Benat Amestoy Alonso1
Tony Donegan1
Isaac Calvis1,2
Justyna Swidrak1,2Edgar Rodriguez1Caribay L. Vargas-Reverón3Andrés Combalia1,3,4
Ramon Oliva Martinez5
Maria V. Sanchez-Vives1,5,6*- 1Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- 2Institute of Psychology Polish Academy of Sciences, Warsaw, Poland
- 3Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Clínic de Barcelona, Barcelona, Spain
- 4Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
- 5Event Lab, Faculty of Psychology, University of Barcelona, Barcelona, Spain
- 6ICREA, Barcelona, Spain
Patient focus groups can be invaluable for facilitating user-centered design of medical devices and new technologies, effectively capturing the richness and depth of patient experiences to help thoroughly assess feasibility, tolerance, and usability. While the metaverse holds promise for healthcare applications, its use in patient focus groups remains unexplored. In this Perspective we discuss the potential of the metaverse for conducting focus groups with patients. The theme of the focus group was the design and development of a therapeutic virtual reality application for patients with chronic low back pain. We carried out a pilot study comparing a focus group in a shared virtual space versus a physical location. This experience was positively received by patients, researchers, and clinicians, suggesting the metaverse is a viable medium for conducting these meetings and has potential advantages for remotely located participants, opening the doors for future expansion beyond focus groups to encompass all kinds of patient support and information groups. This approach fosters patient-centered healthcare by helping to facilitate patient voices directly into the design process, which may help lead to improved healthcare delivery, patient satisfaction, and treatment outcomes.
Introduction
The metaverse is envisioned as a consistent virtual environment and shared space where people can interact and collaborate in real time while represented by avatars (Mystakidis, 2022; Shoa et al., 2023). These avatars can be customized to the users’ real aspect but can also allow other representations. While the metaverse as a space where different systems seamlessly interoperate is not yet a reality, current shared virtual spaces can provide the experience of being with others and are an experimental space for investigating different aspects of virtual social interactions such as rules, feelings, emotions, behaviours, or restrictions (Schroeder, 2001; Giannopoulos et al., 2008; Gottschalk, 2010; Pan et al., 2012; Pan and Hamilton, 2018).
The healthcare landscape is undergoing a digital revolution, with advances in technology continuously reshaping how patients interact with the medical community. Patient engagement in the co-design of studies, medical devices, and intervention strategies has emerged as a critical aspect of modern healthcare (Mummah et al., 2016). This paper explores the potential applications of the metaverse for conducting meetings with patients, in particular focus groups, examining its potential benefits and addressing any existing challenges. We do that based on our own experience using a custom shared virtual space called VR United (Oliva et al., 2023). VR United is a virtual reality application aimed at supporting multiple people interacting simultaneously in the same virtual environment. Each participant is represented by an avatar, facilitating collective virtual experiences. We used VR United to conduct a focus group with patients in the context of the creation of a therapeutic virtual rehabilitation program for people with low back pain. We take this as a departing point in this Perspective so that we can discuss the potential of the metaverse for conducting focus groups with patients and in a wider sense, for meetings of researchers and clinicians with patients, or for peer-to-peer networking.
The need for patient focus groups in the design of digital technologies
Within the context of evidence-based design of medical devices and digital technologies, it is critical to work closely with patients throughout design and development, for developing solutions that are not only technically innovative but also feasible, acceptable, and tolerable for the intended users (Birckhead et al., 2019). Focus groups provide an interactive space in which optimal use can be made of participants’ shared experiences and wide-ranging perspectives. The power dynamic is somewhat different to traditional one-to-one interviews or surveys, in that researchers have less control over the dialogue that unfolds and make themselves open to challenge by participants (Wilkinson, 1999). Focus groups must be well planned, carefully managed, and sensitively mediated to ensure inclusion and fully enable supportive discussion that includes everyone present (Nind et al., 2022), but if run well they can offer unique insights that might not be readily apparent to engineers, designers, or even healthcare professionals (Leung and Savithiri, 2009; Dil et al., 2024), providing wider perspectives than traditional interviews. This approach ensures that the development of medical devices is not only technically viable but also aligned with the actual needs, preferences, and experiences of the end-users—the patients.
Patients can identify potential safety issues or risks associated with the use of the device that might not be evident in laboratory settings or through theoretical analysis. Understanding how devices will be used in real-world settings helps in designing products that maintain their efficacy outside of controlled environments, thereby reducing the likelihood of misuse or errors. Devices designed with input from patients are more likely to be embraced and used correctly, gaining faster acceptance and market penetration, and thus benefiting both the manufacturer and the healthcare community (Garmer et al., 2004; Bevan Jones et al., 2020; Vandekerckhove et al., 2020; Quintero, 2022). Furthermore, ensuring that devices address clinically relevant issues as identified by patients helps in aligning product development with healthcare priorities and outcomes.
Focus groups in the metaverse
There are some considerable potential advantages to conducting focus group meetings in shared virtual settings. While initial setup costs for VR equipment and software may be significant, virtual meetings can ultimately lead to cost savings by reducing the need for in-person appointments, travel expenses, and associated overhead costs for healthcare facilities (Charles, 2000). Since patients with chronic pain often have reduced mobility, allowing them to attend a meeting from home may be beneficial, and unlike other forms of videoconferencing, in immersive VR the user has a strong sense of presence and really being there with other people in the shared environment (Schroeder et al., 2001). In addition, the novelty of VR can provide a heightened engagement, and a potential distraction effect from pain, potentially leading to increased levels of interest and participation in the shared discussion (Matamala-Gomez et al., 2019; Coban et al., 2022).
There may also be some drawbacks or disadvantages. Technical glitches such as hardware malfunction, software bugs or poor internet connection speed, poor usability or discomfort/cybersickness using VR headsets could hinder the meeting for some patients, particularly so with longer meetings. There is also the potential for misinterpretation or miscommunication (Akselrad et al., 2023). While the virtual avatars have mouth animations triggered by the microphone in the HMD, and full upper body and head tracking providing visuomotor congruence with real life movements, other more subtle forms of non-verbal communication such as facial expression and eye gaze are currently not captured (although this is likely to change in future iterations thanks to recent technological advances in VR hardware). Additionally, the security and privacy of patient data within VR platforms would need to be carefully addressed.
To explore some of these issues, we conducted a pilot study with patients with chronic low back pain that had been independently testing a virtual reality rehabilitation program at home for 5 days. The program consisted of a set of therapeutic experiences, games and exercises designed for the rehabilitation of the low back pain, a development within the project “XR-PAIN: eXtended Reality-Assisted Therapy for Chronic Pain Management” (see Funding section). The system is based on embodiment of virtual bodies (Slater et al., 2009; Sanchez-Vives et al., 2010; Blanke, 2012; Maselli and Slater, 2013) and realization of a variety of therapeutic strategies including education/reassurance, gamification, graded exercise, and relaxation, in order to reduce pain and disability and improve range of motion and movement confidence (Matamala-Gomez et al., 2019; Donegan et al., 2022; Álvarez de la Campa Crespo et al., 2023). Four volunteer low-back pain patients were given a VR system (Quest 3, Meta, California) with the program installed. They were instructed to use the program at home for 20 min daily for 1 week in order to pilot test the VR system and the rehabilitation program contents. These patients also agreed to provide a front-facing photograph to have a customized avatar made for when they attended the virtual focus group.
We organized a focus group session in a shared virtual space using VR United with four patients, one clinician (traumatologist), two physiotherapists, two developers and three researchers (Figure 1). A structured session was organized, where in a highly interactive dialogue guided by the researchers, the patients actively reported on their experience with the rehabilitation program, content relevance and appropriateness of the contents, user experience, effectiveness, or suggestions for improvement. They also commented on different aspects of the contents, such as their experience with different games and exercises.
Figure 1. Patients, clinicians, developers and researchers in a shared space in immersive VR United during a focus group.
In a physical focus group meeting with the patients conducted 3 days after the virtual focus group meeting, the patients reported on their experience of the virtual focus group. They valued being able to be at their own homes without the time and physical effort of travelling. They found it comforting to know that they could meet in a common space. They also found it “weird the first 2 minutes and then it’s like a normal meeting.” They found the interaction between participants to be “very natural.” The experience was found to be less stressful and less intimidating than videoconferences, given that one does not need to prepare the environment nor their personal appearance, since the space is virtual and an avatar is used. Curiously, they also saw it as an advantage that the avatar does not show the use’s real emotions. No serious adverse effects were reported after an 80 min meeting, but one of the users found that by the end the head-mounted display felt heavy. Additionally, another patient, using the program at home alone, was momentarily startled when she launched the application and a male attendee suddenly appeared seated next to her. Such experiences highlight the very realistic sense of presence of really being there in the virtual space with other people, as well as the need to account for the potential vulnerability and comfort of users.
Participants also made new suggestions, like having the name of each person by the avatar since after a round of introductions one normally forgets the names of people at the meeting, a clear demand for augmented virtual reality. Interestingly, in a physical meeting after the experience, users had the impression that they had been together previously, they knew and recognized each other not only by their physical aspect but also by their voices and body movements.
A look into the future
The potential applications of the metaverse in healthcare and medical training and practice are numerous. Several recent reviews and surveys have addressed this topic (Bansal et al., 2022; Usmani et al., 2022; Yang et al., 2022; Ahuja et al., 2023; Suh et al., 2023; Ullah et al., 2023), and there are a number of studies exploring the therapeutic potential of virtual reality in a group setting (Tamplin et al., 2020; Dilgul et al., 2021; Ong et al., 2022; Lai et al., 2023). However, none of these studies feature full embodiment of realistic virtual avatars in shared virtual spaces, and the potential use for patient focus groups has not yet been discussed. Incorporating patient focus groups into the design and development of health technologies is crucial for developing solutions that are not only technically innovative but also highly relevant, safe, and effective for the intended users. This approach enhances the quality of healthcare delivery, patient satisfaction, and overall treatment outcomes, marking a significant shift towards more patient-centred healthcare solutions. Our early pilot studies comparing this experience in a shared virtual space versus a physical space have been positively valued by patients, researchers, and clinicians. This opens the door to future expansion, not only for focus groups but also for different types of support and information groups, both between patients themselves and with healthcare practitioners.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies using VR involving humans were approved by the Hospital Clinic de Barcelona CEIm. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
BAA: Investigation, Writing–review and editing. TD: Investigation, Writing–review and editing. IC: Software, Investigation, Writing–review and editing. JS: Investigation, Writing–review and editing. ER: Software, Writing–review and editing. CV-R: Resources, Investigation, Writing–review and editing. AC: Resources, Investigation, Writing–review and editing. RO: Methodology, Investigation, Writing–review and editing. MVSV: Conceptualization, Funding acquisition, Investigation, Supervision, Writing–original draft, Writing–review and editing.
Funding
The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. Supported by XR-PAIN Grant Agreement No. 101070533, funded by the European Media and Immersion Lab project financial support to third parties, which is funded by the European Union, and by Departament de Recerca i Universitats de la Generalitat de Catalunya (AGAUR 2021-SGR-01165—NEUROVIRTUAL), supported by FEDER.
Acknowledgments
We want to thank the patients that participated in the experience.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
Ahuja, A. S., Polascik, B. W., Doddapaneni, D., Byrnes, E. S., and Sridhar, J. (2023). The digital metaverse: applications in artificial intelligence, medical education, and integrative health. Integr. Med. Res. 12 (1), 100917. doi:10.1016/j.imr.2022.100917
Akselrad, D., DeVeaux, C., Han, E., Miller, M. R., and Bailenson, J. N. (2023). “Body crumple, sound intrusion, and embodiment violation: toward a framework for miscommunication in VR,” in Companion publication of the 2023 conference on computer supported cooperative work and social computing (New York, NY, USA: Association for Computing Machinery), 122–125. doi:10.1145/3584931.3606968
Álvarez de la Campa Crespo, M., Donegan, T., Amestoy-Alonso, B., Just, A., Combalía, A., and Sanchez-Vives, M. V. (2023). Virtual embodiment for improving range of motion in patients with movement-related shoulder pain: an experimental study. J. Orthop. Surg. Res. 18 (1), 729. doi:10.1186/s13018-023-04158-w
Bansal, G., Rajgopal, K., Chamola, V., Xiong, Z., and Niyato, D. (2022). Healthcare in metaverse: a survey on current metaverse applications in healthcare. Ieee Access 10, 119914–119946. doi:10.1109/access.2022.3219845
Bevan Jones, R., Stallard, P., Agha, S. S., Rice, S., Werner-Seidler, A., Stasiak, K., et al. (2020). Practitioner review: Co-design of digital mental health technologies with children and young people. J. Child Psychol. Psychiatry 61, 928–940. doi:10.1111/jcpp.13258
Birckhead, B., Khalil, C., Liu, X., Conovitz, S., Rizzo, A., Danovitch, I., et al. (2019). Recommendations for methodology of virtual reality clinical trials in health care by an international working group: iterative study. JMIR Ment. Health 6, e11973. doi:10.2196/11973
Blanke, O. (2012). Multisensory brain mechanisms of bodily self-consciousness. Nat. Rev. Neurosci. 13, 556–571. doi:10.1038/nrn3292
Charles, B. L. (2000). Telemedicine can lower costs and improve access. Healthc. Financ. Manage 54, 66–69.
Coban, M., Bolat, Y. I., and Goksu, I. (2022). The potential of immersive virtual reality to enhance learning: a meta-analysis. Educ. Res. Rev. 36, 100452. doi:10.1016/j.edurev.2022.100452
Dil, N., Castiglioni, A., Kim, K., Aravind, N., and Torre, D. (2024). Use and implementation of focus groups. Med. Teach. 46 (3), 317–319. doi:10.1080/0142159X.2024.2304451
Dilgul, M., Hickling, L. M., Antonie, D., Priebe, S., and Bird, V. J. (2021). Virtual reality group Therapy for the treatment of depression: a qualitative study on stakeholder perspectives. Front. Virtual Real. 1. doi:10.3389/frvir.2020.609545
Donegan, T., Ryan, B., Sanchez-Vives, M. V., and Swidrak, J. (2022). Altered bodily perceptions in chronic neuropathic pain conditions and implications for treatment using immersive virtual reality. Front. Hum. Neurosci. 16, 1024910. doi:10.3389/fnhum.2022.1024910
Garmer, K., Ylvén, J., and Karlsson, I. M. (2004). User participation in requirements elicitation comparing focus group interviews and usability tests for eliciting usability requirements for medical equipment: a case study. Int. J. Industrial Ergonomics 33 (2), 85–98. doi:10.1016/j.ergon.2003.07.005
Giannopoulos, E., Eslava, V., Oyarzabal, M., Hierro, T., Gonzalez, L., Ferre, M., et al. (2008). “The effect of haptic feedback on basic social interaction within shared virtual environments,” in Lecture notes in computer science (Germany: Springer).
Gottschalk, S. (2010). The presentation of avatars in second life: self and interaction in social virtual spaces. Symb. Interact. 33 (4), 501–525. doi:10.1525/si.2010.33.4.501
Lai, B., Young, R., Craig, M., Chaviano, K., Swanson-Kimani, E., Wozow, C., et al. (2023). Improving social isolation and loneliness among adolescents with physical disabilities through group-based virtual reality gaming: feasibility pre-post trial study. JMIR Form. Res. 7, e47630. doi:10.2196/47630
Leung, F.-H., and Savithiri, R. (2009). Spotlight on focus groups. Can. Fam. Physician 55 (2), 218–219.
Maselli, A., and Slater, M. (2013). The building blocks of the full body ownership illusion. Front. Hum. Neurosci. 7, 83. doi:10.3389/fnhum.2013.00083
Matamala-Gomez, M., Donegan, T., Bottiroli, S., Sandrini, G., Sanchez-Vives, M. V., and Tassorelli, C. (2019). Immersive virtual reality and virtual embodiment for pain relief. Front. Hum. Neurosci. 13, 279. doi:10.3389/fnhum.2019.00279
Matamala-Gomez, M., Gonzalez, A. M. D., Slater, M., and Sanchez-Vives, M. V. (2019). Decreasing pain ratings in chronic arm pain through changing a virtual body: different strategies for different pain types. J. Pain 20 (6), 685–697. doi:10.1016/j.jpain.2018.12.001
Mummah, S. A., Robinson, T. N., King, A. C., Gardner, C. D., and Sutton, S. (2016). IDEAS (integrate, design, assess, and share): a framework and toolkit of strategies for the development of more effective digital interventions to change health behavior. J. Med. Internet Res. 18, e317. doi:10.2196/jmir.5927
Nind, M., Kaley, A., and Hall, E. (2022). “Focus group method,” in Handbook of social inclusion: research and practices in health and social sciences. Editor P. Liamputtong (Cham: Springer International Publishing), 1041–1061. doi:10.1007/978-3-030-89594-5_57
Oliva, R., Beacco, A., Gallego, J., Abellan, R. G., and Slater, M. (2023). The making of a newspaper interview in virtual reality: realistic avatars, philosophy, and sushi. IEEE Comput. Graph. Appl. 43 (6), 117–125. doi:10.1109/MCG.2023.3315761
Ong, T., Wilczewski, H., Soni, H., Nisbet, Q., Paige, S. R., Barrera, J. F., et al. (2022). The symbiosis of virtual reality exposure Therapy and telemental health: a review. Front. Virtual Real 3, 848066. doi:10.3389/frvir.2022.848066
Pan, X., Gillies, M., Barker, C., Clark, D. M., and Slater, M. (2012). Socially anxious and confident men interact with a forward virtual woman: an experimental study. PLoS ONE 7, e32931. doi:10.1371/journal.pone.0032931
Pan, X., and Hamilton, A. F. d.C. (2018). Why and how to use virtual reality to study human social interaction: the challenges of exploring a new research landscape. Br. J. Psychol. 109, 395–417. doi:10.1111/bjop.12290
Quintero, C. (2022). A review: accessible technology through participatory design. Disabil. Rehabil. Assist. Technol. 17, 369–375. doi:10.1080/17483107.2020.1785564
Sanchez-Vives, M. V., Spanlang, B., Frisoli, A., Bergamasco, M., and Slater, M. (2010). Virtual hand illusion induced by visuomotor correlations. PloS one 5 (4), e10381. doi:10.1371/journal.pone.0010381
Schroeder, R. (2001). The social life of avatars: presence and interaction in shared virtual environments. Berlin, Germany: Springer Science & Business Media.
Schroeder, R., Steed, A., Axelsson, A.-S., Heldal, I., Abelin, Å., Wideström, J., et al. (2001). Collaborating in networked immersive spaces: as good as being there together? Comput. Graph. 25, 781–788. doi:10.1016/S0097-8493(01)00120-0
Shoa, A., Oliva, R., Slater, M., and Friedman, D. (2023). “Sushi with einstein: enhancing hybrid live events with LLM-based virtual humans,” in Proceedings of the 23rd ACM International Conference on Intelligent Virtual Agents, Würzburg, Germany, September 19-22, 2023, 1–6.
Slater, M., Pérez Marcos, D., Ehrsson, H., and Sanchez-Vives, M. V. (2009). Inducing illusory ownership of a virtual body. Front. Neurosci. 3, 676. doi:10.3389/neuro.01.029.2009
Suh, I., McKinney, T., and Siu, K.-C. (2023). “Current perspective of metaverse application in medical education, research and patient care,” in Virtual worlds (Basel, Switzerland: MDPI), 115–128.
Tamplin, J., Loveridge, B., Clarke, K., Li, Y., and J Berlowitz, D. (2020). Development and feasibility testing of an online virtual reality platform for delivering therapeutic group singing interventions for people living with spinal cord injury. J. Telemed. Telecare 26, 365–375. doi:10.1177/1357633X19828463
Ullah, H., Manickam, S., Obaidat, M., Laghari, S. U. A., and Uddin, M. (2023). Exploring the potential of metaverse technology in healthcare: applications, challenges, and future directions. IEEE Access 11, 69686–69707. doi:10.1109/access.2023.3286696
Usmani, S. S., Sharath, M., and Mehendale, M. (2022). Future of mental health in the metaverse. General Psychiatry 35 (4), e100825. doi:10.1136/gpsych-2022-100825
Vandekerckhove, P., de Mul, M., Bramer, W. M., and de Bont, A. A. (2020). Generative participatory design methodology to develop electronic health interventions: systematic literature review. J. Med. Internet Res. 22, e13780. doi:10.2196/13780
Wilkinson, S. (1999). Focus groups: a feminist method. Psychol. Women Q. 23, 221–244. doi:10.1111/j.1471-6402.1999.tb00355.x
Keywords: metaverse, virtual reality, applications, focus groups, shared spaces, clinical VR, embodiment
Citation: Amestoy Alonso B, Donegan T, Calvis I, Swidrak J, Rodriguez E, Vargas-Reverón CL, Combalia A, Oliva Martinez R and Sanchez-Vives MV (2024) Focus groups in the metaverse: shared virtual spaces for patients, clinicians, and researchers. Front. Virtual Real. 5:1432282. doi: 10.3389/frvir.2024.1432282
Received: 13 May 2024; Accepted: 05 June 2024;
Published: 10 July 2024.
Edited by:
David Swapp, University College London, United KingdomReviewed by:
Triton Ong, Doxy.me Inc., United StatesCopyright © 2024 Amestoy Alonso, Donegan, Calvis, Swidrak, Rodriguez, Vargas-Reverón, Combalia, Oliva Martinez and Sanchez-Vives. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Maria V. Sanchez-Vives, bXNhbmNoZTNAcmVjZXJjYS5jbGluaWMuY2F0