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Abstract

Background:

Diabetes care for older adults is complex and must consider geriatric syndromes, disability, and elder abuse and neglect. Health care providers would benefit from professional training programs that emphasize these risks. One new educational approach is cinematic virtual reality (cine-VR). We conducted a pilot study to evaluate a cine-VR training program based on an older patient with type 2 diabetes and multiple geriatric syndromes who is at risk for elder abuse and neglect.

Methods:

We employed a single-arm, pre-post-test study to assess changes in attitudes to disability and self-efficacy in identifying and managing elder abuse and neglect.

Results:

Thirty health care providers completed the pilot study (83.3% women, 86.7% white, 56.7% physicians, 43.4% practiced in outpatient clinics). We observed change in attitudes toward discrimination (Z = −2.628, P = .009, Cohen’s d = .62). In addition, we observed changes in six of the eight self-efficacy items, including how participants would ask questions about abuse (Z = −3.221, P = .001, Cohen’s d = .59) and helping an older patient make a report to the police or social services (Z = −2.087, P = .037, Cohen’s d = .52). In addition, we observed positive changes in understanding the documentation needed to complete whether a patient reports abuse (Z = −3.598, P < .001) as well as the legal knowledge for how to report elder abuse and neglect (Z = −2.556, P = .011).

Conclusion:

Findings from this pilot study suggest that cine-VR training may increase health care providers’ awareness of discrimination and improve self-efficacy toward identifying and managing elder abuse and neglect. Research with a proper control condition is needed to confirm its effectiveness.

Keywords

virtual reality type 2 diabetes aging elder abuse disability

Diabetes care for older adults necessitates special attention to the clinical and functional heterogeneity of this population. Approximately 88% of people with diabetes have one chronic condition, and 51% have three or more.¹ Among older adults with type 2 diabetes, the median number of comorbid conditions is five.² Furthermore, older adults with diabetes are at increased risk for numerous geriatric syndromes, including cognitive impairment, hearing loss, visual impairment, depression, polypharmacy, urinary incontinence, disability, injurious falls, and fractures.³ Both geriatric syndromes and other comorbid conditions negatively impact older adults’ diabetes self-care behaviors^4
-6 and quality of life^7,8 by posing competing demands that require substantial time, effort, and money to manage effectively.^9,10

In addition, physical and psychosocial changes associated with aging negatively impact diabetes self-care.¹¹ Physical decreases in muscle mass, bone strength, joint flexibility, aerobic capacity, and visual and auditory acuity contribute to physical, functional, and cognitive decline.¹¹ These declines can lead to disability,¹² impairment of activities of daily living,¹³ and lower quality of life,¹⁴ which in turn may contribute to fewer self-care behaviors.¹⁵ Psychosocial changes, such as loss of family members and friends, fears about mortality, loneliness, isolation, and retirement also negatively impact diabetes self-care. These psychosocial changes contribute to increased rates of depression and diabetes distress, which may also interfere with following a healthy diet, physical activity, and medication-taking.^16,17 Last, older adults with disabilities, including type 2 diabetes, are at increased risk for elder abuse and neglect.^18
-20 Unfortunately, elder abuse and neglect are underrecognized and underreported, especially when an older individual has an impaired ability to communicate or is dependent on the abuser for their care.²¹ For these reasons, health care provider education that emphasizes the unique needs of older adults with diabetes is critical to improving quality of care.

A unique educational approach with the ability to capture the clinical and functional complexities of older adults with diabetes is cine-VR.

Cinematic virtual reality combines 360-video with the techniques of cinema to create engaging and educational content using narrative storytelling in a virtual environment. Research has shown that immersive technologies, like cine-VR, enhance educational experiences by allowing multiple perspectives, situated learning, and improved knowledge transfer to real-world settings.^22,23 We created a cine-VR training program based on an older patient with type 2 diabetes and multiple geriatric syndromes who is at risk for elder abuse and neglect. The cine-VR simulation follows this patient, John Chen, an 80-year-old man with a history of type 2 diabetes, a mobility disability, hearing loss, urinary incontinence, and potential dementia. Over the course of six episodes, participants learn about Mr Chen’s health, view interactions with his family and health care providers, and figure out why he is having so many accidents. The objectives of this cine-VR training program were as follows: (1) Discuss disability and elder abuse and neglect, (2) Identify risk factors for elder abuse and neglect, (3) Explain the association between disability and elder abuse and neglect, and (4) List approaches to intervene in cases of suspected elder abuse and neglect. We conducted a pilot study with health care providers to evaluate attitudes toward disability and self-efficacy to identify and manage elder abuse and neglect. We also included a brief evaluation of the cine-VR training program.

Methods

Research Design

We employed a single-arm, pre-post-test study to assess health care providers’ attitudes to disability, self-efficacy to identify and manage elder abuse and neglect, and cine-VR evaluation questions. We utilized a pilot study design to evaluate the feasibility of our methods and procedures to determine whether our methods and procedures are appropriate for a large-scale randomized controlled trial. Pilot studies play a critical role in improving the conduct and quality of randomized controlled trials by evaluating preliminary outcomes, identifying areas for improvement, and addressing uncertainties in the methodology.²⁴

Ethics Approval

Ethics approval for the study was obtained from the Ohio University Office of Research Compliance Institutional Review Board (approval number: #22-X-153). In complying with federal, state, and local laws and regulations for human subjects, we ensured our research met the requirements set forth in the regulations on public welfare in Part 46 of Title 45 of the Code of Federal Regulations (45 CFR 46); the principles set forth in “The Belmont Report,” and the Helsinki Declaration of 1975. All participants provided informed consent to participate in the study.

Cinematic Virtual Reality Content

John Chen is an 80-year-old man with a 14-year history of type 2 diabetes and comorbid hypertension. He is 5’8” 152 pounds, with a body mass index of 23.1 kg/m². His current hemoglobin A1c level is 9.7%. He has been prescribed metformin and glyburide to manage his diabetes and lisinopril to manage his hypertension. He also has osteoarthritis, decreased renal function (estimated glomerular filtration rate (eGFR) = 58 mL/min/1.73 m²), and elevated triglycerides due to his glucose levels (299 mg/dL). He has not been advised on glucose monitoring or specifics of self-care management. He is enrolled in both Medicare and Medicaid.

Mr Chen recently moved in with his son’s family. According to his family, he needs assistance with bathing but can dress himself and uses the bathroom on his own. He moves around on his own, but his ambulation is unsteady and his family reports that he falls often. He does not drive himself or do any shopping or cooking. The episodes capture three separate patient-provider interactions, including visits with a primary care physician, urgent care physician, and emergency department physician. Participants were asked to observe subtle details across the six episodes that explain why Mr Chen is experiencing so many accidents and health emergencies.

Cinematic Virtual Reality Technology

Participants viewed the cine-VR simulations using Pico G2 4K head-mounted displays. These head-mounted displays allowed participants to turn their head and body in any direction so that they could choose which details to pay attention to, thereby facilitating an active learning experience. We synchronized all cine-VR episodes from a central computer using VR Sync software (Utrecht, Netherlands) so that all participants were viewing the same content at the exact same time.

Cinematic Virtual Reality Curriculum

We developed a curriculum taught synchronously with the cine-VR simulations. The curriculum included six brief debriefs that addressed the following content: (1) Diabetes, Disability, and Older Adults; (2) Bias toward Disability; (3) Association between Disability and Elder Abuse and Neglect; (4) Recognizing Elder Abuse and Neglect; (5) Identifying Risk Factors for Elder Abuse and Neglect; and (6) Reporting Abuse. An experienced behavioral diabetes researcher (EAB) delivered both trainings. The simulations and curriculum were designed to reduce bias toward disability and increase recognition of the signs and symptoms of elder abuse and neglect. We ensured integrity of the training program via a written curriculum, preapproved materials, and team member observation of the trainings.

Power Analysis

For the purposes of this pilot study, we did not conduct an a priori power analysis. We followed the recommendation given by Lancaster et al,²⁵ for an overall sample size of 30 participants.

Recruitment

Health care providers were recruited from two regional continuing medical education/continuing education conferences in 2022 that included screenings of the cine-VR training program as a session. Eligibility criteria for participating in the pilot study included English speaking and reading adults aged 18 years and older who were health care providers (eg, physicians, nurse practitioners, nurses, physician assistants, exercise physiologists, physical therapists, dietitians, pharmacists, certified diabetes educators, psychologists, and social workers) with an active licensure in Ohio. There were no other exclusion criteria.

Measures

In addition to sociodemographic factors (age, gender, race, ethnicity, type of provider, years in practice, health care sector, serving Medicaid patients), participants completed the following measures:

Attitudes to Disability Scale²⁶ is a 16-item scale that assesses personal attitudes toward disability and people with disability. The items are answered on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scale includes four domains: Inclusion (Cronbach’s α = 0.76), Discrimination (Cronbach’s α = 0.74), Gains (Cronbach’s α = 0.75), and Prospects (Cronbach’s α = 0.72).

Responding to Elder Abuse in GERiAtric care—Provider²⁷ is a 25-item scale that measures health care providers’ self-efficacy to identify and manage elder abuse and neglect. The scale demonstrates good internal consistency for asking questions about elder abuse and neglect (Cronbach’s α = 0.75) and for managing elder abuse and neglect (Cronbach’s α = 0.87).

Cinematic Virtual Reality Evaluation Questions: a four-item assessment created for the purposes of this pilot study. The items assessed the participants’ perceptions of the content learned and the quality of the training.

Data Collection

All measures were completed online using the electronic questionnaire service Qualtrics (Provo, UT: Qualtrics). To access the measures, participants scanned a QR code from a PowerPoint slide that directed them to the Qualtrics site. The Web site included a description of the study, the online informed consent form, and pre-assessment measures. All participants provided online informed consent prior to completing the measures. At the end of the cine-VR training, participants scanned a different QR code that directed them to the postassessment measures. Data were collected anonymously. To link attendees’ pre-assessment and postassessment responses, we included three questions at the beginning of the assessment which served as a unique identifier (ie, model of first car, high school mascot, and the number day of the month they were born). Total time to complete the pre- and postmeasures took approximately 15 to 20 minutes. For human subject compensation, participants received a US$25.00 gift card. To maintain anonymity, participants clicked on a new Qualtrics link that was not connected to their pre- or postmeasures.

Statistical Analysis

We assessed demographic factors using descriptive statistics and presented them as means and standard deviations or sample size and percentages. Next, we calculated frequencies for each measure, means for the Attitudes to Disability Scale domains, and medians for the evaluation questions. To assess changes in measures pre- and post–cine-VR training, we conducted Wilcoxon signed rank tests. In addition, we determined effect sizes using Cohen’s d by calculating the mean difference between the pre-assessment and postassessment responses divided by the pooled standard deviation. We defined statistical significance as a P value less than .05 and conducted analyses in SPSS statistical software version 28.0 (Chicago, IL: SPSS Inc.).

Results

Thirty health care providers consented to participate in the pilot study and completed all pre- and postassessments. In the sample, 83.3% (n = 25; see Table 1) of participants self-identified as women and 16.7% (n = 5) self-identified as men. The participants self-identified their race as follows: 6.7% (n = 2) Asian or Pacific Islander, 3.3% (n = 1) black or African American, 3.3% (n = 1) Middle Eastern, and 86.7% (n = 26) white; 3.3% (n = 1) of participants self-identified as Hispanic/Latino. The majority of participants, 56.7% (n = 17), identified as physicians, with 3.3% (n = 1) identifying as an allied health professional, 23.3% (n = 7) as behavioral health professionals, and 16.7% (n = 5) as other health care providers. Among these participants, 53.3% (n = 16) reported six or more years of clinical experienced, and 43.4% (n = 13) practiced in outpatient clinics. Last, 86.7% (n = 26) provided care to Medicaid patients; Medicaid is a public health insurance program for people with limited income in the United States.

Table 1.

Provider Demographic Characteristics (n = 30).

Variable	n (%)
Gender
Woman	25 (83.3)
Man	5 (16.7)
Nonbinary	0 (0)
Other	0 (0)
Race
American Indian or Alaska Native	0 (0)
Asian or Pacific Islander	2 (6.7)
Black or African American	1 (3.3)
Middle Eastern	1 (3.3)
Mixed Race	0 (0)
White	26 (86.7)
Other	0 (0)
Ethnicity	0 (0)
Hispanic/Latino	1 (3.3)
Provider type
Advanced practice provider	0 (0)
Allied health professional	1 (3.3)
Behavioral health professional	7 (23.3)
Dental provider	0 (0)
Nurse	0 (0)
Physician	17 (56.7)
Other	5 (16.7)
Years in health care
Less than 1 year	7 (23.3)
1-5 years	7 (23.3)
6-10 years	4 (13.3)
11-20 years	3 (10.0)
21-30 years	5 (16.7)
31 years or more	4 (13.3)
Health care sector (Selected all that apply)
Academic	3 (10.0)
Behavioral health	2 (6.7)
Community-based setting	7 (23.3)
Health department	2 (6.7)
Home health	2 (6.7)
Inpatient/Hospital setting	5 (16.7)
Outpatient clinic	13 (43.3)
School or early intervention setting	1 (3.3)
Skilled nursing facility	2 (6.7)
Other	1 (3.3)
Clinical practice works directly with Medicaid patients
Yes	26 (86.7)
No	4 (13.3)

Attitudes to Disability Scale

Post–cine-VR training, we observed changes in one of the four Attitudes to Disability Subscales: Discrimination Domain (Z = −2.628, P = .009, see Table 2). This change had a Cohen’s d of .62, indicating a medium effect. This finding may suggest that the cine-VR training increased participants’ awareness of discrimination toward people with disability. Single item changes in the scale included a change in participants’ attitudes toward people with a disability making friends (Z = −2.517, P = .012), such that fewer participants “Agreed” and “Strongly Agreed” that “people with a disability found it harder than others to make a new friend.” Also, participants’ attitudes toward people with a disability “being a burden to society” changed post-training (Z = −2.138, P = .033), with more participants “Disagreeing” than “Strongly Disagreeing” after the cine-VR simulation. Additional follow-up research is needed to understand why more participants selected “Disagree” rather than “Strongly Disagree” post–cine-VR training.

Table 2.

Participants’ Attitudes Toward Disability Scale Mean Scores Before and After the Cinematic Virtual Reality Training Program (n = 30).

Questions	Pre-VRn (%)					Post-VRn (%)					Z	P
Questions	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Z	P
Inclusion domain
People with a disability find it harder than others to make new friends.	0 (0)	0 (0)	3 (10.0)	23 (76.7)	4 (13.3)	0 (0)	3 (10.0)	5 (16.7)	21 (70.0)	1 (3.3)	−2.517	.012
People with a disability have problems getting involved in society.	1 (3.3)	2 (6.7)	6 (20.0)	18 (60.0)	3 (10.0)	1 (3.3)	2 (6.7)	7 (23.3)	18 (60.0)	2 (6.7)	−.218	.828
People with a disability are a burden on society.	23 (76.7)	5 (16.7)	1 (3.3)	1 (3.3)	0 (0)	15 (50.0)	13 (43.3)	1 (3.3)	1 (3.3)	0 (0)	−2.138	.033
People with a disability are a burden on their family.	6 (20.0)	11 (36.7)	9 (30.0)	4 (13.3)	0 (0)	4 (13.3)	13 (43.3)	10 (33.3)	3 (10.0)	0 (0)	−.215	.830
	Mean ± SD					Mean ± SD
	2.9 ± .53					2.8 ± .54					−.312	.755
Discrimination domain
People often make fun of disabilities.	0 (0)	7 (23.3)	2 (6.7)	19 (63.3)	2 (6.7)	1 (3.3)	1 (3.3)	6 (20.0)	21 (70.0)	1 (3.3)	−1.069	.285
People tend to become impatient with those with a disability.	0 (0)	2 (6.7)	3 (10.0)	23 (76.7)	2 (6.7)	1 (3.3)	1 (3.3)	0 (0)	24 (80.0)	4 (13.3)	−.825	.409
People tend to treat those with a disability as if they have no feelings.	2 (6.7)	8 (26.7)	10 (33.3)	10 (33.3)	0 (0)	0 (0)	4 (13.3)	7 (23.3)	19 (63.3)	0 (0)	−2.751	.006
People with a disability are easier to take advantage of (exploit or treat badly) compared with other people.	1 (3.3)	1 (3.3)	4 (13.3)	22 (73.3)	2 (6.7)	0 (0)	1 (3.3)	4 (13.3)	19 (63.3)	6 (20.0)	−1.604	.109
	Mean ± SD					Mean ± SD
	3.5 ± .51					3.8 ± .46					−2.628	.009
Gains domain
Having a disability can make someone a stronger person.	1 (3.3)	1 (3.3)	7 (23.3)	18 (60.0)	3 (10.0)	0 (0)	4 (13.3)	8 (26.7)	16 (53.3)	2 (6.7)	−1.072	.284
Having a disability can make someone a wiser person.	1 (3.3)	2 (6.7)	14 (46.7)	11 (36.7)	2 (6.7)	0 (0)	4 (13.3)	16 (53.3)	10 (33.3)	0 (0)	−1.221	.222
Some people achieve more because of their disability (eg, they are more successful).	0 (0)	2 (6.7)	20 (66.7)	7 (23.3)	1 (3.3)	0 (0)	2 (6.7)	17 (56.7)	10 (33.3)	1 (3.3)	−.905	.366
People with a disability are more determined than others to reach their goals.	1 (3.3)	4 (13.3)	17 (56.7)	8 (26.7)	0 (0)	0 (0)	4 (13.3)	20 (66.7)	5 (16.7)	1 (3.3)	−.277	.782
	Mean ± SD					Mean ± SD
	3.3 ± .58					3.3 ± .66					−.206	.837
Prospects domain
Sex should not be discussed with people with disabilities.	12 (40.0)	15 (50.0)	2 (6.7)	1 (3.3)	0 (0)	12 (40.0)	15 (50.0)	1 (3.3)	1 (3.3)	0 (0)	.000	1.0
People should not expect too much from those with a disability.	7 (23.3)	18 (60.0)	3 (10.0)	2 (6.7)	0 (0)	7 (3.3)	19 (63.3)	4 (13.3)	0 (0)	0 (0)	−.749	.454
People with a disability should not be optimistic (hopeful) about their future	6 (20.0)	11 (36.7)	9 (30.0)	4 (13.3)	0 (0)	15 (50.0)	13 (43.3)	2 (6.7)	0 (0)	0 (0)	−1.941	.052
People with a disability have less to look forward to than others.	9 (30.0)	13 (43.3)	5 (16.7)	3 (10.0)	0 (0)	9 (30.0)	13 (43.3)	8 (26.7)	0 (0)	0 (0)	−.714	.475
	Mean ± SD					Mean ± SD
	1.85 ± .549					1.8 ± .46					−.041	.967

Abbreviations: VR, virtual reality; SD, standard deviation.

Responding to Elder Abuse in GERiAtric Care—Provider

Post–cine-VR training, we observed changes in six of the eight items measuring participants’ self-efficacy in identifying and managing elder abuse and neglect (see Table 3). Participants’ self-efficacy increased in regard to how they would ask questions about abuse: to an older patient who has clear indications of being abused (Z = −3.221, P = .001, Cohen’s d = .59), to an older patient who has no clear indications of abuse (Z = −3.084, P = .002, Cohen’s d = .86), and to ensure questions were asked in private (Z = −3.312, P < .001, Cohen’s d = .88). In addition, participants demonstrated increases in self-efficacy for helping an older patient subjected to abuse make a report to the police or social services (Z = −2.087, P = .037, Cohen’s d = .52) and helping and supporting an older patient subjected to abuse who does not want to change their situation (Z = −2.337, P = .019, Cohen’s d = .50). Last, participants’ self-efficacy increased in their ability to manage an older patient who says no to questions about abuse when they still suspect that their patient is being abused (Z = −3.086, P = .002, Cohen’s d = .82).

Table 3.

Participants’ Responses Toward Elder Abuse and Neglect Questions Before and After the Cinematic Virtual Reality Training Program (n = 30).

Questions	Pre-VRn (%) or mean ± SD	Post-VRn (%) or mean ± SD	Z	P
Causes for concern: How concerned are you about the following things when it comes to asking older patients questions about abuse?
That the patient reacts negatively if I ask questions?			−.741	.458
Not at all concerned	10 (33.3)	11 (36.7)
A little concerned	15 (50.0)	17 (56.7)
Somewhat concerned	4 (13.3)	1 (3.3)
Very concerned	1 (3.3)	1 (3.3)
That the patient-care provider relationship will be negatively impacted if I ask questions?			−1.231	.218
Not at all concerned	12 (40.0)	15 (50.0)
A little concerned	14 (46.7)	13 (43.3)
Somewhat concerned	3 (10.0)	2 (6.7)
Very concerned	1 (3.3)	0 (0)
That I will not be able to offer the patient a good follow-up?			−.923	.356
Not at all concerned	11 (36.7)	14 (46.7)
A little concerned	15 (50.0)	12 (40.0)
Somewhat concerned	1 (3.3)	3 (10.0)
Very concerned	3 (10.0)	1 (3.3)
Self-efficacy: At present, how would you manage to do the following things in your work?
Asking questions about abuse to an older patient who has clear indications of now being, or having previously been, subjected to abuse.	6.6 ± 1.8	7.6 ± 1.6	−3.221	.001
Asking questions about abuse to an older patient who has no clear indications of now being or having previously been, subjected to abuse.	5.4 ± 2.2	7.1 ± 1.7	−3.084	.002
Ensuring you are able to ask questions about abuse in private to an older patient who has a relative who insists on being present during all contact.	5.9 ± 2.2	7.6 ± 1.6	−3.312	<.001
In conversation, providing support to an older patient who tells about abuse.	7.6 ± 1.8	8.1 ± 1.6	−1.196	.232
Helping an older patient subjected to abuse on to the right body in health care, or to the right support function in society.	7.3 ± 2.3	8.2 ± 1.4	−1.914	.056
Helping an older patient subjected to abuse to make a report to the police or social services.	7.0 ± 2.4	8.1 ± 1.8	−2.087	.037
Helping and supporting an older patient subjected to abuse, who does not currently want to change his or her situation.	5.8 ± 2.2	6.8 ± 1.8	−2.337	.019
Handling the meeting with an older patient who says no to questions about abuse, but where you still have strong suspicions that the patient is subjected to abuse.	5.2 ± 2.4	6.9 ± 1.7	−3.086	.002
Questions about own previous experiences
How many times in the past six months has an older patient spontaneously told you about experiencing abuse, without you asking questions about it?		—	—	—
None	20 (66.7)
Once	7 (23.3)
2-4 times	3 (10.0)
5 times or more	0 (0)
Do not remember	0 (0)
How many times have you asked older patients questions about abuse in the past six months?		—	—	—
None	15 (50.0)
Once	0 (0)
2-4 times	8 (26.7)
5 times or more	7 (23.3)
Do not remember	0 (0)
How many times did the questions lead to an older patient telling about abuse that he or she experienced?			—	—
None	21 (70.0)
Once	5 (16.7)
2-4 times	3 (10.0)
5 times or more	1 (3.3)
Do not remember	0 (0)
Questions about organizational conditions and potential improvement
In your current work situation, how often do you have time to bring up the issue of abuse of older people with your patients if you would like to?			—	—
Never	2 (6.7)	—
Rarely	18 (60.0)
Often	6 (20.0)
Always	4 (13.3)
If you would like help to handle the situation when an older patient tells you about abuse, do you know who at your workplace you could turn to?			.000	1.0
Yes	29 (96.7)	29 (96.7)
No	1 (3.3)	1 (3.3)
How do you think the preparedness at your workplace is for taking care of older patients subjected to abuse?			−.577	.564
Very good	7 (23.3)	8 (26.7)
Fairly good	15 (50.0)	12 (40.0)
Somewhat inadequate	4 (13.3)	5 (16.7)
Very inadequate	2 (6.7)	2 (6.7)
Don’t know what preparedness there is	2 (6.7)	3 (10.0)
Do you know what you should do to document what patients tell you about abuse in a correct and secure way in the medical record?			−3.598	<.001
Absolutely	5 (16.7)	6 (20.0)
To a large extent	3 (10.0)	16 (53.3)
To some extent	15 (50.0)	7 (23.3)
Not really	7 (23.3)	1 (3.3)
Do you think you have enough legal knowledge, for example about when and to whom one can/must report if an older patient is mistreated and what secrecy rules apply?			−2.556	.011
Absolutely	5 (16.7)	4 (13.3)
To a large extent	7 (23.3)	17 (56.7)
To some extent	14 (46.7)	9 (30.0)
Not really	4 (13.3)	0 (0)
How much responsibility do you think a nurse has at your workplace for asking older patients questions about abuse?			−1.387	.166
A lot	10 (33.3)	16 (53.3)
Quite a lot	19 (63.3)	12 (40.0)
Fairly little	1 (3.3)	2 (6.7)
None	0 (0)	0 (0)
How much responsibility do you think an advance practice provider has at your workplace for asking older patients questions about abuse?			.000	1.0
A lot	10 (33.3)	11 (36.7)
Quite a lot	19 (63.3)	17 (56.7)
Fairly little	1 (3.3)	2 (6.7)
None	0 (0)	0 (0)
How much responsibility do you think an allied health professional has at your workplace for asking older patients questions about abuse?			−1.508	.132
A lot	8 (26.7)	12 (40.0)
Quite a lot	18 (60.0)	16 (53.3)
Fairly little	4 (13.3)	1 (3.3)
None	0 (0)	1 (3.3)
How much responsibility do you think a physician has at your workplace for asking older patients questions about abuse?			−.378	.705
A lot	20 (67.7)	22 (72.3)
Quite a lot	9 (30.0)	8 (26.7)
Fairly little	1 (3.3)	0 (0)
None	0 (0)	0 (0)
How much responsibility do you think a behavioral health provider has at your workplace for asking older patients questions about abuse?			−.277	.782
A lot	20 (66.7)	21 (70.0)
Quite a lot	9 (30.0)	8 (26.7)
Fairly little	1 (3.3)	1 (3.3)
None	0 (0)	0 (0)
How much responsibility do you think a dental provider has at your workplace for asking older patients questions about abuse?			−3.957	<.001
A lot	2 (6.7)	9 (30.0)
Quite a lot	6 (20.0)	14 (46.7)
Fairly little	20 (66.7)	6 (20.0)
None	2 (6.7)	1 (3.3)
Improvements: How much would the following measures make it easier for you in terms of handling the encounter with older persons subjected to abuse?
Appointment of a resource person with special responsibility for helping with managing such cases.			−.159	.873
A lot	19 (63.3)	19 (63.3)
Quite a lot	8 (26.7)	9 (30.0)
Fairly little	3 (10.0)	2 (6.7)
None	0 (0)	0 (0)
Training in how to ask questions about abuse.			−2.324	.020
A lot	12 (40.0)	21 (70.0)
Quite a lot	17 (56.7)	8 (26.7)
Fairly little	1 (3.3)	1 (3.3)
None	0 (0)	0 (0)
Training in what support services are available in society.			−1.134	.257
A lot	20 (66.7)	23 (76.7)
Quite a lot	10 (33.3)	7 (23.3)
Fairly little	0 (0)	0 (0)
None	0 (0)	0 (0)
Written guidelines for the staff that include contact information to the support services available.			−1.732	.083
A lot	18 (60.0)	23 (76.7)
Quite a lot	11 (36.7)	7 (23.3)
Fairly little	1 (3.3)	0 (0)
None	0 (0)	0 (0)
A written document directed at patients containing contact information to the support services available in society.			−2.066	.039
A lot	17 (56.7)	22 (73.3)
Quite a lot	9 (30.0	8 (26.7)
Fairly little	4 (13.3)	0 (0)
None	0 (0)	0 (0)

Abbreviations: VR, virtual reality; SD, standard deviation.

Another important change post–cine-VR training included participants’ understanding of what documentation to complete in the medical record if a patient tells them about abuse. Specifically, more participants changed their response from “To some extent” pretraining to “To a large extent” post-training (Z = −3.598, P < .001; see Table 3). Similarly, more participants indicated that they had enough legal knowledge for when and to whom they should report elder abuse and neglect; more participants also changed their response from “To some extent” pretraining to “To a large extent” post-training (Z = −2.556, P = .011). Participants also recognized that all providers had the responsibility to report elder abuse and neglect, including dental providers (Z = 3.957, P < .001). Last, participants noted that training in how to ask questions about abuse (Z = −2.324, P = .020) and written documents for patients with contact information for support services (Z = −2.066, P = .039) would be helpful resources.

Cinematic Virtual Reality Evaluation Questions

On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), the majority of participants responded 4 (agree) or 5 (strongly agree) to the four evaluation questions (see Table 4). First, 40.0% (n = 12) of participants “Agreed” and 56.7% (n = 17) “Strongly Agreed” that they would be comfortable interacting with a patient similar to the one in the cine-VR simulation. Second, 40.0% (n = 12) of participants “Agreed” and 60.0% (n = 18) “Strongly Agreed” that the cine-VR simulation experience equipped them with new knowledge and resources to apply in their clinical practice to improve the care experience and reduce health disparities for their patients. Third, 40.0% (n = 12) of participants “Agreed” and 60.0% (n = 18) “Strongly Agreed” that they would apply at least one new thing that they learned from this simulation experience in their clinical practice. Finally, 16.7% (n = 5) of participants “Agreed” and 83.3% (n = 25) “Strongly Agreed” that the cine-VR simulation met all of the learning objectives stated at the beginning of the training.

Table 4.

Participants’ Evaluation of the Cinematic Virtual Reality Training Program (n = 30).

	Neutraln (%)	Agreen (%)	Strongly Agreen (%)	Median
As a result of this simulation experience, I would be comfortable interacting with a patient/client similar to the one in the simulation scenario in my clinical or nonclinical role in the future.	1 (3.3)	12 (40.0)	17 (56.7)	5.0
This simulation experience equipped me with new knowledge and resources to apply in my clinical/nonclinical practice to improve the care experience and reduce health disparities for my patients/clients.	0 (0)	12 (40.0)	18 (60.0)	5.0
I will apply at least one new thing that I learned from this simulation experience in my clinical/nonclinical practice.	0 (0)	12 (40.0)	18 (60.0)	5.0
I feel that this simulation met all of the learning objectives listed above.	0 (0)	5 (16.7)	25 (83.3)	5.0

Discussion

In this pilot study, we assessed health care providers’ attitudes toward disability and self-efficacy in identifying and managing elder abuse and neglect. Post–cine-VR training, we observed a change in participants’ attitudes toward discrimination, such that participants were more likely to agree with statements that people with disabilities experience discrimination. This finding suggests that the cine-VR training program may increase health care providers’ awareness about discrimination toward people with disabilities; additional research with a proper control condition is needed to confirm this finding. Next, we observed positive increases in participants’ self-efficacy specific to asking older patients questions about abuse, helping older patients report abuse, and managing situations where an older patient denies abuse despite strong suspicions the patient is being subjected to it. In addition, we observed positive changes in participants understanding of the documentation they need to complete whether a patient reports abuse as well as the legal knowledge for how to report elder abuse and neglect. Participants also identified training in how to ask questions about abuse and written documents for patients with contact information for support services as beneficial. Finally, all participants evaluated the cine-VR training positively and indicated that it provided them with new knowledge and resources that they could use in their clinical practice.

As the US population ages, more Americans will be living with type 2 diabetes, geriatric syndromes, and disability. This also means more older adults will be at risk for elder abuse and neglect. The signs of abuse and neglect in older adults with disabilities may be intentionally hidden out of fear for escalating consequences.²⁰ Injuries to look for include lacerations, bruises, burns, head injuries, and fractures.^28,29 Signs and symptoms of neglect may manifest as malnutrition, infections, bed sores, social isolation, and depression.^28,29 Furthermore, older adults with type 2 diabetes and disabilities may not be able to independently access health care and social services.²⁰ They may miss appointments or receive no health care at all. Signs of abuse and neglect in patients with type 2 diabetes include a sudden elevation in A1C levels, not refilling diabetes medications, missed clinic appointments, and urinary tract infections. In our patient case, Mr Chen’s A1C was elevated (ie, 9.7%); he had not refilled his diabetes medications in a year; he missed several appointments with his primary care physician; and he developed a urinary tract infection due to severe dehydration. His dehydration was caused by family members withholding water to prevent his urinary incontinence.

Those in contact with older adults with disabilities—social services, pharmacists, clinic staff, nurses, primary care and emergency department physicians, diabetes care and education specialists, and home health providers—may be in a position to identify subtle signs of abuse and neglect. However, these opportunities may be missed if subtle signs go unrecognized or ignored. Missed opportunities lead to increased morbidity and mortality.^30,31 Identifying older adults with disabilities at risk for and with signs of abuse and neglect can prevent harm and save lives. Factors contributing to missed opportunities include lack of knowledge, lack of inter-professional communication skills, perceived lack of time, lack of empathy, insight, or resources.²⁹ Professional training programs that provide education on signs and symptoms of elder abuse and neglect as well as the management of suspected cases have the potential to detect elder abuse at an early stage.³² Our cine-VR training program adds to existing professional training programs by offering a glimpse into the life of an older adult with type 2 diabetes and multiple geriatric syndromes.

Finally, lessons learned from this pilot study include recommendations for group size, orientation to the technology, and use of directive probes throughout the virtual reality simulation. First, we recommend a group size of 15 to 30 participants. A smaller group builds a sense of intimacy that opens the door to meaningful and candid discussions about the cine-VR content. We believe if the group size exceeds 30 participants, fewer participants will engage in the conversation. The debrief is essential to identify key points, improve communication skills, and provide emotional support for triggering content. Second, we recommend that the presenter provides a brief overview of the technology prior to starting the training. While VR headsets have become more mainstream, not everyone is familiar with the technology. We have found participants appreciate a brief tutorial on the VR headset, its buttons, and adjustable straps. Last, the presenter should be familiar with the cine-VR content and know which episode reveals what clinical pearls. This is important to guide the conversation after each cine-VR episode so that pertinent content is discussed with every training.

Limitations

Limitations of this pilot study include the small, homogenous sample, selection bias, social desirability bias, lack of a control group, and no long-term follow-up. A final sample of 30 health care providers was small, and the majority were Caucasian (lacked diversity); however, it was sufficient for piloting the cine-VR training program to evaluate the feasibility of our methods and procedures. While we cannot generalize the findings from this pilot study to other health care providers, the findings suggest that the methods and procedures can be replicated in a large-scale randomized controlled trial. A future trial will require a more diverse sample of health care providers to reflect the current workforce from multiple geographic regions, which will help reduce selection bias. To address social desirability bias, we will include a brief social desirability scale in the assessment. Finally, while our pilot study did not include a long-term follow-up, the future randomized controlled trial should include long-term follow-up to determine whether any observed changes are sustained over time.

Conclusion

We created a cine-VR training program that captured the complexities of diabetes care in an older adult with multiple geriatric syndromes who was at risk for elder abuse and neglect. We conducted a pilot study to assess health care providers’ attitudes toward disability and increases in self-efficacy to identify and manage elder abuse and neglect before and after the cine-VR training program. Our findings suggest that the cine-VR training program may increase health care providers’ awareness of discrimination toward people with disabilities as well as improve providers’ ability to identify and manage elder abuse and neglect. Future research comparing the cine-VR training program to a proper control condition is necessary to determine the effectiveness of the training.

Footnotes

Abbreviations

Cine-VR, Cinematic virtual reality; dL, Deciliter; eGFR, estimated glomerular filtration rate; kg, kilogram, m, meter; mg, milligram; mL, milliliter; US, United States; VR, virtual reality.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was part of the Medicaid Care Experience Simulation (MCarES) Project funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in the cine-VR simulations and this manuscript are solely those of the creators and do not represent the views of the state of Ohio or federal Medicaid programs. The participant compensation was supported by the Osteopathic Heritage Foundation Ralph S. Licklider, D.O. Endowed Professorship in Behavioral Diabetes awarded to Elizabeth A. Beverly, PhD.

ORCID iDs

Elizabeth A. Beverly

Carrie Love

Matthew Love

John Bowditch

References

Lin

Kent

Winn

Cohen

Neumann

PJ.

Multiple chronic conditions in type 2 diabetes mellitus: prevalence and consequences. Am J Manag Care. 2015;21(1):e23-34.

Guerrero-Fernández

Alba

Orlando

Monetti

, et al. Comorbidity in an older population with type-2 diabetes mellitus: identification of the characteristics and healthcare utilization of high-cost patients. Front Pharmacol. 2020;11:586187. doi:10.3389/fphar.2020.586187.

Kotsani

Chatziadamidou

Economides

Benetos

Higher prevalence and earlier appearance of geriatric phenotypes in old adults with type 2 diabetes mellitus. Diabetes Res Clin Pract. 2018;135:206-217. doi:10.1016/j.diabres.2017.10.026.

Iovino

De Maria

Matarese

Vellone

Ausili

Riegel

Depression and self-care in older adults with multiple chronic conditions: a multivariate analysis. J Adv Nurs. 2020;76(7):1668-1678. doi:10.1111/jan.14385.

Gatlin

Insel

KC.

Severity of type 2 diabetes, cognitive function, and self-care. Biol Res Nurs. 2015;17(5):540-548. doi:10.1177/1099800414557565.

Aga

Dunbar

Kebede

Gary

RA.

The role of concordant and discordant comorbidities on performance of self-care behaviors in adults with type 2 diabetes: a systematic review. Diabetes Metab Syndr Obes. 2019;12:333-356.

O’Shea

Teeling

Bennett

. Comorbidity, health-related quality of life and self-care in type 2 diabetes: a cross-sectional study in an outpatient population. Ir J Med Sci. 2015;184(3):623-630. doi:10.1007/s11845-014-1190-4.

Pati

Akker

MVD

Schellevis

FFG

Jena

Burgers

JS.

Impact of comorbidity on health-related quality of life among type 2 diabetic patients in primary care. Prim Health Care Res Dev. 2020;21:e9. doi:10.1017/S1463423620000055.

Beverly

Wray

Chiu

Weinger

Perceived challenges and priorities in co-morbidity management of older patients with type 2 diabetes. Diabet Med. 2011;28(7):781-784. doi:10.1111/j.1464-5491.2011.03282.x.

10.

Tomic

Shaw

Magliano

DJ.

The burden and risks of emerging complications of diabetes mellitus. Nat Rev Endocrinol. 2022;18(9):525-539. doi:10.1038/s41574-022-00690-7.

11.

Trief

PM.

Depression in elderly diabetes patients. Diabetes Spectrum. 2007;20(2):71-75.

12.

Wong

Backholer

Gearon

, et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2013;1(2):106-114. doi:10.1016/S2213-8587(13)70046-9.

13.

Jie

Jia

, et al. Activities of daily living and its influencing factors for older people with type 2 diabetes mellitus in urban communities of Fuzhou, China. Front Public Health. 2022;10:948533. doi:10.3389/fpubh.2022.948533.

14.

Laiteerapong

Karter

Liu

, et al. Correlates of quality of life in older adults with diabetes: the diabetes & aging study. Diabetes Care. 2011;34(8):1749-1753. doi:10.2337/dc10-2424.

15.

Comer-HaGans

Austin

Ramamonjiarivelo

Sherman

LD.

Diabetes self-management among individuals with diabetes and physical disabilities. Sci Diabetes Self Manag Care. 2021;47(4):264-278. doi:10.1177/26350106211024136.

16.

Jannoo

Wah

Lazim

Hassali

MA.

Examining diabetes distress, medication adherence, diabetes self-care activities, diabetes-specific quality of life and health-related quality of life among type 2 diabetes mellitus patients. J Clin Transl Endocrinol. 2017;9:48-54. doi:10.1016/j.jcte.2017.07.003.

17.

Longo

Bellastella

Maiorino

Meier

Esposito

Giugliano

Diabetes and aging: from treatment goals to pharmacologic therapy. Front Endocrinol (Lausanne). 2019;10:45. doi:10.3389/fendo.2019.00045.

18.

Bonnie

Wallace

, eds. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (The National Academies Collection: Reports funded by National Institutes of Health). Bethesda, MD: National Institutes of Health; 2003.

19.

Mercier

Nadeau

Brousseau

, et al. Elder abuse in the out-of-hospital and emergency department settings: a scoping review. Ann Emerg Med. 2020;75(2):181-191. doi:10.1016/j.annemergmed.2019.12.011.

20.

Laumann

Leitsch

Waite

LJ.

Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254. doi:10.1093/geronb/63.4.s248.

21.

Ryan

Roman

NV.

Family-centred interventions for elder abuse: a narrative review. J Cross Cult Gerontol. 2019;34(3):325-336. doi:10.1007/s10823-019-09377-5.

22.

Dede

Immersive interfaces for engagement and learning. Science. 2009;323(5910):66-69. doi:10.1126/science.1167311.

23.

Beverly

Love

Williams

Bowditch

Using virtual reality to improve health care providers’ cultural self-efficacy and diabetes attitudes: pilot questionnaire study. JMIR Diabetes. 2021;6(1):e23708. doi:10.2196/23708.

24.

Eldridge

Lancaster

Campbell

, et al. Defining feasibility and pilot studies in preparation for randomised controlled trials: development of a conceptual framework. PLoS ONE. 2016;11(3):e0150205. doi:10.1371/journal.pone.0150205.

25.

Lancaster

Dodd

Williamson

PR.

Design and analysis of pilot studies: recommendations for good practice. J Eval Clin Pract. 2004;10(2):307-312. doi:10.1111/j.2002.384.doc.x.

26.

Power

Green

, WHOQOL-DIS Group. The Attitudes to Disability Scale (ADS): development and psychometric properties. J Intellect Disabil Res. 2010;54(9):860-874. doi:10.1111/j.1365-2788.2010.01317.x.

27.

Simmons

Wenemark

Ludvigsson

Development and validation of REAGERA-P, a new questionnaire to evaluate health care provider preparedness to identify and manage elder abuse. BMC Health Serv Res. 2021;21(1):473. doi:10.1186/s12913-021-06469-2.

28.

Johnson

Fertel

Elder Abuse. Tampa, FL: Statpearls; 2020.

29.

Lachs

Pillemer

KA.

Elder abuse. N Engl J Med. 2015;373(20):1947-1956. doi:10.1056/NEJMra1404688.

30.

Dong

Simon

Beck

, et al. Elder abuse and mortality: the role of psychological and social wellbeing. Gerontology. 2011;57(6):549-558. doi:10.1159/000321881.

31.

Burnett

Jackson

Sinha

Aschenbrenner

AR.

Five-year all-cause mortality rates across five types of substantiated elder abuse occurring in the community. Journal of Elder Abuse and Neglect. 2016;28(2):59-75.

32.

Hess

The role of health care providers in recognizing and reporting elder abuse. J Gerontol Nurs. 2011;37(11):28-34; quiz 36. doi:10.3928/00989134-20111012-50.

Cinematic Virtual Reality for Educating Health Care Providers About Type 2 Diabetes,Disability,and Elder Abuse and Neglect: A Pilot Study