Raisa Aantaki, Chen Xiaobei, Bryan Emma G, Bylund Carma L, Alpert Jordan M, Lok Benjamin, Fisher Carla L, Thomas Lyndsey, Krieger Janice L
Department of Surgery, Division of Public Health, Washington University in St. Louis, 600 S Taylor Avenue, St. Louis, MO, 63110, United States, 1 6463452302.
College of Journalism and Communications, University of Florida, Gainesville, FL, United States.
JMIR Cancer. 2025 Sep 15;11:e73616. doi: 10.2196/73616.
Virtual health assistants (VHAs), interactive digital programs that emulate human communication, are being increasingly used in health care to improve patient education and care and to reduce the burden on health care providers. VHAs have the potential to promote cancer equity through facilitating patient engagement, providing round-the-clock access to information, and reducing language barriers. However, it is unclear to what extent audience-centeredness is being considered in the development of cancer-related applications.
This systematic review identifies and synthesizes strategies used to make VHA-based cancer prevention and screening interventions audience-centered.
Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, we searched 4 databases (PubMed, Embase, Web of Science, and EBSCOhost) for peer-reviewed studies on VHA interventions promoting cancer screening (January 2022). Included studies focused on adult populations in primary care settings, with interventions emphasizing interactivity and immediacy (key VHA features). Excluded studies were on cancer treatment, noninteractive decision aids, or technical VHA development. Screening, data extraction, and quality assessment (Mixed Methods Appraisal Tool) were performed independently by multiple reviewers. Thematic synthesis was used to analyze audience-centered strategies.
Of 1055 records screened, 17 studies met inclusion criteria. Most (n=11) targeted colorectal cancer, with others addressing prostate, breast, cervical, or lung cancer. A total of 16 studies were US-based; 1 study focused on Uganda. Key strategies for audience-centered design included: (1) Demographic Concordance: Race or gender alignment between VHA and users (eg, African American participants interacting with Black-coded avatars); (2) User Feedback: Iterative testing via interviews, think-aloud protocols, or pilot studies to refine interventions; (3) Preintervention Needs Assessment: Identifying cultural, linguistic, or literacy barriers (eg, myths about screening in Ugandan communities); (4) Theoretical Frameworks: The Health Belief Model (most common), the Modality, Agency, Interactivity, and Navigability (MAIN) model, or tailored messaging theories guided design; (5) Information Customization: Culturally adapted content (eg, Spanish-language interfaces, narratives addressing racial disparities); and (6) Feature Customization: Adjusting VHA appearance (eg, animations and fonts) based on user preferences. Notably, 7/17 studies focused on racially minoritized groups (eg, African Americans, Hispanic farmworkers), addressing systemic barriers like mistrust in health care. However, gaps persisted in intersectional tailoring (eg, rurality and income) and non-English languages (only 2/17 studies). Recruitment methods influenced diversity; community-based strategies yielded more representative samples than solely internet-based recruitment approaches.
The systematic review identified the audience-centered development practices currently being used for VHA-based interventions in preventive cancer care. The majority of the studies included processes to diversify and segment the intended audience, focused on medically underrepresented population groups, and implemented strategies to be culturally sensitive to the population of interest. However, opportunities remain to address multidimensional inequities (eg, rural access and low literacy). Future interventions should integrate intersectional frameworks, expand language diversity, and measure social presence to enhance engagement. This review provides a roadmap for developing equity-focused eHealth tools in cancer prevention.
虚拟健康助手（VHA）是模拟人际交流的交互式数字程序，在医疗保健领域的应用日益广泛，旨在改善患者教育与护理，并减轻医疗保健提供者的负担。VHA有潜力通过促进患者参与、提供全天候信息获取渠道以及减少语言障碍来推动癌症公平。然而，在与癌症相关的应用程序开发中，以受众为中心的考量程度尚不清楚。
本系统评价旨在识别并综合用于使基于VHA的癌症预防和筛查干预措施以受众为中心的策略。
遵循PRISMA（系统评价与Meta分析优先报告项目）2020指南，我们在4个数据库（PubMed、Embase、科学网和EBSCOhost）中检索了关于促进癌症筛查的VHA干预措施的同行评审研究（2022年1月）。纳入研究聚焦于初级保健环境中的成年人群，干预措施强调交互性和即时性（VHA的关键特征）。排除关于癌症治疗、非交互式决策辅助工具或VHA技术开发的研究。由多名评审员独立进行筛选、数据提取和质量评估（混合方法评估工具）。采用主题综合法分析以受众为中心的策略。
在筛选的1055条记录中，17项研究符合纳入标准。大多数研究（n = 11）针对结直肠癌，其他研究涉及前列腺癌、乳腺癌、宫颈癌或肺癌。共有16项研究基于美国；1项研究聚焦于乌干达。以受众为中心的设计关键策略包括：（1）人口统计学一致性：VHA与用户之间的种族或性别匹配（例如，非裔美国参与者与编码为黑人的虚拟形象互动）；（2）用户反馈：通过访谈、出声思考协议或试点研究进行迭代测试以完善干预措施；（3）干预前需求评估：识别文化、语言或读写障碍（例如，乌干达社区对筛查的误解）；（4）理论框架：健康信念模型（最常见）、模态、能动性、交互性和可导航性（MAIN）模型或定制化信息传递理论指导设计；（5）信息定制：文化适应性内容（例如，西班牙语界面、解决种族差异的叙述）；（6）功能定制：根据用户偏好调整VHA外观（例如，动画和字体）。值得注意的是，17项研究中有7项聚焦于少数族裔群体（例如，非裔美国人、西班牙裔农场工人），解决了对医疗保健不信任等系统性障碍。然而，在交叉定制（例如，农村地区和收入）和非英语语言方面仍存在差距（仅2/17项研究涉及）。招募方法影响了多样性；基于社区的策略比仅基于互联网的招募方法产生了更具代表性的样本。
该系统评价确定了目前在基于VHA的癌症预防护理干预措施中使用的以受众为中心的开发实践。大多数研究纳入了使目标受众多样化和细分的过程，聚焦于医疗服务中代表性不足的人群群体，并实施了对目标人群具有文化敏感性的策略。然而，解决多维度不平等问题（例如，农村地区的医疗服务获取和低读写能力）的机会仍然存在。未来的干预措施应整合交叉框架，扩大语言多样性，并衡量社会存在感以增强参与度。本评价为开发以公平为重点的癌症预防电子健康工具提供了路线图。
