VR offers a unique way to improve Black maternal health

With Black maternal mortality rates nearly three times that of white people, being pregnant and giving birth as a Black person in America is deadly. The Black birthing experience is fraught with disparities touching nearly every aspect of the prenatal and postpartum journey. In fact, research shows that race is the leading social determinant of health outside of income influencing maternal health outcomes.

From explicit factors like the higher rates of preeclampsia among Black birthing people to less visible ones like implicit bias among clinicians, Black people experience numerous hurdles to positive maternal healthcare experiences and outcomes.

In the Midwest, a new effort is underway to enhance Black maternal healthcare. A team of researchers and physicians from the University of Illinois Urbana-Champaign, Carle Foundation Hospital and Creighton University School of Medicine is developing a curriculum based on virtual reality (VR) to educate physicians on implicit bias, teach cultural competency skills and improve physician-patient communication.

By immersing the training within a VR landscape, the team behind the curriculum aims to create a realistic but safe space for physicians to learn, said Charee Thompson, Ph.D., an associate professor and a Norman P. Jones Professorial Scholar in the department of communication at the University of Illinois at Urbana-Champaign, in an interview.

VR is already being employed in various aspects of healthcare, including medical education. Thompson and her team's new curriculum adds another dimension to the medical education currently offered via VR and provides a low-cost, low-risk setting for physicians to confront their implicit biases.

What is implicit bias and how does it affect maternal healthcare?

Simply put, implicit biases are unconscious prejudices. While they can be positive, they are generally negative beliefs about people based on their race that can affect behaviors and lead to discrimination, explained Thompson, who is also an associate professor in the biomedical and translational sciences department at Carle Illinois College of Medicine.

"Because they're implicit, they can have a really pernicious effect," she said. "If I don't know that I have these biases and the way that they operate is often kind of subtle, then how does anyone really change it?"

There are various ways in which physicians' implicit biases can affect maternal healthcare.

For one, implicit bias leads to unequal maternal care and treatment. Thompson explained that when physicians subconsciously perceive patients of color as less cooperative or difficult or as being more prone to misuse pain medication, they might not take the patients' symptoms seriously and dismiss their concerns around pain.

Thus, implicit bias leads to a lower quality of maternal care for people of color.

"Studies show that Black women and women of color are less likely to receive medication and [more likely to receive] less potent pain medication for the same issues as male counterparts," Thompson said. "They experience longer wait times -- so, unequal treatment, lower quality of care, higher maternal mortality rates."

Further, as a result of past and ongoing experiences with implicit bias, women of color are less likely to trust healthcare providers and the healthcare system.

"We know of racism in medicine like Tuskegee and the syphilis experiments, which were very recent in all reality," Thompson said. "So, when people [of color] or Black women mistrust the healthcare system, they're less likely to go [to the doctor], so their healthcare is delayed, they avoid medical settings, and this leads to poor health outcomes as well."

Finally, implicit bias manifests in interactions, which can have emotional and psychological effects on people of color. Thompson noted that this makes seeking healthcare more stressful and contributes to anxiety, which can worsen maternal mental health and fetal health.

Designing VR modules to curb implicit bias

Because they're implicit, they can have a really pernicious effect. If I don't know that I have these biases and the way that they operate is often kind of subtle, then how does anyone really change it?

The new VR-based curriculum aims to curb the above adverse effects of implicit bias, thereby enhancing maternal healthcare for Black birthing people.

Thompson said that the curriculum comprises three modules. The first module is designed to help physicians learn about implicit bias and observe how it negatively affects maternal care visits. During the module, physicians watch an interaction between a physician and a pregnant Black woman through a VR headset, which offers a 360-degree, photorealistic view of the interaction.

Professional actors play the roles of a white, older male physician and a younger Black mother. Their interaction is peppered with popups noting microaggressions, such as the physicians leaning on negative stereotypes about Black people or engaging in unwanted touch, Thompson described.

The second module asks physicians to turn inward, offering exercises to help them recognize their internal biases. It also provides training on mindfulness and shared decision-making strategies to overcome implicit bias.

"I hope to bridge the chasm between patients and physicians, and I truly believe that physicians want to provide the best care," Thompson said. "And so, I think if I can say, 'Physicians, watch this interaction and see what it does,' and then say, 'Now let's talk through your bias,' rather than coming straight at them and saying, 'Let's address your bias; you have it.'"

Approaching diversity, equity and inclusion (DEI) training in this way is critical because people tend to get defensive if they are told that they are being prejudiced toward a group of people, even unintentionally, she added.

The third module focuses on practicing cultural competency skills. In this module, the physician interacts with the "patient" in the VR environment, Thompson explained. The actor portraying the patient has recorded several responses to questions typically asked during a maternal care visit, and natural language processing (NLP) software simulates the interaction with the physician in real time.

For instance, if the physician asks a question that mentions the word home, the NLP is trained to deliver one of five prerecorded responses.

At the end of the simulated visit, there are short tests. In one, the physician is prompted to ask the patient about their mental health, and the patient answers that they are not doing well.

"That is the learner's cue to then ask a follow-up [question]," Thompson said. "They're not told to ask a follow-up, but part of the test and also the practice is to ask. And if they don't ask that, then [the 'patient'] will bring it up again, and it's their cue."

The research team has conducted a pilot test of the first module, the only one of the three modules with a functional beta version. The team has applied for funding to develop the other two modules.

The researchers recruited 30 medical students and residents who completed a pretraining survey, the VR-based training and a post-training survey. They examined the participants' implicit biases and their willingness to engage in education to eliminate their biases before and after the training.

"What we found is that following the training, participants reported improved attitudes toward implicit bias instruction," Thompson said.

Additionally, the participants' feedback was positive regarding the experience and how immersive it felt. According to Thompson, participants even noted that they've seen instances of implicit bias in their everyday training.

The feedback points to a vital aspect of using VR to provide cultural competency training -- the ability to elicit empathy and emotional responses that drive the lessons home.

"Because when you feel like you're in that patient room [in the first module], right next to the patient watching this interaction, and it's going terribly, you feel a little helpless, I think, in a way to intervene," Thompson said. "And you want to tell the doctor, 'What are you doing?' But it feels real."

Challenges to VR design and use in medical training

Though VR offers unique benefits in bolstering cultural competency, Thompson noted several hurdles in the design and use of the curriculum.

Thompson said that one hurdle was bringing experts from various fields together to design the curriculum in a VR environment. The design and development process requires collaboration between clinicians, communications experts and VR engineers who often don't speak the same language.

"Interdisciplinary work is nonnegotiable for me," she said. "But at the same time, you have to think about -- how do I get folks with an engineering background who speak a fundamentally different language to talk to communications folks who have spent most of their careers teaching other people how to communicate and know nothing about engineering? And how do you get them to talk to each other and meet somewhere in the middle and then design something that has pieces of both of them?"

Another challenge Thompson highlighted was ensuring that the characters created for the VR curriculum did not unknowingly reinforce stereotypes and that the patient-provider interactions within the VR environment resonated with the physicians taking the training. Having a multidisciplinary team that viewed the curriculum from different perspectives was vital in avoiding stereotypes and creating an accurate representation of the physician-patient relationship.

Then, there are challenges related to VR use among physicians undergoing the training, particularly regarding the comfort of using VR.

According to Thompson, there might be a generational or cultural lack of comfort with VR use in some cases, with more traditional physicians resisting training through this new technology. There might also be physical discomfort related to VR use among some physicians with medical conditions themselves, like vertigo.

However, working through these challenges is essential to reaping the benefits of culturally compassionate care, which are sorely needed in maternal healthcare.

"This whole curriculum, the three-part curriculum, is about not only mitigating bias but also simultaneously enhancing culturally competent care because they really go together, and you can't really provide good care without both," Thompson said.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.