Background
Optimizing preconception health in reproductive aged women is a crucial aspect of prevention with the potential to minimize pregnancy complicationsReference Goossens, De Roose, Van Hecke, Goemaes, Verhaeghe and Beeckman1 and the risk of chronic disease later in the lives of women and their children.Reference Langley-Evans2,Reference Stephenson, Heslehurst and Hall3 Preconception care is the provision of biomedical, behavioral, and social health interventions to optimize the health of women (and their partners) before pregnancy to improve health outcomes for themselves and their children.4 The World Health Organization stipulates that preconception care should cover family planning, nutrition and supplementation, tobacco cessation, reducing harmful environmental exposures, improving sexual health and behavior, mental health problems, intimate partner violence and sexual violence, alcohol and drug use, and genetic diseases.4 Maternal exposure to many factors addressed in preconception care, such as suboptimal nutrition, substance use, and stress can led to developmental programming for a range of chronic diseases in offspring.Reference El-Heis and Godfrey5-Reference Godfrey, Costello and Lillycrop7 Considering that approximately 50% of pregnancies are unplanned,Reference Wellings, Jones and Mercer8 preconception care should be extended to all women, regardless of pregnancy intention to protect the health of women and their children.Reference Stephenson, Heslehurst and Hall3
Engaging women in preconception care during their reproductive years is a challenge with many women lacking awareness of its importanceReference Mazza, Chapman and Michie9,Reference Tuomainen, Cross-Bardell, Bhoday, Qureshi and Kai10 and health professionals contending with time and resource constraints to provide this care.Reference Goossens, De Roose, Van Hecke, Goemaes, Verhaeghe and Beeckman1,Reference Mazza, Chapman and Michie9 To address these issues and the higher rates of adverse pregnancy outcomes such as maternal and infant mortality experienced by African-American women compared with white women,Reference Petersen, Davis and Goodman11,12 a preconception care Virtual Patient Advocate (VPA) called “Gabby” was developed in the United States (US)Reference Gardiner, Hempstead and Ring13 A VPA is a computer-generated character, often a health professional, who simulates face-to-face conversations with patients to communicate key health messages.Reference Bickmore, Pfeifer and Byron14 VPAs are proven effective in overcoming barriers to the provision of healthcare such as low levels of patient access and health literacy and have been used as an alternate source of health information and patient education in contexts where human resources are limited.Reference Bickmore, Pfeifer and Byron14,Reference Jack, Bickmore and Hempstead15 Online delivery enables access to healthcare at a time and location that is convenient to patients and alleviates the time burden experienced by many health professionals.Reference Bickmore, Pfeifer and Byron14,Reference Bickmore and Paasche-Orlow16
Gabby was developed via a consultative process between researchers and African-American women to decrease risky lifestyle behaviors in the preconception period.Reference Gardiner, Hempstead and Ring13 Based on the Prochaska’s Stage of Change model,Reference Norcross, Krebs and Prochaska17 Gabby utilizes behavioral change techniques to help women adopt and sustain healthier behaviors based on evidence-based advice and support that was scripted by experts in preconception health with input from the target audience to ensure her health messages were appropriate and achievable.Reference Gardiner, Hempstead and Ring13 After completing a comprehensive online risk assessment that screens for more than 100 preconception health risks, women are encouraged to interact with Gabby (Fig. 1) to resolve risks identified on their individualized “My Health To Do List”.Reference Gardiner, Hempstead and Ring13 The system has undergone continued refinements based on feedback from a state-level randomized-controlled trial (RCT) (n = 100)Reference Jack, Bickmore and Hempstead15 and a subsequent national RCT (n = 520) (in peer review). Women allocated to the state-level RCT intervention group had a greater reduction in the proportion of preconception health risks resolved compared with the control group (27.8% intervention, 20.5% control, p < 0.01) after being given ongoing access to Gabby for 6 months.Reference Jack, Bickmore and Hempstead15 While results from the national RCT are yet to be published, Gabby shows promise as a low-cost and scalable resource to increase women’s access to preconception care. Reported benefits of VPAs include addressing aspects of social inequity such as access to healthcare and low health literacy.Reference Bickmore, Pfeifer and Byron14-Reference Bickmore and Paasche-Orlow16 Therefore, a preconception VPA such as Gabby may have the potential to overcome these challenges in population groups other than African-American women. It is unknown whether this form of preconception health information is acceptable to women of other ethnicities or women living in other countries. Therefore, the aims of this research were to (i) assess the acceptability of a preconception VPA in women living in Australia and (ii) document the changes required to adapt the Gabby system to suit an Australian context.
Fig. 1. Gabby preconception Virtual Patient Advocate.Reference Gardiner, Hempstead and Ring13,Reference Bickmore and Paasche-Orlow16
Methods
Study design
A descriptive qualitative approach was taken to describe women’s perceptions of Gabby.Reference Liamputting18 Focus groups were chosen for data collection to facilitate interaction among participants and highlight similarities and differences of opinions.Reference Liamputting18 Data were collected in July–August 2019 in the state of Victoria, Australia. Ethics approval was obtained from Monash University Human Research Ethics Committee (Ref: 20341).
Participants and recruitment
Women aged 18–45 years were purposefully recruited from the community to gather the views of a range of women (ethnicity, age, and location). Women were excluded if they were pregnant or unable to speak English. Flyers were displayed at post-secondary school educational establishments in metropolitan and regional Victoria, Australia and advertisements were placed on social media (e.g., Facebook). The aim was to recruit 30 women based on formative research conducted in the initial development of Gabby where 31 African-American women participated in focus groups.Reference Gardiner, Hempstead and Ring13 Participants were remunerated with a $50 gift voucher.
Data collection
Focus groups, with a maximum of six participants in each, were divided into two parts. In the first part, participants were given an opportunity to interact with Gabby for approximately 50 min. It was originally intended that participants would complete the risk assessment during this time before interacting with Gabby. After the first two focus groups, the researchers decided to complete the risk assessment on behalf of the participants before the focus groups. This generated a hypothetical My Health To Do Lists for participants and gave them more interaction time with Gabby. The reason for this change was to facilitate more in-depth discussion about participants’ experiences when using Gabby to make health decisions. Participant data collected via the US-based Gabby system and server were not analyzed as this was not required to achieve the study aims. For the US-based research, participant data are used for research purposes only and stored in accord with ethics requirements.Reference Gardiner, Hempstead and Ring13,Reference Jack, Bickmore and Hempstead15 At the end of the first part of the focus group, participants completed a 5-min online questionnaire to obtain demographic information and quantitative data regarding their first impressions of Gabby (usefulness, usability, and satisfaction).Reference Gardiner, Hempstead and Ring13 Questionnaire responses were collected using Qualtrics® Research Suite (Qualtrics®, Sydney, Australia).
The second part of the focus group involved participants responding to questions posed by the focus group facilitator, a female researcher and dietitian with expertise in women’s health (RW). Focus group questions used in the initial development of GabbyReference Gardiner, Hempstead and Ring13 were adapted to meet the aims of this research. Additional questions relating to the acceptability of Gabby within an Australian context were based on previous research in App development.Reference Boyle, Xu and Gilbert19 The draft schedule of questions was piloted in a group of four women who met the inclusion criteria and had expertise in behavioral interventions in preconception health. Small edits were made before a final schedule of questions was finalized (Table 1). Focus group field notes were taken by a second researcher, a female public health Masters student (SD). Discussions were audio-recorded before being transcribed verbatim.
Table 1. Schedule of questions for Gabby focus groups
Data analyses
Analyses and subsequent focus groups occurred concurrently, so pertinent issues identified in earlier focus groups were explored in more depth in later focus groups. In relation to achieving the primary aims of this study, data saturation was attained after three focus groups. Therefore, a decision was made to focus on questions associated with the secondary aim of exploring participants’ characteristics and preferences regarding the provision of preconception care (not reported in detail). An inductive process of thematic analysis was applied. Three transcripts were analyzed by two researchers (RW, SD) to establish an initial coding framework. The same two researchers then coded all transcripts, meeting regularly throughout the coding process to ensure consistency. The categorization of codes into themes was achieved through discussion and consensus between the researchers, with the most commonly identified codes acting as a basis for the themes. A third researcher (JB) supervised the coding process and had input into theme development. Data analysis was supported by NVivo 9 analytical software.
Results
Between July and August 2019, seven focus groups (n = 31) with an average duration of 46 min were conducted. A culturally diverse group of women from metropolitan and regional Victoria participated with most being nulliparous (Table 2). Quantitative data from the online questionnaire revealed that participants were generally satisfied with Gabby and their initial perceptions of usefulness and usability tended to be more favorable than neutral (Table 3). Overall, 6 themes and 12 subthemes were identified. Of these, four themes and seven subthemes relating to the study aims are reported in detail. The remaining themes and subthemes relating to the characteristics of preconception women and their preferences for preconception care are presented in summary form (Table 4).
Table 2. Demographic information of participants (n = 31)
Table 3. Questionnaire data regarding participants’ initial reactions to Gabby (usefulness, usability, and satisfaction), adapted from Gardiner et al. and Boyle et al. Reference Gardiner, Hempstead and Ring13,Reference Boyle, Xu and Gilbert19
*Mean and standard deviation used so that results are comparable with those reported by Gardiner et al.
Table 4. Themes and subthemes with key messages and representative quote
VPA, Virtual Patient Advocate.
Theme one: Perceptions of VPA systems for preconception care and information
Participants gave their general perceptions of VPA systems as preconception care providers and/or sources of health information. The potential of VPA systems to increase information access, particularly for women who have difficulty accessing health services, was acknowledged. Two subthemes emerged regarding the general acceptability of VPAs and characteristics that may be considered important in the future development of VPAs.
Subtheme: Acceptability of VPAs
Participants had high expectations of VPA technology due to their exposure to information technology that is fast, colorful, and easily accessible on smartphones and mobile devices. Logging on to a computer to interact with Gabby was considered a drawback. However, some participants acknowledged that having access to trustworthy information assisted to temper this inconvenience.
I think I’d be more inclined to use Gabby than say, just Google… When you Google you may not be sure where the information is coming from. I could see that [Gabby] would probably become my first resource for information. (Participant 24, Metropolitan)
It seemed quite knowledgeable. Obviously there’s been a lot of research and information that’s been put into the system. So whatever answers that you put in there, you are always going to get a lot of information, which seems good. (Participant 3, Metropolitan)
Being able to interact with Gabby at a time and place that is convenient was considered a positive aspect. Participants discussed particular population groups for whom Gabby may increase access to information including adolescents who rely on their parents to go to the doctor, women in abusive relationships and women with anxiety or mental health issues. Increased access to health information for women living in remote areas was discussed as a potential benefit by metropolitan participants but not by participants living in regional areas.
But even if they [adolescents] can go to the doctor by themselves, there could be a dozen hurdles in between… I was lucky enough that I was like, “Hey Dad, can I go alone?” and he was like, “Yeah, this is how.” Whereas some people, they wouldn’t be allowed. They might not be able to afford it. They might not be able to physically get there… Like teens and stuff, can’t drive yet. (Participant 16, Metropolitan)
I think it’s good if maybe you live a bit more remote, or somewhere where you don’t have access to many health professionals, or if you can’t get out for whatever reason… An injury or you know – whatever. (Participant 2, Metropolitan)
Subtheme: Important VPA characteristics
Tenets of patient-centered care, such as tailored advice, interaction, consistent messages, and follow-up, were deemed important characteristics of VPAs. Satisfaction with Gabby regarding these aspects varied. Some participants expressed that they received in-depth advice, support, and follow-up that met their particular needs, while others wished that Gabby could offer them more specific advice.
I like that she follows up. So, again with the iron thing, later she’s like, “Oh, did you end up taking the supplements?” Or one of them was about seeing my doctor about something and she said, “Maybe you should organise an appointment with your doctor.” She prompts you and then she checks up on you in ways that doctors won’t because they don’t have the time or the memory. (Participant 6, Metropolitan)
It’s more like reading a Google page or Wiki page… I think it’s a bit too generic. (Participant 4, Metropolitan)
Choice was considered important, with participants often discussing this aspect when asked what they like most about the Gabby system.
I liked how Gabby kept asking me what my plans were. “Are you going to go to the dentist? Have you been taking your vitamins? Do you plan to?” And I also like how she gave me the option of postponing. So if I didn’t want to learn more about vitamin D, I didn’t have to right then and it would get added to a checklist. I really liked that part. (Participant 11, Metropolitan)
Theme two: Satisfaction with Gabby
In terms of satisfaction with Gabby, discussion was around (i) the esthetic aspects of the Gabby system including her appearance, speech, and navigation and (ii) the connection that participants developed with Gabby.
Subtheme: Physical characteristics of Gabby
Participants described Gabby’s appearance as “disarming” and “friendly”. Her African-American ethnicity was not raised as a factor that increased or decreased participants’ ability to connect with her. Gabby’s movements and speech were described as “slow” and “robotic”, causing some participants to have difficulty understanding her. On the other hand, some participants reported that the speed of her speech allowed them to process and understand the information presented. Gabby’s North American accent was acceptable and participants suggested that it may be more beneficial for Gabby to able to speak other languages or include subtitles than have an Australian accent.
She was very hard to understand. Like it was very – you could tell it was an automated system. Like, it wasn’t very fluent. So you had to listen – hard. (Participant 29, Regional)
It’s very user-friendly, particularly for me. My first language is not English. She speaks slowly and very clearly and I don’t need to click the “please repeat”. (Participant 27, Metropolitan)
One thing I would have loved to have seen for accessibility reasons would be to have the text of what she’s saying out loud also on the screen. For some people it’s easier to read along… Also, offering this in different languages, which I’m sure is something that’s coming down the road. (Participant 11, Metropolitan)
The physical surroundings and navigation of the Gabby system were generally seen as negative aspects. Participants described the background as dull and boring, asking for more images to support the provision of information. Navigating through the My Health To Do List was sometimes exasperating for participants, particularly when they clicked on an incorrect response and could not return to the main menu or change their answer.
I’m a really visual person, so it was very difficult for me… [The background] looked very gloomy and I mean, a little sad. (Participant 10, Metropolitan)
I didn’t like that you couldn’t go back and amend an answer. At one point I did something and I’m like, “Ahhh, that’s not really where I wanted to take me.” Like I would have liked more information, but I couldn’t go back to re-answer the question. (Participant 29, Regional)
Subtheme: Connections with Gabby
Participants developed varying degrees of connection with Gabby in the 50 min they spent with her. Some reported negative first impressions of Gabby, but after spending time with her, they felt more comfortable and willing to continue to interact with her. Trust was an important factor in the development of the connections made.
My first impression was, “I don’t like it.” Because when the person talked the voice was so slow for me. It was a bit strange, the communication and the voice. But as time goes on I found the information really useful so I started to like it. (Participant 22, Metropolitan)
She looks like she cared about me even though she was like an animated person. She seemed really nice and friendly and I felt comfortable using the system. (Participant 13, Metropolitan)
I felt confident in what she said. I guess because everything she said, she would explain it further. Like there was something about iron as well and she explained what iron is, why you need it and the consequences in pregnancy and stuff if you don’t have iron. So it sounded quite trustworthy I guess. (Participant 18, Metropolitan)
Subtheme: Information
Participants identified topics that need to be added to meet the specific needs of women living in Australia including “Sun Smart” messages and Australia’s Medicare system. They listed information that they felt was missing including the menstrual cycle, health-risk profiles for different ethnicities, vegetarian diets, and tailored contraception advice.
Do Chinese women have different health risks to Australian women? Would you need different Gabbys in different nationalities? … Australia is so diverse… I’ve heard over the years that there’s different health risks in [different ethnicities]… So it might need to be more tailored to your ethnicity, you know what I mean? (Participant 2, Metropolitan)
In the diet aspect, one of them was how to get extra iron in your diet… One of the recommendations was steak but I hadn’t clicked that I eat any meat options. And so there are a lot of vegetarians and vegans who might be looking for specific iron options… So that was something that might be missing in the survey or just generally that my answers preceding that weren’t taken into consideration and so the options she gave me were not valid. (Participant 6, Metropolitan)
Theme three: Wish list for the future
Participants suggested a range of modifications, including technological advancements to enhance navigation, incentives to promote use, and the addition of missing information. Access to information needs to be fast, via smartphones and easy to navigate. Suggestions were influenced by participants’ experiences with other online platforms, such as Google and YouTube and apps.
If it was like a mobile app, if you could get notifications reminding you, “Hey, did you do this yet today?” And maybe it would reward you, kind of like the FitBit app… Like fireworks and stuff when you reach a goal. (Participant 18, Metropolitan)
I can see it like, integrating with Google assistant. That sort of thing, with your phone or maybe an app so that it’s more accessible. And like, whenever you see your phone to remind [you], “There’s Gabby, I can use that now”… It can be really helpful to send you emails like, “Hey, now it’s time to review your health,” or things like that. (Participant 4, Metropolitan)
Participants’ desire for additional information was topic-related, based on topics they perceived to be missing. Context-specific information regarding Medicare and private health insurance came up several times. Having links to other reputable online information, such as recipes, physical activity, and resources in the community, was also requested.
As an immigrant to Australia, I’m not really familiar with the health care system here and I think that will actually benefit people who just come to Australia… There is a lot of immigrants here, so yeah, I think adding this information in Gabby might actually be helpful. (Participant 4, Metropolitan)
Links to other websites or other apps that could help assist or track your health and stuff. Like, Gabby could be the main centre of information and giving advice. But also, say, if this is one of your health risks, there’s this app to help track how much exercise you do and that kind of stuff. (Participant 3, Metropolitan)
Participants discussed incentives for logging on to Gabby, including more opportunities for interaction with Gabby and a wider network of women, reminders, rewards, and tracking change.
And calling on the sisterhood. So if there was a way, like a community, I guess, maybe linked to Gabby or something, where women could anonymously… You don’t have to put your name because talking about health matters which could be private… But a woman can go up and be like, “I’m having this problem. Has anyone else had the same thing? And did Gabby help you with this?” (Participant 16, Metropolitan)
Yeah, I think like definitely the tracking of the information is probably important if it’s a long term thing, because if it’s just providing information and advice, then I’d probably long on one and be like, “Oh, I’ve got the information now.” (Participant 3, Metropolitan)
Participants were generally accepting of Gabby’s appearance, ethnicity, and dress but commented that this may not be the case for all women. Having the ability to choose their own Gabby may be a novel and fun way to engage women.
As long as she is a women. I think that’s probably the only key feature that honestly matters for Gabby. (Participant 3, Metropolitan)
Representation might be important. Some women might feel more comfortable with a Gabby that is of their same descent or even wearing a chador. (Participant 20, Metropolitan)
Theme four: Gabby in the real world
Participants described how they thought Gabby could be integrated into the health system and how they anticipated they would interact with Gabby.
Subtheme: Using Gabby with health professionals
Participants discussed how they would be likely to interact with Gabby before seeking advice from a doctor or to discuss sensitive health-related questions.
I feel like the way it is right now, I will go to Gabby for some pre-information before going to a doctor, maybe, so I know the basic information and what’s out there. And then, because I can’t really ask questions back, I would actually prefer to go to a doctor and kind of take all my notes. (Participant 25, Metropolitan)
Gabby’s ability to offer participants more time and continuity of care were seen to be a positive aspects. They liked that they were able to spend a bit more time with Gabby.
So usually when I am sick, I go to the health centre. So, each time I get different doctors. Most of the time. So, then I have to explain everything. So, I think that if I use Gabby, that could be an advantage. So it stores your history and stuff. So I think that’s a positive point. (Participant 7, Regional)
And I feel like using Gabby would be a really amazing opportunity to really cater to you – especially when with GPs. I’m not from here but I didn’t realize that GP appointments are so short here. So, with Gabby you can really spend 30 minutes if you want to. (Participant 5, Regional)
Subtheme: Anticipated use of Gabby in the future
Despite demonstrating an understanding of the importance for preventive healthcare, participants admitted that they were still likely to seek health information and advice, “when they actually have a problem.” The technological advancements discussed in Theme 3 would assist/motivate participants to interact with Gabby more consistently.
I think I would probably spend quite a lot of time the first time. Just because after your questionnaire you are interested to see what came out and what things she still needs you to do and then maybe check one a month or something to see. (Participant 14, Regional)
I can say that if Gabby was only on my computer, I would probably barely use it at all. For me, it would have to be an app and I could see myself using it. (Participant 11, Metropolitan)
Discussion
This Australia-based qualitative study was the first to test the Gabby VPA system outside of the US. Participants found VPAs to be an acceptable provider of health information with the potential to increase women’s access to general and preconception health advice. A range of modifications to increase the relevance and acceptability of the Gabby system for women living in Australia were identified. These include (i) technological advancements to enhance the ease and speed of navigation through the Gabby system (e.g., adapting Gabby for use on mobile devices and smartphones, exit tabs, notifications), (ii) the inclusion of information that is specific to women living in Australia and different groups of women (e.g., the health system in Australia, vegetarian diets), and (iii) incentives for use (e.g., opportunities to interact with Gabby and other women, goal-setting, and tracking of goals). Context-specific advice, relevant, and trustworthy information were considered more important than Gabby’s physical appearance. These findings highlight important considerations when developing information-technology-generated tools to improve preconception health and for health education.
VPA systems have been found to be acceptable source of health information.Reference Bickmore, Pfeifer and Byron14,Reference Bickmore and Paasche-Orlow16 However, this research highlights the importance of their evolution to keep up with the expectations of younger generations. This study recruited reproductive aged women (18–45 years). This age group is generally classified as Millennial (born 1980–2000), the first generation for whom information access via the Internet has become ubiquitous.Reference Hee Jin, Kyung Lee and Jung Choo20 Labeling and defining generations is not an exact science but key characteristics generally linked with Millennials include (i) higher self-esteem, (ii) increased agency and assertiveness, particularly in women, and (iii) a preference for simplicity and economy when gathering and processing information.Reference Hee Jin, Kyung Lee and Jung Choo20,Reference Giambatista, Hoover and Tribble21 These characteristics were seen in our participants as they discussed what they would like to see in the future development of VPA systems in general and Gabby in particular.
The usefulness, usability, and satisfaction questionnaire gave an overview of participants’ initial perceptions of the Gabby system. Eleven out of 13 questions had a mean response <3.50, indicating that participants’ perceptions were generally favorable. However, three questions generated higher results (less favorable) than those generated by the African-American pilot subjects in the initial development of Gabby system in 2011.Reference Gardiner, Hempstead and Ring13 For example, our participants’ mean response to the question, “Was the Gabby system easy to use?” was 3.03 (standard deviation 1.83), compared with a mean response of 2.44 (standard deviation not reported) by pilot subjects in the development of the Gabby system.Reference Gardiner, Hempstead and Ring13 Questions “Was the design of the Gabby system engaging?” and “If you had the choice, would you interact with Gabby again?” resulted in neutral responses from our participants, compared with positive responses from the pilot subjects. The higher level of satisfaction reported by pilot subjects is not surprising when considering that African-American women were consulted in the development of the Gabby system. It is also likely that our participants in 2019 had higher expectations of information technology than the pilot subjects in 2011.
Participants reported that accessing information needed to be fast and that navigation needed to be simple. They predicted that they would be less likely to interact with Gabby in the future if they had to logon to a computer. Having access on a smartphone was desirable. Research that explored women’s (80% were aged 18–35 years) preferred mode of online health information found that 98% had a smartphone and 93% had an additional mobile device.Reference Boyle, Xu and Gilbert19 Eighty-six percent of these women preferred health information via a mobile app than a website.Reference Boyle, Xu and Gilbert19 Therefore, adapting VPA systems that are targeted to women of a reproductive age to mHealth delivery such as a mobile device or smartphone is likely to be essential for their implementation into real-world settings.
In addition to state-of-the-art information technology, participants’ expected VPAs to have the ability to provide aspects of patient-centered care. Patient-centered care is based on partnerships between healthcare providers and patients that acknowledge patients’ preferences, values, and beliefs as they make health decisions.Reference Jo Delaney22 Our sample appreciated the interaction that was available with Gabby and that they were able to choose how they addressed their identified risks. On the other hand, they also compared Gabby to other online platforms such as Google and Siri where they may be able to ask questions and get answers, and YouTube where they are able to watch and “connect” with real people. In the short time participants were given to interact with Gabby, they were able to describe varying connections. For example, Gabby was described as being genuine, helpful, caring, friendly, and supportive. Participants also reported that they trusted the advice she provided. This is consistent with research reporting the potential of VPAs to develop understanding, empathy, and trust with patients.Reference Bickmore, Gruber and Picard23 In the future, developers of online interventions designed to improve preconception health, and health, in general, should consider how the target audience connects with the information provider as well as the information provided.
Gabby’s ability to be sensitive to different cultures and languages seemed to be more important than her physical appearance and accent. Views of participants born in Australia and who spoke English at home, compared with those of participants born overseas and for whom English was a second language, were similar regarding these aspects. This was an unexpected finding because the initial development of Gabby involved substantial testing around her physical appearance, including her profession, age, ethnicity, and name.Reference Gardiner, Hempstead and Ring13 Our results can perhaps be explained by the fact that over 50%Reference Negin, Rozea, Cloyd and Martiniuk24 of medical practitioners in Australia are born overseas. Women in Australia are likely to have had exposure to a range of health professionals of different ethnicities, and therefore, they may be less sensitive to their physical appearance or accent. Our participant group included women born in 16 countries and over 50% spoke another language at home, perhaps explaining why sensitivity to culture and language was considered more important. In Australia, the availability of subtitles or a language selection function in VPAs such as Gabby may increase access for women who are culturally and linguistically diverse. When considering that one-third of women living in Australia are born overseas,25 this may be a crucial aspect of any online preconception health intervention.
Health topics considered most important to our participants were diet, physical activity, and mental health. The RCT that tested the Gabby system in the US also found that the areas of nutrition and activity were most often selected by participants for more information.Reference Jack, Atrash, Coonrod, Moos, O’donnell and Johnson26 In addition, our participants requested information that is specific to women living in Australia, such as skin protection in an Australian climate, Australia’s Medicare system, and private health insurance. Worldwide, health insurance systems vary greatly and often change quickly in response to national governments and policy changes. Therefore, it is crucial that VPA developers and maintenance staff are able to keep up with these changes so that information is current. In terms of health information, care must be taken to ensure that advice is based on the latest evidence and is in accord with national clinical practice guidelines.
Strengths and weaknesses
This research regarding the development and implementation of VPA technology is of utmost importance when considering that healthcare provider shortages anticipated internationally.Reference Aluttis, Bishaw and Frank27 Alternate sources of health information and patient education provided by VPAs may reinforce health messages from healthcare providers. Further, understanding how to engage younger audiences, including women of a reproductive age, in preventive health via information technology is crucial to improve population health and the health of future generations. Overall, this research highlights important considerations for VPA developers, in Australia and internationally, particularly those targeting preconception women. Easy access via a mobile device or smartphone is women’s preferred option and information needs to be up-to-date, relevant, engaging, and tailored to meet the needs and expectations of a diverse range of women.
We aimed to represent a range of women’s views based on parity, age, country of birth, and location. We were able to do this for all factors except parity as only one participant had children. Our ability to recruit women with children may have been impacted by this subgroup having parenting responsibilities and less time to participate. Over 50% of our sample was born overseas and spoke a language other than English at home. This is not quite representative of women living in Australia with 29%25 of residents being born overseas. Culturally and linguistically diverse women in Australia often experience inequity in access to healthcare; therefore, their over-representation may have assisted to increase their voice regarding the importance of VPAs that consider culture and language in the information they provide and how they present it. We did not collect some aspects of personal demographic information, including self-reported health, food security, and socioeconomic status; therefore, women who experience other aspects of disadvantage may not have been represented in our sample. Larger trials testing the efficacy of preconception VPAs and information technology aimed at improving health should consider these factors to assess and ensure equitable access and reporting.
Conclusions
VPAs have the potential to increase women’s access to preconception care and information. The Gabby system was acceptable to women in Australia and they identified a range of modifications to increase its relevance and appeal such as technological advancements to increase ease of access and address navigation issues. Context-specific, relevant, tailored, and trustworthy information and advice were considered most important to women in Australia.
Acknowledgments
The authors would like to acknowledge the participants who contributed their insights for this research.
Financial support
Funding for this research has been provided from the Australian Government’s Medical Research Future Fund (MRFF). The MRFF provides funding to support health and medical research and innovation, with the objective of improving the health and wellbeing of Australians. MRFF funding has been provided to the Australian Prevention Partnership Centre under the MRFF Boosting Preventive Health Research Program. Further information on the MRFF is available at www.health.gov.au/mrff. Associate Professor Jacqueline Boyle is supported by an National Health and Medical Research Council Career Development Fellowship.
Conflicts of interest
The authors report no conflict of interest.
Ethical standards
Ethics approval was obtained from Monash University Human Research Ethics Committee (Ref: 20341).
