Journal Article2022Cited by 12

A Mobile Application-Based Relational Agent as a Health Professional for COVID-19 Patients: Design, Approach, and Implications

Ashraful Islam, Beenish Moalla Chaudhry

International Journal of Environmental Research and Public Health

Multidisciplinary Digital Publishing Institute, Vol. 19, Issue 21, pp. 13794, ISBN: 1660-4601

  • Good Health and Well-being — Relevance: 64%
DOI: 10.3390/ijerph192113794Open AccessURL

Abstract

Relational Agents’ (RAs) ability to maintain socio-emotional relationships with users can be an asset to COVID-19 patients. The goal of this research was to identify principles for designing an RA that can act as a health professional for a COVID-19 patient. We first identified tasks that such an RA can provide by interviewing 33 individuals, who had recovered from COVID-19. The transcribed interviews were analyzed using qualitative thematic analysis. Based on the findings, four sets of hypothetical conversations were handcrafted to illustrate how the proposed RA will execute the identified tasks. These conversations were then evaluated by 43 healthcare professionals in a qualitative study. Thematic analysis was again used to identify characteristics that would be suitable for the proposed RA. The results suggest that the RA must: model clinical protocols; incorporate evidence-based interventions; inform, educate, and remind patients; build trusting relationships, and support their socio-emotional needs. The findings have implications for designing RAs for other healthcare contexts beyond the pandemic.

Keywords

  • relational agents
  • COVID-19 patients
  • evidence-based interventions
  • socioemotional support
  • chatbots
  • recovered COVID-19 patients
  • mobile health apps
  • health professionals' role
  • trust building

CCDS Authors

Ashraful Islam, PhD
Ashraful Islam

Ashraful Islam, PhD

  • Center Director, CCDS
  • Director, HCI Wing

Assistant Professor

Department of Computer Science and Engineering

Independent University, Bangladesh (IUB)

Published at

CHI, UIST, UbiComp, IJCNN, ICIP, HCII, ICDMW, BLP, IEEE Internet of Things Journal, JMIR, JMIR Human Factors, JMIR Formative Research, IEEE Access, Smart Agricultural Technology, Diabetes Research and Clinical Practice, PLOS ONE

Research Interests

Human-Computer Interaction, AI for Social Good, AI for Public Health, AI for Impact

Beenish Moalla Chaudhry, PhD
Beenish Moalla Chaudhry, PhD

Beenish Moalla Chaudhry, PhD

  • Collaborator, HCI Wing

Associate Professor

School of Computing and Informatics

University of Louisiana at Lafayette

Published at

UIST, HCII, JMIR Human Factors, JMIR Formative Research

References

  1. 1.Virginia Braun, Victoria Clarke. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101[10.1191/1478088706qp063oa]
  2. 2.Laura L. Carstensen, Derek M. Isaacowitz, Susan T. Charles. (1999). Taking time seriously: A theory of socioemotional selectivity.. American Psychologist, 54(3), 165–181[10.1037//0003-066x.54.3.165]
  3. 3.Judd E. Hollander, Brendan G. Carr. (2020). Virtually Perfect? Telemedicine for Covid-19. New England Journal of Medicine, 382(18), 1679–1681[10.1056/nejmp2003539]
  4. 4.Kathleen Kara Fitzpatrick, Alison Darcy, Molly Vierhile. (2017). Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial. JMIR Mental Health, 4(2), e19[10.2196/mental.7785]
  5. 5.Mark É. Czeisler, Kristy Marynak, Kristie E.N. Clarke, Zainab Salah, Iju Shakya, JoAnn M. Thierry, Nida Ali, H McMillan, Joshua F. Wiley, Matthew D. Weaver, Charles A. Czeisler, Shantha M. W. Rajaratnam, Mark E. Howard. (2020). Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morbidity and Mortality Weekly Report, 69(36), 1250–1257[10.15585/mmwr.mm6936a4]
  6. 6.Janet Finch. (1987). The Vignette Technique in Survey Research. Sociology, 21(1), 105–114[10.1177/0038038587021001008]
  7. 7.Jiwei Li, Will Monroe, Alan Ritter, Dan Jurafsky, Michel Galley, Jianfeng Gao. (2016). Deep Reinforcement Learning for Dialogue Generation. , 1192–1202[10.18653/v1/d16-1127]
  8. 8.Thomas Szasz. (1956). A Contribution to the Philosophy of medicine. A M A Archives of Internal Medicine, 97(5), 585[10.1001/archinte.1956.00250230079008]
  9. 9.David Blumenthal, Elizabeth Fowler, Melinda K. Abrams, Sara R. Collins. (2020). Covid-19 — Implications for the Health Care System. New England Journal of Medicine, 383(15), 1483–1488[10.1056/nejmsb2021088]
  10. 10.Brook Calton, Nauzley C. Abedini, Michael Fratkin. (2020). Telemedicine in the Time of Coronavirus. Journal of Pain and Symptom Management, 60(1), e12–e14[10.1016/j.jpainsymman.2020.03.019]
  11. 11.Kien Hoa Ly, Ann-Marie Ly, Gerhard Andersson. (2017). A fully automated conversational agent for promoting mental well-being: A pilot RCT using mixed methods. Internet Interventions, 10, 39–46[10.1016/j.invent.2017.10.002]
  12. 12.Minjin Rheu, Ji Youn Shin, Wei Peng, Jina Huh. (2020). Systematic Review: Trust-Building Factors and Implications for Conversational Agent Design. International Journal of Human-Computer Interaction, 37(1), 81–96[10.1080/10447318.2020.1807710]
  13. 13.Gale Lucas, Albert Rizzo, Jonathan Gratch, Stefan Scherer, Giota Stratou, Jill Boberg, Louis–Philippe Morency. (2017). Reporting Mental Health Symptoms: Breaking Down Barriers to Care with Virtual Human Interviewers. Frontiers in Robotics and AI, 4[10.3389/frobt.2017.00051]
  14. 14.Manu Goyal, Pratibha Singh, Kuldeep Singh, Shashank Shekhar, Neha Agrawal, Sanjeev Misra. (2020). The effect of the COVID‐19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center. International Journal of Gynecology & Obstetrics, 152(2), 231–235[10.1002/ijgo.13457]
  15. 15.Robert R. Morris, Kareem Kouddous, Rohan Kshirsagar, Stephen M. Schueller. (2018). Towards an Artificially Empathic Conversational Agent for Mental Health Applications: System Design and User Perceptions. Journal of Medical Internet Research, 20(6), e10148[10.2196/10148]
  16. 16.Fiorella de Rosis, Catherine Pélachaud, Isabella Poggi, Valeria Carofiglio, Berardina De Carolis. (2003). From Greta's mind to her face: modelling the dynamics of affective states in a conversational embodied agent. International Journal of Human-Computer Studies, 59(1-2), 81–118[10.1016/s1071-5819(03)00020-x]
  17. 17.Qianlan Yin, Zhuoer Sun, Tuanjie Liu, Xiong Ni, Xuanfeng Deng, Yanpu Jia, Zhilei Shang, Yaoguang Zhou, Weizhi Liu. (2020). Posttraumatic stress symptoms of health care workers during the corona virus disease 2019. Clinical Psychology & Psychotherapy, 27(3), 384–395[10.1002/cpp.2477]
  18. 18.Yaser Moradi, Rahim Baghaei, Keyvan Hosseingholipour, Farzin Mollazadeh. (2021). Challenges experienced by ICU nurses throughout the provision of care for COVID‐19 patients: A qualitative study. Journal of Nursing Management, 29(5), 1159–1168[10.1111/jonm.13254]
  19. 19.Farnaz Khoshrounejad, Mahsa Hamednia, Ameneh Mehrjerd, Shima Pichaghsaz, Hossein Jamalirad, Mahdi Sargolzaei, Benyamin Hoseini, Shokoufeh Aalaei. (2021). Telehealth-Based Services During the COVID-19 Pandemic: A Systematic Review of Features and Challenges. Frontiers in Public Health, 9, 711762[10.3389/fpubh.2021.711762]
  20. 20.Paul Barach, Stacy D. Fisher, M. Jacob Adams, Gale R. Burstein, Patrick D. Brophy, Dennis Z. Kuo, Steven E. Lipshultz. (2020). Disruption of healthcare: Will the COVID pandemic worsen non-COVID outcomes and disease outbreaks?. Progress in Pediatric Cardiology, 59, 101254[10.1016/j.ppedcard.2020.101254]
  21. 21.Gopi Battineni, Nalini Chintalapudi, Francesco Amenta. (2020). AI Chatbot Design during an Epidemic like the Novel Coronavirus. Healthcare, 8(2), 154[10.3390/healthcare8020154]
  22. 22.U. O. Karlsson, Carl‐Johan Fraenkel. (2020). Covid-19: risks to healthcare workers and their families. BMJ, 371, m3944[10.1136/bmj.m3944]
  23. 23.Rashid L. Bashshur, Gary W. Shannon, Elizabeth A. Krupinski, Jim Grigsby. (2013). Sustaining and Realizing the Promise of Telemedicine. Telemedicine Journal and e-Health, 19(5), 339–345[10.1089/tmj.2012.0282]
  24. 24.Timothy Bickmore, Lisa B. Caruso, Kerri M. Clough‐Gorr. (2005). Acceptance and usability of a relational agent interface by urban older adults. , 1212–1215[10.1145/1056808.1056879]
  25. 25.Lean L Kramer, Silke ter Stal, Bob C Mulder, Emely de Vet, Lex van Velsen. (2019). Developing Embodied Conversational Agents for Coaching People in a Healthy Lifestyle: Scoping Review. Journal of Medical Internet Research, 22(2), e14058[10.2196/14058]
  26. 26.Sue ‎Turale, Apiradee Nantsupawat. (2021). Clinician mental health, nursing shortages and the COVID‐19 pandemic: Crises within crises. International Nursing Review, 68(1), 12–14[10.1111/inr.12674]
  27. 27.Victoria Groom, Clifford Nass, Tina Chen, Alexia Nielsen, James K. Scarborough, Erica Robles. (2009). Evaluating the effects of behavioral realism in embodied agents. International Journal of Human-Computer Studies, 67(10), 842–849[10.1016/j.ijhcs.2009.07.001]
  28. 28.José Joaquín Mira, Irene Carrillo, Mercedes Guilabert, Aurora Mula, Jimmy Martín-Delgado, Virtudes Pérez‐Jover, María Asunción Vicente, César Fernández. (2020). Acute stress of the healthcare workforce during the COVID-19 pandemic evolution: a cross-sectional study in Spain. BMJ Open, 10(11), e042555[10.1136/bmjopen-2020-042555]
  29. 29.Myrthe L. Tielman, Mark A. Neerincx, Rafael Bidarra, Ben Kybartas, Willem‐Paul Brinkman. (2017). A Therapy System for Post-Traumatic Stress Disorder Using a Virtual Agent and Virtual Storytelling to Reconstruct Traumatic Memories. Journal of Medical Systems, 41(8), 125[10.1007/s10916-017-0771-y]
  30. 30.David H. Jiang, Rozalina G. McCoy. (2020). Planning for the Post-COVID Syndrome: How Payers Can Mitigate Long-Term Complications of the Pandemic. Journal of General Internal Medicine, 35(10), 3036–3039[10.1007/s11606-020-06042-3]
  31. 31.Onil Bhattacharyya, Kathryn Mossman, Lovisa Gustafsson, Eric C. Schneider. (2018). Using Human-Centered Design to Build a Digital Health Advisor for Patients With Complex Needs: Persona and Prototype Development. Journal of Medical Internet Research, 21(5), e10318[10.2196/10318]
  32. 32.Feifei Ren, Rongjuan Guo. (2020). PUBLIC MENTAL HEALTH IN POST-COVID-19 ERA. Psychiatria Danubina, 32(2), 251–255[10.24869/psyd.2020.251]
  33. 33.Rasita Vinay, Holger Baumann, Nikola Biller‐Andorno. (2021). Ethics of ICU triage during COVID-19. British Medical Bulletin, 138(1), 5–15[10.1093/bmb/ldab009]
  34. 34.Nick Bott, Sharon Stahl Wexler, Lin J. Drury, Chava Pollak, Victor Wang, Kathleen Scher, Sharon Narducci. (2019). A Protocol-Driven, Bedside Digital Conversational Agent to Support Nurse Teams and Mitigate Risks of Hospitalization in Older Adults: Case Control Pre-Post Study. Journal of Medical Internet Research, 21(10), e13440[10.2196/13440]
  35. 35.Stefán Ólafsson, Teresa K. O’Leary, Timothy Bickmore. (2020). Motivating Health Behavior Change with Humorous Virtual Agents. , 1–8[10.1145/3383652.3423915]
  36. 36.Mollie M. McKillop, Brett R. South, Anita M. Preininger, Mitch Mason, Gretchen Purcell Jackson. (2020). Leveraging conversational technology to answer common COVID-19 questions. Journal of the American Medical Informatics Association, 28(4), 850–855[10.1093/jamia/ocaa316]
  37. 37.Mohan Zalake, Fatemeh Tavassoli, Lauren Griffin, Janice L. Krieger, Benjamin Lok. (2019). Internet-based Tailored Virtual Human Health Intervention to Promote Colorectal Cancer Screening. , 15(2), 73–80[10.1145/3308532.3329471]
  38. 38.Leo Wanner, Elisabeth André, Josep Blat, Stamatia Dasiopoulou, Mireia Farrús, Thiago Fraga, Eleni Kamateri, Florian Lingenfelser, Gerard Llorach, Oriol Martínez, Γεώργιος Μεδίτσκος, Simon Mille, Wolfgang Minker, Louisa Pragst, Dominik Schiller, Andries Stam, Ludo Stellingwerff, Federico M. Sukno, Bianca Vieru, Stefanos Vrochidis. (2017). KRISTINA: A Knowledge-Based Virtual Conversation Agent. Lecture notes in computer science, 284–295[10.1007/978-3-319-59930-4_23]
  39. 39.Stephan Diederich, Alfred Brendel, Lutz M. Kolbe. (2019). Towards a Taxonomy of Platforms for Conversational Agent Design.. Journal of the Association for Information Systems, 1100–1114[link]
  40. 40.Myrthe L. Tielman, Mark A. Neerincx, Willem‐Paul Brinkman. (2019). Design and Evaluation of Personalized Motivational Messages by a Virtual Agent that Assists in Post-Traumatic Stress Disorder Therapy. Journal of Medical Internet Research, 21(3), e9240[10.2196/jmir.9240]
  41. 41.Hannah Gaffney, Warren Mansell, Sara Tai. (2020). Agents of change: Understanding the therapeutic processes associated with the helpfulness of therapy for mental health problems with relational agent MYLO. Digital Health, 6, 2055207620911580[10.1177/2055207620911580]
  42. 42.Wai Lok Woo, Bin Gao, Raid Rafi Omar Al-Nima, Bingo Wing‐Kuen Ling. (2020). Development of Conversational Artificial Intelligence for Pandemic Healthcare Query Support. International Journal of Automation Artificial Intelligence and Machine Learning, 54–79[10.61797/ijaaiml.v1i1.35]
  43. 43.Jin Kang, Lewen Wei. (2018). "Give Me the Support I Want!". , 106–113[10.1145/3284432.3284462]
  44. 44.Md Faisal Kabir, Daniel Schulman, Abu S. Abdullah. (2019). Promoting Relational Agent for Health Behavior Change in Low and Middle - Income Countries (LMICs): Issues and Approaches. Journal of Medical Systems, 43(7), 227[10.1007/s10916-019-1360-z]
  45. 45.Andreea I. Niculescu, Rafael E. Banchs. (2019). Humor Intelligence for Virtual Agents. Lecture notes in electrical engineering, 285–297[10.1007/978-981-13-9443-0_25]
  46. 46.Timothy Bickmore, Daniel Schulman. (2006). The comforting presence of relational agents. , 550–555[10.1145/1125451.1125568]
  47. 47.Stéphanie Buisine, Yun Wang, Ouriel Grynszpan. (2009). Empirical investigation of the temporal relations between speech and facial expressions of emotion. Journal on Multimodal User Interfaces, 3(4), 263–270[10.1007/s12193-010-0050-4]
  48. 48.Timothy Bickmore. (2014). Evidence-Based Approaches to Harnessing Technology to Provide Social-Emotional Support. Oxford University Press eBooks, 139–150[10.1093/med/9780199314027.003.0010]
  49. 49.Nourchène Ouerhani, Ahmed Maalel, Henda Ben Ghézala, Soulaymen Chouri. (2020). Smart Ubiquitous Chatbot for COVID-19 Assistance with Deep learning Sentiment Analysis Model during and after quarantine. Research Square (Research Square)[10.21203/rs.3.rs-33343/v1]
  50. 50.T. B. Brown, Gao, Song. (2023). Aion Framework: Dimensional Emergence of AI Consciousness, Observer-Induced Collapse, and Cosmological Portal Dynamics. DROPS (Schloss Dagstuhl – Leibniz Center for Informatics)[10.4230/lipics.giscience.2023.43]
  51. 51.Joseph Weizenbaum. (1966). ELIZA—a computer program for the study of natural language communication between man and machine. Communications of the ACM, 9(1), 36–45[10.1145/365153.365168]
  52. 52.Laura L. Carstensen, Derek M. Isaacowitz, Susan T. Charles. (1999). Taking time seriously: A theory of socioemotional selectivity.. American Psychologist, 54(3), 165–181[10.1037/0003-066x.54.3.165]
  53. 53.Leigh Clark, Nadia Pantidi, Orla Cooney, Philip R. Doyle, Diego Garaialde, Justin Edwards, Brendan Spillane, Emer Gilmartin, Christine Murad, Cosmin Munteanu, Vincent Wade, Benjamin R. Cowan. (2019). What Makes a Good Conversation?. , 1–12[10.1145/3290605.3300705]
  54. 54.Parham Amiri, Elena Karahanna. (2022). Chatbot use cases in the Covid-19 public health response. Journal of the American Medical Informatics Association, 29(5), 1000–1010[10.1093/jamia/ocac014]
  55. 55.Ashraful Islam, Beenish Moalla Chaudhry. (2021). Identifying User Personas for Engagement with a COVID-19 Health Service Delivery Relational Agent. , 364–366[10.1145/3472307.3484658]

Cited By

Showing the 10 most-cited of 12 citing works recorded by OpenAlex.

  1. 1.Xiang Wang, Chang-Franw Lee, Jiabei Jiang, Xiaoyang Zhu. (2023). Factors Influencing the Aged in the Use of Mobile Healthcare Applications: An Empirical Study in China. Healthcare, 11(3), 396[10.3390/healthcare11030396]
  2. 2.Emil Chiauzzi, Andre Williams, Timothy Y. Mariano, Sarah Pajarito, Athena Robinson, Andrew Kirvin-Quamme, Valerie Forman-Hoffman. (2024). Demographic and clinical characteristics associated with anxiety and depressive symptom outcomes in users of a digital mental health intervention incorporating a relational agent. BMC Psychiatry, 24(1), 79[10.1186/s12888-024-05532-6]
  3. 3.Hee Jeong Han, Sanjana Mendu, Beth K Jaworski, Jason E Owen, Saeed Abdullah. (2023). Preliminary Evaluation of a Conversational Agent to Support Self-management of Individuals Living With Posttraumatic Stress Disorder: Interview Study With Clinical Experts. JMIR Formative Research, 7, e45894[10.2196/45894]
  4. 4.Ashraful Islam, Beenish Moalla Chaudhry. (2022). Design Validation of a Relational Agent by COVID-19 Patients: Mixed Methods Study. JMIR Human Factors, 10, e42740[10.2196/42740]
  5. 5.Emil Chiauzzi, Andre Williams, Timothy Y. Mariano, Sarah Pajarito, Athena Robinson, Andrew Kirvin-Quamme, Valerie Forman-Hoffman. (2023). Demographic and clinical characteristics associated with anxiety and depressive symptom outcomes in users of a digital mental health intervention incorporating a relational agent. Research Square[10.21203/rs.3.rs-2488688/v1]
  6. 6.Hyeon Jo, Eun-Mi Baek. (2024). Virtual resonance: analyzing IPA usage intensity under COVID-19's isolating canopy. Scientific Reports, 14(1), 15048[10.1038/s41598-024-64809-8]
  7. 7.Muhammet Fatih Şengüllendi. (2025). How does organizational sacralization affect healthcare professionals’ work engagement and turnover intentions through perceived organizational support?. Journal of Health Organization and Management, 40(1), 124–149[10.1108/jhom-08-2024-0352]
  8. 8.A. Suri, G. Sindwani. (2025). Mothers’ Assistant for Labor analgesia (MALA): a novel artificial intelligence interactive avatar for patient education in obstetric anesthesia. International Journal of Obstetric Anesthesia, 64, 104762[10.1016/j.ijoa.2025.104762]
  9. 9.Ashraful Islam, Beenish Moalla Chaudhry, Aminul Islam. (2023). Designing Healthcare Relational Agents: A Conceptual Framework with User-Centered Design Guidelines. , 1–4[10.1109/iscc58397.2023.10218039]
  10. 10.Ashraful Islam, Beenish Moalla Chaudhry, Aminul Islam. (2024). RACares: a conceptual design to guide mHealth relational agent development based on a systematic review. mHealth, 10, 11[10.21037/mhealth-23-46]
← All publications