Gender-Based Violence (GBV) remains a global concern, often under-identified due to limited healthcare professional training. This study aimed to explore the potential effect of a virtual reality (VR)-based experiential training on primary care professionals from Barcelona (n = 38). A mixed-methods design was used, including a single-group pre-post quantitative test and qualitative observations recorded during the sessions. The training comprised VR scenarios presented as 360° videos, followed by debriefing with key theoretical points. Results indicated that the VR-based training was associated with an increase in participants’ self-perception of competence, knowledge, and perspectives in addressing GBV. These findings suggest that immersive VR environments may be a useful tool for professional development and could support improved identification and management of GBV in clinical practice.
gender-based violencewomen's healthvirtual realityprofessional educationinterprofessional educationThe author(s) declared that financial support was not received for this work and/or its publication.section-at-acceptanceVirtual Reality in MedicineIntroduction
Gender-based violence (GBV) is a present concern, transcending national borders and affecting individuals regardless of their cultural background, social class, educational level, income, or race. It represents a profound violation of women’s human rights worldwide (Cepeda et al., 2022). Quantifying the scale of the issue, it has been revealed that nearly 1 in 3 women globally have experienced physical and/or sexual violence by an intimate partner or non-partner sexual violence (World Health Organization, 2021a). In many countries, healthcare professionals are often the first or only point of contact for victims. However, many cases of GBV are not properly identified due to a lack of resources and training (World Health Organization, 2021b). Fortunately, there is a growing emphasis on assessing the health systems’ preparedness to address the needs of women who suffer violence. This focus aims to identify gaps and enhance certain integrative approaches’ effectiveness in specific contexts (Colombini et al., 2022).
Healthcare professionals (HCPs), as individuals whose primary work’s aim is to provide healthcare and medical attention to others, have a unique opportunity to identify and support victims of GBV through their interventions. This promotes women’s safety and aims to prevent further consequences (Hewitt, 2015). However, a lack of high-quality studies has also been identified, which indicates that these conclusions should be treated prudently (Sawyer et al., 2016; Crombie et al., 2017). This is aligned with the claims that research in this area must be enhanced due to the impact on women’s health, there must be an increase in research to improve responses to violence (García-Moreno Z. et al., 2015). HCPs should be equipped to provide initial support, which includes empathetic listening, ongoing psychosocial support, referrals to social care and other services, and comprehensive care for sexual assault survivors (García-Moreno C et al., 2015). In addition, scientific literature highlights primary care as a suitable setting for screening GBV, positioning it as the most appropriate context for detection and evaluation for several reasons (Benet et al., 2020): I) its universal accessibility, II) the ability on building trust with patients, III) continuity of care, and IV) the multidisciplinary and interdisciplinary nature of PC, which allows for comprehensive and coordinated management.
Specific training and skill development for HCPs are identified as key challenges in providing care to GBV victims. The self-reported knowledge level of professionals is often classified as basic or deficient, with the majority acknowledging the need for further training in this area (Alhalal, 2020). In recent years, numerous training interventions have been implemented worldwide (Arora et al., 2023; Gürkan and Kömürcü, 2017; McGregor et al., 2019). However, the content and effectiveness of these interventions vary considerably, depending on the study and the population being targeted (Sprague et al., 2018). These initiatives intend to improve HCPs’ skills and knowledge in identifying and addressing various forms of GBV, thereby fostering a more supportive healthcare environment for survivors. Several systematic reviews have been conducted regarding international training programs for HCPs to support them in addressing GBV (Kalra et al., 2021; Ogbe et al., 2020; Sawyer et al., 2016). Review’s findings generally indicate a positive relationship between education and improvements in providers’ knowledge, attitudes and self-perceived readiness (Kalra et al., 2021). However, in light of the identified gaps in training, it is recommended to implement more structured and formal education on GBV, encompassing both theoretical foundations and practical skills related to detection procedures (Benet et al., 2020). Moreover, evidence suggests that HCPs are better prepared to respond effectively when they receive targeted and specific training (Murillo et al., 2018).
Several teaching and learning methodologies are described in the literature for training HCPs on GBV, ranging from theoretical courses to practical activities, such as the use of visual support materials, open and case-based discussions, role plays (Crombie et al., 2017) or simulations (Blumling et al., 2018). GBV education programs can enhance HCPs’ confidence and competencies, with simulation-based learning proving particularly effective (Blumling et al., 2018). However, changes in staff attitudes towards women appear limited, suggesting the need for further investigation and more targeted, evidence-based educational strategies (Crombie et al., 2017). Integrating experiential learning could facilitate the application of theoretical knowledge in clinical scenarios, promoting critical thinking, skill development, and empathy towards victims.
Virtual Reality (VR) can provide this immersive environment for practicing effective communication skills in complex and realistic scenarios (Plotzky et al., 2021), such as those that involve GBV situations. This setting allows for safe and controlled training in the management of GBV through repeated exposure to learning scenarios, thereby promoting continuous improvement in the performance and competence of HCPs (Coyne et al., 2019). This approach aligns with the principles of experiential learning, which is essential for addressing the complexity involved in GBV management. Specifically, HCPs’ ability to develop clinical skills and competencies can be reinforced by implementing experiential learning techniques, which actively engage participants in direct experience while emphasizing reflective practice (Sadat et al., 2022).
Furthermore, the advantages of VR over traditional and other digital education formats in improving post-intervention outcomes and practical skills has been demonstrated in a recent systematic review and meta-analysis (Kyaw et al., 2019). It was found that VR improves not only post-intervention knowledge scores when compared with traditional learning, but also HCP’ cognitive skills. Additional studies also confirm VR’s effectiveness in ability’s acquisition, leading to increased user confidence and competence (Lie et al., 2023; Fertleman et al., 2018).
Despite the multiple educational interventions described to date (Alhalal, 2020; Sprague et al., 2018), many healthcare professionals still report feeling insufficiently prepared to address issues related to Gender-based violence, highlighting the growing need to strengthen training in this area. In response to this gap, virtual reality (VR) offers a promising strategy for the identification and management of GBV, enabling healthcare professionals to integrate skills, knowledge, and values. By exploring and interacting with three-dimensional sensory environments in real time, participants can acquire practical insights that are directly applicable to clinical practice. For this purpose, training materials were developed based on four virtual reality (VR) scenarios. These scenarios were identified in collaboration with a panel of experts, who also defined the key competencies to be addressed among healthcare professionals. The training program was structured around an immersive experience with the VR scenarios, followed by an in-depth debriefing and subsequent conceptualization phase. The underlying hypothesis is that this training approach will enhance healthcare professionals’ self-perceived ability to address GBV. Additionally, prior to the intervention, we explored whether participants’ professional experience, previous training, and baseline levels of empathy influence their initial self-perceived capacity to manage situations of gender-based violence.
Materials and methods
The present study evaluates the effect of a training intervention based on virtual reality (VR) scenarios followed by a debriefing session among primary care healthcare professionals (HCPs), using a mixed-methods approach that integrates quantitative and qualitative data for a comprehensive understanding of the intervention’s effects (Creswell and Creswell, 2018). The quantitative strand employed a pre-experimental, single-group pre–post design to measure changes in participants’ self-perceived ability to address GBV cases. Data were collected before and after participation in the VR-based training session. Complementarily, qualitative data were gathered through field notes documenting direct observations during the training and debriefing sessions. These observations provided contextual and experiential insights that were crucial for a deeper understanding of the intervention’s effects (Phillippi and Lauderdale, 2017). Additionally, baseline information about participants, such as professional experience, prior training, and empathy levels, was collected before the intervention to explore potential relationships with their ability to address GBV or the impact of the training. Figure 1 illustrates the study flowchart.
Diagram of data collection in the study. Thirty-eight healthcare professionals from seven primary care centers participated. Pre-test quantitative data captured sociodemographics and baseline measures. The VR-based intervention included scenario presentations and debriefing (two cases per session, ∼2 h). Qualitative data were collected via field notes. Post-test quantitative data assessed intervention effects.
Flowchart of a VR-based educational intervention. It begins with a sample of 38 healthcare professionals from seven primary care centers. Pre-test involves sociodemographic data, IRI, and PREMIS. Educational intervention includes VR scenarios (10 minutes) and debriefing (50 minutes) with case-based discussion and theoretical conceptualization. Two cases per session are covered in approximately 2 hours. Post-test involves PREMIS and an ad hoc satisfaction questionnaire. Field notes with qualitative data are used for session observations.VR scenarios
The virtual reality scenarios were developed using an expert-informed approach. A focus group was conducted with six professionals experienced in working with victims of GBV. The group included two healthcare providers (a physician and a midwife), two social workers, and two specialists from organizations dedicated to supporting women affected by GBV. Insights from this discussion were used to identify both the essential skills healthcare professionals need to provide appropriate care and the most frequent cases they are likely to encounter. From there, four cases were designed to represent the most frequent and relevant situations encountered by professionals: (I) psychological violence perpetuated throughout married life, (II) physical violence during pregnancy, (III) violence in a drug addiction context, and (IV) vicarious violence towards children. The scripts were written with the guidance of experts, professional actors were sought, and the scenarios were recorded in 360° video format. They last between 3 and 5 min. No interaction or movement was required within the virtual environment, as the design aims to minimise the usual discomforts associated with virtual reality, such as dizziness or the risk of falls or collisions. For the recording and editing of the VR cases, we collaborated with Immersium Studio, a company specialized in the design of educational virtual reality resources. Each scenario was associated with specific expected learning outcomes, and instructional guides were developed to assist facilitators in conducting the debriefing process. Table 1 presents the learning outcomes for the four VR scenarios, along with representative images, to provide readers with a clearer understanding of their design and content. The VR scenarios and the detailed facilitator guides for each scenario are provided in Supplementary Data Sheet 1.
Summary of the four VR scenarios used in the training intervention. For each scenario, a brief description of the scene, the intended learning outcomes, and a representative image illustrating the immersive design of the VR simulation are provided.
VR scenario & learning outcomes
Representative image
Scenario 1: Doctor, these pills make me drowsyIsabel is a woman in her 60s who visited her primary care regular doctor due to daytime sleepiness following the initiation of a new insomnia treatment. Having been married for numerous years and serving as the primary caregiver for her disabled daughter, she shared details during the appointment about certain behaviors exhibited by her husband. These descriptions raised concerns for the doctor, prompting suspicions of potential GBV.
Learning outcomes:
1. Strengthening interview techniques, active listening and empathy.
2. Applying different communication and relational strategies based on the victim’s situation.
3. Recognizing individual value systems, promoting critical examination of these constructs.
4. Raising students’ awareness of GBV as a determinant of women’s health.
A doctor wearing a white coat sits at a desk with a laptop, speaking to a patient seated on the opposite side. The room is bright, with a window showing trees outside. A pen and some office items are on the desk.
Scenario 2: Spotting during pregnancyAndrea is a 27-year-old girl who met her current partner, Miquel, some years ago. She discovered she was pregnant last month and decided to go ahead with the pregnancy. Today they both attended the gynecology emergency room for vaginal bleeding that had started that morning. Andrea is very worried, but Miquel plays down the incident and does not let her speak. The physician suspects domestic violence and attempts to find an opportunity to talk to Andrea alone, but Miquel obstructs these efforts.
Learning outcomes:1. Analysing the ethical dilemmas faced by healthcare professionals when they suspect or become aware of a situation of GBV.2. Recognising the circumstances of vulnerability faced by pregnant women and their specific needs.3. Applying risk assessment tools for women who suffer GBV.4. Building a decision-making framework that incorporates complexity, always placing the needs of women at the forefront.
A healthcare setting with a young girl sitting on an examination table, looking down. A man is seated beside her, gently placing a hand on her shoulder and knee. A female healthcare professional, in a white coat, stands nearby, appearing to engage with them. Medical equipment and supplies are visible in the background.
Scenario 3: Laia, have you been using again?Laia Roldan, a 27-year-old woman is attending her follow-up appointment with her mental health nurse. Laia has a history of drug addiction but is currently undergoing detoxification. During her visit, she wishes to discuss a problem with a new medication. However, the nurse also observes suspicious marks, leading to further investigation.
Learning outcomes:
1. Recognising indicators of GBV in complex contexts, as situations involving addiction, as well as appropriate interventions.
2. Identifying stereotypes and beliefs that may affect the practices of healthcare professionals through the application of critical thinking and reflective practice.
3. Acknowledging the concept of institutional violence and secondary revictimization, as well as its manifestation in professional practices.
A medical professional in a white coat is speaking with a seated young woman in a doctor's office. The woman is wearing jeans and a sleeveless top, appearing engaged in conversation. A laptop and office supplies are on the desk between them.
Scenario 4: Mati has a bellyacheMarisol has come to the pediatric clinic with her son, Mati, who is feeling unwell. She appears very nervous and concerned about what might be causing her child’s discomfort. The pediatrician has decided that it may be necessary for a social worker to speak with her. Mati has been experiencing stomach pain since returning from a few days with his father.
Learning outcomes:
1. Analysing protocols for responding to situations of suspected GBV, particularly in cases involving children.
2. Identifying a case of vicarious violence through the narrative and examination of a child or their mother.
3. Recognising the importance of documenting aspects related to GBV in medical records and their advantages and disadvantages.
A person in a white lab coat gestures while speaking to another person in a yellow shirt holding a purse. They appear to be in a hallway with red chairs.
The training session
The intervention consisted of a 2-h group session involving 4 to 6 healthcare professionals. In total, seven sessions were conducted with different participant groups. Across these sessions, the four VR scenarios developed were used to ensure exposure to all the designed learning situations. Each session began with the signing of the informed consent form, an introduction to the topic, completion of the pre-intervention questionnaire, and a brief orientation on the use of virtual reality (VR) headsets and potential discomforts.
Each session included the visualization and analysis of two VR scenarios depicting different cases of GBV. The first scenario consistently focused on the detection of psychological violence in a primary care setting, while the second scenario presented a more complex case incorporating one of the following axes of inequality: pregnancy, drug addiction, or vicarious violence.
Following the immersive experience, the training session progressed to an extensive debriefing process consisting of two parts: (I) a brainstorming activity to analyze participants’ reactions and questions generated by the cases, followed by a group discussion to address emerging concerns and explore how participants would respond to similar real-life situations; and (II) a brief closing lecture delivered by the facilitator to clarify key theoretical concepts related to addressing GBV and to discuss techniques for managing comparable situations. This reflective process provided a foundation for analyzing the lived experience through VR and for enriching future professional practice.
Finally, the session concluded with instructions for completing the post-intervention questionnaires, and the facilitator completed an observation template to document the qualitative data collected. All training sessions were conducted by one of the researchers.
Study participants
The study population consisted of HCPs (physicians, nurses, physiotherapists, psychologists and social workers, among others) from several primary care centers in the area of Barcelona. Participant recruitment followed a convenience sampling method. Invitations were extended through an open call to HCPs. The training program was communicated via email to each center, which agreed to participate, and it managed participant sign-ups based on the order of interest and confirmation of availability during their work schedule. Every session was performed in each healthcare center to facilitate participants’ attendance.
Finally, the sample included seven groups of HCPs, each group consisting of 4-6 participants, with heterogeneity in the health professions represented and resulting in a total sample size of 38 professionals (see Table 2).
Socio-demographic characteristics of study participants. Categorical variables (age groups, gender, profession, years of work experience) are presented as number of participants (n) and percentage (%). Mean values are reported for continuous variables (age and years of work experience).
Socio-demographic variables
n
Percent
Age
20–29 years old
6
15.79
30–39 years old
4
10.53
40–49 years old
22
57.89
>50 years old
6
15.79
Mean age
42.24
Gender
Male
7
18.42
Female
31
81.58
Profession
Nurse
17
44.74
Physician
7
18.42
Clinical psychologist
4
10.53
Social worker
6
15.78
Others (nursing assistant + lab technician)
4
10.53
Years of work experience
0–3 years
14
36.84
4–10 years
5
13.16
11–20 years
11
28.95
>20 years
8
21.05
Mean
12.35
Data collection
The quantitative data was collected through a paper-based questionnaire. After signing the informed consent, every participant was assigned a numerical code to anonymize the data. The pre- and post-intervention questionnaires were completed immediately before and after the training session.
The sociodemographic data collected included age, gender, profession, years of experience as HCP, and whether the participants had received any prior training on GBV. In addition, the main variables of the study were measured using three instruments: (I) The Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), Spanish version. A standardized and validated questionnaire specifically designed to assess HCPs’ ability to respond to such situations. Due to the extensive length of the scale, only Sections 1–3 were applied. According to the authors who translated and validated the scale, Cronbach’s alpha values for most indices were above 0.7 or very close to it, so the scale provides acceptable intern consistency (Cases et al., 2015). Sections 1, 2 analyze self-perceived knowledge and competence to respond to GBV situations, while Section 3 originally labeled “Opinions,” explores professionals’ actions in these cases. For clarity in interpreting the results, the term “Perspectives on GBV addressing” was used in this study instead of “Opinions,” as it was considered a more accurate term of the items in Section 3, which focus on how professionals approach cases of gender-based violence. This third section is further divided into eight sub-sections (see Table 3); (II) The Interpersonal Reactivity Index (IRI). One of the most widely used validated instruments for measuring empathy, Spanish version. In this instance, in terms of intern consistency, the authors of the translation and validation of the scale reported Cronbach’s alpha values ranging between 0.68 and 0.80 for the entire item set (Mestre-Escrivá et al., 2004); and (III) A version adapted to our context of the Satisfaction with Simulation Experience Scale (Levett-Jones et al., 2011) was utilized alongside additional questions designed to evaluate the satisfaction of HCPs participating in the training. Responses were measured using a Likert scale.
PREMIS’ questionnaire sections used in the pre- and post-test evaluation. Number of questions (n) is shown for each section. “Level of perceived competence” assesses self-reported ability, “Level of perceived knowledge” evaluates factual understanding, and “Perspectives” covers perceptions on addressing GBV, legal requirements, available resources, self-efficacy, substance use, victim understanding and autonomy, and perceived barriers.
PREMIS’ scale sections
Questions (n)
I. Level of perceived competence
10
II. Level of perceived knowledge
14
III. Perspectives
32
- About capacity to address GBV
- About legal requirements
- About facilities and time to assess GBV
- About self-efficiency
- About alcohol and drug use
- About victim understanding
- About victim autonomy
- About barriers
For qualitative data collection, the session facilitator, who was also a study researcher, took brief field notes during the educational sessions to aid in recalling important details for writing more comprehensive notes afterward (Phillippi and Lauderdale, 2017). Immediately after each session, while memories were still fresh, the researcher completed a bespoke template designed to capture the emotions most commonly expressed by participants when observing cases of GBV. The template also documented key discussion points and other notable observations arising during the session.
Quantitative data analysis
The statistical analysis was divided into two main parts. First, a descriptive analysis of the sample’s socio-demographic characteristics and pre-training scores on the self-perceived ability to manage GBV (PREMIS questionnaire) was conducted. Second, the impact of the training intervention was assessed using pre- and post-intervention data.
In the PREMIS instrument, the first two domains—Level of Perceived Competence and Level of Perceived Knowledge—are composed of 10 and 14 items, respectively. Each item is rated on a 1–7 Likert scale, and for both domains the subscale score is computed as the mean of all constituent items. Consequently, the theoretical score range for these domains is 1–7, and all descriptive and inferential analyses were conducted using these averaged scores. In contrast, the Perspectives domain comprises 32 items, also rated on a 1–7 Likert scale, but in this case the scoring procedure was performed by calculating the sum of all item responses rather than the mean (with 224 points as maximum attainable score). This product allows the domain to be further decomposed into predefined subscales, each corresponding to the specific subsets of items within the 32-item structure. It was hypothesised that participants would demonstrate significant improvements in Perceived Competence, Perceived Knowledge, and overall Perspectives scores following the training intervention, reflecting enhanced competence, understanding, and attitudes related to the identification and management of GBV cases.
Pre-training data were analyzed by comparing scores across the different sections of the PREMIS scale among the sample groups. After assessing the normality of the variables through graphical diagnostics using Q–Q plots, Spearman’s correlation coefficient was used for non-normally distributed variables, and the paired Student’s t-test for normally distributed variables, with a significance level set at p < 0.05.
To evaluate the effect of the training intervention in PREMIS scores before and after the intervention, a paired t-test comparing pre–post scores was performed. Meanwhile, a linear mixed models were used to assess these changes, as well as to examine whether relevant covariates, such as gender, professional experience, prior training, and empathy levels, influenced these scores, while accounting for inter-individual variability. The models included fixed effects for group, time point, and their interaction, and random intercepts for participants. When residual diagnostics indicated violations of normality assumptions, robust linear mixed models were fitted using the DAStau estimation method to reduce the influence of outliers and improve the stability of parameter estimates. Finally, to guarantee the validity of the statistical inferences, the Benjamini–Hochberg FDR correction for multiple comparisons was applied. Internal consistency for the PREMIS subscales was assessed using Cronbach’s α at both measurement points.
Qualitative data analysis
The qualitative data collected were subjected to thematic analysis conducted by three researchers. The textual corpus for the analysis comprises field notes gathered during the educational sessions and completed after the intervention. These notes cover the following topics: 1) participants’ emotional landscape (insights, feelings, and reactions); 2) dilemmas and discrepancies emerging during debriefing sessions; and 3) underlying tensions.
The analysis followed these steps: 1) a general overview through multiple readings of the field notes; 2) codification combining both deductive and inductive approaches; 3) categorization; and 4) intracode and intercode comparison, followed by recodification to ensure internal consistency of codes and categories. Codification was both deductive, allowing comparability with other theoretical frameworks, and inductive, enabling the generation of codes grounded in observed perspectives, behaviors, and emotions (Vaismoradi et al., 2013). First, the researchers coded the data independently. To enhance methodological rigor and the credibility of the qualitative analysis, a triangulation process was conducted, during which the researchers iteratively discussed coding discrepancies, recoded when necessary, and collaboratively finalized the categorization through consensus.
The qualitative component was primarily used to identify the dilemmas that emerged when participants worked through the VR scenarios created. These dilemmas offered insight into the challenges that healthcare professionals encounter when addressing gender-based violence in clinical practice, and provided essential information for evaluating the educational usefulness of the training resources. In addition, the qualitative findings complemented the quantitative results by helping to explain the patterns observed in the questionnaire data. This integration strengthened the overall interpretation of the intervention’s effect and enhanced the trustworthiness of the study through methodological triangulation (Deggs and Hernandez, 2018).
ResultsPre-intervention assessment of participants’ self-perceived preparedness and perspectives on GBV
The following section presents the results obtained from the pre-intervention questionnaire, which provide valuable insights into the baseline situation of the participants regarding GBV’s addressing. By establishing this previous reference point, the analysis facilitates a more precise evaluation of subsequent changes and the potential effect of the implemented intervention on participants’ self-perceived competence, knowledge and perspectives towards GBV. To ensure a comprehensive interpretation of these findings, three moderating variables were also considered: participants’ prior professional experience, previous exposure to formal training on the topic, and their empathy levels, measured by IRI score.
Self-perceived competence and knowledge
Before the intervention, participants demonstrated relatively low levels of self-perceived competence (mean = 2.919/7) and knowledge (mean = 3.013/7). Moreover, we examined the influence of professional experience, empathy, and prior knowledge on participants’ self-perceived competence and knowledge, and the analyses revealed distinct patterns across these factors.
Firstly, referring to years of professional experience, it neither did correlate significantly with perceived competence or knowledge. Interestingly, professionals with extensive experience (>20 years) and those in the early stages of their careers (0–3 years) reported comparable levels of perceived competence. This finding was unanticipated, given the conventional expectation of a gradual increase in perceived competence corresponding with accumulated years of professional experience. However, it suggests that factors beyond years in practice, such as specific training or exposure to GBV-related cases, may play a more critical role in shaping professionals’ confidence in addressing these situations.
Secondly, no statistically significant relationships were observed between participants’ self-perceived competence for addressing GBV and their empathy levels, (p = 0.556). Similarly, no significant association was found between participants’ self-perceived knowledge and empathy (p = 0.303). These findings suggest that, within this sample, variations in personal empathy levels were not systematically related to participants’ self-assessed readiness or knowledge in addressing GBV.
Finally, in terms of prior training experiences about GBV, the findings demonstrated that prior training had a substantial impact on both perceived competence and knowledge among participants, with significant p-values (p < 0.001). Despite the strong relationship between training hours and perceived knowledge (p = 0.07), this association did not extend to perceived competence. Concretely analyzing how the kind of prior preparation impacted on self-perceived competence and knowledge, those who engaged in reading protocols, watching instructional videos, and attending courses, exhibited significantly higher scores. Additionally, theoretical training during their curricular programs was identified as a key contributor to greater self-evaluation, too. Finally, although the statistical significance was not established, a positive correlation was identified between the time invested in prior formation on the matter and the self-perceived competence and knowledge (p = 0.14 and p = 0.079, respectively) prior to the intervention.
Perspectives on GBV addressing
Regarding participants’ perspectives of GBV, the baseline data indicated a generally limited level of appropriate attitudes and perspectives prior to the intervention. Given that the maximum attainable score on subscale III of the PREMIS scale was 224 points, the pre-intervention mean of 82.45 points may reflect a limited baseline level of understanding and sensitivity regarding issues related to GBV.
In reference to years of professional experience, they were positively associated with improvements in two perspectives’ subcategories, understanding victims (p = 0.012) and perceived barriers to intervention (p = 0.042). These results highlight the role of accumulated experience in enhancing empathy and the ability to navigate systemic challenges in GBV addressing.
Empathy emerged as a significant factor influencing attitudes toward GBV. Although female participants reported slightly higher empathy levels compared to men, with a near-significant result (p = 0.068), there were no significant differences in IRI scores in terms of age or occupation. Even so, a significant positive correlation was found between empathy and promising perspectives toward GBV previous to the training session (p = 0.026) (see Figure 2). This suggests that individuals with greater empathic capacity demonstrate a deeper engagement with the subject matter. These findings highlight the potential role of empathy in shaping professionals’ attitudes and responses, reinforcing the importance of integrating emotional and cognitive components into educational interventions aimed at improving competence for addressing GBV.
Association between participants’ empathy levels, measured by the Interpersonal Reactivity Index (IRI), and their perspectives toward Gender-based violence (GBV).
Scatter plot showing IRI score on the y-axis and Perspectives score on the PREMIS scale on the x-axis. A red trend line indicates a positive correlation between the two variables.
While prior training was generally associated with a more informed perspective towards GBV, no significant relationship was found between the total number of training hours and overall perspective toward victim management. However, a significant positive trend (p = 0.001) was identified in the subcategory of barriers to intervention, suggesting that more training hours could be associated with greater awareness and understanding of systemic obstacles in GBV. The type of training participants had received prior to the intervention also appeared to influence their baseline perspectives, producing variations across the different PREMIS’s perspectives subscales. On the one hand, activities like reading protocols or watching videos about how to address GBV were associated with higher scores in legal requirements, facilities and time management, and self-efficacy. Consequently, procedural knowledge and practical decision-making skills seem to be strengthened by these forms of independent learning. On the other hand, theoretical training seemed particularly impactful in the sub-scales of time management, self-efficacy and victim understanding and autonomy. This suggests that while both types of training contribute to HCPs competence, theoretical training may be also critical in framing professionals’ perspectives and approaches to victim-centered care.
Effects of the VR-based training intervention on professionals’ self-perceived preparedness and perspectives on GBV
The subsequent section presents the results of the pre- and post-intervention comparison, offering a comprehensive view of the changes observed in participants’ self-perceived competence, knowledge, and perspectives regarding GBV.
Changes in self-perceived competence and knowledge
The PREMIS subscales demonstrated high internal consistency in the current sample. For Perceived Competence, Cronbach’s α was 0.958 at pre-intervention and 0.953 at post-intervention. For Perceived Knowledge, α values were 0.967 at pre-intervention and 0.954 at post-intervention. These findings support the stability of the measures used for subsequent analyses.
The quantitative analysis revealed significant pre–post improvements in participants’ perceived competence and knowledge (p < 0.001; see Table 4). Qualitative impressions echoed these findings: whereas participants initially expressed a sense of uncertainty and lack of preparedness when facing cases of intimate partner violence—“This is a situation I would have never wanted to encounter”—by the end of the intervention they emphasised the value of being exposed to realistic scenarios, noting that “Once you clearly recognise a case, you start seeing them everywhere”. This shift was further reflected in the final satisfaction ratings, with the average score for perceived knowledge and skills acquired during the training session reaching 4.62 out of 5. Together, these results indicate that the intervention enhanced participants’ self-perceived competence and understanding of the subject matter, as evidenced by both objective test outcomes and the qualitative and satisfaction data showing relief of initial concerns and increased confidence after the training.
Pre- and post-test quantitative results are shown as mean ± SD, with minimum (Min) and maximum (Max) values.
PREMIS’ scale sections test
Mean
SD
Min
Max
IC 95%
p-value
Perceived competence
Pre
2.919
1.406
1.000
5.700
1.010 1.642
<0.001
Post
4.270
1.321
1.400
6.600
Perceived knowledge
Pre
3.013
1.465
1.071
6.000
1.119 1.857
<0.001
Post
4.502
1.190
2.071
6.786
Perspectives (total)
Pre
82.450
15.149
42.000
108.00
1.73 11.69
0.010
Post
89.160
17.130
48.000
119.00
About capacity to address GBV
Pre
10.000
4.517
3.000
18.000
−3.255–0.270
0.022*
Post
8.158
4.309
0.000
18.000
About legal requirements
Pre
5.816
2.827
2.000
10.000
0.786 2.582
<0.001
Post
7.500
3.02
2.000
14.000
About facilities and time to assess GBV
Pre
18.320
7.785
6.000
36.000
1.218 5.412
0.003
Post
21.630
8.238
7.000
40.000
About self-efficiency
Pre
9.184
3.999
3.000
19.000
1.236 3.237
<0.001
Post
11.420
3.710
3.000
20.000
About alcohol and drug use
Pre
10.61
3.963
2.000
19.000
−0.431 1.747
0.229
Post
11.26
4.516
2.000
20.000
About victim understanding
Pre
10.500
5.649
1.000
23.000
−2.022 0.338
0.157
Post
11.000
5.133
1.000
23.000
About victim autonomy
Pre
13.000
3.166
5.000
21.000
−0.564 1.933
0.274
Post
13.500
3.379
6.000
21.000
About barriers
Pre
4.500
2.947
0.000
10.000
−0.276 1.749
0.149
Post
5.000
2.393
0.000
10.000
The p-value indicates statistical significance of pre-vs. post-test differences.
Levels of empathy did not substantially influence how participants responded to the intervention in these areas. However, prior training appeared to influence the magnitude of improvement. Participants without prior training exhibited significantly greater gains in perceived competence and knowledge compared to those with previous training (p = 0.015 and p = 0.012, respectively) (see Figure 3). These findings suggest that individuals without prior exposure to the topic could have a larger capacity for improvement and derived greater benefits from the intervention, underscoring the potential for structured educational programs to bridge gaps in competence among professionals with varying levels of initial knowledge.
Pre- and post-intervention self-perceived preparedness and knowledge, disaggregated by prior training experience. Boxplots illustrate the change in perceived preparedness (left) and perceived knowledge (right) before (Pre) and after (Post) the intervention. Data are stratified by participants’ previous training experience: “With prior training” (red) and “Without prior training” (blue).
Box plots showing perceived preparation and knowledge pre and post-intervention for groups with and without prior training. The y-axis is labeled from one to six. The group with prior training shows higher perceived preparation and knowledge than the group without training. The post-intervention scores improve for both groups across both metrics.Changes in perspectives on GBV addressing
The following results integrate both quantitative and qualitative data collected during the study, offering a comprehensive and thematically organised overview that encompasses not only measurable patterns, as determined by the analysis of test scores, but also the contextual dimensions of the educational intervention, as reflected in the coding of dilemmas that emerged during the sessions (Figure 4). While the quantitative results capture the objective changes in participants’ perspectives, the qualitative findings illuminate the underlying processes driving these changes such as the themes that surfaced during discussions, the dilemmas articulated by participants, and the tensions they navigated throughout the sessions. These qualitative insights help explain the mechanisms behind the quantitative shifts and clarify why certain areas showed greater or lesser change, thereby strengthening the overall interpretation of the intervention’s effects.
Thematic coding of dilemmas faced by healthcare professionals when addressing Gender-based violence (GBV). This figure maps the qualitative analysis process, illustrating the relationship between the identified axes of inequality (left column) and the corresponding emerging dilemmas. These dilemmas were subsequently condensed into core codes and grouped into three overarching categories: Healthcare Professionals’ Role, Ethical and Legal Challenges, and Victim’s Context.
Diagram illustrating the relationship between axes of inequality (drug addiction, pregnancy, vicarious violence) and emerging dilemmas in healthcare. The dilemmas, such as reporting requirements and sensitivity when children are involved, are linked to categories like healthcare professionals' role, ethical and legal challenges, and victim's context. Codes connecting these include HCP intervention, duty to report, and credibility concerns, leading to broader categories of health roles and victim's context.
The internal consistency analysis of the Perspectives scale yielded an overall Cronbach’s α of 0.609 at pre-intervention, increasing to 0.749 post-intervention, indicating good global reliability after the training. Most subscales demonstrated acceptable reliability, with clear improvements from pre-to post-intervention. Notably, the Legal Requirements and Victim Autonomy subscales—although still reflecting modest reliability due to their very small number of items—showed higher internal consistency in the post-intervention assessment. This improvement suggests that participants responded to these items in a more coherent and stable manner after the training, likely reflecting enhanced clarity and understanding of the concepts addressed. Only the Barriers subscale remained low in reliability, which is expected given its two-item structure, a condition known to constrain coefficient stability. Consequently, findings from these specific subscales should be interpreted with caution, while still providing complementary information within the broader pattern of results. In addition, qualitative data offer important contextual depth that helps illuminate these domains, supporting a more comprehensive interpretation despite the lower reliability observed in these particular subscales. Moreover, across all cases and scenarios, participants constructed narratives that highlighted several professional barriers that difficults effective action in situations of GBV. First, they described the challenge of managing emotional responses during critical moments in clinical practice, noting that “We should be able to separate our personal feelings from the care we provide”. Second, their reflections underscored difficulties in ensuring adequate follow-up and coordination with other services—“If she does not come back, that would be a failure”—including technical obstacles such as poor inter-service connectivity—“The digital connection between services is weak”. Third, participants identified training as a key structural barrier, with most groups emphasising that “this type of training should be provided to the entire team”.
As shown in Table 4, a statistically significant p-value (p = 0,01) suggests a substantial overall evolution in participants’ perspectives between the pre- and post-intervention scores. Among the subcategories, the following showed significant changes between pre-post scores: understanding of legal requirements, perceptions of facilities and time to assess GBV, and self-efficiency. These subscales, which exhibited a statistically significant change following the training session, closely align with the final main thematic categories identified through qualitative data coding. These categories include the role of healthcare professionals in addressing GBV, the significance of the victim’s contextual factors—as well as the intersecting structural inequalities affecting her experience—, and the ethical and legal challenges inherent in providing care to victims.
Participants demonstrated a substantial enhancement in their comprehension of the legal requirements subscale (p < 0.001), as well as in perceptions about facilities and time to assess GBV (p = 0.002). This quantitative gain is reflected in the qualitative data, where dilemmas regarding registration, referral to specific services and notification to the judicial system were the most frequently discussed across groups. The analysis of the participants’ reflections highlighted the existence of complex considerations and disparities of opinions regarding legal responsibilities, illustrating how the training fostered greater awareness of the ethical dimensions involving GBV.
Interestingly, although the self-efficacy subscale demonstrated a significant increase (p < 0.001), the subscale measuring capacity to address GBV showed a slight decrease post-intervention (p = 0.021). This latter subscale encompasses participants’ self-reported competence to assist victims, confidence in discussing abuse, and ability to gather relevant information for case detection. Qualitative insights help contextualize this apparent discrepancy: participants frequently described feelings of “insecurity,” “helplessness,” and “anxiety” during the sessions, reflecting an emerging recognition of the emotional and practical complexities involved in addressing GBV in clinical practice. Together, these quantitative and qualitative findings suggest that, although participants perceive themselves as more knowledgeable and prepared following the intervention, their heightened awareness of the multifaceted nature of GBV may temper their confidence in applying this knowledge, rather than indicating a true decline in capability. This intricate correlation among competence, self-perceived competence, and other related factors demands further exploration in future studies.
In addition, in the subcategory about alcohol and drug abuse, no significant improvement was observed in participants’ perspective scores, even when analyzing responses from groups who watched the scenario portraying drug addiction as an additional axis of inequality. Qualitative observations from these sessions highlighted the persistence of deeply ingrained biases and preconceptions among participants, which could help explain these results. While concepts such as re-victimization were occasionally acknowledged, some participants expressed judgmental attitudes, exemplified by statements like, “She would have gone back to drugs”. The persistence of mistrust toward victims represented in some codes accentuates how prior beliefs and experiences can shape professional responses, potentially limiting GBV’s addressing in clinical practice and the effectiveness of training interventions. Conversely, other participants regretted the approach taken by the professional in the case, remarking that “If the professional had not started with the question about drug use… The outcome might have been different”.
Although empathy was identified as a significant factor influencing perception scores from the early stages of this study, it did not appear to significantly impact the degree of change between pre- and post-intervention assessments. However, an exception to this trend was observed in the legal requirements subcategory, where a significant change was detected (p = 0.015). This suggests that individuals with higher baseline empathy may have been particularly attuned to aspects related to legal considerations during the training session. Qualitative data complemented these findings reflecting that whether or not to alert the judicial system when a GBV situation was identified, it was the most repeated dilemma in the different groups.
Finally, prior training also showed a nuanced effect on participants’ perspectives. While there were no significant differences in the overall improvement of perspectives between participants with and without previous training, the subcategory of self-efficacy revealed a significant advantage (p = 0.034), especially for those without prior training. These participants experienced greater gains in self-efficacy’s vision post-intervention, consistent with the trends observed for perceived competencetion and knowledge.
Discussion
This exploratory study evaluated the effect of an educational intervention using virtual reality (VR) and experiential learning (EL) as a pedagogical tool to prepare healthcare professionals to address gender-based violence (GBV). While the primary aim was to explore potential impacts rather than to provide confirmatory evidence, the findings suggest that the intervention may be effective in fostering participants’ self-perceived competence and knowledge on GBV. The intervention involved immersing participants in realistic and commonly encountered GBV scenarios through VR headsets, followed by a structured and in-depth debriefing session. This reflective phase connected the experiential component with established theoretical knowledge on the subject.
The methodology employed shares significant similarities with clinical simulation training, although the experiential component is mediated through VR technology. The results align with previous evidence from simulation-based educational approaches, which emphasize that the integration of theoretical frameworks with practical experiences enhances both competence and competence among healthcare professionals (Diaz-Navarro et al., 2024). This approach may represent a valuable complement to clinical training, helping professionals to manage the complexity of GBV more effectively while fostering deeper confidence and the ability to apply acquired skills in real-world contexts (Gadappa et al., 2022). Indeed, both quantitative and qualitative outcomes demonstrated improvements in self-perceived knowledge and attitudes following the intervention, enabling HCPs to recognize GBV as a critical public health issue rather than a private matter (Arora et al., 2023; Kalra et al., 2021).
Beyond individual skill development, addressing GBV also involves confronting the emotional and ethical dimensions of care. Empathy and ingrained values significantly influence HCPs’ attitudes toward supporting survivors of GBV. Participants with higher baseline empathy scores tended to show greater sensitivity to legal and ethical considerations, reinforcing findings that highlight empathy’s vital role in fostering effective survivor interactions (Kalra et al., 2021). However, these empathetic insights often coexist with entrenched cultural and societal prejudices, which hinder healthcare responses. The present findings, aligned to recent evidence, reveal that biases such as normalizing violence or mistrusting women who suffer or have suffered violence, create substantial barriers to effective care (Arora et al., 2023). These challenges are placed parallel to themes identified in HCPs personal barriers, such as seeing intimate partner violence as a private matter, frustration when survivors do not follow advice, or beliefs that addressing GBV falls outside their responsibility (Tarzia et al., 2021). Addressing these issues requires not only targeted educational interventions but also systemic reforms within healthcare institutions. WHO underscores the importance of organizational shifts to reduce stigma and promote survivor-centered care (2021b). Furthermore, recent studies advocate for cultural competency training to dismantle biases and align practices with global recommendations for enhancing healthcare responses to GBV (Rubini et al., 2023; Storm-Mathisen, 2024). These reforms must prioritize both structural changes and training programs that challenge societal norms, fostering a healthcare environment capable of providing empathetic and effective support for survivors.
Our findings indicate that perceived competence to address GBV could be more closely related to the training received on this topic than to professional experience. Training programs that engage both cognitive and emotional dimensions, such as the VR-based intervention tested here, appear particularly effective. Given the complexity and emotional intensity of GBV-related situations, theoretical knowledge alone is insufficient; immersive and reflective approaches are needed to foster meaningful learning, empathy, and attitudinal change (Álvarez et al., 2017).
Consistent with these observations, recent innovations in health sciences education have increasingly explored active learning strategies that integrate experiential and reflective components, yielding promising outcomes. Examples include role-play exercises (Cahil and Dadvand, 2021) and the use of dramatized problem-based videos, both of which have been shown to foster engagement, empathy, and critical reflection among learners (Adánez-Martínez et al., 2022; Adánez-Martínez et al., 2023; Cahil, 2020). These approaches share with VR the ability to immerse participants in realistic, emotionally charged scenarios that stimulate both cognitive and affective engagement, thereby facilitating deeper reflection and more meaningful learning experiences.
In this regard, the immersive virtual reality scenarios based on 360° video developed for this intervention provided a highly realistic experience set in authentic clinical contexts, allowing participants to engage with situations in a vivid and meaningful way. This shared experience fosters rich discussions during the debriefing phase, where learners reflect on professional actions, confront dilemmas, and exchange possible responses. It is during this phase that learning is conceptualised and consolidated, and the facilitator plays a crucial role in guiding reflection. Our results are consistent with previous studies showing that VR resources followed by debriefing sessions can be highly valuable for developing social skills relevant to clinical practice, such as communication, decision-making, time management, and critical thinking (Mørk et al., 2024). Although the lack of interactivity may be considered a limitation in fostering decision-making skills, VR scenarios based on 360° videos have significant advantages: they are feasible and cost-effective, they ensure that all participants experience the same situation, and they can be reviewed as many times as necessary to analyse the case in greater depth. Therefore, further research is warranted to explore the potential of these resources in health sciences education.
Several limitations must be acknowledged. Firstly, although the improvement in post-test scores appears to result from the intervention, we cannot be entirely certain of the specific contribution of the VR scenarios themselves. The absence of a control group limits our ability to determine whether the outcomes are attributable to VR or to other components of the intervention, nor whether similar results might have been achieved with conventional 2D videos. However, our field notes document that the immersive experience triggered a powerful emotional engagement during the intervention. This aligns with existing literature, which indicates that immersive 360° video in health and social care education significantly enhances learner attention and motivation. A scoping review found consistent evidence that immersive 360° videos increase attention, relevance to skills, learners’ confidence, and satisfaction, key dimensions of the ARCS motivational model (Blair et al., 2021).
Secondly, the potential influence of the Hawthorne effect cannot be overlooked, as participants were aware that their performance during the training was being monitored for research purposes. Thirdly, self-selection bias may have led to an overrepresentation of HCPs who were already sensitized to GBV-related issues, potentially interfering on the observed effects of the intervention. If participation had been mandatory, including individuals with no prior awareness or engagement with the topic, the impact of the training might have been even greater. Moreover, the female-dominant composition of the sample could have influenced the findings, as gender differences may shape perceptions and responses to GBV training. While the triangulation of quantitative and qualitative data enhances the study’s interpretative depth, the small sample size, the brief duration of the intervention, and the absence of long-term follow-up constrain the robustness and generalizability of the results. Finally, given that the analysis was exploratory in nature, no correction for multiplicity was applied between the subscales of the PREMIS instrument. The main objective was to identify possible patterns and relevant associations to guide future research rather than performing confirmatory hypothesis testing. Consequently, sensitivity of the analysis was prioritised over strict control of type I error, recognising that the results should be interpreted with caution.
To address these limitations, future research should implement multicenter studies with larger, more diverse samples to enhance external validity. Employing random sampling and prospective follow-up designs would help mitigate selection bias and assess long-term effects, thereby strengthening the evidence base for scalable, sustainable training programs for HCPs addressing GBV.
Conclusion
This study provides evidence that suggests that VR-based training may enhance HCPs’ self-perceived competence, knowledge and perspectives in addressing GBV. By integrating experiential learning with realistic clinical dilemmas, VR simulations can bridge the gap between theoretical knowledge and practical application, fostering critical thinking and ethical reflection. The findings indicate that these scenarios facilitated deeper cognitive and emotional engagement, supporting HCPs in confronting personal biases and complex decision-making processes and refining their approach to survivor-centred care.
This research offers preliminary insights into how innovative, evidence-informed educational strategies may support HCPs’ responses to GBV, by providing repeated exposure to challenging cases in a controlled environment and helping participants work toward the intended learning outcomes while reducing the emotional pressure of real-life encounters. In addition, the integration of qualitative and quantitative analysis suggests that VR-based training may encourage attitudinal shifts in areas such as legal decision-making, self-efficacy, and the recognition of systemic barriers.
Despite these promising effects, these results should be interpreted with caution and viewed as exploratory. Future research is needed to confirm these findings, assess the long-term impact of VR-based interventions, evaluate their scalability across different healthcare settings, and explore their integration into standardized professional training curricula as a component of GBV education. Overall, given the persistent gaps in healthcare responses to GBV despite numerous training initiatives worldwide, immersive training methods may represent a potentially useful approach to supporting professionals in developing the skills and confidence needed to provide comprehensive, survivor-centred care.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
The studies involving humans were approved by Clinical Research Ethics Committee - IDIAP Jordi Gol. 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.
Author contributions
BV: Conceptualization, Investigation, Methodology, Writing – original draft, Writing – review and editing, Formal Analysis. MB: Conceptualization, Investigation, Methodology, Supervision, Writing – original draft, Writing – review and editing. MC: Conceptualization, Investigation, Methodology, Supervision, Writing – original draft, Writing – review and editing.
Acknowledgements
We gratefully acknowledge the collaboration and technical expertise of Jose Ferrer Costa for his support in the use of virtual reality glasses and in the organization of the training sessions. We also wish to thank all the health care professionals who participated in the training sessions and completed the questionnaires; this research would not have been possible without their valuable contribution. Finally, we greatly appreciate Sol Balcells’ technical assistance in the statistical analysis.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was used in the creation of this manuscript. AI tools were used solely to support the language editing and formulation of the manuscript. No AI tools were used for data analysis, interpretation, or generation of scientific content.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frvir.2025.1648180/full#supplementary-material
Edited by:Marientina Gotsis, University of Southern California, United States
Reviewed by:Saranraj Loganathan, Mepco Schlenk Engineering College, India
M. De Gracia Adanez, University of Murcia, Spain
Derya Sivuk, Ankara Haci Bayram Veli University, Türkiye
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