We structured the development process around regular meetings between the 3 teams. The communication science team held weekly core meetings to coordinate development progress and integration into the larger university health system. The communication science and computer science teams met twice monthly to work on the hardware and software design of the app, with the communication science team providing feedback from potential users.
The communication science and computer science teams also met with information technology IT representatives from UF Health as needed. We held these meetings in-person or online using a virtual meeting service. All 3 teams—communication science, computer science, and clinical—attended blended virtual and in-person meetings monthly and in-person meetings biannually.
This structure ensured that all teams understood how the app and clinical trial were evolving, even if they were not directly involved in a given branch of the work. It created flexibility for individual teams to meet as frequently as needed to accomplish their goals. Thus, individual teams could troubleshoot problems in a small-group setting and larger issues could receive input from all teams.
We gained valuable feedback representing different disciplinary perspectives.
During this phase, we developed the app conceptually, tested acceptability to our target audience, and began creating the software. The communication science team and clinical team began by identifying the medical content necessary for the app, specifically what it would need to convey to patients. The clinical team identified, through their experience with patients, common barriers to screening, including cost, time, and feelings of embarrassment caused by collecting a fecal sample.
They paid specific attention to barriers that were common among minority and rural patients. To understand how clinicians address these barriers, the communication science team video-recorded a simulated conversation about CRC screening between a patient and clinician. A member of the clinical team played the role of the clinician and a member of the communication science team played the patient.
The clinician described in lay terms the risks of CRC, the benefits of screening, and the biological changes that occur in older people, which raise the risk of CRC. This conversation formed the medical basis of script between the virtual human health care provider and the patient. We also discussed the needs of clinicians and health care staff through over 50 interactions with the medical staff, including family medicine physicians, colorectal surgeons, health care administrators, patient navigators, and other players in the biomedical field.
We asked questions about their processes and workflow when interacting with patients, incentives at the provider and practice levels for screening patients, and structural challenges in getting patients screened. Through these interviews, we learned that physicians would likely welcome a tool to help them communicate about CRC with their patients. PCPs often have multiple topics to discuss with patients and limited time in which to do so. Providing patients with information about CRC before their appointment provides shared background for a conversation.
Similarly, the amount of new information patients receive during an appointment can be overwhelming and stressful for patients, particularly those with lower health literacy. Providing some information beforehand reduces the amount of new information patients must absorb. However, routine and regulation tend to govern medical environments. This means that physicians are unlikely to accept mHealth apps unless they fit into the regular workflow.
They are particularly important for the long-term dissemination of the app, as physicians and medical practices are a key channel for widespread distribution and adoption of the app by patients. The computer science team began development of the virtual human health care provider. The computer science team created different versions of ALEX for focus group testing, designing a total of 8 characters varying along 3 dimensions: age younger vs older , race black vs white , and gender man vs woman. They also had versions of the character in different attires, namely scrubs or business-casual office wear.
Making Connections: Teaching and the Human Brain
The computer science team began discussion of the hardware and software requirements of the app. With the larger team, they started the process of narrowing down which devices, browsers, and operating systems the app would support. This included the need for subtitles and clear audio to accommodate visual and hearing impairments.
Similarly, the app interface needed to be understandable for people with limited smartphone experience. These conversations continued throughout the development. Participants were aged older than 50 years, and the team held groups broken down by race and gender with black men, white men, black women, and white women. They recorded, transcribed, and analyzed the focus group data qualitatively. This first round of focus groups provided the team with valuable information about the preferences, needs, and opinions of potential users before prototype development.
Discussion centered around 4 areas: health information seeking What features make health information trustworthy? During the discussion, moderators showed participants still photos of different versions of the virtual human health care provider. The most important finding was that participants were open to discussing their health with a virtual human health care provider, providing an essential rationale for proceeding with the app development.
Overall, Phase 1 provided information on patient and clinician user requirements for the app. It established, through community involvement, the general acceptability of using a virtual human health care provider to encourage CRC screening. It also generated insights into the technical requirements of the app and potential accessibility challenges.
Developing the prototype required multiple steps including the animation of the virtual human health care provider, coding the internal logic of the app including options for randomization for the clinical trial , and designing the user interface. The computer science team and the communication science team met biweekly to discuss progress and address potential problems, creating an iterative workflow. The communication science team originally asked colleagues in their college to serve as voice actors for a prototype ALEX. However, the varied speed and diction of nonprofessional voice recordings made it difficult for the computer science team to accurately sync the audio recordings with the lips of the virtual characters.
To address this problem, the communication science team contracted professional voice actors to record the script. Paid voice actors recorded the scripts using professional equipment, which resulted in higher sound quality and greater syncing accuracy. The professional actors were also able to split audio files into segments to ease the process of syncing with the animation. As MyUFHealth is an existing platform with its own constraints, the team was originally unsure whether it would be able to house the app entirely or whether it would be necessary to host portions of the intervention on an external server.
Using an external site would allow for easier tracking of users but raised security concerns. Particularly problematic was the need to import demographic information—considered Protected Health Information PHI —into the app to customize the virtual human health care provider. Finally, it was decided that the app would be housed on its own secure server and users sent customized links with encrypted identification codes that allow us to track their movements and responses as they worked through the app.
They sought to understand what clinicians were currently doing to increase CRC screening so as to avoid designing an intervention that duplicates ongoing work. This is important both from a messaging perspective—ensuring that patients are not receiving competing messages—as well as from an experimental perspective.
Design and the Social Sciences
In evaluating the effectiveness of the app during the clinical trial, it is important to understand and avoid confounding influences to the greatest extent possible. The clinical team also collected information about screening rates at the various clinic locations and within the different departments at UF Health.
This information allows us to evaluate the effectiveness of the app by comparing past screening rates with screening rates during the clinical trial. It also helps us account for influences such as seasonal variation in screening rates. All participants were aged between 50 and 73 years. Owing to changes in the recruitment process, we separated some focus groups out by race and gender and others by gender only. Participants first filled out a questionnaire gauging their perceptions of CRC risk and screening. They then tested the prototype app on a Samsung Galaxy S7 smartphone provided to them by the moderators.
We recorded the focus groups and transcribed them for analysis.
The communication science team also held 38 think-aloud interviews during this timeframe, again using participants between the ages of 50 and 73 years. During think-aloud interviews, participants were asked to describe their thoughts and mental processes while using the app in real time [ 53 ].
The stream-of-consciousness data collected through think-aloud interviews let researchers see how participants are interacting with a tool, such as an mHealth app, in real time to better understand points of confusion and initial reactions. Participants felt generally favorable toward the concept and script, with several indicating that they intended to ask their own PCP about FIT as a result of the experience.
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They also expressed concern about the look and movement of the virtual human health care provider. Many found the virtual human health care provider creepy and unsettling , with several saying that they averted their eyes from the character and listened to the voice instead of engaging visually. In February , we held a meeting of our Community Advisory Board, a group of patients, advocates, and professionals in the medical field. At the meeting, we sought feedback from the Community Advisory Board on the prototype version of the app and script.
As with the focus groups, the Community Advisory Board members felt that the look and movement of the virtual human health care provider was unrealistic and distracting. The communication science team incorporated the medical information collected during Phase 1 into a conversational script for the virtual human health care provider. The original script identified 12 tailoring dimensions such as perceived susceptibility [ 54 ], perceived severity [ 55 ], perceived benefits [ 56 ], perceived barriers [ 23 ], self-efficacy [ 57 ], response efficacy [ 28 ], comparative risk feedback [ 58 ], risk probability [ 59 ], message source [ 60 ], narrative persuasion [ 61 ], demographic matching [ 62 ], and message framing [ 63 ].
Design and the Social Sciences by Jorge Frascara
Evidence suggests that these constructs can increase knowledge of cancer risks and screening and encourage behavioral change. The team refined the script through input from multiple writers and readers, as well as the full app team and Community Advisory Board members. The team also collapsed some constructs together for analytical purposes. Although the experimental design can accommodate multiple variables, analysis is complicated by each additional construct. The final message constructs are message source, susceptibility, severity, risk probability, response efficacy, benefits, barriers, narrative persuasion, and self-efficacy.
In Phase 3, the communication science team adapted the script and messaging to reflect community preferences gleaned from Phase 2. They clarified the constructs within the script for ease of analysis in the clinical trial and sent the script to an expert at the American Cancer Society to read for clarify, accuracy, and comprehensiveness. These comments, as well as additional feedback from the clinical team, were used to finalize the script.
The communication science team also tested the near-final app with community members by conducting additional think-aloud interviews between September and January We held additional 7 focus groups and 15 think-aloud interviews. The think-aloud interviews initially revealed that significant problems remained with the appearance of the virtual human health care provider, particularly the black female version.
To address these concerns, the computer science team created alternative versions of the black female character for testing by the communication science team with subsequent think-aloud and focus group participants. At this point, the development of the app became more intensively iterative, with the communication science team providing rapid feedback to the computer science team on changes that needed to be made to the app to achieve minimal acceptability from participants.
The computer science team refined the app during the evaluation phase, making changes as a result of community feedback, in particular, the results of the think-aloud interviews and focus groups. The idea was that by going to a more stylized—but not cartoonish—look, participants would not be primed for photorealism and then put off by the limitations of the animation software and rendering process. Ultimately, the computer science team adapted models in Adobe Fuse to create a look that was somewhat stylized but also recognizable to viewers. They also worked to integrate the app with MyUFHealth, ensuring that it was possible to demographically customize the virtual human health care provider for patients as per the study protocol.
They paid particular attention to the need to track patients within MyUFHealth, as well as within the app itself, and the subsequent questionnaire hosted on Qualtrics and the need to link up these datasets for later analysis. They accomplished this through the aforementioned customized URLs and deidentification system. Using UCD principles helped ensure that the mHealth app we created was acceptable to patients along 4 major dimensions of user needs: credibility, usability, effectiveness, and accessibility.
By describing the creation of an mHealth app using UCD principles, we are able to better understand both the iterative nature of development when incorporating user feedback as well as the unique contributions of researchers across disciplines. Communication scientists, computer scientists, clinicians, and community participants all played specific and interrelated roles in ensuring that the final product was credible, usable, effective, and accessible for patients.
We now summarize the specific components of these criteria and the contributions of each team in meeting them. Credibility had 3 main components: 1 accurate medical information, 2 association with the UF Health Network, and 3 a professional look and feel to the app design. Community members were ultimately the arbiters of what app features were and were not credible, as interpreted by the communication science team. First, the communication science team worked with the clinical team during Phases 1 and 2 to create accurate content that reflects best clinical practices.
This is in line with recommendations that health interventions be designed with input from subject matter experts [ 64 ]. Participants expressed skepticism about Web-based medical information, noting that such information is often misleading and inaccurate. However, they generally trusted the UF Health Network to provide them with credible information. Associating the app specifically with UF Health—a trusted medical provider—increased its credibility. Patients described this look as unprofessional and said that putting the virtual human health care provider in a lab coat would increase credibility.
The computer science team made these changes for the think-aloud interviews and focus groups in Phase 3. Third, participants said an app needed to have a professional look and feel to be seen as credible. Participants in Phase 2 focus groups and early Phase 3 think-aloud interviews expressed discomfort with the look and animation of the virtual human health care provider. A key theme was that participants wanted the app to look like it was made by professional graphic designers to set it apart from other untrustworthy Web-based content.
In other words, participants associated professional design and animation with medical credibility. Usability had 2 main components: 1 intuitive app design and integration and 2 easily understood dialogue. As with credibility, community involvement helped operationalize these concepts in a way that reflected best practices from an academic perspective as well as from the perspective of the users themselves. First, usability requires that the app design and interface be intuitive for both patients as well as clinicians and health workers.
For patients, this meant that the app use and navigation needed to be self-explanatory even without instruction. Community feedback suggested a number of changes, which we incorporated into the app. For instance, the original working prototype had both a chat log and subtitles, which were seen as redundant. Similarly, although the app had a pause button, tapping the screen did not pause or play the interaction, which confused participants.
Both these issues were corrected in the final version of the app. For clinicians and health care workers, the app needed to intuitively fit into the clinical workflow to be usable, particularly with regard to requesting FIT. In designing this feature, the computer science team interfaced with UF Health to ensure that the appropriate medical professionals received the request through the appropriate channels, integrating with MyUFHealth. UF Health IT representatives indicated that clinical workers were accustomed to receiving information and requests from patients through the system.
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We have another programme at postgraduate level i. It is designed to cater the need of modern industrial society. This programme offers the students specialized knowledge and skills required to meet the challenges of the corporate world. The core strength of the programme lies in developing skills which are relevant to the current trend in the area of Human Resource Management.
It is indeed a testimony that our alumni are placed at top management positions in leading organizations across all the sectors and are guiding them on the road of inclusive growth. In the Institute, our Department will keep on playing a vital role to import knowledge to engineering, science and other students which will enable them to face the challenges related to human value and ethics.