Table 3. VHA usage barriers.

Theme	Properties	Description	Exemplar
Lack of control	❖ Navigation	Perceived control of the progression or the pacing of the interaction (e.g., being able to skip or rewind or fast-forward); being able to choose what information they want to see or don’t want to see	“Yeah. For example, if I go to say Mayo Clinic, what it does is it has lots of different subjects, right. It’ll say, ‘Are you at risk? What are the treatment options?’ I can skip, right? I can decide which part I want to read first. I wish the video did that as well. A lot of different options, so I can pick and choose instead of going in order.”—P25, male, 46
	❖ Limited options
Lack of interactiveness	❖ Cannot ask follow-up questions	Participants mention a lack of interactivity with the VHA in terms of not being able to ask questions if they have any, or emotionally connect with the VHA as they would with a human clinician, and the interaction being too long to pay attention to	“Well of course you can’t really ask any—it’s one way, right? The avatar will provide you with instruction of the information and then ask you a question and you will basically click and answer at the bottom. And then just—so that’s very specific to the information that the avatar is providing.”—P11, male, 34
	❖ Preference for human contact
	❖ Lacks social cues (e.g., emotional response, familiarity with the patient)
	❖ Too lengthy
	❖ Lacks engaging materials to sustain user attention
Lack of a trustworthy source	❖ Who is sending the intervention	A need to receive the VHA intervention from a trustworthy source or the intervention containing logos or insignia of a renowned medical/research institution	“Is it a product that University of Florida created? Or is it a company? Because if it is a company then immediately after thinking about how sometimes doctors will try to kind of push a medicine or a drug on you because they’re getting some sort of incentive from the company.”—P25, male, 46
	❖ Endorsement of trustworthy institutions
	❖ Need to be sent by insurance company or provider
Lack of sophistication in VHA animation features	❖ Need for better animation	Participants express a negative perception of the animated agent’s appearance (e.g., the animation being subpar or the voice sounding robotic)	“If you do use avatar, then the avatar probably should look more real. I just felt like a Barbie or some kind of that kind of thing is speaking, which doesn’t necessarily synchronize with the emotion and hand body movement or facial movement, or even the synchronizing of the lips. Together everything felt less connected to me when I’m seeking something so personal so important.”—P16, female, 40
	❖ Need for more natural human voice

VHA, virtual health assistant.