability-­as-­enhancer
and ability-­as-­compensator hypotheses may be more nuanced as it
would seem to depend on whether physical object rotation is possi-
ble. Overall, although the main finding of the present study is novel,
future research should be conducted to confirm the result and pro-
vide further insight into why such a modality difference might exist.
Limitations and future directions
Although the results of the present study provide novel insight into
how spatial ability affects both virtual and physical learning, there are
some important limitations to note with regard to the findings. First,
the reliability of the knowledge test was slightly lower than what is
typically reported in the literature. The test reliability in the study was
within acceptable standards for a measurement instrument in science
education; however, it is more common to see larger reliability values
in the range of 0.7 to 0.8 (Taber, 2018). The primary driver behind
this disparity is likely the multidimensional nature of the knowledge
test. The test questions were designed to assess both 2D and 3D un-
derstanding; in multidimensional cases like this, Cronbach's alpha will
underestimate the true reliability value as the method makes some
assumptions about the item pool being unidimensional (Simms, 2008).
The limited sample size in the present study makes assessment of
multidimensionality difficult and moving forward it is recommended
to replicate the study using more participants so multidimensional re-
liability can be more accurately assessed. The larger data set could
also then be used to refine the knowledge test, resulting in an im-
proved measurement instrument that can be used in future studies.
Second, the present study focused on allocentric spatial ability;
however, this is only part of the picture when working in a virtual en-
vironment. When using virtual user interfaces, users are often inter-
acting with menu systems that exist in 3D space, which requires some
degree of egocentric spatial ability in order to know where those
items are in relation to their hand. Egocentric performance would be
interesting to incorporate; however, there are technical challenges
associated with its measurement, specifically in the recording of
hand locations relative to virtual menus. A few methods for mixed-­
reality hand tracking have been proposed in the literature, but they
require either a fixed recording location (Lee et al., 2017) or the use
of markers and additional cameras and sensors (Piekarski et al., 2004).
Furthermore, neither of these approaches address the central prob-
lem, which is the translation of virtual coordinates into a real-­world
|
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1083
coordinate system, or vice versa. The recommended approach for this
relies on the use of specialized 3D motion capture cameras, which is
beyond the scope and capabilities of the present study (Bajana et al.,
2016). As it stands, the relative importance of egocentric and allocen-
tric ability in virtual learning environments remains an open question
and is an interesting direction for future research.
Finally, there were a few differences between the HoloLens and
plastic model learning conditions that may have confounded the
results. As mentioned previously, some of these differences were
unavoidable due to the fact that learning in mixed reality is funda-
mentally different from learning with a physical model. For example,
information in mixed reality is typically accessed through a menu
system and requires navigation between different screens, which
limits how much information the user is exposed to at any one time.
Another difference was the color/saturation/contrast of the brain
regions. The HoloBrain application used higher contrast colors for
technology-­related reasons. Virtual objects presented in mixed re-
ality are semi-­transparent due to the display technology that is used,
which causes the objects to have a dynamic level of contrast with
the background. The unfortunate reality of working with mixed re-
ality is that the perceptual qualities of virtual objects are not con-
stant and cannot be strictly controlled due to a constantly changing
background behind the object (Lee et al., 2019). These differences
may have made the mixed reality condition easier and potentially
confounded the knowledge test finding. It is interesting to note,
however, that mixed reality knowledge test performance was not
significantly better than the plastic model, despite potentially hav-
ing these advantages. It is unlikely that this confound extended to
the correlational spatial ability findings, as those were not direct
comparisons of knowledge test performance, however, that remains
to be tested. To overcome these issues, it would be prudent to rep-
licate the main findings using identical models in both learning mo-
dalities, or by overlaying the virtual brain regions over the physical
model to further equalize the conditions (McJunkin et al., 2018).
CO N C LU S I O N S
Overall, the present study showed that although there was no test
performance difference between the two modalities, mixed real-
ity was seen as a more helpful and engaging way of learning neu-
roanatomy than traditional methods involving physical models.
Furthermore, spatial ability played a bigger role when learning in vir-
tual environments compared to physical environments. As immersive
virtual reality and mixed reality usage increases in science education,
it is becoming increasingly important to understand the role spatial
ability plays in that learning, as existing literature on spatial perfor-
mance might not necessarily generalize to these virtual environments.
AC K N OW L E D G E M E N T S
The authors wish to thank Young Ji Tuen for her work on the the-
matic analysis of the qualitative responses. The research project
was supported through Mitacs Accelerate Internships in partnership
 |
1084
with Microsoft Canada. Equipment (HoloLenses) was donated by
Microsoft; however, Microsoft was not involved in the study design,
data collection, or data analysis.
C O N FL I C T O F I N T E R E S T
The authors declare no financial or non-­financial competing interests.
E T H I C S S TAT E M E N T
Ethical approval was received through the University of British
Columbia's Behavioral Research Ethics Board (protocol #: H19-­
02328), written informed consent was obtained from each partici-
pant prior to the start of the study, and research was performed in
accordance with ethics board guidelines.
F U N D I N G I N FO R M AT I O N
This work was supported by MITACS, Inc., Vancouver, BC, Canada
Grant number: F18-­02840
ORCID
Simon Ho https://orcid.org/0000-0003-3080-8900
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