Not just a Barbie in hijab: participant perspectives on culturally tailoring a virtual health assistant for Bangladeshi immigrants in the US promoting colorectal cancer screening

Background: Colorectal cancer (CRC) screening uptake among South Asian immigrants in the US is the lowest (61.1%) of all immigrant groups (e.g., 65.9% among East Asians and 71.3% among Hispanics). Culture-specific factors influence their reluctance to screen for CRC, despite the availability of easily accessible, non-invasive screening tools, like the fecal immunochemical test (FIT). The current study utilizes a virtual health assistant (VHA) tailored to inform and educate Bangladeshi immigrants about FIT.

Methods: We conducted usability tests to understand Bangladeshi immigrants' informational needs, barriers, facilitators, and visual and linguistic preferences. After 20 minutes of interaction with the VHA, we conducted semi-structured interviews with 30 participants. Participants also filled out a questionnaire of demographic information and VHA gender and ethnic appearance preferences. A qualitative content analysis using the constant comparative method generated themes.

Results: A total of 30 participants (16 women, 14 men) with a mean age of 39.2 years participated. Informational needs included eight themes: (I) risk-reducing behaviors/habits, (II) post-intervention (information desired after interacting with the VHA), (III) CRC-related content (e.g., symptoms, causes, impact on the body, etc.), (IV) financial considerations of FIT, (V) personalized content/options, (VI) pre-test information (how to prepare for the FIT kit use, e.g., "do I need to fast?"), (VII) comparison to other CRC screening options, and (VIII) more specificity of information (i.e., using more measurable language, avoiding vague language like "some", "more", etc.). Major barriers were (I) lack of control, (II) lack of sophistication in VHA animation features, (III) lack of interactiveness, and (IV) lack of a trustworthy source. Facilitators were (I) convenience (of using VHA), (II) social cues (of interacting with a VHA), and (III) content (provided by the VHA). In terms of VHA's appearance, which was a combination of its apparent gender and ethnicity, participants demonstrated varied preferences but the majority (n=17) preferred gender concordant VHA. As for linguistic preference, participants generally mentioned either English or an option to choose a language for themselves while claiming that other Bangladeshi immigrants would prefer the Bangla language.

Conclusions: Participants were open to using a VHA to learn about CRC, either instead of or along with talking to a clinician about it. However, recommendations to improve animated features of the VHA included more detailed and Bangladeshi population-specific information and provided choices to select preferred languages and appearance of the VHA. Future studies should empirically test the required levels of tailoring to effectively increase CRC screening among Bangladeshi immigrants.