Table 2.

Insights and Strategies for Improving Perceptions of VHA Credibility Derived From Focus Groups With Adults 50–73 Years Old

VHA Cue	Definition	Insights/Communication Strategies	Participant Quotes
Trust	The degree to which a message recipient believes the VHA is conveying the truth as they know it. Indicates a positive belief about the perceived reliability or dependability of the VHA (includes perceived fairness or lack of bias)	Similarities: Participants desired a VHA connected to a trusted source. Trust of this study’s VHA was contextualized by perceptions of the local university hospital. Perceptions of the VHA costing money, or of any money-making intentions, lowered trust. Differences: White participants would trust the VHA if it came directly from their doctor. White adults’ privacy concerns were balanced by the potential benefits of personalized information. Black adults reported that a VHA who could provide help with health questions, normalize fears, and reduce uncertainty enhanced trust. Black men responded positively to interacting with the Black male VHA. Potential communication strategies: Race and gender concordance may be particularly important for Black men. For Black participants, trust included interpersonal considerations such as friendliness and ability to alleviate uncertainty. White participants commented on the structural ways their privacy and security might be violated.	BW: I think we all agree we would be more likely to use it because it came from UF. (P7) BW: Yes, because of the rep. They have a good reputation. (P8) BM: Like I say, bein’ as that he was a brother-doctor look, it was more acceptable to listen to it opposed to another type. (P150) BM: Yeah. I was just looking at her picture that we’ve been talking about. It seems like more—not the doctor part, but this person can explain it to me more. (P107) WW: You know, maybe you do voices for different regions, you know, because people relate and sort of trust, you know. Hopefully nobody’s from New York, but if you have a New Yorker (indicates accent) or somebody from Massachusetts speaking, people are going to go, what? Where are they? (P9) WW: If my doctor told me at an appointment, “I recommend that you do this,” then I would find a way to do it. (P10). WM: Well, the question is how do I trust it. And when it presents itself as “I’m a person” when I know, but, and I’m looking at it, and it’s very, very clear, this is not a person, that uh, that leads me to not trust it. (P42) WM: I would want to not only put in my information once I trusted the system. I would want to put in what happened to my dad, and my great-aunt, and my uncles and my sisters, brother, cousins. (P96)
VHA Cue	Definition	Insights/Communication Strategies	Participant Quotes
Expertise	The degree to which a message recipient believes the VHA to be knowledgeable about a topic, with a specific level of skill derived from training or experience	Similarities: Visual attributes of the VHA (e.g., age, clothing) were important cues to expertise. The VHA’s ability to integrate relevant patient information and communicate on a variety of topics during the interaction was viewed as a type of expertise. Listening skills were considered an area of VHA expertise. Differences: Black adults primarily commented on the VHA’s professional appearance. Only a few Black males discussed expertise. Only White adults wanted to evaluate the external sources of information that informed the messages (e.g., seeing a diploma on the wall, or hearing the message was backed by research) as a way to assess the VHA’s expertise. Potential communication strategies: Visual expectations of expertise can be cued by different features (appearance vs. evidence). Gender may play a strong role in perceptions of expertise and can be explored further.	BW: She sounded young. Like she was too young to be a doctor giving us this important advice. (P18) BW: I think with the virtual human, I think they have all that information just readily, as opposed to a doctor that may not think of something, you know, so. I would definitely go for that ‘cuz I like all that information type thing coming in. (P10) BM: If you wanted the [virtual] doctor to seem an expert, I probably would have done a better job on the animation … I hadn’t seen many doctors dressed that way. He had his shirttail out … but his voice was very clear, and his diction was really good. (P19) BM: Like it was informative, … seem like he had some kinda medical background to speak on it, and that’s what I looked at. (P150) WW: I would enjoy it—because the virtual human is backed by the research and profession, it’s not just a website or some testimony. (P88) WM: But a virtual doctor with a resource of background information that can bring this together, I think would actually be better than an actual doctor. (P95) WM: A patient advocate. They would know things, but would they articulate my needs of why I’m there? I’d like the doctor’s opinion then. Eight years of schools of schooling as opposed to three years of junior college. (P81)
			VHA Cue	Definition	Insights/Communication Strategies	Participant Quotes
Authority	The degree to which the VHA is observed to have credentials or training as a medical authority. Perception of the VHA having a formal position/job indicating specific education or requiring relevant experience (e.g., doctor)	Similarities: Black and White participants both wanted the VHA to represent a medical authority. When the VHA was perceived as a community health worker, it was a less acceptable source of screening messages. Differences: Black adults accepted and endorsed the authority of the VHA itself. White adults conferred authority on the VHA based on it being recommended directly by a medical doctor. For White adults, perceptions that a “real doctor” maintained authority was important. Potential communication strategies: Add an introduction from a medical doctor. Disseminate via a local, reputable health organization or a patient portal.	BW: When you look at the way she was dressed … you knew that she was a doctor or a nurse. Yeah, she was 100 percent. (P30) BW: I would definitely go for that ‘cuz I like all that information coming in … basically be an expert authority on different things. (P10) BM: Being that he [the VHA] was a brother-doctor … it was more acceptable to listen to. (P150) BM: His voice was knowledgeable and patient, um, kind of, has some authority … but he wasn’t judgmental. (P17) WW: I would say phooey, because if the doctor hasn’t asked me to do an exam, the question is, then why are you asking me to do this? I don’t have time to do this. (P80) WW: I know studies show that you put the white coat on and that’s where people see authority, I see what I think you’re trying to get at with like, a step down from a doctor, here, but still a medical person, and I do think that’s probably a smart way to go. (P86) WM: I just think if you’re going to do it [create a VHA], you might as well go all the way and have a medical doctor. (P97) WM: No, I’m just saying. It, he’s not an authority. He’s an authority on the subject, but he’s not an authority as a doctor or a nurse or a policeman or something. He is helping us to make a decision, so does he really need our personal information to do that? (P95)
			VHA Cue	Definition	Insights/Communication Strategies	Participant Quotes
Friendliness	The degree to which an individual feels an affective bond toward the VHA For example, people agree… with those they like based on the reasoning that “People I like usually have correct opinions on issues”	Similarities: Both Black and White participants desired a friendly and likable VHA. Adjusting VHA appearance (e.g., smiling) and voice cues improved perceptions of friendliness. Participants referenced the VHA acting like a “friend” or “best friend” when it comes to helping them navigate their health. Differences: None discerned. Potential communication strategies: Perceived friendliness of the message source was universally desired. In this context, friendliness may not require specific or extensive tailoring beyond a basic perception of an engaged, caring, and kind communicator.	BW: Make her a little more friendly. (P21) BW: The one they said sounded country sounded fun to me. She was like, “Alright y’all, let’s get it” (laughter). (P19) BM: He look like he more could be a doctor or a friend or something. Somebody that’s concerned about your problem with cancer—that you could trust, really trust. (P109) BM: You probably feel more comfortable with the—the virtual human walking you through it than sitting there listening to the doctor talking about it. (P107) WW: It would have been nice to be a little more human, a little bit warmer. I want to hear the smile. (P10) WW: I like more of a smile. … But more receptive look on the face, like they’re hearing you and interacting, and something that’s positive. (P76) WM: I like the woman’s voice on my GPS, and I would like to have a VHA that was a nice friendly woman that was very knowledgeable, an artificial intelligence that when I ask it a question, it could become my best friend in terms of getting me the right answer. (P96) WM: You want your Virtual Human to be your more loving, affectionate friend. Your dear most friend. The one that’s always going to be there for you, that’s always trustworthy, that’s always gonna support you when you’re down. (P96)

Note. BM = Black man, BW = Black woman, VHA = virtual health assistant, WM = White man, WW = White woman.