Genetic counseling is an important process for patients and their families to understand a disease and allow clinicians to make informed decisions based on their situation.

Although the importance of genetic counseling is well understood among healthcare professionals in Korea, this service is not readily available. Some barriers include genetic counselors not being recognized as healthcare professionals under the National Health Insurance system, the limited length of a genetic counseling session per patient, and a lack of awareness of the service. Every country has adapted genetic counseling services to different healthcare systems. As the need for genetic counseling increases, healthcare providers in each country should consider effective ways of providing genetic counseling to their own populations.

Korea has a National Health Insurance system, and under Korean medical law, medical doctors and nurses are recognized as medical professionals who can provide genetic counseling. Doctors are required to see many patients within a limited time (e.g., 30–60 patients in a 3–4-hr clinic), which means that doctors can only spend 4–6 mins with each patient.

In this type of healthcare setting, traditional genetic counseling sessions that require 30–60 mins of counseling per patient cannot be implemented well. Therefore, new methods of genetic counseling should be considered and designed based on this need.

Genetic counseling is typically conducted in one-on-one sessions, which is crucial to maintain patient privacy and to protect personal health information. However, general explanations of genes, chromosomes, inheritance, genetic testing methods, possible test results, and familial implications discussed during the session do not necessarily include private information. In healthcare systems with a limited number of genetic counselors or healthcare professionals who can provide genetic counseling, implementing group genetic counseling could be beneficial not only to save time and resources but also to serve more patients in need.

A metaverse is a space in which a society is built and activities are carried out in the virtual world. Metaverse has been implemented in medical education. For example, using a smart camera built into the operating room, the surgical procedures were livestreamed in the metaverse for medical students to observe and learn [1]. In the last few years, there has been a movement toward implementing the metaverse in digital healthcare. Studies have discussed the effectiveness of using a metaverse platform in occupational therapy or mental health with virtual reality (VR) or augmented reality (AR) [2^-4]. In Korea, several hospitals have opened clinics in this virtual world to provide various services such as health consultations and patient education [5, 6].

Metaverse is already a hot topic in the healthcare industry; however, no studies have examined the effectiveness and usefulness of its implementation in genetic counseling. We evaluated whether the metaverse platform can be an alternative service-delivery model for group genetic counseling to supplement time and labor limitations. We investigated these issues while providing group genetic counseling for patients, families, and/or people with indications for counseling related to hereditary breast cancer.

Study design

Group genetic counseling for hereditary breast cancer was provided on the metaverse platform ifland from May 7, 2023, to May 31, 2023. Prior to the session, the participants were asked to complete a questionnaire to collect basic characteristics (Supplemental Material 1) and a hereditary breast cancer knowledge assessment questionnaire (Supplemental Material 2) comprising 10 questions about hereditary breast cancer. After the session, the participants were asked to complete the same questionnaire to evaluate whether the session was effective in improving their knowledge. A satisfaction survey (Supplemental Material 3) was conducted to measure participants’ experiences.

This study was conducted according to the ethical standards of the Institutional Bioethics Committee of Mokdong Hospital affiliated with Ewha Womans University College of Medicine, Seoul, Korea, and approved by the same Committee (No. 2022-02-003-003).

Participants

Participants were recruited from Ewha Womans University, College of Medicine, Mokdong Hospital (Seoul, Korea) between April 15, 2022, and May 31, 2022. Recruitment posters were posted at the hospital, and study participation was voluntary. At the beginning of the study, 140 people expressed their intention to participate, but nine did not participate in the scheduled session (6.4% rejection rate).

The remaining 131 participants were divided into three groups: a patient group (N=45; patients who had been diagnosed as having breast or ovarian cancer), a family group (N=43; individuals who had never been diagnosed as having cancer but had a family history of cancer), and an interested group (N=43; individuals, including nurses, who were interested in learning about hereditary breast cancer). All participants were Korean.

Metaverse platform

The metaverse platform developed by SK Telecom ifland (https://ifland.io/) was used in this study; ifland is downloadable only to people with Korean accounts.

Study procedures

Group genetic counseling session via ifland

The researcher provided a manual to the study participants regarding how to access the group genetic counseling session in ifland and asked them to select the date of participation between May 7, 2022, and May 31, 2022. Each session was repeated 20 times.

The study participants were required to download the app on their smartphones, create an ID, and set an avatar to participate. Each session was conducted in private mode, and only those with a link provided by the researcher were able to access the virtual conference room. As only avatars were used, none of the participants’ personal health information was revealed. The virtual conference room used for group genetic counseling is presented in Supplemental Data Fig. S1.

In each session, a minimum of two and a maximum of 12 participants participated. When the participants entered the virtual conference room, they could move their avatar to a spot where they wanted to sit and watch a video recorded by the researcher. The video included topics such as the definition and characteristics of hereditary breast cancer, types of available genetic tests, interpretation of genetic testing, and the importance of genetic testing and counseling (Supplemental Data Table S1). The session lasted 30 mins, including watching the video for 20 mins and a subsequent question-and-answer round for 10 mins. Participants were encouraged to ask questions using a microphone on the metaverse platform. The same two individuals facilitated every group of genetic counseling sessions and answered questions: one was a doctor with a specialty in genetics and the other was a nurse who obtained a Master’s degree from the Graduate School of Genetic Counseling.

After the session, the participants were asked to come up to the stage to take a group photo. The participants were able to pose and dance as they desired.

Questionnaire and evaluation

The knowledge questionnaire (Supplemental Material 2) was a revised form of the Breast Cancer Genetic Counseling Knowledge Questionnaire developed by Erblich, et al. [7]. A total of 10 questions were included; correct answers were scored as “1” and incorrect or “I don’t know” answers were scored as “0.”

Another questionnaire (Supplemental Material 3) was used to investigate participants’ satisfaction with the content of the video, use of the metaverse platform, and advantages and disadvantages of using this new method of education. Each question was evaluated on a 5-point scale: 5 for “strongly agree,” 4 for “agree,” 3 for “neutral,” 2 for “disagree,” and 1 for “strongly disagree.”

Data analysis

The collected data were analyzed using SPSS Statistics (version 28.0, IBM, Chicago, IL, USA), and the differences in the general characteristics of each study group were analyzed using the chi-square test. The Kruskal–Wallis test was used to determine whether there was a difference in knowledge among the study groups. The Wilcoxon rank-sum test was used to analyze the differences in knowledge scores before and after the genetic counseling sessions in each study group. P<0.05 was considered to indicate a significant difference.

Participant characteristics

The participant characteristics are summarized in Table 1. Significant differences were found among the three study groups in terms of age (P=0.017), sex (P=0.001), marital status (P= 0.002), having children (P=0.001), educational background (P=0.008), genetic testing (P=0.001), and genetic counseling (P=0.001).

Table 1 . Characteristics of study participants

Variable	Total (N=131), N (%)	Patient group (N=45), N (%)	Family group (N=43), N (%)	Interested group (N=43), N (%)	P*
Age, yrs					0.017
20–29	12 (9.2)	1 (2.2)	6 (14.0)	5 (11.6)
30–39	46 (35.1)	8 (17.8)	19 (44.2)	19 (44.2)
40–49	45 (34.4)	23 (51.1)	11 (25.6)	11 (25.6)
50–59	21 (16.0)	10 (22.2)	4 (9.3)	7 (16.3)
60–69	7 (5.3)	3 (6.7)	3 (7.0)	1 (2.3)
Sex					0.001
Male	11 (8.4)	0 (0.0)	10 (23.3)	1 (2.3)
Female	120 (91.6)	45 (100)	33 (76.7)	42 (97.7)
Marital status					0.002
Single	35 (26.7)	4 (8.9)	18 (41.9)	13 (30.2)
Married	96 (73.3)	41 (91.1)	25 (58.1)	30 (69.8)
Children					0.001
Yes	87 (66.4)	39 (86.7)	21 (48.8)	27 (62.8)
No	44 (33.6)	6 (13.3)	22 (51.2)	16 (37.2)
Education					0.008
High school certificate or equivalent	26 (19.8)	15 (33.3)	8 (18.6)	3 (7.0)
College graduate and above	105 (80.2)	30 (66.7)	35 (81.4)	40 (93.0)
Cancer history					Not applicable
Breast cancer	44 (33.6)	44 (97.8)	0 (0.0)	0 (0.0)
Ovarian cancer	1 (0.8)	1 (2.2)	0 (0.0)	0 (0.0)
Unaffected	86 (65.6)	0 (0.0)	43 (100)	43 (100)
Family† history of cancer‡					0.001
0	59 (45.0)	16 (35.6)	0 (0.0)	43 (100)
1 individual	43 (32.8)	15 (33.3)	28 (65.1)	0 (0.0)
2 individuals	13 (9.9)	7 (15.6)	6 (14.0)	0 (0.0)
≥3 individuals	16 (12.3)	7 (15.6)	9 (20.9)	0 (0.0)
Sources of cancer information§					Not applicable
Internet	94 (71.8)	39 (86.7)	30 (69.8)	25 (58.1)
Television/radio	12 (9.2)	5 (11.1)	5 (11.6)	2 (4.7)
Friends	17 (13.0)	3 (6.7)	9 (20.9)	5 (11.6)
Books	20 (15.3)	3 (6.7)	7 (16.3)	10 (23.3)
Patients	6 (4.6)	5 (11.1)	1 (2.3)	0 (0.0)
Family	1 (0.8)	0 (0.0)	1 (2.3)	0 (0.0)
Genetic testing use					0.001
Yes	30 (22.9)	25 (55.6)	5 (11.6)	0 (0.0)
No	101 (77.1)	20 (44.4)	38 (88.4)	43 (100)
Type of genetic test (N=30)					Not applicable
BRCA	24 (80.0)	21 (84.0)	3 (60.0)	0 (0.0)
Unknown	6 (20.0)	4 (16.0)	2 (40.0)	0 (0.0)
Genetic counseling experience					0.001
Yes	23 (17.6)	20 (44.4)	2 (4.7)	1 (2.3)
No	108 (82.4)	25 (55.6)	41 (95.3)	42 (97.7)
Heard of metaverse					0.160
Yes	84 (64.1)	29 (64.4)	31 (72.1)	24 (55.8)
No	47 (38.9)	16 (35.9)	12 (27.9)	19 (44.2)
Metaverse use experience					0.149
Yes	13 (9.9)	2 (4.4)	8 (18.6)	3 (7.0)
No	118 (90.1)	43 (95.6)	35 (81.4)	40 (93.0)

*Chi-square test.

^†Family: 3rd degree relative.

^‡Cancer: breast/ovarian cancer or other cancers (prostate, pancreatic, biliary tract, and melanoma).

^§Multiple responses possible.

In the patient group, more than half of the participants were in their 40s (51.1%), whereas the age group with the highest representation in the family and interested groups was the 30s (44.2% for both). In the patient group, 86.7% of the participants had children, 55.6% had undergone genetic testing, and 44.4% had undergone genetic counseling, which were the highest proportions for these categories among the three study groups. There were no male participants in the patient group, whereas 23.3% and 2.3% of the family and interested group participants were male, respectively. The percentage of married individuals was 73.3% overall, which was the highest in the patient group (91.1%). Approximately four-fifths of the participants were college graduates (80.2%), and this proportion was the highest in the interested group (93.0%). One of the reasons for the higher education in the interested group was that 55.8% (24/43) of the participants in this group were nurses. In the patient group, the majority of participants had breast cancer (97.8%, 44/45) and one participant had ovarian cancer (2.2%); 64.5% of participants in the patient group had a family history of cancer in more than one family member.

More participants in the family group had already heard about the metaverse than those in the other two groups; however, the difference was not significant (P=0.16). In addition, 18.6% of participants in the family group had previously used a metaverse platform; this value was higher than the proportions in the other two groups (4.4% and 7.0% in the patient and interested groups, respectively), but the difference was not significant (P=0.149).

In the patient group, 25 participants met the genetic testing indications of the Korean National guidelines (ovarian cancer, breast cancer diagnosed at or before the age of 40 yrs, breast cancer, triple-negative breast cancer, breast cancer with ovarian cancer or pancreatic cancer, breast cancer with one or more relatives having breast cancer, ovarian cancer, male breast cancer, metastatic prostate cancer, pancreatic cancer, etc.). In the family group, five participants required genetic testing because they carried a known pathogenic variant associated with hereditary cancer in the family or had three or more family members with a history of cancer. The interested group included only participants who did not have cancer themselves or in their families.

Knowledge evaluations before and after group genetic counseling

Comparison of knowledge among study groups

We compared the study groups to determine whether there were differences in knowledge before and after group genetic counseling. The median knowledge score before the group genetic counseling was higher in the interested group (7.0; interquartile range [Q1–Q3]=4.5–9.0) than in the patient (5.0; Q1–Q3= 3.0–8.0) and family (5.0; Q1–Q3=3.0–7.0) groups, but the difference was not statistically significant (P=0.130). There was also no significant difference in knowledge level after genetic counseling education, with a median value of 9.0 (Q1–Q3=8.0–10.0) in all three groups (P=0.887).

Comparison of knowledge before and after group genetic counseling in each study group

For all groups, the median pre-genetic counseling knowledge score was 6.0 (Q1–Q3=3.0–8.0) and the median post-genetic counseling knowledge score was 9.0 (Q1–Q3=8.0–10.0), representing a statistically significant difference (P<0.001). All groups showed a significant increase in knowledge score after the group genetic counseling session (P<0.001; Table 2).

Table 2 . Comparison of knowledge scores before and after the group genetic counseling in each study group

Study group	Pre-group genetic counseling, median (Q1–Q3)	Pre-group genetic counseling, median (Q1–Q3)	Z	P
Total	6.0 (3.0–8.0)	9.0 (8.0–10.0)	−9.026	<0.001
Patient group	5.0 (3.0–8.0)	9.0 (8.0–10.0)	−5.374	<0.001
Family group	5.0 (3.0–7.0)	9.0 (8.0–10.0)	−5.393	<0.001
Interested group	7.0 (4.0–9.0)	9.0 (8.0–10.0)	−4.824	<0.001

Abbreviations: Q1, first quartile; Q3, third quartile.

The complete results of the comparison of knowledge according to each question before and after group genetic counseling are presented in Supplemental Data Fig. S2.

Participants’ experiences of group genetic counseling in the metaverse

In the evaluation of the educational video content, 93.2% of the participants stated that it was easy to understand (answered “strongly agree” or “agree”). Regarding the adequacy of the educational video length, sound, and screen quality, 95.1% of participants responded that it was appropriate. In addition, 95.4% of the participants answered that their level of understanding of hereditary breast cancer improved after the metaverse-based education session (Fig. 1).

Figure 1. Results of the group genetic counseling satisfaction survey.

Among all participants, 87.8% answered that the metaverse session was more effective than face-to-face sessions (“strongly agree” or “agree”), while 1.5% answered that it was not as effective. In addition, 93.1% of participants stated that they would recommend group genetic counseling using the metaverse platform to family members or acquaintances, and 92.4% of the participants stated that they would want to participate in other educational sessions using a metaverse platform in the future.

The advantages and disadvantages of the metaverse were evaluated using multiple-choice questions (Table 3). The majority of the participants stated “Can participate regardless of location” (96.9%) and “Time can be used efficiently” (76.3%) as advantages of the metaverse-based session. The main disadvantages stated were that it is “Possible to miss some content if the internet connection is unstable” (67.2%) and that “Maintaining concentration throughout the session is difficult” (27.5%).

Table 3 . Evaluation of the participants’ experiences of the metaverse-based group genetic counseling

Question	Total (N=131), N (%)	Patient group (N=45), N (%)	Family group (N=43), N (%)	Interested group (N=43), N (%)
Advantages
Can participate regardless of location	127 (96.9)	43 (91.5)	43 (100)	41 (95.3)
Time can be used efficiently	100 (76.3)	37 (78.7)	31 (72.1)	32 (74.4)
Participation can be repeated	34 (26.0)	7 (14.9)	17 (39.5)	10 (23.3)
Asking questions and receiving answers are easy	33 (25.2)	11 (23.4)	11 (25.6)	11 (25.6)
Can meet people with same interest within the virtual space and communicate easily	54 (41.2)	19 (40.4)	19 (44.2)	16 (37.2)
Participating is enjoyable	59 (45.0)	17 (36.2)	22 (51.2)	20 (46.5)
Others*	4 (3.1)	0 (0.0)	2 (4.7)	2 (4.7)
Disadvantages
Using the metaverse is burdensome and difficult	11 (8.4)	2 (4.4)	3 (7.0)	6 (14.0)
Maintaining concentration throughout the session is difficult	36 (27.5)	8 (17.8)	17 (39.5)	11 (25.6)
The contents are not delivered clearly	9 (6.9)	3 (6.7)	5 (11.6)	1 (2.3)
Questions and answers are less effective	11 (8.4)	6 (13.3)	4 (9.3)	1 (2.3)
Possible to miss some content if the internet connection is unstable	88 (67.2)	29 (64.4)	30 (69.8)	29 (67.4)
The new platform is unfamiliar	23 (17.6)	12 (6.7)	4 (9.3)	7 (16.3)
None	2 (1.5)	1 (2.2)	0 (0.0)	1 (2.3)
Others†	3 (2.3)	0 (0.0)	0 (0.0)	3 (7.0)

*“It was fun and interesting,” “It was nice to participate privately,” “I was able to communicate and relieve stress by meeting people,” and “I was able to participate comfortably.”

^†“It was awkward because it was my first time using it” and “Older people who have difficulty in accessing the internet could have a harder time using it.”

To the best of our knowledge, this is the first study to examine the possibility of an alternative service-delivery model for group genetic counseling via the metaverse. The participants’ knowledge level increased significantly after the group genetic counseling session, and the participants were satisfied with the program. Overall, our results show that group genetic counseling via the metaverse is an acceptable alternative service-delivery model.

Many healthcare providers are now familiar with telemedicine, which utilizes telephone or video formats, because its use has increased significantly since the coronavirus disease pandemic [8^-10]. Studies have examined the effectiveness of telegenetic counseling. Danylchuk, et al. [11] provided a systematic review of patients’ and providers’ experiences and access to telehealth services. They concluded that telegenetic counseling is as effective as in-person counseling despite some limitations. For one-on-one counseling, telegenetic counseling using Zoom, Google Meet, or any other format could be helpful, as it provides an environment similar to that of in-person sessions. However, these formats may be less effective for group genetic counseling. Because protecting patient privacy while providing a sense of participation is important in a group setting, the metaverse can provide these factors by asking participants to use an avatar. The metaverse could be more effective in certain groups of people such as younger generations, including teenagers, as they are more interested in and prone to accepting new technologies. Informing patients about certain genetic conditions, reviewing pre-symptomatic genetic testing options based on their family history, or receiving assent for genetic testing using metaverse methods could increase their interest and understanding. Despite some limitations, the study participants were highly satisfied with the metaverse platform, and we believe that it could be considered for widespread utilization in the field of genetic counseling and medicine.

Group genetic counseling may only be effective under certain circumstances. An educational portion of genetic counseling with general information can be provided to a group. This can increase the efficiency of limited time and medical resources [12]. Recent studies have discussed the effectiveness of group genetic counseling when addressing this educational information to patients in a group setting [13, 14]. Hynes, et al. [14] concluded that pre-test group genetic counseling with a short individual session in patients with cancers was effective and that both the participating patients and genetic counselors were satisfied with the new method. Cloutier, et al. [13] compared group and individual genetic counseling sessions in women with a positive prenatal screening result. They found that both methods resulted in high satisfaction in terms of patient care and concluded that group genetic counseling with brief individual sessions was effective.

Lohn, et al. [12] suggested that one of the strengths of group genetic counseling is that by sharing the questions and answers of other patients, each patient could explore related information. We expected that there would be many questions during the question-and-answer sessions in our study, as the avatar in the metaverse could make people feel more comfortable talking; however, only three of 131 participants asked questions. This could simply reflect a general cultural characteristic of Koreans being averse to asking questions in front of people or it may have reflected that the participants felt uncomfortable asking questions related to their personal health in a public forum. Koreans are known to be more active in asking questions in the form of writing such as in a chat window than out loud by voice. Encouraging asking questions in the chat window of the metaverse may be helpful in increasing interaction and complementing the characteristics of Koreans who are not comfortable with direct questions. We believe that private sessions after group genetic counseling will be beneficial for participants who want to ask questions more specific to their personal history, as suggested previously [13, 14]. Cloutier, et al. [13] stated that 86% of participants attended an individual session after group genetic counseling was performed. This indicates that there is information that cannot be fully covered by group genetic counseling and that people are eager for more information. As tailoring the session based on the patient’s medical and family histories is necessary for genetic counseling, providing individual genetic counseling after the group session would be helpful. Additional customized one-on-one genetic counseling sessions can be conducted in the personal space of the metaverse platform or through in-person visits for effective genetic counseling.

Another factor to consider with group genetic counseling is that it may provide emotional/psychosocial support to patients in similar disease groups. Spiers, et al. [15] conducted a qualitative study on group genetic counseling in patients testing positive for Huntington’s disease (HD) (predictive testing). They used a narrative group exercise facilitated by both a clinical psychologist and genetic counselor and found that participants were able to connect and provide “peer support” to each other, which gave them a positive outlook in living with an HD diagnosis.

Finally, the content of group genetic counseling should be developed based on the understanding and needs of the target audience. This sounds very basic; however, it is important to remember. As a healthcare professional, one invests many years to become an expert and this knowledge may become natural, resulting in skipping the longer process of decision-making through following an algorithm in favor of coming to a quick conclusion. However, as a genetic counseling session can be the first time that patients and families are learning about the relevant contents provided, a more comprehensive explanation may be required. This is important because the patients are ultimately those making important decision related to their health.

It is not easy to meet the informational needs of all individuals, as people’s educational backgrounds, life experiences, and matters of interest are all different. If there is a way to evaluate people’s understanding after each group’s genetic counseling session, genetic counselors will be able to develop more specific private sessions, even if people might not want to be evaluated. Future studies could be conducted with modified group genetic counseling sessions based on our findings to re-evaluate participants’ understanding. In addition, comparing the understanding of people who received only group genetic counseling to that of people who received both group genetic counseling and private sessions would be interesting.

A limitation of this study was that we were not able to compare the effectiveness of group genetic counseling using the metaverse with other methods/platforms such as in-person meetings or telehealth platforms (e.g., Zoom and Google Meet). Peshkin, et al. [16] compared telephone and in-person genetic counseling and concluded that non-traditional methods were viable options in that they maintained similar levels of patient knowledge and satisfaction as found for the traditional method. This indicates that other platforms can be expected to be effective. Buchanan, et al. [17] and Greenberg, et al. [18] mentioned that alternative service-delivery models are becoming more important. In the future, it would be interesting to compare the effectiveness of all the platforms currently available to determine if all methods could offer the same level of understanding, which could be helpful to improve access to genetic counseling and the quality of patient care.

In conclusion, genetic counseling via the metaverse platform is an acceptable alternative service for group genetic counseling. As this is the first study utilizing the metaverse for telegenetic counseling, more studies will be needed to ensure that this platform is applied constructively in current practice.

Supplementary materials can be found via https://doi.org/10.3343/alm.2024.44.1.82

None.

Huh J and Kim A contributed to the study organization, design, and supervision. Kim A and Yoo B drafted the manuscript. Yoo B and Moon H were involved in data collection. So M, Jeong T, Lee K, Moon B, and Huh J were involved in data interpretation. All the authors have read and approved the final manuscript.

None declared.

None declared.