This is a part of the series of profiles on our Hub’s scholarship students who have completed their PhDs.
Congratulations to Dr Judith Hocking who graduated with her PhD in December 2022 from Flinders University in Adelaide, South Australia. Dr Hocking was one of the earlier HDR students to join the ARC Research Hub for Digital Enhanced Living and was supervised by Associate Professor Belinda Lange, Professor David Powers, Emeritus Professor Anthony Maeder and Dr Lua Perimal-Lewis.
Dr Judith Hocking
What is the title of your PhD project?
Design and Development of a Motivational Conversational Agent for Brain Injury Rehabilitation.
Did you work with any industry partner?
- Clevertar Pty Ltd
- South Australian Brain Injury Rehabilitation Services
Can you give us a summary of your project?
Adults with traumatic brain injury (TBI) can experience functional impairments, decreased memory, and low motivation. Recovery following TBI is possible due neuroplasticity – in which the brain is able to form new neuronal connections in response to rehabilitative training. Rehabilitation following TBI is supported through multi-disciplinary rehabilitation, in which client-centred goals are set and then pursued. However, rehabilitation care is time limited. Novel care approaches which leverage service provision and are motivational for clients, are needed. Conversational Agents (CAs) provide a personal, human-computer conversation interface and can be designed to engage the user in a focused task with motivational content. Specific motivational behaviour change approaches can be applied to CA design: Motivational Interviewing (MI) has been integrated into CAs for users without cognitive impairment; and Self-Determination Theory (SDT) has been recommended for human-centred design for digital technologies including CAs. Additionally, both MI and SDT have been recommended for brain injury rehabilitation.
This PhD outlines the design and development of a motivational embodied CA (ECA) for brain injury rehabilitation. This type of ECA for this purpose has not previously been developed. Key considerations for developing the ECA were: addressing the clinical needs of clients with TBI: contextualizing the ECA to the clinical setting, and incorporating SDT and MI within the conversation dialogues. Living Laboratory design methodology was utilised for this project: including co-design with clinicians and clients and testing of the ECA in the real-life setting (two ambulatory care clinics, and the client’s home environment). The three phases of development of the ECA – RehabChat – were conducted to optimise the feasibility and acceptability of this ECA. The phases were in-house development and testing, co-design workshops, and a mixed methods feasibility pilot trial. In-house development incorporated alpha testing to check thoroughly for glitches as well as general usability; and beta testing to detect any glitches and appraise usability more closely.
For the co-design workshops and the feasibility pilot trial, full ethics approval was gained, and clients and clinicians of the collaborating clinics were recruited. The co-design workshops comprised three cohorts (current clients, discharged clients and clinicians) and four rounds of co-design workshops. Separate meetings were conducted for each cohort for the first three rounds of meetings, followed by one final fourth workshop meeting comprising all cohorts. Iterative changes were made to the ECA during these workshops. The ECA was then thoroughly checked by completing second alpha testing. The refined stable model ECA was then used in the feasibility pilot trial. For the mixed methods feasibility pilot trial, client-clinician dyads completed a two-week intervention using RehabChat alongside usual rehabilitation care. As well, clinician-participants, for whom no clients could be recruited, participated in a mock client-clinician session to use the ECA and then provide feedback. Results which revealed that participants thought RehabChat was motivational and that it was easy to use alongside usual care, are discussed and recommendations for future research and development of RehabChat are presented.
Which of the Hub’s key research theme/s did your project align with?
P4 – Digitally assisted physical and mental behaviour enhancement
P6 – In-home support deployment
P8 – Conversational agents for sustained mental well-being
What were the key learnings from this project?
Recruitment was difficult due not only to the known challenges of recruiting clients with a brain injury, but also due to COVID-19 related issues which impacted directly upon the clinical setting. These included the settings needing to adjust to changing requirements regarding PPE, staff density limits and allowed interactions, and the increased use of tele-rehabilitation. Future research should pro-actively aim to identify the needs of the clinical settings early, and have pre-developed solutions ready to deploy if needed. Such solutions could include simple User Guides in paper and electronic formats, participants being able to suspend their involvement for a few weeks during times of upheaval (e.g. due to COVID-19 requirements or due to health reasons), and ensuring robust systems are in place for supporting participants remotely in using the software (i.e. not at all rely on being able to see participants in-person) for trouble-shooting and reiterative teaching and learning.
As well, strong ties should be well established with the services’ I.T. team and manager/s to ensure very easy ability for the researchers to implement any tweaks to the software in a prompt way. In my project this was done as needed as the project progressed and with very effective outcomes, but in hindsight it would have been better to have done this earlier and in a more structured way.
What were some of the research outcomes from this project?
- Hocking J, Oster C, Maeder A, Lange B. Design, development, and use of conversational agents in rehabilitation for adults with brain-related neurological conditions: a scoping review. JBI Evidence Synthesis. 2023;21(2)
- Hocking, Judith; Oster, Candice; Maeder, Anthony. Use of conversational agents in rehabilitation following brain injury, disease, or stroke: a scoping review protocol, JBI Evidence Synthesis: June 2021 – Volume 19 – Issue 6 – p 1369-1381. DOI: 10.11124/JBIES-20-00225
- Hocking J, Maeder A. Motivational Embodied Conversational Agent for Brain Injury Rehabilitation. In: Maeder A, Higa C, van den Berg M, Gough C, editors. Ebook: Telehealth Innovations in Remote Healthcare Services Delivery Global TeleHealth 2020. 2772021. p. 37 – 46. DOI: 10.3233/SHTI210026
- (Under review by Clinical Rehabilitation Journal) Hocking J, Powers D, Perimal-Lewis L, Maeder A, Dodd B, Lange B. ‘Mixed methods feasibility trial of a motivational conversational agent for brain injury rehabilitation’.
- Australian Living Laboratory Conference, Feb 2021: co-presentation
- Australian Institute of Digital Health: Emerging SA talent presentation, Sep 2020: presentation
- Australian-Japan Joint Neurodegenerative Disease Symposium, Jun 2019: presentation
- Australian Research Council Industrial Transformation Research Hub for Digital Enhanced Living PhD Student Symposiums, Dec 2019 and Sep 2021: presentations
- G-I-N & JBI (Guidelines International Network & Joanna Briggs Institute) Conference, Oct-Nov 2019: poster
- Australian Physiotherapy Association Conference, Oct 2019: presentation
- Flinders University DocFest, Aug 2019: poster
- RehabChat was feasible to use alongside usual ambulatory brain injury rehabilitation care, had high usability and acceptability to the client and clinician study participants.
- Two stakeholder consultation meetings were held in 2019 with senior SABIRS staff (clinicians and clinical managers).
- Initial information talks were presented to staff of two (South Australian Brain Injury Rehabilitation Services) SABIRS clinics prior to commencement of the co-design workshops.
- Short fortnightly presentations were delivered to the two SABIRS ambulatory care clinic settings who participated in the feasibility pilot trial over a six-month period of the project.
- Two ambulatory care clinic settings of the South Australian Brain Injury Rehabilitation Services participated in the feasibility pilot trial (the final stage of this PhD).
Did this PhD project result in the end-product being commercialised, an IP filing, or taken further?
- We received a 1-year grant from the Lifetime Support Authority to conduct a larger feasibility pilot trial of RehabChat across multiple clinical services in South Australia.
- We received a Flinders University Accelerator Grant to investigate rehabilitation goal-setting practices for clients with brain injury or stroke in Australian settings, and to explore how these results may inform the design of assistive technology, including RehabChat.
So what’s next for you after graduation?
I am currently working as a researcher for the two grant-funded research projects noted above.
An abstract of Judith’s thesis can be viewed online here (Flinders University).