Usability and Acceptance of the Embodied Conversational Agent Anne by People With Dementia and Their Caregivers: Exploratory Study in Home Environment Settings

Evaluating the Potential and Pitfalls of AI-Powered Conversational Agents as Humanlike Virtual Health Carers in the Remote Management of Noncommunicable Diseases: Scoping Review

BACKGROUND

The rising prevalence of noncommunicable diseases (NCDs) worldwide and the high recent mortality rates (74.4%) associated with them, especially in low- and middle-income countries, is causing a substantial global burden of disease, necessitating innovative and sustainable long-term care solutions.

OBJECTIVE

This scoping review aims to investigate the impact of artificial intelligence (AI)-based conversational agents (CAs)-including chatbots, voicebots, and anthropomorphic digital avatars-as human-like health caregivers in the remote management of NCDs as well as identify critical areas for future research and provide insights into how these technologies might be used effectively in health care to personalize NCD management strategies.

METHODS

A broad literature search was conducted in July 2023 in 6 electronic databases-Ovid MEDLINE, Embase, PsycINFO, PubMed, CINAHL, and Web of Science-using the search terms "conversational agents," "artificial intelligence," and "noncommunicable diseases," including their associated synonyms. We also manually searched gray literature using sources such as ProQuest Central, ResearchGate, ACM Digital Library, and Google Scholar. We included empirical studies published in English from January 2010 to July 2023 focusing solely on health care-oriented applications of CAs used for remote management of NCDs. The narrative synthesis approach was used to collate and summarize the relevant information extracted from the included studies.

RESULTS

The literature search yielded a total of 43 studies that matched the inclusion criteria. Our review unveiled four significant findings: (1) higher user acceptance and compliance with anthropomorphic and avatar-based CAs for remote care; (2) an existing gap in the development of personalized, empathetic, and contextually aware CAs for effective emotional and social interaction with users, along with limited consideration of ethical concerns such as data privacy and patient safety; (3) inadequate evidence of the efficacy of CAs in NCD self-management despite a moderate to high level of optimism among health care professionals regarding CAs' potential in remote health care; and (4) CAs primarily being used for supporting nonpharmacological interventions such as behavioral or lifestyle modifications and patient education for the self-management of NCDs.

CONCLUSIONS

This review makes a unique contribution to the field by not only providing a quantifiable impact analysis but also identifying the areas requiring imminent scholarly attention for the ethical, empathetic, and efficacious implementation of AI in NCD care. This serves as an academic cornerstone for future research in AI-assisted health care for NCD management.

TRIAL REGISTRATION

Open Science Framework; https://doi.org/10.17605/OSF.IO/GU5PX.

The Role of Humanization and Robustness of Large Language Models in Conversational Artificial Intelligence for Individuals With Depression: A Critical Analysis

Unlabelled

Large language model (LLM)-powered services are gaining popularity in various applications due to their exceptional performance in many tasks, such as sentiment analysis and answering questions. Recently, research has been exploring their potential use in digital health contexts, particularly in the mental health domain. However, implementing LLM-enhanced conversational artificial intelligence (CAI) presents significant ethical, technical, and clinical challenges. In this viewpoint paper, we discuss 2 challenges that affect the use of LLM-enhanced CAI for individuals with mental health issues, focusing on the use case of patients with depression: the tendency to humanize LLM-enhanced CAI and their lack of contextualized robustness. Our approach is interdisciplinary, relying on considerations from philosophy, psychology, and computer science. We argue that the humanization of LLM-enhanced CAI hinges on the reflection of what it means to simulate "human-like" features with LLMs and what role these systems should play in interactions with humans. Further, ensuring the contextualization of the robustness of LLMs requires considering the specificities of language production in individuals with depression, as well as its evolution over time. Finally, we provide a series of recommendations to foster the responsible design and deployment of LLM-enhanced CAI for the therapeutic support of individuals with depression.

Embodied Conversational Agents for Chronic Diseases: Scoping Review

BACKGROUND

Embodied conversational agents (ECAs) are computer-generated animated humanlike characters that interact with users through verbal and nonverbal behavioral cues. They are increasingly used in a range of fields, including health care.

OBJECTIVE

This scoping review aims to identify the current practice in the development and evaluation of ECAs for chronic diseases.

METHODS

We applied a methodological framework in this review. A total of 6 databases (ie, PubMed, Embase, CINAHL, ACM Digital Library, IEEE Xplore Digital Library, and Web of Science) were searched using a combination of terms related to ECAs and health in October 2023. Two independent reviewers selected the studies and extracted the data. This review followed the PRISMA-ScR (Preferred Reporting Items of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) statement.

RESULTS

The literature search found 6332 papers, of which 36 (0.57%) met the inclusion criteria. Among the 36 studies, 27 (75%) originated from the United States, and 28 (78%) were published from 2020 onward. The reported ECAs covered a wide range of chronic diseases, with a focus on cancers, atrial fibrillation, and type 2 diabetes, primarily to promote screening and self-management. Most ECAs were depicted as middle-aged women based on screenshots and communicated with users through voice and nonverbal behavior. The most frequently reported evaluation outcomes were acceptability and effectiveness.

CONCLUSIONS

This scoping review provides valuable insights for technology developers and health care professionals regarding the development and implementation of ECAs. It emphasizes the importance of technological advances in the embodiment, personalized strategy, and communication modality and requires in-depth knowledge of user preferences regarding appearance, animation, and intervention content. Future studies should incorporate measures of cost, efficiency, and productivity to provide a comprehensive evaluation of the benefits of using ECAs in health care.

Intrinsic Capacity and Active and Healthy Aging Domains Supported by Personalized Digital Coaching: Survey Study Among Geriatricians in Europe and Japan on eHealth Opportunities for Older Adults

BACKGROUND

The worldwide aging trend requires conceptually new prevention, care, and innovative living solutions to support human-based care using smart technology, and this concerns the whole world. Enabling access to active and healthy aging through personalized digital coaching services like physical activity coaching, cognitive training, emotional well-being, and social connection for older adults in real life could offer valuable advantages to both individuals and societies. A starting point might be the analysis of the perspectives of different professionals (eg, geriatricians) on such technologies. The perspectives of experts in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective pointed out by the intrinsic capacity framework.

OBJECTIVE

The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals in the field of intrinsic capacity, and how it can be supported by eHealth interventions. To our knowledge, this is the first study to explore geriatric care providers' perspectives about technology-based interventions to support intrinsic capacity.

METHODS

A survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and active and healthy aging was conducted in Italy, France, Germany, and Japan between August and September 2021.

RESULTS

The qualitative findings pointed out relevant domains for eHealth interventions and provided examples for successful practices that support subjective well-being under the intrinsic capacity framework (the benefits offered by personalized interventions, especially by promoting health literacy but avoiding intrusiveness). Moreover, eHealth interventions could be used as a bridge that facilitates and enables social engagement; an instrument that facilitates communication between doctors and patients; and a tool to enrich the monitoring actions of medical staff.

CONCLUSIONS

There is an unexplored and significant role for such geriatric perspectives to help the development process and evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults.

Factors Influencing the Acceptability, Acceptance, and Adoption of Conversational Agents in Health Care: Integrative Review

BACKGROUND

Conversational agents (CAs), also known as chatbots, are digital dialog systems that enable people to have a text-based, speech-based, or nonverbal conversation with a computer or another machine based on natural language via an interface. The use of CAs offers new opportunities and various benefits for health care. However, they are not yet ubiquitous in daily practice. Nevertheless, research regarding the implementation of CAs in health care has grown tremendously in recent years.

OBJECTIVE

This review aims to present a synthesis of the factors that facilitate or hinder the implementation of CAs from the perspectives of patients and health care professionals. Specifically, it focuses on the early implementation outcomes of acceptability, acceptance, and adoption as cornerstones of later implementation success.

METHODS

We performed an integrative review. To identify relevant literature, a broad literature search was conducted in June 2021 with no date limits and using all fields in PubMed, Cochrane Library, Web of Science, LIVIVO, and PsycINFO. To keep the review current, another search was conducted in March 2022. To identify as many eligible primary sources as possible, we used a snowballing approach by searching reference lists and conducted a hand search. Factors influencing the acceptability, acceptance, and adoption of CAs in health care were coded through parallel deductive and inductive approaches, which were informed by current technology acceptance and adoption models. Finally, the factors were synthesized in a thematic map.

RESULTS

Overall, 76 studies were included in this review. We identified influencing factors related to 4 core Unified Theory of Acceptance and Use of Technology (UTAUT) and Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) factors (performance expectancy, effort expectancy, facilitating conditions, and hedonic motivation), with most studies underlining the relevance of performance and effort expectancy. To meet the particularities of the health care context, we redefined the UTAUT2 factors social influence, habit, and price value. We identified 6 other influencing factors: perceived risk, trust, anthropomorphism, health issue, working alliance, and user characteristics. Overall, we identified 10 factors influencing acceptability, acceptance, and adoption among health care professionals (performance expectancy, effort expectancy, facilitating conditions, social influence, price value, perceived risk, trust, anthropomorphism, working alliance, and user characteristics) and 13 factors influencing acceptability, acceptance, and adoption among patients (additionally hedonic motivation, habit, and health issue).

CONCLUSIONS

This review shows manifold factors influencing the acceptability, acceptance, and adoption of CAs in health care. Knowledge of these factors is fundamental for implementation planning. Therefore, the findings of this review can serve as a basis for future studies to develop appropriate implementation strategies. Furthermore, this review provides an empirical test of current technology acceptance and adoption models and identifies areas where additional research is necessary.

TRIAL REGISTRATION

PROSPERO CRD42022343690; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=343690.

Designing Mindfulness Conversational Agents for People With Early-Stage Dementia and Their Caregivers: Thematic Analysis of Expert and User Perspectives

BACKGROUND

The number of people with dementia is expected to grow worldwide. Among the ways to support both persons with early-stage dementia and their caregivers (dyads), researchers are studying mindfulness interventions. However, few studies have explored technology-enhanced mindfulness interventions for dyads and the needs of persons with dementia and their caregivers.

OBJECTIVE

The main aim of this study was to elicit essential needs from people with dementia, their caregivers, dementia experts, and mindfulness experts to identify themes that can be used in the design of mindfulness conversational agents for dyads.

METHODS

Semistructured interviews were conducted with 5 dementia experts, 5 mindfulness experts, 5 people with early-stage dementia, and 5 dementia caregivers. Interviews were transcribed and coded on NVivo (QSR International) before themes were identified through a bottom-up inductive approach.

RESULTS

The results revealed that dyadic mindfulness is preferred and that implementation formats such as conversational agents have potential. A total of 5 common themes were also identified from expert and user feedback, which should be used to design mindfulness conversational agents for persons with dementia and their caregivers. The 5 themes included enhancing accessibility, cultivating positivity, providing simplified tangible and thought-based activities, encouraging a mindful mindset shift, and enhancing relationships.

CONCLUSIONS

In essence, this research concluded with 5 themes that mindfulness conversational agents could be designed based on to meet the needs of persons with dementia and their caregivers.

Social Robotics and Dementia: Results from the eWare Project in Supporting Older People and Their Informal Caregivers

The aim of this paper is to describe the results collected with the Italian study conducted within eWare project, aimed at supporting the autonomy and health of the older people affected by dementia and their informal caregivers, through the use of an innovative system based on a social robot and a sensorized environmental infrastructure. Nine dyads of older participants with their caregivers were enrolled in testing the system for 6 months. The results show a positive impact of the system in supporting the achievement of personal goals of the participants, as well as in supporting the quality of life of the informal caregivers. Nevertheless, the impact of the system in reducing the caregivers' burden needs to be deeply investigated. This research highlights the potential of the eWare system but modifications will have to be made, especially on the interactivity capabilities, in order to meet the peculiar needs and wishes of older people with dementia and to favor the long-term use of the system.

Assisting Personalized Healthcare of Elderly People: Developing a Rule-Based Virtual Caregiver System Using Mobile Chatbot

To assist personalized healthcare of elderly people, our interest is to develop a virtual caregiver system that retrieves the expression of mental and physical health states through human-computer interaction in the form of dialogue. The purpose of this paper is to implement and evaluate a virtual caregiver system using mobile chatbot. Unlike the conventional health monitoring approach, our key idea is to integrate a rule-based virtual caregiver system (called "Mind Monitoring" service) with the physical, mental, and social questionnaires into the mobile chat application. The elderly person receives one question from the mobile chatbot per day, and answers it by pushing the optional button or using a speech recognition technique. Furthermore, a novel method is implemented to quantify the answers, generate visual graphs, and send the corresponding summaries or advice to the specific elder. In the experimental evaluation, we applied it to eight elderly subjects and 19 younger subjects within 14 months. As main results, its effects were significantly improved by the proposed method, including the above 80% in the response rate, the accurate reflection of their real lives from the responses, and high usefulness of the feedback messages with software quality requirements and evaluation. We also conducted interviews with subjects for health analysis and improvement.

A Digital Human for Delivering a Remote Loneliness and Stress Intervention to At-Risk Younger and Older Adults During the COVID-19 Pandemic: Randomized Pilot Trial

BACKGROUND

Loneliness is a growing public health issue that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Computer agents are capable of delivering psychological therapies through the internet; however, there is limited research on their acceptability to date.

OBJECTIVE

The objectives of this study were to evaluate (1) the feasibility and acceptability of a remote loneliness and stress intervention with digital human delivery to at-risk adults and (2) the feasibility of the study methods in preparation for a randomized controlled trial.

METHODS

A parallel randomized pilot trial with a mixed design was conducted. Participants were adults aged 18 to 69 years with an underlying medical condition or aged 70 years or older with a Mini-Mental State Examination score of >24 (ie, at greater risk of developing severe COVID-19). Participants took part from their place of residence (independent living retirement village, 20; community dwelling, 7; nursing home, 3). Participants were randomly allocated to the intervention or waitlist control group that received the intervention 1 week later. The intervention involved completing cognitive behavioral and positive psychology exercises with a digital human facilitator on a website for at least 15 minutes per day over 1 week. The exercises targeted loneliness, stress, and psychological well-being. Feasibility was evaluated using dropout rates and behavioral observation data. Acceptability was evaluated from behavioral engagement data, the Friendship Questionnaire (adapted), self-report items, and qualitative questions. Psychological measures were administered to evaluate the feasibility of the trial methods and included the UCLA Loneliness Scale, the 4-item Perceived Stress Scale, a 1-item COVID-19 distress measure, the Flourishing Scale, and the Scale of Positive and Negative Experiences.

RESULTS

The study recruited 30 participants (15 per group). Participants were 22 older adults and 8 younger adults with a health condition. Six participants dropped out of the study. Thus, the data of 24 participants were analyzed (intervention group, 12; waitlist group, 12). The digital human intervention and trial methods were generally found to be feasible and acceptable in younger and older adults living independently, based on intervention completion, and behavioral, qualitative, and some self-report data. The intervention and trial methods were less feasible to nursing home residents who required caregiver assistance. Acceptability could be improved with additional content, tailoring to the population, and changes to the digital human's design.

CONCLUSIONS

Digital humans are a promising and novel technological solution for providing at-risk adults with access to remote psychological support during the COVID-19 pandemic. Research should further examine design techniques to improve their acceptability in this application and investigate intervention effectiveness in a randomized controlled trial.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12620000786998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380113.

Use and effect of embodied conversational agents for improving eating behavior and decreasing loneliness among community-dwelling older adults: A randomized controlled trial (Preprint)

Background

Embodied conversational agents (ECAs) have been proposed as a promising interaction modality for the delivery of programs focused on promoting lifestyle changes. However, it is not understood what factors influence the health effects of ECAs or their use.

Objective

We aimed to (1) identify whether ECAs could persuade community-dwelling older adults to change their dietary behavior and whether ECA use could decrease loneliness, (2) test the pathways to these effects, and (3) understand factors influencing the use of ECAs.

Methods

A randomized controlled trial was conducted. The intervention group received access to the PACO service for 8 weeks. The waitlist group started PACO use after waiting for 4 weeks. Two primary outcomes (eating behavior and loneliness) were assessed via online questionnaires at intake, upon joining the waitlist, after 4 weeks, and after 8 weeks. The third primary outcome (use) was assessed via data logs. Secondary outcomes were measured at the same time points, via questionnaires or an optional interview.

Results

In total, 32 participants completed the intervention. We found a significant correlation between use in minutes on the one hand, and perceived usefulness (r=0.39, P=.03) and enjoyment on the other (r=0.38, P=.03). However, these did not predict use in the full regression model (F_2,29=1.98, P=.16, R²=0.12). Additionally, PACO use did not lead to improvement in eating behavior (χ²₂=0.34, P=.85) or a decrease in loneliness (χ²₂=0.02, P=.99).

Conclusions

Our study did not provide any concluding evidence about factors that are linked to the use or health effects of ECAs. Future service design could benefit from either creating a functional design catering to the predominant stage in the precaution adoption process model of the targeted population, or by personalizing the service based on an intake in which the end user’s stage is determined.

Trial Registration

ClinicalTrials.gov NCT04510883; https://clinicaltrials.gov/ct2/show/NCT04510883

International Registered Report Identifier (IRRID)

RR2-10.2196/22186

Toward the Integration of Technology-Based Interventions in the Care Pathway for People with Dementia: A Cross-National Study

BACKGROUND

The integration of technology-based interventions into health and care provision in our aging society is still a challenge especially in the care pathway for people with dementia.

OBJECTIVE

The study aims to: (1) identify which socio-demographic characteristics are independently associated with the use of the embodied conversational agent among subjects with dementia, (2) uncover patient cluster profiles based on these characteristics, and (3) discuss technology-based interventions challenges.

METHODS

A virtual agent was used for four weeks by 55 persons with dementia living in their home environment.

RESULTS

Participants evaluated the agent as easy-to-use and quickly learnable. They felt confident while using the system and expressed the willingness to use it frequently. Moreover, 21/55 of the patients perceived the virtual agent as a friend and assistant who they could feel close to and who would remind them of important things.

CONCLUSIONS

Technology-based interventions require a significant effort, such as personalized features and patient-centered care pathways, to be effective. Therefore, this study enriches the open discussion on how such virtual agents must be evidence-based related and designed by multidisciplinary teams, following patient-centered care as well as user-centered design approaches.