Acceptability of an Embodied Conversational Agent for Type 2 Diabetes Self-Management Education and Support via a Smartphone App: Mixed Methods Study

Abstract

Background Embodied conversational agents (ECAs) are increasingly used in health care apps; however, their acceptability in type 2 diabetes (T2D) self-management apps has not yet been investigated. Objective This study aimed to evaluate the acceptability of the ECA (Laura) used to deliver diabetes self-management education and support in the My Diabetes Coach (MDC) app. Methods A sequential mixed methods design was applied. Adults with T2D allocated to the intervention arm of the MDC trial used the MDC app over a period of 12 months. At 6 months, they completed questions assessing their interaction with, and attitudes toward, the ECA. In-depth qualitative interviews were conducted with a subsample of the participants from the intervention arm to explore their experiences of using the ECA. The interview questions included the participants’ perceptions of Laura, including their initial impression of her (and how this changed over time), her personality, and human character. The quantitative and qualitative data were interpreted using integrated synthesis. Results Of the 93 intervention participants, 44 (47%) were women; the mean (SD) age of the participants was 55 (SD 10) years and the baseline glycated hemoglobin A1c level was 7.3% (SD 1.5%). Overall, 66 of the 93 participants (71%) provided survey responses. Of these, most described Laura as being helpful (57/66, 86%), friendly (57/66, 86%), competent (56/66, 85%), trustworthy (48/66, 73%), and likable (40/66, 61%). Some described Laura as not real (18/66, 27%), boring (26/66, 39%), and annoying (20/66, 30%). Participants reported that interacting with Laura made them feel more motivated (29/66, 44%), comfortable (24/66, 36%), confident (14/66, 21%), happy (11/66, 17%), and hopeful (8/66, 12%). Furthermore, 20% (13/66) of the participants were frustrated by their interaction with Laura, and 17% (11/66) of the participants reported that interacting with Laura made them feel guilty. A total of 4 themes emerged from the qualitative data (N=19): (1) perceived role: a friendly coach rather than a health professional; (2) perceived support: emotional and motivational support; (3) embodiment preference acceptability of a human-like character; and (4) room for improvement: need for greater congruence between Laura’s words and actions. Conclusions These findings suggest that an ECA is an acceptable means to deliver T2D self-management education and support. A human-like character providing ongoing, friendly, nonjudgmental, emotional, and motivational support is well received. Nevertheless, the ECA can be improved by increasing congruence between its verbal and nonverbal communication and accommodating user preferences. Trial Registration Australian New Zealand Clinical Trials Registry CTRN12614001229662; https://tinyurl.com/yxshn6pd

My Diabetes Coach, a Mobile App–Based Interactive Conversational Agent to Support Type 2 Diabetes Self-Management: Randomized Effectiveness-Implementation Trial

“…The MDC app incorporated interactive voice recognition and an embodied conversational agent, Laura , with human-like characteristics who used a very conversational style of speech to provide people with T2DM with personalized coaching and support on a range of essential diabetes self-management activities in their home environment. The process evaluation that received response from 66 out of 93 participants at 6 months showed that more than 80% of them considered Laura as a helpful, friendly and competent assistant and 72% described Laura as trustworthy [ 33 ].…”

A Systematic Review on Healthcare Artificial Intelligent Conversational Agents for Chronic Conditions

“…The complete list of included studies (26 studies) used CAs to support tasks undertaken by patients ( n = 14), clinicians ( n = 1), and both ( n = 11). Fourteen studies focused on patients mostly supporting education and self-care [ 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. One study focused on clinicians, where the CAs were used to educate and increase awareness of the introductory psychology students in mental and physical health [ 42 ].…”

“…The most common chronic condition was diabetes ( n = 5). Two studies were for type 1 [ 29 , 39 ], one study was for type 2 [ 28 ], and one focused on diabetes in general, whether the patients have type 1 or 2 [ 40 ]. One study focused on prediabetes with obesity [ 51 ].…”

Patient Experience and Predictors of Improvement in a Group Behavioral and Educational Intervention for Individuals With Diabetes and Serious Mental Illness: Mixed Methods Case Study

“…Future studies of diabetes and health management in this population would do well in considering the increasing role and, at times, the necessity of incorporating virtual care models into interventions such as the group intervention presented here, when traditional in-person models may not be possible. Studies have demonstrated the potential role of text messaging and mobile apps in increasing engagement and symptom tracking for individuals with psychosis [ 41 , 42 ] and a growing role for virtual components for enhancing diabetes self-management and support [ 43 , 44 ]; however, to our knowledge, no studies have examined a virtual group intervention for diabetes or a mobile intervention for diabetes tailored for individuals with serious mental illness.…”