Hazardous drinking poses a significant public health problem and is a critical issue in the lives of a large population of Veterans. In the Veterans Health Administration (VHA), 15-30% of Veterans seen in Primary Care are identified as hazardous drinkers based on a positive screen on the Alcohol Use Disorder Identification Test for Consumption (AUDIT-C); however, due to a number of barriers such as time constraints on providers and behavioral costs to patients (e.g., traveling to VA for regular treatment sessions), the vast majority of these
Veterans go untreated. Smartphone technology and the development of specialized applications ("apps") can overcome these barriers by extending care for hazardous drinking beyond the onsite appointment through prescribing a self-directed, evidence-based treatment application. The scientific literature provides a compelling case for smartphone-based interventions in treating hazardous drinking, as well as underscores the role of peer support in behavioral change. The program of research initiated by this pilot study proposes use of a comprehensive, no-cost smartphone application ("Step Away") to provide continuous access to evidence-based intervention methods for hazardous drinking, coupled with support from a trained VA Peer Support Specialist. This "Low Threshold Intervention" (LTI) is designed to be easily accessible, engaging, flexible, private, and self-directed, thus circumventing many of the often-cited barriers to treatment.
Despite empirical support for mobile-based technology to improve outcomes for hazardous drinkers, as well as the strong theoretical foundation for integration of mobile technology with peer support, there remains a lack of knowledge regarding the adaptability, acceptability, and utility of (a) these apps, and (b) integration of these apps with peer support among the target participants in our program of research - i.e., Veterans seen in VHA Primary Care who screen positive for hazardous drinking. We will address these knowledge gaps in the
proposed pilot study and use qualitative and quantitative methods to achieve the following aims:
Aim 1: Use the M-PACE (Method for Program Adaptation through Community Engagement) model to modify a mobile application for hazardous drinking ("Step Away") for use with Veterans.
Aim 2: Conduct a field test of the LTI (app+peer support) to evaluate its (a) acceptability, and (b) utility in improving drinking outcomes among Veteran Primary Care patients who are engaging in hazardous drinking.
Aim 1: Twelve VA Primary Care patients who screen positive for hazardous drinking (per the AUDIT-C), and 12 VA Peer Support Specialists will be recruited to systematically review the un-modified app and provide feedback on its content
and presentation via online surveys and a semi-structured interview. This feedback will guide modification of Step Away to maximize its engagement and effectiveness with Veteran Primary Care patients.
Aim 2: A total of 32 VA Primary Care patients with a positive AUDIT-C screen and not currently in alcohol use treatment will be recruited to use the modified app for four weeks and receive two phone calls per week from a VA Peer Support Specialist. Objective app usage data and self-reported drinking patterns (e.g.,
quantity and frequency) will be gathered daily by the app during this four-week period and extracted from the app thereafter. In Week 5, follow-up phone interviews will be conducted to obtain patients' feedback related to the app's content and design, suggestions for improvement, perceived utility for reducing drinking, and overall satisfaction with the LTI. Notably, this field test will also help to establish the (i) feasibility of recruitment and retention, and (ii) sociodemographic and drinking characteristics of the target sample to be enrolled in a subsequent trial of the LTI, as well as barriers/facilitators to integrating Peer Support with use of the app.
Aim 1 of the project yielded a total of n=12 veteran patients, and n=11 peer specialists. Of the veteran patients, 92% were male, 58% were White/Caucasian, 58% were older than 60, 41.7% had a 4-year college degree, 58.3% were of Moderate risk of drinking, 33% were enrolled in mental health treatment, and 66.7% were comfortable using a smartphone. Majority of the patients who used the Step Away mobile app for 10 days, reported that the app will help veterans reduce the amount they drink or how often they drink (n=10). Majority of patients reported they were likely to continue using the mobile app even after completion of the study (n=7). Aim 1 of the study yielded themes of strengths, weaknesses and proposed changes to improve the app for veterans. The strengths reported included rewards for reaching drinking goals and being able to track progress towards these goals. The weaknesses reported included lack of accessibility to some features, and proposed changes reported included adding veteran testimonials, and more veteran-specific activities. The app was redesigned based on the feedback from Aim 1 participants as well as a project Steering Committee of stakeholders (Veteran Engagement Council, Co-Investigators, etc.). A new veteran-specific version of the app was launched for Aim 2 of the study. Aim 2 is currently under way to test the integration of the newly designed app in addition to peer phone support.
By obtaining data on the adaptability, acceptability, and utility of the LTI, we will be well-positioned to submit a subsequent HSR&D IIR, which would entail a large randomized controlled trial to test the effectiveness of this advanced healthcare innovation with Veterans in VHA Primary Care. The goal of this larger program of research is to increase the value and accessibility of evidence-based care for the "silent majority" of Veterans in Primary Care who engage in hazardous levels of drinking but rarely seek treatment.
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