The United States Healthy Living Study

Primary outcomes

1. Intention to Talk to Doctor About Colorectal Cancer Screening

   Time frame: immediately after the intervention, up to 1 hour

   Measure: Intention to talk to doctor about colorectal cancer screening. Construct: Behavioral intention to communicate Item: The virtual appointment made me want to discuss colon cancer screening options with my doctor.

   Scale: 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Mean scores near 1 indicate a lower intention to talk to a healthcare professional about colorectal cancer screening. Mean scores near 5 indicate a high intention to talk to a healthcare professional about colorectal cancer screening.

   No subscales

2. Intention to Screen for Colorectal Cancer

   Time frame: immediately after the intervention, up to 1 hour

   Measure: Intention to Screen for Colorectal Cancer Item: I want to get screened for colorectal cancer. Scale: 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Mean scores near 1 indicate a lower intention to get screened for colorectal cancer. Mean scores near 5 indicate a higher intention to get screened for colorectal cancer.

   Construct: Behavioral intention to screen No subscales

3. Intention to Talk About Screening With FIT

   Time frame: immediately after the intervention, up to 1 hour

   Measure: Intention to Talk about Screening with FIT Item: I will talk to my healthcare provider about colon cancer screening with FIT.

   Scale: 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Mean scores closer to 1 indicate a lower intention to screen with FIT. Mean scores closer to 5 indicate a high intention to screen with FIT.

   Construct: Behavioral intention to screen with FIT No subscales

4. Intention to Recommend Intervention (ALEX)

   Time frame: immediately after the intervention, up to 1 hour

   Measure: Intention to Recommend Intervention (ALEX) Item: Imagine you received a link to ALEX from your healthcare provider. Would you like to share it by sending the link to someone? Scale: 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Mean scores near 1 indicate a lower intention to recommend ALEX. Mean scores near 5 indicate a high intention to recommend ALEX.

   Construct: Behavioral intention to recommend ALEX No subscales

5. Source Credibility

   Time frame: immediately after the intervention, up to 1 hour

   Measure:

   Construct: Source Credibility

   Scale description: An 18-item unidimensional 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Mean scores near 1 indicate that information provided by ALEX was perceived as not credible. Mean scores near 5 indicate the information provided by ALEX was perceived as highly credible. No subscales. The scale includes the following items:

   • Intelligent-Unintelligent-Intelligent
   • Untrained- Trained
   • Doesn't care about me-Cares about me
   • Dishonest- Honest
   • Doesn't have my interests at heart-Has my interests at heart
   • Untrustworthy-Trustworthy
   • Inexpert -Expert
   • Self-centered-Not self-centered
   • Not concerned with me-Concerned with me
   • Dishonorable-Honorable
   • Uninformed-Informed
   • Immoral-Moral
   • Incompetent-Competent
   • Unethical-Ethical
   • Sensitive-Insensitive
   • Stupid-Bright
   • Phony-Genuine
   • Not understanding-Understanding

6. Argument Strength

   Time frame: immediately after the intervention, up to 1 hour

   Construct: Argument Strength; Description: Argument Strength is a 9-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions of the strength of the argument about colon cancer screening. Mean scores near 1 indicate that ALEX's argument about colon cancer screening was perceived as not strong. Mean scores near 5 indicate that ALEX's argument about colon cancer screening was perceived as very strong. No subscales.

   • The reason ALEX gives me for screening with FIT is believable
   • The reason ALEX gives me for screening with FIT is convincing
   • The reason ALEX gives me for screening with FIT is important to me
   • ALEX helps me feel confident about how best to screen with FIT
   • ALEX would help my friends screen with FIT
   • ALEX encouraged me to screen with FIT
   • ALEX encouraged me to avoid screening.
   • I agree with ALEX's reasoning for screening
   • ALEX gives a strong reason for screening with FIT

7. Homophily

   Time frame: immediately after the intervention, up to 1 hour

   Construct: Internal Homophily

   Scale: an 8-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions of their similarity to ALEX's characteristics. Mean scores near 1 indicate participants perceive strong dissimilarity to ALEX's characteristics. Mean scores near 5 indicate participants perceive strong similarity to ALEX's characteristics. No subscales. Items:

   • Doesn't think like me-thinks like me
   • Doesn't behave like me-Behaves like me
   • Is different from me-Is similar to me
   • Unlike me-Is like me
   • Has a background different to mine-Has a background similar from mine
   • Has morals unlike mine-Has morals like mine
   • Looks different from me-Looks similar to me
   • Is a different body size than I am-Has the same body size as I do

8. Usability of App

   Time frame: immediately after the intervention, up to 1 hour

   Construct: Usability of App; Description: Usability is a 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree). This scale measures participants' experience using the ALEX app. Mean scores near 1 indicate a negative experience using the ALEX app. Mean scores near 5 indicate a positive experience using the ALEX app. No subscales. Items:

   • Enjoyable
   • Easy to use
   • Awkward
   • Uncomfortable

9. Perceived Severity

   Time frame: immediately after the intervention, up to 1 hour

   Construct: Perceived Severity; Description: A 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions regarding the likelihood of developing colon cancer at some point in their lives. Mean scores near 1 indicate low severity, while mean scores near 5 indicate high severity. No subscales. Items:

   • I am at risk for getting colon cancer in my lifetime.
   • It is possible that I will get colon cancer in my lifetime.
   • I am susceptible to getting colon cancer in my lifetime.
   • It is likely that I will get colon cancer in my lifetime.

10. Perceived Susceptibility

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Perceived Susceptibility Description: Perceived Susceptibility is a 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) assessing participants' perceptions regarding being susceptible to developing colon cancer at some point in their lives. Mean scores near 1 indicate low susceptibility, while mean scores near 5 indicate high susceptibility. No subscales. Items:

    • I am at risk for getting colon cancer in my lifetime.
    • It is possible that I will get colon cancer in my lifetime.
    • I am susceptible to getting colon cancer in my lifetime.
    • It is likely that I will get colon cancer in my lifetime.

11. Response Efficacy

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Response Efficacy Description: A 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measured participants' perceptions of the effectiveness of FIT screening in detecting and preventing colon cancer. Mean scores near 1 indicate low perceived efficacy, while mean scores near 5 indicate high perceived efficacy. No subscales. Items:

    • FIT screening leads to early detection if something is wrong.
    • FIT screening leads to the detection of small abnormalities.
    • FIT screening will help me find cancer early.
    • FIT screening will decrease my chances of dying from colon cancer.

12. Self-Efficacy

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Self-Efficacy Description: A 12-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' confidence in completing FIT screening or a colonoscopy. Mean scores near 1 indicate low self-efficacy, while scores near 5 indicate high self-efficacy. No subscales. Items:

    • I am confident that I can use the FIT
    • Arranging my schedule to use the FIT is an easy thing to do
    • FIT screening would be easy for me to do
    • It would be easy for me to take a stool sample
    • It would be easy for me to mail my kit back
    • It would be easy for me to use all the tools in the kit
    • I know how to collect a stool sample
    • I am confident that I can get a colonoscopy
    • Arranging my schedule to get a colonoscopy is an easy thing to do
    • Finding time to get a colonoscopy would be difficult for me to do
    • Screening for colon cancer with a colonoscopy would be easy for me to do
    • It would be easy for me to get a colonoscopy

13. Perceived Barriers

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Perceived Barriers Description: A 6-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) assessed participants' perceived obstacles to undergoing FIT screening. Mean scores closer to 1 indicate fewer perceived barriers. Mean scores closer to 5 indicate more perceived barriers. No subscales. Items:

    • My doctor would never recommend the FIT.
    • The FIT would be too expensive.
    • The FIT would be too embarrassing.
    • Preparation for the FIT is too hard.
    • The FIT takes too much time.
    • The FIT is difficult because it is too hard to understand all the instructions.

14. Perceived Benefits

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Perceived Benefits Description: A 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measured participants' perceptions of the benefits of FIT screening. Mean scores near 1 indicate low perceived benefits. Mean scores near 5 indicate high perceived benefits. No subscales. Items:

    • The FIT will decrease my chances of dying from colon cancer.
    • The FIT will help me not worry as much about colon cancer.
    • I believe that if I had a normal screening test result, I wouldn't have to worry about developing colon cancer.
    • I believe that when colon cancer is found early, it can be cured.

15. Comparative Risk Feedback

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Comparative Risk Feedback Description: A single-item unidimensional measure assessing participants' perceived risk of developing colon cancer compared to others on a 7-point Likert Scale. Mean scores near 1 indicate low perceived comparative risk. Mean scores near 7 indicate a high perceived risk of developing colon cancer compared to others. Item:

    • Compared to the average person your age, gender, and race, how would you rate your chances of developing colon cancer in your life?

16. Cancer Information Overload

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Cancer Information Overload Description: A 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions regarding the amount and clarity of cancer-related information. Mean scores near 1 indicate lower overload. Mean scores near 5 indicate higher overload. No subscales. Items:

    • There are so many different recommendations about preventing cancer, it's hard to know which ones to follow.
    • There is not enough time to do all of the things recommended to prevent cancer.
    • It has gotten to the point where I don't even care to hear new information about cancer.
    • I feel overwhelmed by the amount of cancer information I am supposed to know.

17. Perceived Message Relevance

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Perceived Message Relevance Description: A 6-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions of how relevant and personalized the health message felt to them. Mean scores near 1 indicate low relevance. Mean scores near 5 indicate high relevance. No subscales. Items:

    • The message seemed to be written personally for me.
    • The message was very relevant to my situation.
    • The message was applicable to me.
    • The message was very customized to me.
    • This message was manipulative.
    • This message was misleading.

18. Trust in Physician

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Trust in Physician Description: An 11-item 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring physician trust. Mean scores near 1 indicate low trust, while scores near 5 indicate high trust. No subscales. Items:

    • I doubt that my doctor really cares about me as a person
    • My doctor usually puts my needs first
    • I trust my doctor so much I always try to follow his/her advice
    • If my doctor tells me something is so, then it must be true
    • I sometimes distrust my doctor's opinion
    • I trust my doctor's judgments about my medical care
    • I feel my doctor does not do everything he/she should about my medical care
    • I trust my doctor to put my medical needs above all other considerations
    • My doctor is well qualified to manage my medical problems
    • I trust my doctor to tell me if a mistake was made about my treatment
    • I sometimes worry that my doctor may not keep the information we discuss totally private

19. Patient-Provider Communication

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Patient-Provider Communication Description: A 5-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' perceptions of how well their doctor communicates with them. Mean scores near 1 indicate poor communication. Mean scores near 5 indicate good communication. No subscales. Items:

    • I receive enough understandable information from my doctor/healthcare provider to make good decisions about my health.
    • I feel rushed during visits.
    • My doctor/healthcare provider involves me in decisions about my health care treatment.
    • I feel uncomfortable asking my doctor for tests or information if he/she doesn't mention it.
    • My doctor/healthcare provider understands my health needs.

20. Patient General Health

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Patient General Health Description: A 3-item unidimensional measure assessing participants' overall health and pain levels on 5-point Likert Scales. Mean scores near 1 indicate low general health. Mean scores near 5 indicate high general health. Items:

    • In general, would you say your health is: (1=Poor, 5=Excellent)
    • How much bodily pain have you had during the past 4 weeks? (1= Very severe, 5= None)
    • During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (1 = Extremely, 5= Not at all)

21. Health Literacy (eHeals)

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Health Literacy (eHeals) Description: An 8-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) measuring participants' confidence in using the internet for health-related information. Mean scores near 1 indicate low health literacy. Mean scores near 5 indicate high health literacy. No subscales. Items:

    • I know how to find helpful health resources on the Internet.
    • I know how to use the Internet to answer my health questions.
    • I know what health resources are available on the Internet.
    • I know where to find helpful health resources on the Internet.
    • I know how to use the health information I find on the Internet to help me.
    • I have the skills I need to evaluate the health resources I find on the Internet.
    • I can tell high quality from low quality health resources on the Internet.
    • I feel confident in using information from the Internet to make health decisions.

22. Interpersonal Distance

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Interpersonal Distance Description: A 4-item unidimensional 5-point Likert scale (1=strongly disagree/5=strongly agree) that measures participants' perceptions of the virtual human's presence. Mean scores near 1 indicate low perceived presence. Mean scores near 5 indicate high perceived presence. No subscales. Items:

    • I perceive that I am in the presence of Alex in the room with me.
    • I feel that Alex is aware of my presence.
    • The thought that Alex is not a real person crosses my mind often.
    • I perceive Alex as being only a computerized image, not as a real person.

23. Attitudes Towards Fecal Immunochemical Test (FIT) - Sad

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Sad

    Description: We measured participant's emotional attitudes of sadness towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of sadness regarding FIT screening. Mean scores near 5 indicate strong feelings of sadness regarding FIT screening. Item:

    • How much sadness would you feel if a doctor asked you to get screened for colon cancer using FIT?

24. Attitudes Towards Fecal Immunochemical Test (FIT) - Worried

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Worried

    Description: We measured participant's emotional attitudes of worry towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of worry regarding FIT screening. Mean scores near 5 indicate strong feelings of worry regarding FIT screening. Item:

    • How much worried would you feel if a doctor asked you to get screened for colon cancer using FIT?

25. Attitudes Towards Fecal Immunochemical Test (FIT) - Relieved

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Relieved Description: We measured participant's emotional attitudes of relief towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of relief regarding FIT screening. Mean scores near 5 indicate strong feelings of relief regarding FIT screening. Item:

    • How relieved would you feel if a doctor asked you to get screened for colon cancer using FIT?

26. Attitudes Towards Fecal Immunochemical Test (FIT) - Tense

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Tense

    Description: We measured participant's emotional attitudes of tensity towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of tenseness regarding FIT screening. Mean scores near 5 indicate strong feelings of tenseness regarding FIT screening. Item:

    • How tense would you feel if a doctor asked you to get screened for colon cancer using FIT?

27. Attitudes Towards Fecal Immunochemical Test (FIT) - Anxious

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Anxious

    Description: We measured participant's emotional attitudes of anxiety towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of anxiousness regarding FIT screening. Mean scores near 5 indicate strong feelings of anxiousness regarding FIT screening. Item:

    • How anxious would you feel if a doctor asked you to get screened for colon cancer using FIT?

28. Attitudes Towards Fecal Immunochemical Test (FIT) - Calm

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Calm

    Description: We measured participant's emotional attitudes of calmness towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of calmness regarding FIT screening. Mean scores near 5 indicate strong feelings of calmness regarding FIT screening. Item:

    • How calm would you feel if a doctor asked you to get screened for colon cancer using FIT?

29. Attitudes Towards Fecal Immunochemical Test (FIT) - Afraid

    Time frame: immediately after the intervention, up to 1 hour

    Construct: Attitudes towards Fecal Immunochemical Test (FIT) - Afraid

    Description: We measured participant's emotional attitudes of fear towards FIT using single-items on a 5-point Likert scale (1=not at all, 5=very much). Mean scores near 1 indicate little to no feelings of fear regarding FIT screening. Mean scores near 5 indicate strong feelings of fear regarding FIT screening. Item:

    • How afraid would you feel if a doctor asked you to get screened for colon cancer using FIT?