The prevalence of unhealthy alcohol use among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) Veterans is high. Common barriers to receiving treatment reported by OEF/OIF Veterans include preference for anonymity, long wait times, concern about the quality of Veteran Affairs (VA) care, stigma, and distance from treatment facilities. Mobile applications, delivered on smartphones, have tremendous promise as means to deliver alcohol interventions to a large segment of Veterans who prefer to remain anonymous, have little time for conventional treatments or live too far away to attend treatment in person. This pilot study evaluated the feasibility, acceptability and usability of a mobile application, named Step Away, to reduce unhealthy alcohol use and enhance treatment initiation among OEF/OIF Veterans.
The aims of this project were to assess: 1) recruitment feasibility, recruitment approaches, compliance with follow-up assessments and patterns of Step Away use, and 2) acceptability and usability dimensions of efficiency, effectiveness, satisfaction, learnability and attractiveness of Step Away among OEF/OIF Veterans. An exploratory aim of the project was to evaluate change on alcohol use, psychological distress and health-related quality of life outcomes associated with use of Step Away.
Over 7 months, this mixed-methods, single-arm prospective cohort study recruited OEF/OIF Veterans using social media advertisements, invitation letters and telephone contacts. Data sources included questionnaires, semi-structured interviews and the VA Corporate Data Warehouse to identify OEF/OIF Veterans with AUDIT-C scores >4 for recruitment by letters and follow-up contacts. Participants who were between the ages of 18-55, exceeded NIAAA "low-risk" drinking guidelines (>5 drinks on any day or >15 drinks per week for men; >4 drinks on any day or >8 drinks per week for women), served in OEF/OIF and owned an iPhone were eligible for study participation. Eligible Veterans were given access to Step Away and completed a baseline research assessment and follow-up at 1- and 3-months by telephone. Recruitment feasibility was measured using the enrollment rate index, defined as the total number of recruitment days divided by the number of Veterans enrolled in the study. Percentages were used to estimate 1- and 3- month follow-up rates and mean number of minutes in the first week and subsequent weeks assessed Step Away use. (Aim 1). A subsample of Veterans, based on early Step Away use, completed qualitative interviews to assess acceptability and usability of the app. Learnability was assessed by use of Step Away in the first week. The 10-item System Usability Scale (SUS; scaled 1 to 100) assessed the effectiveness, efficiency and satisfaction dimensions of Step Away at 1- and 3-months, while a 1-item questionnaire (scaled 1 to 9) measured attractiveness (Aim 2). Alcohol consumption in the prior 30 days and psychological distress were assessed using the Time-Line Follow-Back and Kessler-10, respectively. Health-related quality of life was assessed using the brief World Health Organization Quality of Life questionnaire (WHOQOL-BREF). Exploratory analyses assessed pre-post changes on substance use, psychological distress and quality of life (Aim 3).
Recruitment using social media advertisements was difficult due to VA policies and regulations for research involving social media. After three months, advertisements yielded no contacts from interested participants. Over 140 days, 1000 potentially eligible Veterans were invited to participate by mail and contacted by telephone. Of this group, 621 (62%) Veterans did not respond or declined to participate, and 324 (32.4%) screened ineligible (e.g., did not own iPhone). A total of 55 Veterans enrolled in the study. On average, 3.5 days were required to enroll one participant. Participants' mean age was 37.4 (SD=7.6), 16.4% were female and 81.8% were Caucasian. Eighty-two percent of Veterans had an alcohol use disorder.
Among all participants, completion rates of assessments at 1- and 3-months were 90.9% and 87.3%, respectively. On average, participants used Step Away 55 (SD=57.6) minutes in week 1 and less than 15 minutes in weeks 2 to 12. Step Away was used by 96% of participants in week 1 and 40% in week 12. Participants' mean SUS scores were 69.3 (SD=19.7) and 71.9 (SD=15.8) at 1- and 3-months follow-up, respectively, which is considered acceptable. Attractiveness scores ranged from a median of 5 to 8, with lower ratings given to text-laden screens.
Among 21 participants who completed semi-structured interviews, several themes were identified. Nearly all participants reported that Step Away made them more aware or conscious of their alcohol consumption. Participants' responses also indicated that most had an intent to change their drinking, while a majority had both the intent and had enacted efforts to change their drinking. Among Step Away components, the most commonly discussed and regarded as helpful were the daily interview and weekly feedback, two features that prompted participants to respond. Both features were reported as being helpful in creating awareness about alcohol consumption. Participants suggestions to improve Step Away included adding Veteran-related content on posttraumatic stress disorder, traumatic brain injury and stressors related to military service and a direct link to additional support such as VA providers and support groups. With regards to using Step Away outside the study and recommending it to others, 13 participants reported they would continue to use it after the study and 19 recommend it to others.
Participants' total drinks in the past 30 days decreased from 98.1 (SD=72.4) drinks at baseline to 71.1 (SD=64.5) drinks at 3-month follow-up. Heavy drinking days ( 5 drinks per day for men and 4 drinks per day for women) also decreased from 8.7 (SD=8.7) days at baseline to 6.8 (SD=8.4) days at 3-month follow-up. On average, Kessler-10 scores decreased from 18.7 (SD=6.6) at baseline to 16.9 (SD=4.8) at 3-month follow-up. Minimal change in mean WHOQOL-BREF scores were observed from baseline to 3-months.
Results suggest that Step Away may increase OEF/OIF Veterans' awareness of their alcohol consumption, which may influence their motivation and efforts to reduce consumption of alcohol.
None at this time.
Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
Technology Development and Assessment, Treatment - Observational, TRL - Applied/Translational