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Cited by 140Digital Mental Health InterventionsMobile Health and mHealth ApplicationsSocial Robot Interaction and HRI

Engaging women with an embodied conversational agent to deliver mindfulness and lifestyle recommendations: A feasibility randomized control trial

Open access
Gardiner, Paula M., McCue, Kelly D., Negash, Lily M., Cheng, Teresa, White, Laura F., Yinusa-Nyahkoon, Leanne, Jack, Brian W., Bickmore, Timothy W.·2017·Patient Education and Counseling
DOI 10.1016/j.pec.2017.04.015PMC PMC5559098
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Abstract

Objective This randomized controlled trial evaluates the feasibility of using an Embodied Conversational Agent (ECA) to teach lifestyle modifications to urban women. Methods Women were randomized to either 1) an ECA (content included: mindfulness, stress management, physical activity, and healthy eating) or 2) patient education sheets mirroring same content plus a meditation CD/MP3 once a day for one month. General outcome measures included: number of stress management techniques used, physical activity levels, and eating patterns. Results Sixty-one women ages 18 to 50 were enrolled. On average, 51% identified as white, 26% as black, 23% as other races; and 20% as Hispanic. The major stress management techniques reported at baseline were: exercise (69%), listening to music (70%), and social support (66%). After one month, women randomized to the ECA significantly decreased alcohol consumption to reduce stress (p = 0.03) and increased daily fruit consumption by an average of 2 servings compared to the control (p = 0.04). Conclusion It is feasible to use an ECA to promote health behaviors on stress management and healthy eating among diverse urban women. Practice implications Compared to patient information sheets, ECAs provide promise as a way to teach healthy lifestyle behaviors to diverse urban women.

AI snapshot

Written from the paper’s full text.

TL;DR

This feasibility randomized controlled trial enrolled 61 urban women ages 18–50 to compare an embodied conversational agent (ECA), Gabby, with patient education sheets plus a meditation CD/MP3 for one month. The ECA was feasible and was associated with significantly decreased alcohol use for stress and increased daily fruit servings compared with control.

Key findings

  • Sixty-one women were enrolled and 57 had outcome data from baseline to follow-up; mean age was 35, 51% identified as white, 26% as black, 2% as Asian/Pacific Islander, 21% as other races, and 20% as Hispanic.
  • At 30 days, women randomized to the ECA significantly decreased alcohol consumption to reduce stress compared with control (35% to 14% for intervention, 30% to 31% for control; p = 0.03).
  • ECA users significantly increased daily fruit servings compared with control (μ = 2 to 4 for intervention, μ = 2 to 2 for control; p = 0.04).
  • ECA users spent a median total of 52 min interacting with Gabby (IQR = 101.4, N = 31) and logged in 5 times (IQR = 7, N = 31); average session time was 12.1 min (σ = 6.1, min = 3.9, max = 25.8). Satisfaction was higher but not statistically significant for using Gabby suggestions for healthy eating (69% vs 66%), physical activity (52% vs 49%), and stress management (70% vs 66%).

Methods

  • Two-arm feasibility RCT recruiting women from primary care outpatient clinics at Boston Medical Center; inclusion criteria were self-identified women, ages 18–50, telephone and computer internet access, English-speaking, and not pregnant. Participants were randomized by computer-generated permuted block to ECA or control; the research assistant was not blinded to allocation.
  • Intervention participants used the Gabby ECA system, with content on mindfulness, stress management, physical activity, and healthy eating, and were asked to log on once daily for 30 days. Control participants reviewed patient information sheets mirroring the same content plus a meditation CD/MP3 recorded by a live meditation teacher, and were encouraged to listen once daily for 30 days.
  • Outcomes included feasibility metrics (recruitment, racial minority proportion, completion, outcome data collection, satisfaction), demographics, SF-12, PHQ-9, NHANES-adapted eating questions, Stanford Exercise Behaviors Questionnaire, Self-Efficacy for Exercise Scale, Perceived Stress Scale, confidence ratings, and qualitative interviews. Analysis used descriptive statistics, Chi-square tests, two-sample t-tests, Wilcoxon Rank Sum tests, and SAS 9.3.

Limitations

  • The paper states limitations including small sample size, short intervention duration, specific inclusion criteria, and self-reported information; internet access inclusion may bias toward women with favorable technology use; the Gabby system was developed in English, excluding non-fluent English speakers; and participants could inaccurately report health behaviors due to lack of knowledge or discomfort sharing with a web-based system.
  • Evident from the text: the research assistant was not blinded to group allocation, and the feasibility study lacked statistical power to measure differences in adherence or efficacy, so many outcomes were not statistically significant.
  • Evident from the text: control group meditations were recorded by a live meditation teacher while Gabby used an electronic voice, which may confound comparisons of the meditation components.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.pec.2017.04.015

Cites

54 of 54 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 62 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    At baseline, women in both groups were identified as being mildly depressed, with an average PHQ-9 score of 7.

    “At baseline, women in both groups were identified as being mildly depressed, with an average PHQ-9 score of 7.”
    Quote in the paperNot a substantial claim
  • Findingown data

    At 30 days, there was a significant decrease in the number of women who used alcohol for stress management in the intervention compared to the control group (35% to 14% for intervention, 30% to 31% for control; p = 0.03).

    “At 30 days, there was a significant decrease in the number of women who used alcohol for stress management in the intervention compared to the control group (35% to 14% for intervention, 30% to 31% for control; p = 0.03).”
    Quote in the paperSubstantial claim
  • Findingown data

    At one month, there was no significant difference in the number of adaptive coping techniques between groups.

    “At one month, there was no significant difference in the number of adaptive coping techniques between groups.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Consumption of whole grains, red meat, and fish did not differ significantly between the two groups from baseline to follow-up.

    “Consumption of whole grains, red meat, and fish did not differ significantly between the two groups from baseline to follow-up.”
    Quote in the paperNot a substantial claim
  • Findingown data

    PHQ-9 scores decreased by two units in the ECA group compared to a one unit decrease in the control group.

    “However, it is worth noting that PHQ-9 scores decreased by two units in the ECA group compared to a one unit decrease in the control group.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 30
  • Classified as probably not a substantial claim. 40
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    The amount of vegetable servings increased for both groups, but not significantly.

    “The amount of vegetable servings increased for both groups, but not significantly.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The number of stress management techniques increased in both groups, though there was no significant difference (μ = 1 to 4 for intervention, μ=2 to 3 for control).

    “The number of stress management techniques increased in both groups, though there was no significant difference (μ = 1 to 4 for intervention, μ=2 to 3 for control).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    At baseline, 51% identified as white, 26% as black, 2% as Asian/Pacific Islander, and 21% as other races.

    “51% identified as white, 26% as black, 2% as Asian/Pacific Islander, and 21% as other races;”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Although statistically insignificant, duration of exercise increased in both groups for stretching/strengthening (p = 0.18) and aerobic exercise (p = 0.27).

    “Although statistically insignificant, duration of exercise increased in both groups for stretching/ strengthening (p = 0.18) and aerobic exercise (p = 0.27).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    84% primarily spoke English at home, while 11% primarily spoke Spanish.

    “Eighty-four percent of participants primarily spoke English at home, while 11% primarily spoke Spanish.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The average time spent per individual session was 12.1 min (σ = 6.1, min = 3.9, max = 25.8).

    “The average time spent per individual session was 12.1 min (σ = 6.1, min = 3.9, max = 25.8).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At baseline, participants' average age was 35 years.

    “On average, participants were 35 years old;”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The study enrolled 61 women between the ages of 18 and 50 during a 12-month recruitment window.

    “We recruited 61 participants in a 12-month period; all 61 recruited women were screened eligible and enrolled into the study for one month.”
    • Also stated in: § Results · plain
      “Sixty-one women ages 18 to 50 were enrolled.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    3% reported smoking, and 70% reported drinking alcohol at least once a month or more.

    “Three percent of participants reported smoking, and 70% reported drinking alcohol at least once a month or more.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Outcome data were collected from baseline to follow-up for 57 participants.

    “We collected outcome data from baseline to follow-up on 57 participants (Fig. 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There was no significant difference in food knowledge, food insecurity, and breakfast consumption between groups (p = 0.15, p = 0.99, and p = 0.11, respectively).

    “There was no significant difference in food knowledge, food insecurity, and breakfast consumption between groups (p = 0.15, p = 0.99, and p = 0.11, respectively).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    20% of participants identified as Hispanic.

    “and 20% identified as Hispanic.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At follow-up, PHQ-9 and SF-12 scores did not differ significantly between the two groups (p = 0.36 and p = 0.28, respectively).

    “At follow-up, PHQ-9 and SF-12 scores did not differ significantly between the two groups (p = 0.36 and p = 0.28, respectively).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    All 61 recruited women were screened eligible and enrolled for one month.

    “We recruited 61 participants in a 12-month period; all 61 recruited women were screened eligible and enrolled into the study for one month.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    On average, women had a BMI of 28 kg/m3 and scored 7 on the PHQ-9.

    “On average, women in the study had a BMI of 28 kg/m3 and scored a 7 on the PHQ-9 assessment;”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    69% utilized suggestions from Gabby to improve healthy eating, 52% to increase physical activity, and 70% to manage stress: all of which were greater-but not statistically significant-relative frequencies than participants using patient information sheets (66%, 49% and 66%, respectively).

    “Sixty-nine percent utilized suggestions from Gabby to improve healthy eating, 52% to increase physical activity, and 70% to manage stress: all of which were greater–but not statistically significant–relative frequencies than participants using patient information sheets (66%, 49% and 66%, respectively).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Women favored using Gabby to improve stress management and increase physical activity more than women using patient information sheets.

    “Women favored using Gabby to improve stress management and increase physical activity more than women using patient information sheets.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There was no significant difference in self-confidence to manage stress, to engage in physical activity, and to eat healthy between groups.

    “There was no significant difference in self-confidence to manage stress, to engage in physical activity, and to eat healthy between groups.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    44% reported yearly household income less than $49,000, 46% more than $50,000, and 10% refused to disclose.

    “In regards to yearly household income, 44% reported making less than $49,000, and another 46% reported making more than $50,000. Ten percent of participants refused to disclose their income status.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    At baseline, the most popular stress management techniques were physical activity (69%), listening to music (70%), and spending time with friends (66%).

    “the most popular stress management techniques at baseline among participants included: engaging in physical activity (69%), listening to music (70%),and spending time with friends (66%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    ECA users spent a median total of 52 min (IQR = 101.4, N = 31) interacting with Gabby and logged in 5 times (IQR = 7, N = 31).

    “For one month, ECA users spent a median total of 52 min (interquartile range [IQR] = 101.4, N = 31) interacting with Gabby and logged in 5 times (IQR = 7, N = 31).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    30% reported chronic health problems, and 67% regularly took prescribed medication.

    “30% reported having chronic health problems, and 67% regularly took prescribed medication.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    79% had completed at least some college, and 89% worked full-time or part-time.

    “Seventy-nine percent of women had completed at least some college, and 89% of them worked full-time or part-time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There was a trend increase in the number of stress management techniques used, with Gabby users reporting use of more such techniques than at baseline.

    “There was also a trend increase in the number of stress management techniques used.”
    • Also stated in: § 4.1. Discussion · plain
      “Gabby users reported utilizing more stress management techniques from baseline”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants in both groups generally described their assigned intervention as very informative, easy to use, and a good reminder to keep their health status in check through mindfulness, physical activity and healthy eating.

    “Users from both groups generally highlighted that their assigned intervention was very informative, easy to use, and served as a good reminder to keep their health status in check through mindfulness, physical activity and healthy eating.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Reported challenges in using the Gabby system were the sound and quality of her voice, the time commitment required, and limitations in program accessibility.

    “Challenges using the Gabby system included the sound and quality of her voice, time commitment to use the system, and program accessibility.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Clinicians often address multiple health behaviors simultaneously and supplement office visits with written materials such as patient information sheets or brochures.

    “Clinicians often address multiple health behaviors simultaneously and supplement office visits with additional health education through written materials, such as patient information sheets or brochures [1, 2].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [1] Buck ML Providing patients with written medication information Ann. Pharmacother 32 1998 962 969 9762384 source

      Not checked in the free run.

    • cites [2] Harvey I O'Brien M Addressing health disparities through patient education: the development of culturally-tailored health education materials at Puentes de Salud J. Community Health Nurs 28 2011 181 189 22053763 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Technology-based interventions are becoming increasingly popular for delivering health-related behavioral changes.

    “Today, technology-based interventions are becoming increasingly popular for delivering health-related behavioral changes [5–7].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [5] Gibbons CM Use of health information technology among racial and ethnic underserved communities Perspect. Health Inf. Manag 8 2011 Winter PMC3035830 21307989

      Not checked in the free run.

    • cites [6] Matthews J Win KT Oinas-Kukkonen H Freeman M Persuasive technology in mobile applications promoting physical activity: a systematic review J. Med. Syst 40 2016 72 26748792 source

      Not checked in the free run.

    • cites [7] Harris J Felix L Miners A Murray E Michie S Ferguson E Free C Lock K Landon J Edwards P Adaptive e-learning to improve dietary behavior: a systematic review and cost-effectiveness analysis Health Technol. Assess 15 2011 1 8 doi:http://dx.doi.org/10.3310/hta15370 PMC4781244 22030014 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Many clinicians endorse lifestyle changes or assist in managing chronic stress related problems (e.g., obesity, alcohol, and tobacco abuse) which require patients to change several behaviors at a time.

    “Furthermore, many clinicians endorse lifestyle changes or assist in managing chronic stress related problems (e.g. obesity, alcohol, and tobacco abuse) which require patients to change several behaviors at a time [4].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4] Khusid MA Vythilingam M The emerging role of mindfulness meditation as effective self-management strategy, part 1: clinical implications for depression, post-traumatic stress disorder, and anxiety Mil. Med 181 2016 961 968 27612338 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although patient information sheets are standard of care, their content and readability may not benefit patients with cultural or economic differences or lower literacy.

    “Although these sheets are considered standard of care, the content and readability may not necessarily benefit patients with cultural or economic differences or lower literacy [3].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Kutner M Greenburg E Jin Y Paulsen C The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483 National Center for Education Statistics 2006

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Because the Gabby system was developed in English, participants who are not fluent in English were excluded.

    “The Gabby system was also developed in English, excluding participants who are not fluent in English.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Only 13% of adults in the United States consume the recommended daily amount of fruits (4 to 5 servings).

    “Only 13% of the adults in the United States consume the recommended daily amount of fruits (4 to 5 servings) [56, 57].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [56] American Heart Association, Suggested Servings from Each Food Group Healthy Living 2015 Accessed Feb 15 2017 Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/HealthyDietGoals/Suggested-Servings-from-Each-Food-Group_UCM_318186_Article.jsp#.WKR36tIrKUl

      Not checked in the free run.

    • cites [57] Centers for Disease Control and Prevention Overview: BRFSS 2013. Behavioral Risk Factor Surveillance System 2013 Accessed Feb 15 2017 Retrieved from http://www.cdc.gov/brfss/annual_data/2013/pdf/overview_2013.pdf

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The research assistant was not blinded to group allocation.

    “The RA was not blinded to group allocation.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Perceived stress was measured using the Perceived Stress Scale (PSS-4).

    “For stress management, we asked participants to report self-perceived stress levels using the Perceived Stress Scale (PSS-4) [45].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] Cohen S Williamson G Perceived stress in a probability sample of the United States Soc. Psychol. Health 3 1988 1 67

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study was approved by the BMC Institutional Review Board.

    “The study was approved by the BMC Institutional Review Board.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Physical activity recommendations were based on governmental guidelines.

    “Finally, physical activity recommendations were based on governmental guidelines for physical activity [20, 21, 37, 38].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [20] Ellis T Latham N DeAngelis T Thomas CA Saint-Hilaire M Bickmore TW Feasibility of a virtual exercise coach to promote walking in community-dwelling persons with Parkinson Disease Am. J. Phys. Med. Rehabil 92 2013 472 485 quiz 482-5 23552335 PMC4266140 source

      Not checked in the free run.

    • cites [21] Bickmore TW Silliman RA Nelson K Cheng DM Winter M Henault L Paasche-Orlow MK A randomized controlled trial of an automated exercise coach for older adults J. Am. Geriatr. Soc 61 2013 1676 1683 24001030 source

      Not checked in the free run.

    • cites [37] US Department of Health and Human Services Physical Activity Guidelines for Americans US Department of Health and Human Services 2008

      Not checked in the free run.

    • cites [38] Centers for Disease Control and Prevention How Much Physical Activity Do Adults Need? Physical Activity 2015 Accessed Sept 10 2016 Retrieved from http://www.cdc.gov/physicalactivity/basics/adults/index.htm

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Physical activity was measured based on the Stanford Patient Education Research Center's Exercise Behaviors Questionnaire.

    “Based on the Stanford Patient Education Research Center’s Exercise Behaviors Questionnaire, we compiled the total amount of time, in minutes, participants reported engaging in physical activity during a typical week [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Stanford Patient Education Research Center, Exercise Behaviors Research Instruments Developed, Adapted or Used by the Stanford Patient Education Research Center 2017 Accessed on Sept 10 2016 Retrieved from http://patienteducation.stanford.edu/research/exercise.pdf

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    ECAs may help patients adhere to behavioral changes through improved decision making and experiential learning rather than passive reading.

    “ECAs may help patients adhere to behavioral changes through improved decision making and experiential learning as opposed to passive reading.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    Reliance on self-reported information is a limitation, because participants may have inaccurately reported their health behaviors through lack of knowledge or discomfort sharing information with a web-based system.

    “Limitations to this feasibility study include a small sample size, short duration of the intervention, specific inclusion criteria, and self-reported information.”
    • Also stated in: § 4.1. Discussion · hedged
      “Lastly, participants could have inaccurately reported their health behaviors due to a lack of knowledge or feeling uncomfortable sharing information with a web-based system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Participants were randomized using a computer-generated permuted block method.

    “After obtaining baseline information, participants were randomized to either the intervention or control using a computer-generated permuted block method.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A recent systematic review identified 21 RCTs of MBSR: eleven showed improvement in mental health measures compared to waitlist or standard care controls, and improved pain scores and mental health status for patients with chronic pain.

    “A recent systematic review identified 21 RCTs of MBSR: eleven of these studies showed improvement in mental health measures compared to waitlist or standard care controls, and improved pain scores and mental health status for patients with chronic pain [32];”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [32] Fjorback L Arendt M Ørnbøl E Fink P Walach H Mindfulness-based stress reduction and mindfulness-based cognitive therapy – a systematic review of randomized controlled trials Acta Psychiatr. Scand 124 2011 102 119 21534932 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Food access was measured using the Household Food Insecurity Access Scale (HFIAS).

    “and inquired about food access and assistance programs using the Household Food Insecurity Access Scale (HFIAS) [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] Coates J Swindale A Bilinsky P Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide Food and Nutrition Technical Assistance Project Academy for Educational Development Washington, DC 2007

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Physical and mental health statuses were measured by the Short Form Health Survey (SF-12) and depression levels by the Patient Health Questionnaire (PHQ-9).

    “physical and mental health statuses by the Short Form Health Survey (SF-12) [39] and depression levels by the Patient Health Questionnaire (PHQ-9) [40].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [39] Ware JE Jr Kosinski M Keller SD A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity Med. Care 34 1996 220 233 8628042 source

      Not checked in the free run.

    • cites [40] Kroenke K Spitzer RL The PHQ-9: a new depression diagnostic and severity measure Psychiatr. Ann 32 2002 509 515 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Use of technologies among non-dependent alcoholic drinkers has been found to be promising.

    “Research has found the use of technologies among non-dependent alcoholic drinkers to be promising [47, 48].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [47] Sankaranarayanan J Sallach RE Rural patients' access to mobile phones and willingness to receive mobile phone-based pharmacy and other health technology services: a pilot study Telemed. J. E Health 20 2014 182 185 24205837 source

      Not checked in the free run.

    • cites [48] Fowler LA Holt SL Joshi D Mobile technology-based interventions for adult users of alcohol: a systematic review of the literature Addict. Behav 62 2016 25 34 27310031 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Effectiveness of randomization was assessed by comparing sociodemographic factors between groups using Chi-square tests and two-sample t-tests.

    “Effectiveness of randomization was assessed by comparing sociodemographic factors between the intervention and control using Chi-square tests for dichotomous and categorical variables and two-sample t-tests for continuous variables.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Self-efficacy for exercise was measured with the Self-Efficacy for Exercise Scale (SEE).

    “We also collected information on participants’ self-efficacy to participate in physical activity with the Self-Efficacy for Exercise Scale (SEE) [44].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [44] Resnick B Jenkins LS Testing the reliability and validity of the self-efficacy for exercise scale Nurs. Res 49 2000 154 159 10882320 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Nutrition questions were adapted from the National Health and Nutrition Examination Survey (NHANES).

    “Adapting questions from the National Health and Nutrition Examination Survey (NHANES), participants reported the total number of fruit and vegetable servings they consumed daily;”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] National Center for Health Statistics (US) National Health and Nutrition Examination Survey, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics 2008

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Fewer than 10% of adults in the United States, including women, follow a healthy lifestyle pattern that includes stress management.

    “Adherence to a healthy lifestyle includes stress management; however, fewer than 10% of adults in the United States follow this pattern, including women [46].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [46] King DE Mainous AG III Carnemolla M Everett CJ Adherence to healthy lifestyle habits in US adults, 1988–2006 Am. J. Med 122 2009 528 534 19486715 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    MBSR is a promising mind-body intervention.

    “Information on stress management was adapted from principles of Mindfulness Based Stress Reduction (MBSR) [16], a promising mind-body intervention [28–31].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [28] National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Prevention Program. Diabetes Diabetes Prevention Program 2008 Accessed Sept 10 2016 Retrieved from https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx

      Not checked in the free run.

    • cites [29] Reiner K Tibi L Lipsitz JD Do mindfulness-based interventions reduce pain intensity? A critical review of the literature Pain Med 14 2013 230 242 23240921 source

      Not checked in the free run.

    • cites [30] Cramer H Haller H Lauche R Dobos G Mindfulness-based stress reduction for low back pain: a systematic review BMC Complement. Altern. Med 12 2012 162 23009599 PMC3520871 source

      Not checked in the free run.

    • cites [31] Niazi AK Niazi SK Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses N. Am. J. Med. Sci 3 2011 20 23 22540058 PMC3336928 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Users would have used the ECA system more if it had been available on multiple technology platforms such as mobile devices, since installation on a frequently used device would create more opportunities for engagement.

    “Based on our qualitative feedback, we believe that users would have utilized the ECA system more had it been available on multiple technology platforms, such as mobile devices.”
    • Also stated in: § 4.1. Discussion · hedged
      “With smartphone ownership increasing steadily [60], having the Gabby system installed on a frequently used device would provide more opportunities for patients to engage in learning and practicing meaningful health behaviors.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Poushter J Smartphone Ownership and Internet Usage Continues to Climb in Emerging Economies Pew Research Center: Global Attitudes & Trends 2016

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care encourage healthcare organizations and providers to use multimedia when communicating health information to culturally diverse patients.

    “The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care encourage healthcare organizations and providers to use multimedia when communicating health information to culturally diverse patients [61].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61] Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Patience US Department of Health and Human Services Washington (DC) 2013

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Female ethnic minority college students ate more servings of fruit when they received motivational text messages.

    “another study revealed that female ethnic minority college students ate more servings of fruit when they received motivational text messages [59].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [59] Rodgers RF Pernal W Matsumoto A Shiyko M Intille S Franko DL Capitalizing on mobile technology to support healthy eating in ethnic minority college students J. Am. Coll. Health 64 2016 125 132 26630479 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Smartphone ownership is increasing steadily.

    “With smartphone ownership increasing steadily [60]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Poushter J Smartphone Ownership and Internet Usage Continues to Climb in Emerging Economies Pew Research Center: Global Attitudes & Trends 2016

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Mindfulness training has been shown to reduce stress levels and may as a result partially reduce engagement in alcohol use.

    “Furthermore, mindfulness training has been shown to help decrease stress levels and as a result, may partially decrease engagement in alcohol use [52–55].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [52] Bodenlos JS Noonan M Wells SY Mindfulness and alcohol problems in college students: the mediating effects of stress J. Am. Coll. Health 61 2013 371 378 23930751 source

      Not checked in the free run.

    • cites [53] Zgierska A Rabago D Chawla N Kushner K Koehler R Marlatt A Mindfulness meditation for substance use disorders: a systematic review Subst. Abus 30 2009 266 294 19904664 PMC2800788 source

      Not checked in the free run.

    • cites [54] Sinha R The role of stress in addiction relapse Curr. Psychiatry Rep 9 2007 388 395 17915078 source

      Not checked in the free run.

    • cites [55] Marcus MT Fine PM Moeller FG Khan MM Pitts K Swank PR Liehr P Changes in stress levels following mindfulness based stress reduction in a therapeutic community Addict. Disord. Their Treat 2 2003 63 68 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In studies aimed at reducing alcohol use among college students, those who received tailored text messages were more likely to report reduced alcohol consumption and increased awareness of managing drinking behaviors.

    “In several studies to reduce alcohol use among college students, participants who received tailored text messages were more likely to report a reduction in alcohol consumption and an increased awareness to manage drinking behaviors [49–51].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [49] Mason M Ola B Zaharakis N Zhang J Text messaging interventions for adolescent and young adult substance use: a meta-analysis Prev. Sci 16 2015 181 188 24930386 source

      Not checked in the free run.

    • cites [50] Witkiewitz K Desai SA Bowen S Leigh BC Kirouac M Larimer ME Development and evaluation of a mobile intervention for heavy drinking and smoking among college students Psychol. Addict. Behav 28 2014 639 650 25000269 PMC6143292 source

      Not checked in the free run.

    • cites [51] Weitzel JA Bernhardt JM Usdan S Mays D Glanz K Using wireless handheld computers and tailored text messaging to reduce negative consequences of drinking alcohol J. Stud. Alcohol Drugs 68 2007 534 537 17568957 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a pilot study of a virtual coach delivering mindfulness training, participants with coach-based training performed the techniques more effectively and regularly than those who taught themselves using paper and audio materials.

    “Similarly, one pilot study implemented a virtual coach to provide mindfulness training, and found that participants who had coach-based training performed the techniques more effectively and regularly than participants who had to teach themselves the same techniques using paper and audio materials [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Hudlicka E Virtual training and coaching of health behavior: example from mindfulness meditation training Patient Educ. Couns 92 2013 160 166 23809167 PMC3970714 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A web-based nutrition program produced an increase in fruit consumption that was not statistically significant compared with traditional in-person nutrition education among low-income adults.

    “one study found that a web-based nutrition program led to increased–but not statistically significant–fruit consumption compared to a traditional in-person nutrition education among low-income adults [58]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Neuenschwander LM Abbott A Mobley AR Comparison of a web-based vs in-person nutrition education program for low-income adults J. Acad. Nutr. Diet 113 2013 120 126 23092741 source

      Not checked in the free run.

57 of 57

  • The paper relies on this without support.

    The ECA's content and dialogue are culturally appropriate and effective for the diverse urban women in the study.

    “The ECA is an animated African American female character programmed to deliver culturally aware patient strategies and health information (e.g. recommending specific popular recipes or foods, mentioning prayer or spiritual traditions) to increase skills in self-management.”

  • The paper relies on this without support.

    The patient information sheets plus meditation CD/MP3 are an adequate control that mirrors the ECA content and dose.

    “If participants were randomized to the control, the RA reviewed patient information sheets in person for 60 min, which mirrored the content from the Gabby system.”

  • The paper relies on this without support.

    The feasibility outcomes (recruitment, retention, satisfaction) are sufficient to conclude feasibility for a larger RCT.

    “A primary goal of this study was to gather feasibility data on ECA utilization among multiracial women ages 18 to 50 years within an outpatient setting in order to design a larger fully powered RCT.”

  • The paper relies on this without support.

    The one-month follow-up period is long enough to detect meaningful changes in health behaviors.

    “After one month from baseline, the RA conducted post-study interviews in person or by phone.”

  • The paper relies on this without support.

    The self-reported measures of diet, physical activity, and stress management are accurate and not subject to significant bias.

    “We asked questions assessing eating patterns, physical activity routines, and stress management levels at baseline and post-intervention.”

  • The paper relies on this without support.

    The ECA system's electronic voice is not a barrier compared to a live meditation teacher.

    “Control group meditations were recorded by a live meditation teacher in contrast to Gabby’s electronic voice.”

  • The paper relies on this without support.

    The sample of 61 women recruited from Boston primary care clinics is representative of diverse urban women.

    “Participants were recruited from primary care outpatient clinics at Boston Medical Center (BMC).”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Baseline alcohol use for stress is reported as both 67% and about one-third

    Major

    The reported baseline rates of alcohol use for stress management are 35% in the intervention group and 30% in the control group. The combined rate must lie between those values, not at 67%.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Ehrenfeld, 2010, Use of a computer agent to explain anesthesia concepts to patients, Annual Meeting of the American Society of Anesthesiologists, vol. 3

Cited by

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Related

Authors
Gardiner, P. M., McCue, K. D., Negash, L. M., Cheng, T., White, L. F., Yinusa-Nyahkoon, L., Jack, B. W., & Bickmore, T. W.
Affiliations
  • Boston University (US)
  • Northeastern University (US)
Corresponding author
Gardiner, Paula M.
ORCID
Venue
Patient Education and Counseling
Publisher
Elsevier BV
Published
2017-09
Volume
100
Issue
9
Pages
1720-1729
ISSN
0738-3991 (ISSN-L)
DOI
10.1016/j.pec.2017.04.015
PMC
PMC5559098
OpenAlex
W2608852370
Semantic Scholar
20d862b9b18b68ee28728b34b61de596469c0b10
Cited by
139
References
54
Citations by year
2026: 10 · 2025: 21 · 2024: 14 · 2023: 27 · 2022: 20 · 2021: 20 · 2020: 12 · 2019: 13 · 2018: 2
FWCI
8.40
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Patient Education and Counseling (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • The Journal of the American Medical Association (JAMA) Network (American Medical Association) (submittedVersion)
Funders
National Center for Complementary and Integrative Health (K07AT005463)
Topics
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Social Sciences › Psychology › Social Psychology › Social Robot Interaction and HRI
Keywords
embodied conversational agents, mindfulness, stress management, healthy lifestyle intervention, urban women, alcohol consumption, fruit consumption, physical activity, dietary habits, meditation, health behavior change, feasibility
MeSH terms
Adolescent, Adult, Behavior Therapy, Communication, Feeding Behavior, Female, Humans, Life Style, Stress, Psychological, Exercise, Outcome Assessment, Health Care, Meditation, Young Adult, Mindfulness

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