Many laypeople are motivated to improve the health behavior of their family or friends but do not know where to start, especially if the health behavior is potentially stigmatizing or controversial. We present an approach that uses virtual agents to coach community-based volunteers in health counseling techniques, such as motivational interviewing, and allows them to practice these skills in role-playing scenarios. We use this approach in a virtual agent-based system to increase COVID-19 vaccination by empowering users to influence their social network. In a between-subjects comparative design study, we test the effects of agent system interactivity and role-playing functionality on counseling outcomes, with participants evaluated by standardized patients and objective judges. We find that all versions are effective at producing peer counselors who score adequately on a standardized measure of counseling competence, and that participants were significantly more satisfied with interactive virtual agents compared to passive viewing of the training material. We discuss design implications for interpersonal skills training systems based on our findings.

Smartphone-based conversational agents offer a convenient way to deliver health education, particularly for managing complex health conditions such as chronic diseases. The present study explores using a smartphone-based virtual agent system to aid patients with a chronic heart condition—atrial fibrillation—to manage their health by encouraging the use of a heart rhythm sensor integrated with their smartphones. We report the results of a randomized clinical trial with 240 patients experiencing atrial fibrillation who were provided with smartphones and heart rhythm sensors for 4 months. Participants in the intervention group interacted with a virtual agent, while the control group received general health education via the WebMD app. Intervention participants completed a median 91 interactions with the agent over the 4 months of the study period, and agent features designed to increase engagement–such as storytelling–were effective at increasing use. The agent’s promotion of heart rhythm sensor use was effective, with intervention participants taking significantly more heart rhythm readings compared to those in the control group. Participants were followed for 8 months thereafter to assess the sustainability of the effects, specifically focusing on medication adherence.

Standardized, validated questionnaires are vital tools in research and healthcare, offering dependable self-report data. Prior work has revealed that virtual agent-administered questionnaires are almost equivalent to self-administered ones in an electronic form. Despite being an engaging method, repeated use of virtual agent-administered questionnaires in longitudinal or pre-post studies can induce respondent fatigue, impacting data quality via response biases and decreased response rates. We propose using large language models (LLMs) to generate diverse questionnaire versions while retaining good psychometric properties. In a longitudinal study, participants interacted with our agent system and responded daily for two weeks to one of the following questionnaires: a standardized depression questionnaire, question variants generated by LLMs, or question variants accompanied by LLM-generated small talk. The responses were compared to a validated depression questionnaire. Psychometric testing revealed consistent covariation between the external criterion and focal measure administered across the three conditions, demonstrating the reliability and validity of the LLM-generated variants. Participants found that the variants were significantly less repetitive than repeated administrations of the same standardized questionnaire. Our findings highlight the potential of LLM-generated variants to invigorate agent-administered questionnaires and foster engagement and interest, without compromising their validity.

Faith institutions provide social support and community care for many in the United States (U.S.). Notably, churches with predominantly Black populations have served as a site for social change and care provision, historically and in contemporary society. However, the pandemic has emphasised how localising these care networks in physical spaces can limit access to social support. Information and communication technologies offer opportunities for expanding access to care in these communities. However, integrating care networks into online contexts remains a challenge for many churches, and the potential for technology to expand these networks is not well understood. Through interviews and focus groups with nine church members, we explore how hybrid faith communities that bridge offline and online contexts can enable social support and care provision. Our findings highlight care network structures in Black churches, barriers to embedding these networks online and strategies for building more seamless hybrid support systems.

Over 55 million adults worldwide have dementia, a syndrome characterized by deterioration in cognitive functioning. Screening for mild cognitive impairment is important to identify dementia early to facilitate diagnosis and initiate treatment that may modify the disease trajectory. However, standard cognitive screening tools are time-consuming, require expert administration, and make people feel as if they are being tested and are thus potentially stigmatizing. Consequently, standard cognitive screening tools are underutilized, and dementia is often identified much later in the disease process leading to greater health-related and societal harms. We explored cognitive ability assessments using virtual agents, in which assessments are made during conversational dialogues. We evaluated four strategies for the assessment of cognitive ability in a sample of 41 individuals with varying cognitive ability, comparing each strategy to scores on the Mini Mental Status Exam (MMSE), the gold standard clinical screening tool for cognitive impairment. One of the four conversational strategies demonstrated significant agreement with the MMSE, with a sensitivity of 92.3% and a specificity of 48.3% for identification of impairment compared to the MMSE. Participants reported moderate levels of satisfaction with the agent-based conversational assessment. This approach could be used to identify individuals warranting more evaluation for possible cognitive impairment.

Parental permission is required for medical care for children, and decisions may be made without incorporating children's views, even for adolescents. We explore the impact of including adolescents in virtual agent-based multiparty health counseling to promote Human Papillomavirus (HPV) vaccination. The agent is designed to encourage HPV vaccination for children aged 9-12 by engaging co-present parent/adolescent dyads in an online interaction. Several techniques are incorporated, including HPV education, motivational interviewing, persuasion, modeling, and enablement, to address parents' intent to vaccinate their children. We conduct a between-subjects randomized study comparing a version of the agent exclusively for the parent, to one that includes the adolescent in the conversation and incorporates the child's views in counseling strategies. We measure pre- and post-intervention changes in intent to vaccinate, vaccination hesitancy, and knowledge in both the parent and the adolescent, hypothesizing greater improvements in these measures when the adolescent is included in the conversation. We also examine the satisfaction, engagement, and comfort of the parent/child interactions with the virtual agent. We found significant pre-post increases in parent intent to vaccinate their adolescent for both versions of the agent. Our work provides insights into the effectiveness of the virtual agent in promoting HPV vaccination, the impact of child participation on healthcare decision-making, and the user experience of multi-party interaction with the virtual agent.

OBJECTIVE: To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data. METHODS: Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity. RESULTS: Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96). CONCLUSIONS: In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.

HCI researchers have increasingly examined how social context shapes health behaviors. Much of this work operates at the interpersonal level. Communities such as churches play important roles in supporting wellbeing and addressing health inequities. While some work has investigated creating digital health tools for religious populations, few have explicitly focused on the incorporation of community support in the form of prayer support. Embedding health interventions in any community has the potential to support or challenge the community’s dynamics. We report on findings from interviews with 17 church members who used a church-based mHealth application over a 4-week period and provide guidelines for developers based on these results. Through their use of the system, participants characterized several community dynamics including a desire for social intimacy, communicating care, creating opportunities for fellowship, maintaining privacy and discretion, and building community connections, and how these dynamics influence their aspirations for a church-based health app.

Churches have historically played an important role in Black American communities, catalyzing the pursuit of aims such as social justice, community organization, and health promotion. However, researchers have rarely examined how technology can support an assets-based approach to these efforts, nor the implications of race, traditions, and history when creating such systems. Addressing this gap, we conducted research with two predominantly Black churches to explore health promotion design opportunities. We used photovoice, a research method where participants led their own data collection and analysis. Participants provided nuanced descriptions of the racial and ethnic identities of their communities, and how church history and aspirations for the future impacted these identities. Our findings characterize tensions between tradition and ‘modernization,’ implications for technology design, and the need for a temporal approach to understanding communities. We conclude with broader implications for studying the intersection of race and religion in community technology design.

Churches play a major role in providing social support to address health inequities within Black communities, in part by connecting members to key organizations and services. While public health has a history of disseminating interventions in faith communities, little work has explored the use of crowdsourcing to tailor interventions to the unique culture of each church community. Following Community Based Participatory Research principles, we partnered with two predominantly Black churches, and report on a series of three participatory design sessions with nine participants. We developed a novel storyboarding method to explore how crowdsourcing could promote health in these faith-based communities. Our findings characterize existing supports within the church community, and how church social structures impact member access to these supports. We further identify motivations to engage with a church-situated health application, and how these motivations translate to crowdsourcing tasks. Finally, we discuss considerations for public health crowdsourcing tasks.

Culturally informed design for virtual agents has been shown to positively impact health outcomes when tailored to target audiences. We present a participatory design methodology for culturally tailoring virtual agents. Investigators worked with key informants from our target population, members of predominantly Black church communities, to design culturally-relevant and sensitive virtual agent health promotion interventions. In the first participatory session, key informants designed agents to assist them with different aspects of their lives, providing input on agent appearance and agent functionality. In a second design session, participants re-wrote the content of a health conversation with an agent, to include personally-relevant content related to their community (e.g., religious and scriptural references). We report design principles for religious tailoring derived from these studies. We conducted a validation study to assess the effects of applying these principles to agents that promoted two health behaviors, finding that participants responded very positively to the tailored agents.

When deployed on mobile devices, virtual agents have the potential to deliver advice regarding medical conditions, as well as provide a ubiquitous channel for health education and behavior change for a variety of chronic health conditions. We describe design guidelines for mobile agent dialogues to support chronic disease management, a general-purpose smartphone-based architecture for a conversational virtual agent that simulates face-to-face health counseling conversations with patients, and an initial agent implementation that provides counseling to patients with the chronic heart condition atrial fibrillation in conjunction with a mobile heart rhythm monitor that is attached to the back of the phone. Preliminary results from a randomized trial with 120 patients with atrial fibrillation indicate that the agent results in significant improvements in self-reported quality of life relative to a standard of care control group.

OBJECTIVES: Readmission following colorectal surgery, typically due to surgery-related complications, is common. Patient-centered discharge warnings may guide recognition of early complication signs after colorectal surgery. MATERIALS AND METHODS: User-centered design of a discharge warnings tool consisted of iterative health literacy review and a heuristic evaluation with human factors and clinical experts as well as patient end users to establish content validity and usability. RESULTS: Literacy evaluation of the prototype suggested >12th-grade reading level. Subsequent revisions reduced reading level to 8th grade or below. Contents were formatted during heuristic evaluation into 3 action-oriented zones (green, yellow, and red) with relevant warning lexicons. Usability testing demonstrated comprehension of this 3-level lexicon and recognition of appropriate patient actions to take for each level. DISCUSSION: We developed a discharge warnings tool for colorectal surgery using staged user-centered design. The lexicon of surgical discharge warnings could structure communication among patients, caregivers, and clinicians to improve post-discharge care.

Depression affects approximately 15% of the US population, and is recognized as an important risk factor for poor outcomes among patients with various illnesses. Automated health education and behavior change programs have the potential to help address many of the shortcomings in health care. However, the role of these systems in the care of patients with depression has been insufficiently examined. In the current study, we sought to evaluate how hospitalized medical patients would respond to a computer animated conversational agent that has been developed to provide information in an empathic fashion about a patient's hospital discharge plan. In particular, we sought to examine how patients who have a high level of depressive symptoms respond to this system. Therapeutic alliance-the trust and belief that a patient and provider have in working together to achieve a desired therapeutic outcome- was used as the primary outcome measure, since it has been shown to be important in predicting outcomes across a wide range of health problems, including depression. In an evaluation of 139 hospital patients who interacted with the agent at the time of discharge, all patients, regardless of depressive symptoms, rated the agent very high on measures of satisfaction and ease of use, and most preferred receiving their discharge information from the agent compared to their doctors or nurses in the hospital. In addition, we found that patients with symptoms indicative of major depression rated the agent significantly higher on therapeutic alliance compared to patients who did not have major depressive symptoms. We conclude that empathic agents represent a promising technology for patient assessment, education and counseling for those most in need of comfort and caring in the inpatient setting.