Democratizing the Development of Chatbots to Improve Public Health: Feasibility Study of COVID-19 Misinformation.

BACKGROUND: Chatbots enable users to have humanlike conversations on various topics and can vary widely in complexity and functionality. An area of research priority in chatbots is democratizing chatbots to all, removing barriers to entry, such as financial ones, to help make chatbots a possibility for the wider global population to improve access to information, help reduce the digital divide between nations, and improve areas of public good (eg, health communication). Chatbots in this space may help create the potential for improved health outcomes, potentially alleviating some of the burdens on health care providers and systems to be the sole voices of outreach to public health. OBJECTIVE: This study explored the feasibility of developing a chatbot using approaches that are accessible in low- and middle-resource settings, such as using technology that is low cost, can be developed by nonprogrammers, and can be deployed over social media platforms to reach the broadest-possible audience without the need for a specialized technical team. METHODS: This study is presented in 2 parts. First, we detailed the design and development of a chatbot, VWise, including the resources used and development considerations for the conversational model. Next, we conducted a case study of 33 participants who engaged in a pilot with our chatbot. We explored the following 3 research questions: (1) Is it feasible to develop and implement a chatbot addressing a public health issue with only minimal resources? (2) What is the participants' experience with using the chatbot? (3) What kinds of measures of engagement are observed from using the chatbot? RESULTS: A high level of engagement with the chatbot was demonstrated by the large number of participants who stayed with the conversation to its natural end (n=17, 52%), requested to see the free online resource, selected to view all information about a given concern, and returned to have a dialogue about a second concern (n=12, 36%). CONCLUSIONS: This study explored the feasibility of and the design and development considerations for a chatbot, VWise. Our early findings from this initial pilot suggest that developing a functioning and low-cost chatbot is feasible, even in low-resource environments. Our results show that low-resource environments can enter the health communication chatbot space using readily available human and technical resources. However, despite these early indicators, many limitations exist in this study and further work with a larger sample size and greater diversity of participants is needed. This study represents early work on a chatbot in its virtual infancy. We hope this study will help provide those who feel chatbot access may be out of reach with a useful guide to enter this space, enabling more democratized access to chatbots for all.

A Web-Based Public Health Intervention for Addressing Vaccine Misinformation: Analysis of Learner Engagement and Shift in Hesitancy to Vaccinate.

Web-based public health interventions can be a useful tool for disseminating evidence-based information to the public. However, completion rates are traditionally low, and misinformation often travels at a faster pace than evidence-based sources. This study describes the design of a web-based public health intervention to address COVID-19 vaccine hesitancy. A quasi-experimental approach was used in which a validated instrument, the Adult Vaccine Hesitancy Survey, was given to learners both pre and post intervention to observe any change in attitude towards vaccination. Our pilot observed a small positive shift in vaccine hesitancy and experienced higher than average completion rates. By integrating motivational learning design into public health interventions we increase the likelihood that learners finish the entire intervention, creating greater chance for positive behavior change.

Contextual Conversational Agent to Address Vaccine Hesitancy: Protocol for a Design-Based Research Study.

BACKGROUND: Since the beginning of the COVID-19 pandemic, people have been exposed to misinformation, leading to many myths about SARS-CoV-2 and the vaccines against it. As this situation does not seem to end soon, many authorities and health organizations, including the World Health Organization (WHO), are utilizing conversational agents (CAs) in their fight against it. Although the impact and usage of these novel digital strategies are noticeable, the design of the CAs remains key to their success. OBJECTIVE: This study describes the use of design-based research (DBR) for contextual CA design to address vaccine hesitancy. In addition, this protocol will examine the impact of DBR on CA design to understand how this iterative process can enhance accuracy and performance. METHODS: A DBR methodology will be used for this study. Each phase of analysis, design, and evaluation of each design cycle inform the next one via its outcomes. An anticipated generic strategy will be formed after completing the first iteration. Using multiple research studies, frameworks and theoretical approaches are tested and evaluated through the different design cycles. User perception of the CA will be analyzed or collected by implementing a usability assessment during every evaluation phase using the System Usability Scale. The PARADISE (PARAdigm for Dialogue System Evaluation) method will be adopted to calculate the performance of this text-based CA. RESULTS: Two phases of the first design cycle (design and evaluation) were completed at the time of this writing (April 2022). The research team is currently reviewing the natural-language understanding model as part of the conversation-driven development (CDD) process in preparation for the first pilot intervention, which will conclude the CA's first design cycle. In addition, conversational data will be analyzed quantitatively and qualitatively as part of the reflection and revision process to inform the subsequent design cycles. This project plans for three rounds of design cycles, resulting in various studies spreading outcomes and conclusions. The results of the first study describing the entire first design cycle are expected to be submitted for publication before the end of 2022. CONCLUSIONS: CAs constitute an innovative way of delivering health communication information. However, they are primarily used to contribute to behavioral change or educate people about health issues. Therefore, health chatbots' impact should be carefully designed to meet outcomes. DBR can help shape a holistic understanding of the process of CA conception. This protocol describes the design of VWise, a contextual CA that aims to address vaccine hesitancy using the DBR methodology. The results of this study will help identify the strengths and flaws of DBR's application to such innovative projects.

Conversational Agent to Address COVID-19 Infodemic: A Design-Based Research Approach.

Since the beginning of the year 2020, we have been suffering from the COVID-19 pandemic and are daily exposed to misinformation, leading to myths around vaccination and COVID-19. This study focuses on creating and distributing a Conversational Agent (CA), named VWise, for a health intervention using Design-Based Research (DBR), to help profile, guide, and inform the public about COVID-19 and COVID-19 vaccination in the EMRO (Eastern Mediterranean Region of Operations) region.

A Web-Based Public Health Intervention for Addressing Vaccine Misinformation: Protocol for Analyzing Learner Engagement and Impacts on the Hesitancy to Vaccinate.

BACKGROUND: A barrier to successful COVID-19 vaccine campaigns is the ongoing misinformation pandemic, or infodemic, which is contributing to vaccine hesitancy. Web-based population health interventions have been shown to impact health behaviors positively. For web-based interventions to be successful, they must use effective learning design strategies that seek to address known issues with learner engagement and retention. To know if an intervention successfully addresses vaccine hesitancy, there must be some embedded measure for comparing learners preintervention and postintervention. OBJECTIVE: This protocol aims to describe a study on the effectiveness of a web-based population health intervention that is designed to address vaccine misinformation and hesitancy. The study will examine learner analytics to understand what aspects of the learning design for the intervention were effective and implement a validated instrument-the Adult Vaccine Hesitancy Scale-to measure if any changes in vaccine hesitancy were observed preintervention and postintervention. METHODS: We developed a fully web-based population health intervention to help learners identify misinformation concerning COVID-19 and share the science behind vaccinations. Intervention development involves using a design-based research approach to output more effective interventions in which data can be analyzed to improve future health interventions. The study will use a quasi-experimental design in which a pre-post survey will be provided and compared statistically. Learning analytics will also be generated based on the engagement and retention data collected through the intervention to understand what aspects of our learning design are effective. RESULTS: The web-based intervention was released to the public in September 2021, and data collection is ongoing. No external marketing or advertising has been done to market the course, making our current population of 486 participants our pilot study population. An analysis of this initial population will enable the revision of the intervention, which will then be marketed to a broader audience. Study outcomes are expected to be published by August 2022. We anticipate the release of the revised intervention by May 2022. CONCLUSIONS: Disseminating accurate information to the public during pandemic situations is vital to contributing to positive health outcomes, such as those among people getting vaccinated. Web-based interventions are valuable, as they can reach people anytime and anywhere. However, web-based interventions must use sound learning design to help incentivize engagement and motivate learners to learn and must provide a means of evaluating the intervention to determine its impact. Our study will examine both the learning design and the effectiveness of the intervention by using the analytics collected within the intervention and a statistical analysis of a validated instrument to determine if learners had a change in vaccine hesitancy as a result of what they learned. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38034.

Adult Vaccine Hesitancy Scale in Arabic and French: Protocol for Translation and Validation in the World Health Organization Eastern Mediterranean Region.

BACKGROUND: The world as we know it changed during the COVID-19 pandemic. Hope has emerged with the development of new vaccines against the disease. However, many factors hinder vaccine uptake and lead to vaccine hesitancy. Understanding the factors affecting vaccine hesitancy and how to assess its prevalence have become imperative amid the COVID-19 pandemic. The vaccine hesitancy scale (VHS), developed by the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization, has been modified to the adult VHS (aVHS) and validated in English and Chinese. To our knowledge, no available aVHS has been designed or validated in Arabic or French. OBJECTIVE: The aim of this research is to translate the aVHS from its original English language to Arabic and French and validate the translations in the WHO Eastern Mediterranean region. METHODS: The study will follow a cross-sectional design divided into 5 phases. In phase 1, the original aVHS will be forward-translated to Arabic and French, followed by backward translation to English. An expert committee will review and rate all versions of the translations. Expert agreement will then be measured using the Cohen kappa coefficient (k). In phase 2, the translated aVHS will be pilot-tested with 2 samples of participants (n=100): a group that speaks both Arabic and English and another that speaks French and English. Participants' responses to the English version will also be collected. In phase 3, responses will then be compared. Descriptive statistics and paired t tests or one-way analyses of variance (ANOVA) and Pearson correlation coefficient will be used in the preliminary validation. In phase 4, prefinal versions (Arabic and French) will be tested with larger sample sizes of Arabic speakers (n=1000) and French speakers (n=1000). Sociodemographic information and vaccination status will be collected and used for further analysis. In phase 5, the scale's statistical reliability and internal consistency will be measured using Cronbach alpha. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) will be used to examine the model fit resulting from the EFA. ANOVA and regression models will be constructed to control for confounders. All data will be electronically collected. RESULTS: As of January 2022, the scale had been translated to Arabic and French and was undergoing the process of back translation. All data collection tools have been prepared (ie, sociodemographics, vaccination status, and open-ended questions) and are ready to go into their electronic formats. We expect to reach the desired sample size in this phase by June 2022. CONCLUSIONS: This study will provide researchers with a validated tool to assess adult vaccine hesitancy within populations that speak Arabic and/or French and provide a road map to scale translation and ensure cross-cultural adaptation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36928.

Conversational Agents in Health Education: Protocol for a Scoping Review.

BACKGROUND: Conversational agents have the ability to reach people through multiple mediums, including the online space, mobile phones, and hardware devices like Alexa and Google Home. Conversational agents provide an engaging method of interaction while making information easier to access. Their emergence into areas related to public health and health education is perhaps unsurprising. While the building of conversational agents is getting more simplified with time, there are still requirements of time and effort. There is also a lack of clarity and consistent terminology regarding what constitutes a conversational agent, how these agents are developed, and the kinds of resources that are needed to develop and sustain them. This lack of clarity creates a daunting task for those seeking to build conversational agents for health education initiatives. OBJECTIVE: This scoping review aims to identify literature that reports on the design and implementation of conversational agents to promote and educate the public on matters related to health. We will categorize conversational agents in health education in alignment with current classifications and terminology emerging from the marketplace. We will clearly define the variety levels of conversational agents, categorize currently existing agents within these levels, and describe the development models, tools, and resources being used to build conversational agents for health care education purposes. METHODS: This scoping review will be conducted by employing the Arksey and O'Malley framework. We will also be adhering to the enhancements and updates proposed by Levac et al and Peters et al. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews will guide the reporting of this scoping review. A systematic search for published and grey literature will be undertaken from the following databases: (1) PubMed, (2) PsychINFO, (3) Embase, (4) Web of Science, (5) SCOPUS, (6) CINAHL, (7) ERIC, (8) MEDLINE, and (9) Google Scholar. Data charting will be done using a structured format. RESULTS: Initial searches of the databases retrieved 1305 results. The results will be presented in the final scoping review in a narrative and illustrative manner. CONCLUSIONS: This scoping review will report on conversational agents being used in health education today, and will include categorization of the levels of the agents and report on the kinds of tools, resources, and design and development methods used. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31923.

Unilateral retinoblastoma; natural history and an age-based protocol in 248 patients.

OBJECTIVES: We aimed to study the clinical state and prognosis of patients with unilateral retinoblastoma who were being treated at a paediatric comprehensive cancer centre in a limited-resource country, to assess the different phases of treatment and the success of different, more complex real-life models. SUBJECTS: In this retrospective study, we created a snapshot of our retinoblastoma database for the period between 2007 and 2015. Patients whose data were included in the study were followed up until 2016. Out of a total of 744 screened patients, we included data of 248 patients who had been diagnosed with unilateral retinoblastoma. RESULTS: As classified as per the International Retinoblastoma Classification, 1 patient presented with group A, 21 with group B, 39 with group C, 104 with group D and 83 with group E retinoblastoma. Chemotherapy was the initial line of treatment in 115 patients and enucleation in 133 others. Later, 141 patients (56.9%) required further management. Patients had a mean ocular survival time of 20.8 months. Nine patients developed extraocular disease at a later stage of management: five after upfront enucleation and four after neoadjuvant chemotherapy. Mean overall survival time stood at 90.2 months. Four and three deaths were recorded in groups D and E, respectively. A single patient died in the initial chemotherapy arm, while six passed away in the initial enucleation arm. CONCLUSION: Our study highlights the importance of initial chemotherapy and close follow-up after enucleation of classes D and E affected eyes even in absence of germline mutations.

A multidisciplinary approach to improving the care and outcomes of patients with retinoblastoma at a pediatric cancer hospital in Egypt.

BACKGROUND: Retinoblastoma poses a substantial burden in developing countries. We conducted this study to assess the effect of implementing a multidisciplinary approach and standardized protocols for treating pediatric patients with retinoblastoma at the Children's Cancer Hospital Egypt (CCHE). MATERIALS AND METHODS: In January 2011, the CCHE implemented standardized protocols for the diagnosis, treatment, and reporting of retinoblastoma cases. The hospital also introduced a new retinoblastoma management algorithm and data analysis system. In this study, we compared the pathologic features, tumor invasiveness, reporting, and survival of 276 pediatric patients who underwent enucleations of 290 eyes before or after the implementation of the retinoblastoma protocols. RESULTS: Time to enucleation (indicating time needed for decision taking) decreased significantly within the neoadjuvant chemotherapy group for intraocular disease after January 2011 (68.7 ± 48 weeks vs. 47.3 ± 28.3 weeks; p < 0.05). Mean optic nerve stump length increased from 5.6 mm in the earlier period to 7.2 mm in the later period (p = 0.004). The overall quality of pathology reporting also improved during the later period. The probability of 3-year survival was significantly higher for patients during the later period (94.2% vs. 79.2%; p = 0.018). CONCLUSIONS: The implementation of standardized protocols and a multidisciplinary approach improved reporting; discrepancies in disease classification and the amount of missing data were reduced; and quality measures and prognostic capabilities of the team were substantially improved. Such established data-driven practice supports faster decision making to enucleate diseased eyes and save patients' lives through providing measurable indicators.

A change roadmap towards research paradigm in low-resource countries: retinoblastoma model in Egypt.

Research on childhood diseases represents a great global challenge. This challenge is maximized in both childhood cancer disciplines and developing world. In this paper, we aim at describing our institution experience in starting a structured childhood cancer research program in one of the developing countries in a short time based on philanthropic efforts. We used retinoblastoma as an example for what was conducted in this program. Starting in 2008, this program included improving clinical practice and its related supporting services besides developing new research services that both complement the clinical activities and pave the way towards creating a research foundation in the country. Results included developing hospital standard treatment protocols, developing national clinical trials, joining international consortia for childhood cancers clinical trials, developing data collection tools and real-time analytics, establishing a biobanking facility, and developing highly qualified team for conducting clinical, epidemiologic, and translational research studies. Moreover, this effort resulted in improving both clinical practice and patients' awareness nationally. This model can be used for other startup facilities that aim at finding answers for their national health problems in low-resource setting.

Clinical presentation of intraocular retinoblastoma; 5-year hospital-based registry in Egypt.

PURPOSE: To study the presenting signs of Retinoblastoma in Egypt at Egypt's main pediatric oncology referral center. METHODS: This is a prospective descriptive study (hospital-based registry) conducted at Children's Cancer Hospital Egypt between July 2007 and December 2012. RESULTS: Out of 262 patients diagnosed with retinoblastoma, 244 were suffering from intra-ocular disease at presentation. One hundred thirty-nine (57%) patients presented with unilateral disease, while 105 (43%) suffered bilateral disease. The mean age at presentation was 20.6 ± 17 months, averaging 18.87 ± 11.76 months for bilateral and 25.72 ± 18.78 months for unilateral disease. The most common clinical presentation was leukocoria in 180 (73.8%) patients, strabismus in 32 (13.1%) patients and decreased visual acuity in 12 (4.9%) patients. Group D and E disease represented 62% of all affected eyes. Patients with advanced disease (Group C-E) had longer duration of symptoms. CONCLUSION: In Egypt, retinoblastoma patients present more frequently with advanced disease. There is an ever-increasing need to develop a national team dedicated to studying disease significance and formulating a national awareness program.

Phthisis bulbi: clinical and pathologic findings in retinoblastoma.

PURPOSE: Phthisis bulbi represents an ocular end-stage disease characterized by shrinkage and disorganization of the eye. We aim at identifying the pathologic changes of phthisis bulbi associated with retinoblastoma. DESIGN: Retrospective observational case series study. METHODS: 16 enucleated eyes were enrolled retrospectively between 2007 and 2012. Pathologic gross and microscopic findings were assessed. RESULTS: Cases showed grossly shrunken eyes with a mean volume of 4.3 cc. Sclera was markedly thickened in the majority of cases with mean of 2272.8 µ. Choroid showed an average thickness of 1029 µ. Necrosis, dystrophic calcification, ossification, gliosis, residual viable tumor was identified in many cases. Pathologic high risk factors were seen in three specimens. CONCLUSIONS: We conclude that retinoblastoma must be considered in the differential diagnosis of phthisis bulbi in the pediatric patients and active tumor was present in half of the patients.