Development of a Virtual Human for Supporting Tobacco Cessation During the COVID-19 Pandemic.

People who consume tobacco are at greater risk of developing severe COVID-19. Unfortunately, the COVID-19 pandemic reduced the accessibility of tobacco cessation services as a result of necessary social restrictions. Innovations were urgently needed to support tobacco cessation during the pandemic. Virtual humans are artificially intelligent computer agents with a realistic, humanlike appearance. Virtual humans could be a scalable and engaging way to deliver tobacco cessation information and support. Florence, a virtual human health worker, was developed in collaboration with the World Health Organization to remotely support people toward tobacco cessation during the COVID-19 pandemic. Florence delivers evidence-based information, assists with making quit plans, and directs people to World Health Organization-recommended cessation services in their country. In this viewpoint, we describe the process of developing Florence. The development was influenced by a formative evaluation of data from 115 early users of Florence from 49 countries. In general, Florence was positively perceived; however, changes were requested to aspects of her design and content. In addition, areas for new content were identified (eg, for nonsmoker support persons). Virtual health workers could expand the reach of evidence-based tobacco cessation information and personalized support. However, as they are a new innovation in tobacco cessation, their efficacy, feasibility, and acceptability in this application needs to be evaluated, including in diverse populations.

The Impact of Virtual Humans on Psychosomatic Medicine.

OBJECTIVE: Virtual humans are likely to enhance the delivery of health care over the next decade. Virtual humans are artificially intelligent computer agents with hyperrealistic, autonomously animated embodiments based on affective computing techniques. Virtual humans could be programmed to screen for health conditions, triage patients, and deliver health interventions, with appropriate facial expressions and body gestures, functioning as a supplement to human care. This article provides a perspective on the implications of virtual humans for behavioral and psychosomatic medicine, and health psychology. METHODS: A narrative review was conducted to integrate observations and findings from research on virtual humans from 91 articles in this multidisciplinary area. RESULTS: Virtual humans can be used for multimodal behavior analysis of patients, individualized tailoring of interventions, and detection of changes of psychological and behavioral measures over time. Virtual humans can also pair the scalability of a website with the interactivity and relational skills of a human tele-therapist. Research is beginning to show the acceptability, feasibility, and preliminary effectiveness of virtual humans in a range of populations. Virtual humans can be easily tailored in terms of their appearance, voice, and language, and may be adapted to fit the characteristics of a patient population or hard-to-reach groups. If co-designed with these communities, virtual humans may help to promote health care engagement and improve outcomes. CONCLUSIONS: Virtual humans can engage and motivate patients, and deliver personalized psychological and behavioral health care. This article provides an overview of the potential impact of virtual humans on psychosomatic medicine and discusses ethical implications.

Comparing the Feasibility and Acceptability of a Virtual Human, Teletherapy, and an e-Manual in Delivering a Stress Management Intervention to Distressed Adult Women: Pilot Study.

BACKGROUND: Virtual humans (VHs), teletherapy, and self-guided e-manuals may increase the accessibility of psychological interventions. However, there is limited research on how these technologies compare in terms of their feasibility and acceptability in delivering stress management interventions. OBJECTIVE: We conducted a preliminary comparison of the feasibility and acceptability of a VH, teletherapy, and an e-manual at delivering 1 module of cognitive behavioral stress management (CBSM) to evaluate the feasibility of the trial methodology in preparation for a future randomized controlled trial (RCT). METHODS: A pilot RCT was conducted with a parallel, mixed design. A community sample of distressed adult women were randomly allocated to receive 1 session of CBSM involving training in cognitive and behavioral techniques by a VH, teletherapy, or an e-manual plus homework over 2 weeks. Data were collected on the feasibility of the intervention technologies (technical support and homework access), trial methods (recruitment methods, questionnaire completion, and methodological difficulty observations), intervention acceptability (intervention completion, self-report ratings, therapist rapport, and trust), and acceptability of the trial methods (self-report ratings and observations). Qualitative data in the form of written responses to open-ended questions were collected to enrich and clarify the findings on intervention acceptability. RESULTS: Overall, 38 participants' data were analyzed. A VH (n=12), teletherapy (n=12), and an e-manual (n=14) were found to be feasible and acceptable for delivering 1 session of CBSM to distressed adult women based on the overall quantitative and qualitative findings. Technical difficulties were minimal and did not affect intervention completion, and no significant differences were found between the conditions (P=.31). The methodology was feasible, although improvements were identified for a future trial. All conditions achieved good satisfaction and perceived engagement ratings, and no significant group differences were found (P>.40). Participants had similar willingness to recommend each technology (P=.64). There was a nonsignificant trend toward participants feeling more open to using the VH and e-manual from home than teletherapy (P=.10). Rapport (P<.001) and trust (P=.048) were greater with the human teletherapist than with the VH. The qualitative findings enriched the quantitative results by revealing the unique strengths and limitations of each technology that may have influenced acceptability. CONCLUSIONS: A VH, teletherapy, and a self-guided e-manual were found to be feasible and acceptable methods of delivering 1 session of a stress management intervention to a community sample of adult women. The technologies were found to have unique strengths and limitations that may affect which works best for whom and in what circumstances. Future research should test additional CBSM modules for delivery by these technologies and conduct a larger RCT to compare their feasibility, acceptability, and effectiveness when delivering a longer home-based stress management program. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620000859987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380114&isReview=true.

Effects of Emotional Expressiveness of a Female Digital Human on Loneliness, Stress, Perceived Support, and Closeness Across Genders: Randomized Controlled Trial.

BACKGROUND: Loneliness is a growing public health problem that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Social support interventions have been shown to reduce loneliness, including when delivered through technology. Digital humans are a new type of computer agent that show promise as supportive peers in health care. For digital humans to be effective and engaging support persons, it is important that they develop closeness with people. Closeness can be increased by emotional expressiveness, particularly in female relationships. However, it is unknown whether emotional expressiveness improves relationships with digital humans and affects physiological responses. OBJECTIVE: The aim of this study is to investigate whether emotional expression by a digital human can affect psychological and physiological outcomes and whether the effects are moderated by the user's gender. METHODS: A community sample of 198 adults (101 women, 95 men, and 2 gender-diverse individuals) was block-randomized by gender to complete a 15-minute self-disclosure conversation with a female digital human in 1 of 6 conditions. In these conditions, the digital human varied in modality richness and emotional expression on the face and in the voice (emotional, neutral, or no face; emotional or neutral voice). Perceived loneliness, closeness, social support, caring perceptions, and stress were measured after each interaction. Heart rate, skin temperature, and electrodermal activity were assessed during each interaction. 3-way factorial analyses of variance with post hoc tests were conducted. RESULTS: Emotional expression in the voice was associated with greater perceptions of caring and physiological arousal during the interaction, and unexpectedly, with lower feelings of support. User gender moderated the effect of emotional expressiveness on several outcomes. For women, an emotional voice was associated with increased closeness, social support, and caring perceptions, whereas for men, a neutral voice increased these outcomes. For women, interacting with a neutral face was associated with lower loneliness and subjective stress compared with no face. Interacting with no face (ie, a voice-only black screen) resulted in lower loneliness and subjective stress for men, compared with a neutral or emotional face. No significant results were found for heart rate or skin temperature. However, average electrodermal activity was significantly higher for men while interacting with an emotional voice. CONCLUSIONS: Emotional expressiveness in a female digital human has different effects on loneliness, social, and physiological outcomes for men and women. The results inform the design of digital human support persons and have theoretical implications. Further research is needed to evaluate how more pronounced emotional facial expressions in a digital human might affect the results. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000865819; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381816&isReview.

A Digital Human for Delivering a Remote Loneliness and Stress Intervention to At-Risk Younger and Older Adults During the COVID-19 Pandemic: Randomized Pilot Trial.

BACKGROUND: Loneliness is a growing public health issue that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Computer agents are capable of delivering psychological therapies through the internet; however, there is limited research on their acceptability to date. OBJECTIVE: The objectives of this study were to evaluate (1) the feasibility and acceptability of a remote loneliness and stress intervention with digital human delivery to at-risk adults and (2) the feasibility of the study methods in preparation for a randomized controlled trial. METHODS: A parallel randomized pilot trial with a mixed design was conducted. Participants were adults aged 18 to 69 years with an underlying medical condition or aged 70 years or older with a Mini-Mental State Examination score of >24 (ie, at greater risk of developing severe COVID-19). Participants took part from their place of residence (independent living retirement village, 20; community dwelling, 7; nursing home, 3). Participants were randomly allocated to the intervention or waitlist control group that received the intervention 1 week later. The intervention involved completing cognitive behavioral and positive psychology exercises with a digital human facilitator on a website for at least 15 minutes per day over 1 week. The exercises targeted loneliness, stress, and psychological well-being. Feasibility was evaluated using dropout rates and behavioral observation data. Acceptability was evaluated from behavioral engagement data, the Friendship Questionnaire (adapted), self-report items, and qualitative questions. Psychological measures were administered to evaluate the feasibility of the trial methods and included the UCLA Loneliness Scale, the 4-item Perceived Stress Scale, a 1-item COVID-19 distress measure, the Flourishing Scale, and the Scale of Positive and Negative Experiences. RESULTS: The study recruited 30 participants (15 per group). Participants were 22 older adults and 8 younger adults with a health condition. Six participants dropped out of the study. Thus, the data of 24 participants were analyzed (intervention group, 12; waitlist group, 12). The digital human intervention and trial methods were generally found to be feasible and acceptable in younger and older adults living independently, based on intervention completion, and behavioral, qualitative, and some self-report data. The intervention and trial methods were less feasible to nursing home residents who required caregiver assistance. Acceptability could be improved with additional content, tailoring to the population, and changes to the digital human's design. CONCLUSIONS: Digital humans are a promising and novel technological solution for providing at-risk adults with access to remote psychological support during the COVID-19 pandemic. Research should further examine design techniques to improve their acceptability in this application and investigate intervention effectiveness in a randomized controlled trial. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12620000786998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380113.

Peek-a-who? Exploring the dynamics of early communication with an interactive partner swap paradigm and state space grid visualization.

Effective caregiver-infant communication occurs when interactive partners successfully coordinate multiple modalities (e.g., body movements, affect, eye gaze). The complex interplay of multiple modalities during caregiver-infant interactions is difficult to capture, which has made a comprehensive, evidence-based understanding of caregiver-infant communication difficult to achieve. We present a novel methodological approach to address this challenge by combining an Interactive Partner Swap (IPS) paradigm with a longitudinal design, detailed multimodal coding, and data visualization via state space grids (SSGs). We demonstrate the utility of our approach by presenting three sets of SSGs which reveal both dyadic flexibility and stability in caregiver-infant peek-a-boo interactions across three levels: micro (moment-to-moment), meso (interactive context), and macro (infant development). By using SSGs to explore the patterns that hold and others that differ systematically across interactive partner and infant development, our novel approach promises to offer critical first steps to creating a more detailed understanding of the dynamics of early multimodal communication.

The Effect of Multimodal Emotional Expression on Responses to a Digital Human during a Self-Disclosure Conversation: a Computational Analysis of User Language.

Digital humans show promise for use in healthcare as virtual therapists to deliver psychotherapy or companions for social support. For digital humans to be effective and engaging in these roles, it is important they can build close relationships with people. Emotional expressiveness can improve social closeness in human relationships, especially for females. However, it is unknown whether multimodal emotional expression improves relationships with digital humans. Participants were 185 adults aged 18 years or older with English fluency. Participants were block-randomized by gender to complete the Relationship Closeness Induction Task with one of six versions of a digital human. The digital humans varied in modality richness (face, no face) and emotional expression (emotional voice, neutral voice; emotional face, neutral face). Participants' language was analysed for emotional content using Linguistic Inquiry and Word Count software. A series of three-way ANOVA and ANCOVA were conducted to evaluate the effect of digital human face type, voice type, and participant gender on emotional content in participant language. A digital human with no face was associated with more first-person singular pronoun use than a neutral face and an emotional face digital human. A digital human with no face and a neutral voice received more general negative emotion language than a digital human with no face and an emotional voice. Findings suggest the presence of a face and emotion in the voice may improve emotional responses to digital humans. Results provide evidence for aspects of the theoretical framework of embodied agent-patient communication.

Reducing Patient Loneliness With Artificial Agents: Design Insights From Evolutionary Neuropsychiatry.

Loneliness is a growing public health issue that substantially increases the risk of morbidity and mortality. Artificial agents, such as robots, embodied conversational agents, and chatbots, present an innovation in care delivery and have been shown to reduce patient loneliness by providing social support. However, similar to doctor and patient relationships, the quality of a patient's relationship with an artificial agent can impact support effectiveness as well as care engagement. Incorporating mammalian attachment-building behavior in neural network processing as part of an agent's capabilities may improve relationship quality and engagement between patients and artificial agents. We encourage developers of artificial agents intended to relieve patient loneliness to incorporate design insights from evolutionary neuropsychiatry.

Reinforcement determines the timing dependence of corticostriatal synaptic plasticity in vivo.

Plasticity at synapses between the cortex and striatum is considered critical for learning novel actions. However, investigations of spike-timing-dependent plasticity (STDP) at these synapses have been performed largely in brain slice preparations, without consideration of physiological reinforcement signals. This has led to conflicting findings, and hampered the ability to relate neural plasticity to behavior. Using intracellular striatal recordings in intact rats, we show here that pairing presynaptic and postsynaptic activity induces robust Hebbian bidirectional plasticity, dependent on dopamine and adenosine signaling. Such plasticity, however, requires the arrival of a reward-conditioned sensory reinforcement signal within 2 s of the STDP pairing, thus revealing a timing-dependent eligibility trace on which reinforcement operates. These observations are validated with both computational modeling and behavioral testing. Our results indicate that Hebbian corticostriatal plasticity can be induced by classical reinforcement learning mechanisms, and might be central to the acquisition of novel actions.Spike timing dependent plasticity (STDP) has been studied extensively in slices but whether such pairings can induce plasticity in vivo is not known. Here the authors report an experimental paradigm that achieves bidirectional corticostriatal STDP in vivo through modulation by behaviourally relevant reinforcement signals, mediated by dopamine and adenosine signaling.

Upright posture improves affect and fatigue in people with depressive symptoms.

BACKGROUND AND OBJECTIVES: Slumped posture is a diagnostic feature of depression. While research shows upright posture improves self-esteem and mood in healthy samples, little research has investigated this in depressed samples. This study aimed to investigate whether changing posture could reduce negative affect and fatigue in people with mild to moderate depression undergoing a stressful task. METHODS: Sixty-one community participants who screened positive for mild to moderate depression were recruited into a study purportedly on the effects of physiotherapy tape on cognitive function. They were randomized to sit with usual posture or upright posture and physiotherapy tape was applied. Participants completed the Trier Social Stress Test speech task. Changes in affect and fatigue were assessed. The words spoken by the participants during their speeches were analysed. RESULTS: At baseline, all participants had significantly more slumped posture than normative data. The postural manipulation significantly improved posture and increased high arousal positive affect and fatigue compared to usual posture. The upright group spoke significantly more words than the usual posture group, used fewer first person singular personal pronouns, but more sadness words. Upright shoulder angle was associated with lower negative affect and lower anxiety across both groups. LIMITATIONS: The experiment was only brief and a non-clinical sample was used. CONCLUSIONS: This preliminary study suggests that adopting an upright posture may increase positive affect, reduce fatigue, and decrease self-focus in people with mild-to-moderate depression. Future research should investigate postural manipulations over a longer time period and in samples with clinically diagnosed depression.

Participatory medicine: model based tools for engaging and empowering the individual.

The long-term goal of the Virtual Physiological Human and Digital Patient projects is to run 'simulations' of health and disease processes on the virtual or 'digital' patient, and use the results to make predictions about real health and determine the best treatment specifically for an individual. This is termed 'personalized medicine', and is intended to be the future of healthcare. How will people interact and engage with their virtual selves, and how can virtual models be used to motivate people to actively participate in their own healthcare? We discuss these questions, and describe our current efforts to integrate and realistically embody psychobiological models of face-to-face interaction to enliven and increase engagement of virtual humans in healthcare. Overall, this paper highlights the need for attention to the design of human-machine interfaces to address patient engagement in healthcare.

Do slumped and upright postures affect stress responses? A randomized trial.

OBJECTIVE: The hypothesis that muscular states are related to emotions has been supported predominantly by research on facial expressions. However, body posture also may be important to the initiation and modulation of emotions. This experiment aimed to investigate whether an upright seated posture could influence affective and cardiovascular responses to a psychological stress task, relative to a slumped seated posture. METHOD: There were 74 participants who were randomly assigned to either a slumped or upright seated posture. Their backs were strapped with physiotherapy tape to hold this posture throughout the study. Participants were told a cover story to reduce expectation effects of posture. Participants completed a reading task, the Trier Social Stress speech task, assessments of mood, self-esteem, and perceived threat. Blood pressure and heart rate were continuously measured. RESULTS: Upright participants reported higher self-esteem, more arousal, better mood, and lower fear, compared to slumped participants. Linguistic analysis showed slumped participants used more negative emotion words, first-person singular pronouns, affective process words, sadness words, and fewer positive emotion words and total words during the speech. Upright participants had higher pulse pressure during and after the stressor. CONCLUSIONS: Adopting an upright seated posture in the face of stress can maintain self-esteem, reduce negative mood, and increase positive mood compared to a slumped posture. Furthermore, sitting upright increases rate of speech and reduces self-focus. Sitting upright may be a simple behavioral strategy to help build resilience to stress. The research is consistent with embodied cognition theories that muscular and autonomic states influence emotional responding.