Deliberative and Paternalistic Interaction Styles for Conversational Agents in Digital Health: Procedure and Validation Through a Web-Based Experiment

Background Recent years have witnessed a constant increase in the number of people with chronic conditions requiring ongoing medical support in their everyday lives. However, global health systems are not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. Moreover, different aspects of CAs have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the interaction between patients and physicians. Patient-physician interaction is recognized as a critical success factor for patient satisfaction, treatment adherence, and subsequent treatment outcomes. However, so far, it remains effectively unknown how different interaction styles can be implemented into CA interactions and whether these styles are recognizable by users. Objective The objective of this study was to develop an approach to reproducibly induce 2 specific interaction styles into CA-patient dialogs and subsequently test and validate them in a chronic health care context. Methods On the basis of the Roter Interaction Analysis System and iterative evaluations by scientific experts and medical health care professionals, we identified 10 communication components that characterize the 2 developed interaction styles: deliberative and paternalistic interaction styles. These communication components were used to develop 2 CA variations, each representing one of the 2 interaction styles. We assessed them in a web-based between-subject experiment. The participants were asked to put themselves in the position of a patient with chronic obstructive pulmonary disease. These participants were randomly assigned to interact with one of the 2 CAs and subsequently asked to identify the respective interaction style. Chi-square test was used to assess the correct identification of the CA-patient interaction style. Results A total of 88 individuals (42/88, 48% female; mean age 31.5 years, SD 10.1 years) fulfilled the inclusion criteria and participated in the web-based experiment. The participants in both the paternalistic and deliberative conditions correctly identified the underlying interaction styles of the CAs in more than 80% of the assessments (X21,88=38.2; P<.001; phi coefficient rφ=0.68). The validation of the procedure was hence successful. Conclusions We developed an approach that is tailored for a medical context to induce a paternalistic and deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the procedure in a web-based experiment involving 88 participants. Future research should implement and test this approach among actual patients with chronic diseases and compare the results in different medical conditions. This approach can further be used as a starting point to develop dynamic CAs that adapt their interaction styles to their users.

Wofür kann ich dich noch benutzen? Bei was kannst du mir noch helfen? It's ni ce to meet you. Great, I've always wanted someone like that.
It's ni ce to meet you. Great, I've always wanted someone like that.
I am a robot... A so-called "chatbot" because I can write ("chat") back and forth with you.
I am a robot... A so-called "chatbot" because I can write ("chat") back and forth with you.
Aha -I know chat bots . I want to know more! Aha -I know chat bots . I want to know more! I consist of a little artificial intelligence and a lot of scientific work.
I consist of a little artificial intelligence and a lot of scientific work.
Who are you really? Who are you really?
That is a very good question! Just think of me as a faithful friend at your side during this journey.

Emotional Talk_Partnership [High]
That is a very good question! Just think of me as a seasoned COPD expert, telling you what to do to get better.

Emotional Talk_Partnership [Low]
I am curious . This is exciting.
I am curious . This is exciting.
It's i mporta nt to ta l k a bout your concerns. You can tell me anything, even secrets.

Psychosocial Exchange about problems of daily living, issues about social relations, feelings, emotions [High]
You can tell me anything, even secrets.

Psychosocial Exchange about problems of daily living, issues about social relations, feelings, emotions [Low]
Thank you -I will do that. Great, this is important for me.
Thank you -I will do that. Great, this is important for me.

By the way, I won't tell anyone what you entrust me with.
Emotional Talk_Reassurance  I will share interesting facts about COPD with you and together we will consider how you can improve your diet and manage your breathing difficulties, for example. Your needs are very important to me.

Emotional Talk_Partnership [High]
I will tell you interesting facts about COPD and show you, for example, how you can improve your diet and manage your shortness of breath better.

Emotional Talk_Partnership [Low]
What els e can I us e you for? What else can you help me with?
What els e can I us e you for? What else can you help me with?
For example for sports: I will show you videos from our physiotherapist and explain various exercises.
For example for sports: I will show you videos from our physiotherapist and explain various exercises. This week we will focus on your first lesson. This week we will focus on your first lesson.
We look at how to prevent complaints and how to control them better. Emotional Talk_Partnership  Above all, the quality of the air plays an important role in the subject of respiration. Air quality is of course also influenced by weather phenomena.

Emotional Talk_Partnership [Low]
Oka y. I already knew that. << empty >> << empty >> But it is the pollutants in the air that make breathing most difficult.
But it is the pollutants in the air that make breathing most difficult. Air pollution has various causes and can occur everywhere.
Exhaust fumes, for example, introduce many pollutants into our environment.
Exhaust fumes, for example, introduce many pollutants into our environment.
(A) Yeah, that makes sense.
(A) Yeah, that makes sense.
(B) I already knew that.
(B) I already knew that.
But tha t i s not a l l . But tha t i s not a l l .
Tobacco smoke also represents a major pollution of the air we breathe.
Tobacco smoke also represents a major pollution of the air we breathe.
And even less obvious sources such as detergents, paints and varnishes or perfumes strongly influence the air we breathe.
And even less obvious sources such as detergents, paints and varnishes or perfumes strongly influence the air we breathe. Okay, I'm curious .
What do you think: Is the following statement right or wrong?
What do you think: Is the following statement right or wrong?
Cigarettes contain more than 4000 different chemical substances. Most of these substances are toxic and can cause respiratory diseases or cancer.
Cigarettes contain more than 4000 different chemical substances. Most of these substances are toxic and can cause respiratory diseases or cancer.  In addition to tobacco smoke, however, there are numerous other pollutants in the air that pollute our airways and lungs.
In addition to tobacco smoke, however, there are numerous other pollutants in the air that pollute our airways and lungs.
If the airways are continuously attacked by pollutants, they become inflamed and swell.
If the airways are continuously attacked by pollutants, they become inflamed and swell.
Tell me more Robo. This is interesting.
Tell me more Robo. This is interesting.
The self-cleaning mechanism of the bronchi is then no longer effective.
The self-cleaning mechanism of the bronchi is then no longer effective.
Secretion accumulates in the bronchi and you have to cough more often.
Secretion accumulates in the bronchi and you have to cough more often.
If you produce secretion daily, you have chronic bronchitis.
If you produce secretion daily, you have chronic bronchitis. (B) Do you also know the following? (B) Do you also know the following?
Later the bronchial tubes become clogged and constricted, so that you get out of breath during exertion, later increasingly during everyday activities.
Later the bronchial tubes become clogged and constricted, so that you get out of breath during exertion, later increasingly during everyday activities.
Your breathing can become whistling. Your breathing can become whistling.
With a lung function test, chronic obstruction, i.e. a permanent narrowing of the bronchi, can be detected.
With a lung function test, chronic obstruction, i.e. a permanent narrowing of the bronchi, can be detected. That's why I'm here, to help you the best I can.

Emotional Talk_Empathy [High]
That's why I'm here. Emotional Talk_Empathy [Low] Qui z But first a short quiz question again. But first a short quiz question again.
What do you think the following statement is right or wrong?
What do you think the following statement is right or wrong?
Cigarette smoke slows down or even paralyses the self-cleaning mechanism of the airways.
Cigarette smoke slows down or even paralyses the self-cleaning mechanism of the airways. (B) The statement was true. Cigarettes are super harmful and one of the worst pollutants that can ca us e COPD. You will certainly answer the next quiz question correctly. I have complete confidence in you.
Emotional Talk_Reassurance / Optimism [High] (B) Wrong! Cigarettes are super harmful and one of the wors t pol l uta nts tha t ca n ca us e COPD. Emotional Talk_Reassurance / Optimism [Low] Oka y. Got i t.
Oka y. Got i t.
Exerci s e In order to counteract the disease, it is important that we train your cardiovascular system with specific strengthening and endurance exercises. Physical training is the most important and effective non-drug measure you can take to influence the course of your disease yourself. Did you already know that?
Partnering and activation_Asking for patient option [High] In order to countera ct the di s ea s e, i t i s i mporta nt to train the cardiovascular system through specific strengthening and endurance exercises. Physical training is the most important and effective non-drug measure you can take to influence the course of your disease yourself.
Partnering and activation_Asking for patient option [Low] This is news to me. I already knew that.
This is news to me. I already knew that.
As a first exercise I suggest you to walk 10 steps without a break.
Therapeutic regimen_closed-ended question [Low] As a first exercise you take 10 steps without a break. Are you rea dy? Are you rea dy?