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. 2021 Feb 22;23(2):e23612.
doi: 10.2196/23612.

Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies

Tobias Kowatsch  1   2   3 , Kim-Morgaine Lohse  1 , Valérie Erb  4   5 , Leo Schittenhelm  2 , Helen Galliker  1 , Rea Lehner  3 , Elaine M Huang  5
Affiliations

Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies

Tobias Kowatsch et al. J Med Internet Res. .

Abstract

Background: Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments.

Objective: To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment.

Methods: We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients' perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges.

Results: Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality-based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks.

Conclusions: The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders.

Keywords: adherence; augmented reality; chronic back pain; chronic pain; conversational agent; design science research; exercise; health care; mobile phone; pain; physiotherapy; smartphone; treatment; treatment adherence; ubiquitous coaching.

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Conflict of interest statement

Conflicts of Interest: TK, KML, LS, and HG are affiliated with the Centre for Digital Health Interventions, a joint initiative of the Department of Management, Technology and Economics at ETH Zurich and the Institute of Technology Management at the University of St Gallen, which is funded in part by the Swiss health insurer CSS. TK is also a cofounder of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, Pathmate Technologies is not involved in any of the 4 studies described in this paper. All other authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Overview of hybrid ubiquitous coaching (HUC).
Figure 2
Figure 2
Augmented reality–based conversational agent and female humanlike model demonstrating the squat exercise.
Figure 3
Figure 3
Predefined answer options. The conversational agent communicated visually and auditorily.
Figure 4
Figure 4
Participant performing the squat exercise while wearing the augmented reality hardware.
Figure 5
Figure 5
Virtual guides embedded into the revised augmented reality–based conversational agent and used in studies 2, 3, and 4.
Figure 6
Figure 6
Paper-based instructions of study 3.
Figure 7
Figure 7
Video-based instructions of study 3.
Figure 8
Figure 8
Thematic map of the patients' qualitative feedback of study 1. Note: the number in brackets indicates the frequency a topic was mentioned.
Figure 9
Figure 9
Thematic map of the patients' qualitative feedback of study 3. Note: the number in brackets indicates the frequency a topic was mentioned. HUC: hybrid ubiquitous coaching.
Figure 10
Figure 10
Box plot of the exercise execution errors during the 4 weeks. The number of errors was aggregated for each week.
See this image and copyright information in PMC

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References

    1. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, Borges GLG, Bromet EJ, Demytteneare K, de Girolamo G, de Graaf R, Gureje O, Lepine J, Haro JM, Levinson D, Oakley Browne MA, Posada-Villa J, Seedat S, Watanabe M. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008 Oct;9(10):883–91. doi: 10.1016/j.jpain.2008.05.005. - DOI - PubMed
    1. Briggs AM, Cross MJ, Hoy DG, Sànchez-Riera Lídia, Blyth FM, Woolf AD, March L. Musculoskeletal Health Conditions Represent a Global Threat to Healthy Aging: A Report for the 2015 World Health Organization World Report on Ageing and Health. Gerontologist. 2016 Apr;56 Suppl 2:S243–55. doi: 10.1093/geront/gnw002. - DOI - PubMed
    1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov 10;392(10159):1789–1858. doi: 10.1016/S0140-6736(18)32279-7. https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(18)32279-7 - DOI - PMC - PubMed
    1. Briggs AM, Woolf AD, Dreinhöfer K, Homb N, Hoy DG, Kopansky-Giles D, Åkesson K, March L. Reducing the global burden of musculoskeletal conditions. Bull World Health Organ. 2018 May 01;96(5):366–368. doi: 10.2471/BLT.17.204891. http://europepmc.org/abstract/MED/29875522 - DOI - PMC - PubMed
    1. March L, Smith EUR, Hoy DG, Cross MJ, Sanchez-Riera L, Blyth F, Buchbinder R, Vos T, Woolf AD. Burden of disability due to musculoskeletal (MSK) disorders. Best Pract Res Clin Rheumatol. 2014 Jun;28(3):353–66. doi: 10.1016/j.berh.2014.08.002. - DOI - PubMed

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