South Africa's public health nurses are infamous for having bad attitudes. Google goggles could help them change their ways.
Phumza Dayimani unpacks a set of grey goggles, headphones and a cellphone from her cream-coloured bag and places them on the table next to her.
It's mid-morning in the Weltevreden Valley Clinic, approximately 20km outside of Cape Town. About 50 people are seated on wooden benches along the clinic's corridors, waiting to be served.
But Dayimani isn't here to see patients. Instead, she's going to help nurses to better understand young clients.
Dayimani, who is a peer educator, slips the goggles over the head of the nurse sitting on the spinning chair next to her. She and Vuyelwa Grey are meeting in consultation room nine in the mid-section of the clinic.
Dayimani carefully straps a cellphone to the front of the goggles. There's a video on the screen of the phone. She locates the play button, hits it and a few moving red arrows against a white background appear.
The video was recorded with a 360° video camera. When Grey views it through her special glasses - Google goggles that turn everything she watches into three-dimensional images - it creates the feeling that she's part of the scenes that are playing off in front of her. The experience is called virtual reality (VR).
Written instructions appear on the cellphone screen, which tells Grey to spin her chair to the left, where she "enters" a clinic reception area. Seconds later, a grumpy nurse, dressed in a navy blue-and-white uniform just like Grey's, comes out of her consultation room. The nurse, whom Grey soon learns is a character called Sister Vece, calls out a young, female patient's name in a rough tone. She's a teenager who still attends school.
Vece shouts: "Oh, it's you again. Are you here to take another HIV test?"
Other patients look on.
"Why didn't you use a condom?" Vece bellows.
Grey shuffles in her chair. Then she watches as Sister Vece belittles the girl, and whispers: "I see myself in that nurse."
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Grey is watching a VR film produced by the Desmond Tutu HIV Foundation and Makhulu Media at the University of Cape Town. Over the past decade, the technology has been used in everything from treating pain and anxiety to health worker training.
A 2019 research review published in the Journal of Medical Internet Research found healthcare workers who received training through methods such as a virtual patient or surgery simulations were slightly better able to retain what they learned when compared with people who had used traditional methods such as textbooks, lectures or computer programmes. This was even truer when professionals were asked to recall skills they'd been taught during the training.
The Desmond Tutu HIV Foundation is hoping its new film can help to change the way in which nurses like Grey talk to young people.
Numerous studies have shown that nurses' negative attitudes towards young men and women isolate them from clinics, especially when they want to access sexual reproductive services such as birth control and HIV testing.
Yet, South Africa's latest HIV plan aims to get more young people to use condoms and other birth control methods to decrease sexually transmitted infections and teenage pregnancies by 2022.
The foundation's VR programme seeks to help nurses to contribute towards reaching the plan's targets.
Grey has been a nurse for 14 years. She acknowledges that she and many of her colleagues are harsh with youngsters. "When they come to the clinic we act like their parents, which is something we are not supposed to do," she says. "For example, if a patient's pregnancy test results are positive, we would shout at her and ask her why she didn't use a condom, instead of educating her."
A 360° camera was used to record a virtual reality film that helps nurses to better serve young people. The camera records different angles simultaneously. (Sydelle Willow Smith)
If the foundation's programme can help nurses to be less judgmental towards young people, they may feel more comfortable to use sexual health services without fear of being mistreated, says Laura Myers, a socio-behavioural expert who heads up the foundation's VR project.
She explains: "We really want to encourage healthcare workers to provide a good service to all young people seeking sexual health care. Being as caring, non-judgmental and supportive as possible, healthcare workers will help them to make good, informed choices about their health."
So far, the 12-minute film has been piloted in five clinics outside of Cape Town. Nurses fill out questionnaires before donning the Google VR goggles. The form includes questions like: "How comfortable do you feel talking about sexual health with young people?" or "What would you do if you witnessed a colleague speaking harshly to a young person?"
Almost half of the 60 nurses who watched the VR video reported that they thought young people felt welcomed at their clinic before watching the film. Yet, about a third said they'd seen a co-worker be judgmental towards a patient. Five percent of 45 nurses surveyed also admitted they'd seen co-workers refuse to touch HIV-positive patients or use two pairs of gloves to examine infected patients - despite the fact that health workers medically did not need the extra protection.
Although a high proportion of nurses said that if they witnessed behaviour like this, they'd speak to their colleague or supervisor, most workers who took a spin through Sister Vece's virtual clinic said they were more likely to report bad behaviour after having watched the film.
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Later this year, the foundation and Makhulu Media will be expanding its programme to 12 000 nurses working in other Western Cape and also Eastern Cape clinics and nursing colleges.
Meyers says they would also like to expand the use of VR to promoting awareness of the HIV prevention pill, but the cost of the headsets, phones and goggles - which comes to about R1500 per set - remain a challenge.
The programme's filmmaker and concept developer Rowan Pybus hopes to rally cellphone manufacturing companies to sponsor mobile devices and headsets to add to the 15 VR kits that the project currently has.
If the foundation's project works, it could make for friendlier clinics and provide evidence of VR's potential to not only train healthcare workers but also to shape the way they act.
A 2019 review in the Journal of Medical Internet Research reveals that we still don't know how well VR works to help to change clinicians' behaviour or whether it is cost-effective.
Lihle plays the character of a young woman that a nurse, Sister Vece, belittles in a virtual reality film that is used to change the attitudes of nurses towards young people seeking sexual healthcare. (Sydelle Willow Smith)
Back on her blue swivel chair at the Weltevreden Valley Clinic, Grey has just returned from a short break and is about to start the second part of the film. This time, however, Sister Vece calls her young patient in a sweet tone before leading her into a consultation room.
There, the young woman takes an HIV test. The results are positive.
The foundation has also made virtual reality videos to tackle HIV stigma among young people. Before watching the VR flick, about a quarter of the 60 young people surveyed said they were too afraid to get tested for HIV. Almost everyone who saw the movie said they were more likely to test for HIV, preliminary data seen by Bhekisisa show.
Vece hugs the patient and tells her that it isn't the end of her life before counselling her about antiretroviral drugs.
It's made Grey - and more than half of the other nurses who've watched the film - want to be more sensitive to young people's sexual health needs.
A few weeks after she had seen the video, the clock strikes 2pm in the clinic where Grey works. It's the start of the facility's youth-only hours.
Learners in school uniforms begin to fill the passage to access services like HIV tests, birth control and antiretroviral treatment.
Grey explains: "I now make sure that I find the time to fit them in, even if it's late or if I'm busy with other work.
"Before, when I saw a young person coming into the clinic and didn't have time to see them, I would turn them away."