We were not surprised that children who had access to eADVICE had improvement in their incontinence (more became completely dry or had less frequent and less severe wetting and had greater improvement in quality of life). However, we were surprised that despite the clinical improvement, the number of parents still wanting a clinic appointment did not reduce. This may be due to a lack of confidence in the clinical improvement or a desire for human interaction with the treating specialist and highlights that factors other than the child’s clinical status impact the decision to seek specialist care. Nevertheless, many patients who had used eADVICE prior to their appointment needed fewer clinic visits to achieve total continence because they had already addressed their basic urotherapy needs.
Another surprising finding was that the treatments received between the eADVICE intervention group and the control group 6 months after enrolment were very similar, with the only difference being that more in the eADVICE group had received tailored urotherapy (fluid advice, bowel care, toileting advice, caffeine reduction). As the proportion of children receiving first line care for enuresis (alarm training or desmopressin) was similar between the two groups, the improvement in treatment response can reasonably attributed to tailored urotherapy with Dr. Evie.
Dr Evie is a type of chatbot in the sense that you can have a conversation with it. Chatbots are becoming increasingly common in health as a means to help consumers manage their health and well-being. Sometimes they act as a coach, for example, to help someone lose weight or quit smoking, or as an advisor who provides cognitive behavioural therapy (CBT) to manage stress. Chatbots fall under the category of persuasive technologies and they are commonly used for behaviour change. But how do you know if you can trust the advice provided and even if the advice is correct, how do you get someone to follow that advice when we know from reported adherence rates of around 50% that people don't like to be told what to do? The key to making the chatbot trustworthy is by ensuring the content is evidence-based and developed with health professionals and validated by patients. The key to getting adherence to the advice is to develop what is called a working or therapeutic alliance where the human and chatbot agree on goals and the tasks to reach those goals, and a sense of bond and trust in the chatbot has been cultivated. We built this relationship through empathic dialogue which included relational cues such as affirmation. The dialogues aim to be empowering through offering choices and explanations based on what the user has told us about themselves. Face-to-face communication also improves adherence, which is why our chatbots have a virtual face, which is why they are technically called embodied conversational agents.
With the advanced capabilities of generative AI using tools like ChatGPT, it seems that anyone can have a computer-based conversation to get answers to their health questions. However, we need to be careful that the advice someone receives is evidence-informed and personally applicable. We also want to be careful about confidentiality and privacy and the offer of support and assistance in reality. We don't want someone to think they have reached out for help when in reality their cry is lost in cyberspace.
While chatbots such as embodied conversational agents can fill some gaps in access to professional help, overcome health literacy barriers or reluctance to speak to a human, and even offer empathic and personalised advice, they are not a substitute or replacement for human-delivered healthcare, but a tool that we as a community need to shape to ensure their ethical use.
Written by:
- Patrina H.Y. Caldwell, The Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
- Deborah Richards, School of Computing, Macquarie University, Sydney, Australia
- Jonathan C. Craig, College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Karen M. Scott, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia