Impact Stories

What is “Behavioral Diabetes”?

Diabetes is a chronic disease that people live with every day. In its simplest terms, diabetes is a disease where the body cannot regulate the amount of glucose (sugar) in the blood leading to long-term health problems like heart disease, vision loss and kidney disease. It is a difficult and complicated disease for people and their providers to manage and can cause distress for both the patients and caregivers. Behavioral diabetes looks at the disease and the emotional toll it takes on patients through a psychosocial lens.

Southeastern Ohio is an underserved region with high rates of diabetes – double the national average – and we have established that people in southeastern Ohio with diabetes also have high rates of other conditions, such as depression or anxiety, which can negatively impact quality of life. My research at the Heritage College of Osteopathic Medicine focuses on developing new tools and strategies that help osteopathic physicians and other healthcare professionals provide the best possible care for people with diabetes, leading to better health outcomes and improved quality of life.

What discoveries have been made through research collaborations between Heritage College and OHIO Game Research and Immersive Design Lab?

The OHIO GRID Lab has been named the best Augmented/Virtual Reality (AR/VR) program in Ohio and is ranked 19th in the nation among public schools. In collaboration with the AR/VR experts at the GRID Lab, we have used cine-VR technology to create a fully immersive patient story experience for medical students and healthcare providers. This manner of storytelling is about the whole person and how they fit in with the greater world, their family, their community and medicine. Our research suggests that use of cine-VR in this way improves affective learning and creates emotional connections for the learner that elicit empathy. It is literally putting oneself in another’s shoes and helps address the stigma associated with diabetes, especially type 2 diabetes, as well as stigma associated with mental health.

Our research compared participants using cine-VR to experience a patient story with those watching the same story as a video. The cine-VR experience led to an increase in empathy among participants while the video did not. The ability to increase empathy through storytelling with cine-VR is a significant discovery that has the potential to change how we train and prepare physicians and other healthcare providers to care for patients with diabetes and other chronic conditions.

How will these findings impact medicine and patient care in the future?

The initial findings demonstrate use of cine-VR training can improve healthcare provider attitudes toward patients with diabetes, including their understanding of the emotional toll of the disease. The use of cine-VR has also been an effective tool for improving providers’ cultural awareness and their understanding of social determinants of health and how to address those challenges. This is especially important in a place like southeastern Ohio where the Regional Diabetes Needs Assessment Study suggests a conservative estimate is that 20% of the population has diabetes.

Other research conducted over a ten-year period has demonstrated increased provider empathy is associated with significantly decreased mortality for patients in their care. Identifying effective ways to increase and sustain provider empathy can ultimately lead to people living longer with improved quality of life. While our initial research indicates that delivering patient stories through cine-VR increases empathy, future research will focus on understanding if cine-VR creates a sustained increase in empathy. If providers trained with this tool have greater empathy for the patients in their care and if cine-VR’s effects on empathy are sustained over time, then cine-VR training may ultimately lead to lower mortality rates for patients of providers trained in this way.

During the COVID-19 pandemic, we partnered with OhioHealth to explore using cine-VR in ways that directly benefit healthcare providers themselves. Based on existing research that demonstrates spending time in nature can relieve stress, our team developed Tranquil VR which uses cine-VR to bring the experience of nature to healthcare providers in the hospital setting. Using cine-VR headsets, care providers were immersed in nature scenes during their shift. Initial findings indicate that providers who experienced Tranquil VR reported a decrease in their perceived stress levels. Additional research is needed to assess whether this perceived reduction in stress increases provider empathy and improves patient care.

How does conducting this research at a college of osteopathic medicine and the osteopathic profession’s focus on treating the whole person influence your work?

Behavioral diabetes, the consideration of a patient’s mental, emotional and social wellbeing in the context of a chronic disease, is aligned with osteopathic principles and practices. It is truly a whole person approach, as is cine-VR. Virtual reality tools provide a holistic approach to patient care that allows providers to see the patient in their full environment and all the barriers to care they experience. Fortunately, Ohio University has one of the best virtual reality programs in the country and it has been exciting to bring this to the world of healthcare and medical education.

How did the Osteopathic Heritage Foundation’s funding investment help you identify how this technology could impact patients and healthcare workers?

The Foundation’s funding is incredibly important in supporting proof of concept research. Most grant-funding agencies do not provide funding for concepts and only provide funding once the proof of concept is realized. The Osteopathic Heritage Foundation Ralph S. Licklider, D.O., Endowed Professor in Behavioral Diabetes award supported the initial research proving the effectiveness of cine-VR as an intervention to be used with healthcare providers and as a new mode of delivery for medical education. With this preliminary data, our team can seek additional funding from federal agencies that will support this research on a larger scale. The Foundation’s support, and the commitment of Heritage College leadership, has been key to advancing cine-VR research.

What is next for your research?

Based upon our initial experiences with diabetes and healthcare provider stress reduction interventions, we are exploring other conditions and models where cine-VR could be an effective tool. We are currently developing a cine-VR experience to help both medical students and faculty recognize and respond to the signs of hypoglycemia.  We are also collaborating with Case Western Reserve University and the University of Toledo, with funding from Ohio Medicaid, to develop new cine-VR simulations addressing unmet needs related to abuse of older adults with disabilities, maternal and infant health and intimate partner violence.

New Tranquil VR tools are being developed for healthcare providers within OhioHealth and for Appalachian behavioral healthcare providers. These new tools will be tested with more measures, including physiological ones, to better understand cine-VR’s impact on stress levels among healthcare providers. The endowment provides important funding to support these projects and allows our team to innovate and experiment with many ways to apply cine-VR to healthcare.

The next big step in our cine-VR research will focus on understanding its sustained effect on empathy among healthcare providers and students. Empathy is strongly correlated to improved patient outcomes and we have solid evidence that cine-VR influences empathy positively in the short-term. Cine-VR provides an opportunity for emotional engagement that is very different than reading a case study or watching a video. We need to see if the increase in empathy associated with cine-VR can be sustained over time.