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US military veterans who screen positive for hazardous drinking during primary care visits may benefit from a mobile app. Step Away is an evidence-based mobile intervention system for the self-management of hazardous drinking. However, Step Away was not designed for veterans, and differences between veterans and civilians could limit the reach and effectiveness of the app with this population.
The primary objective of this study was to repurpose Step Away to address the needs and preferences of the veteran primary care population. The Method for Program Adaptation through Community Engagement (M-PACE) model was used to guide the adaptation process. This model can serve as a generalizable approach that other researchers and intervention developers can follow to systematically tailor mobile health tools for a new population.
Veteran patients who screened positive for hazardous drinking during a primary care visit (n=12) and peer providers employed by the US Veterans Health Administration (n=11) were recruited to systematically review Step Away and provide feedback on its content and presentation via Web-based surveys and a semistructured interview. Participant feedback was reviewed through an iterative process by key stakeholders who adjudicated which suggested modifications to the app could enhance engagement and effectiveness with veterans while maintaining program integrity.
Usability ratings of the individual modules of Step Away were uniformly positive across patients and peers, as was the perceived utility of the app overall. Personalized feedback on the health consequences and costs of drinking, options for customization, and the measurement-based care capabilities of the app were viewed as facilitators of engagement. Conversely, lengthy text, small font, and a lack of interactive features were viewed as potential barriers with the older primary care population. Modifications to create a veteran version of the app (
The M-PACE model provided a systematic approach to repurpose Step Away to fit the needs and preferences of veteran primary care patients who engage in hazardous drinking. Stand Down may serve as an innovative, low-cost means of expanding access to care for veterans who engage in hazardous drinking.
The evidence for various smartphone apps to improve users’ mental health is expanding [
Hazardous drinking
Mobile apps offer an innovative and low cost means of expanding access to care for veterans who engage in hazardous drinking. Such apps have the benefit of overcoming key barriers to care access. For example, an app would make appointments unnecessary, thus reducing the burden on both the VHA (eg, staffing) and patients (eg, travel costs) [
Step Away is a mobile-based intervention program for individuals who want to reduce or abstain from drinking but are unable or unwilling to receive in-person care [
Published research on Step Away has focused exclusively on the prototype version. In a pilot randomized controlled trial of 54 adults with an AUD diagnosis, the use of the prototype version was associated with significant reductions in heavy drinking days and drinks per drinking day over 6 weeks and more percentage days abstinent relative to use of a Web-based program (Drinker’s Check-up) plus bibliotherapy [
Step Away was not designed for US veterans
The objective of this study was to repurpose the Step Away mobile intervention system to create a version of the app that would maximize engagement and effectiveness with US veterans. To achieve this objective, we applied the Method for Program Adaptation through Community Engagement (M-PACE) model [
The long-term goal of this research program is to integrate the use of a veteran version of Step Away with telephone support from peer providers. Such providers would be veterans who are currently in recovery from addiction and have been trained to serve other veterans who are actively struggling with these issues. By encouraging utilization of the app and monitoring Veterans’ progress toward their recovery goals, a peer provider can provide supportive accountability to patients who use Step Away, thus increasing the reach and sustainability of this app with the veteran population [
VHA administrative data were used to identify eligible patients who received a positive screen on the AUDIT-C (scores of >4 for women and >5 for men) during a visit to a VHA primary care clinic between July and October 2017. A total of 150 eligible patients were sent a study invitation letter in the mail; patients who did not respond to the letter were called approximately 1 week later. Overall, 81 patients (81/150, 54.0%) opted out, 33 (33/150, 22.0%) did not respond to a voicemail message, and 13 (13/150, 8.7%) were unable to be reached because of their message inbox being full or the phone number listed in patients’ medical records being incorrect or not in service. Furthermore, 23 patients (23/150, 15.3%) were able to be reached and expressed interest in the study. Among this pool of interested patients, quota sampling based on gender, age, and race and ethnicity was used to select a representative sample of VHA primary care patients who screened positive for hazardous drinking. A total of 13 patients were initially enrolled, and 1 withdrew, yielding a sample of 12 (see sample characteristics in
Sample characteristics.
Variable | Patients (N=12) | Peers (N=11) | |||
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Male | 11 (92) | 9 (82) | ||
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Female | 1 (8) | 2 (18) | ||
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African American/black | 4 (33) | 1 (9) | ||
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White (non-Hispanic) | 7 (58) | 7 (64) | ||
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Hispanic | 0 (0) | 3 (27) | ||
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Other | 3 (25) | 0 (0) | ||
Age, mean (SD) | 58.9 (19.4) | 48.3 (9.4) | |||
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High school diploma/General Equivalency Degree | 1 (8) | 5 (46) | ||
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Some college | 2 (17) | 3 (27) | ||
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4-year college/university | 5 (42) | 2 (18) | ||
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Graduate degree | 4 (33) | 1 (9) | ||
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4.5 (0.8) | 4.4 (0.9) | |||
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1=very uncomfortable, n (%) | 0 (0) | 0 (0) | ||
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5=very comfortable, n (%) | 8 (67) | 7 (64) | ||
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Personal device | 8 (67) | 5 (46) | ||
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Study-provided iPod Touch | 4 (33) | 6 (55) |
A convenience sample of peer providers was recruited across 5 VHA facilities. Peer providers were eligible if they were veterans, worked with other veterans with alcohol use problems, and had been employed by VHA for at least 6 months. Approximately 71 peer providers were informed about the study through passive recruitment strategies, that is, mass emails to provider listservs and phone and in-person meetings with teams of peer support specialists and addiction therapists) rather than individual contacts. Overall, 13 peer providers contacted the study staff to express an interest and were enrolled, 2 of whom ultimately withdrew, yielding a sample of 11 (see sample characteristics in
The M-PACE model guided adaptation of Step Away for the veteran population [
After enrollment, patients and providers completed a baseline interview to assess demographics and rate their comfort using a smartphone on a 5-point scale (1=
Usability ratings of the Step Away modules from veteran patients and peer providers.
Module | Total sample | Patients | Peers | Sample responses to free-text questions | |||||||
Usefulness, mean (SD) | Difficulty, mean (SD) | Usefulness, mean (SD) | Difficulty, mean (SD) | Usefulness, mean (SD) | Difficulty, mean (SD) | Liked | Disliked/would change | ||||
Drinking patternsa | 3.76 (0.9) | 1.88 (1.1) | 3.63 (0.9) | 1.86 (1.2) | 3.90 (0.7) | 1.90 (0.9) | “Allows user to see how much they drink and the financial cost of drinking.” [Peer-004] | “Shorten, simplify. I find alcoholics are impatient while actively drinking.” [Peer-002] | |||
Goalsb | 4.06 (0.9) | 1.88 (0.8) | 3.67 (1.1) | 1.86 (0.9) | 4.44 (0.7) | 1.89 (0.8) | “Health and money as benefits of not drinking.” [Patient-001] | “Explanations were very long.” [Patient-005] | |||
Rewardsc | 3.76 (1.3) | 1.62 (1.2) | 3.38 (1.1) | 1.06 (0.2) | 4.11 (1.4) | 2.11 (1.5) | “Allows for custom input for rewards.” [Peer-012] | “Add reward choices that will appeal to lower income vets.” [Patient-008] | |||
Cravingsd | 4.21 (1.1) | 1.64 (1.2) | 3.83 (1.3) | 1.50 (0.8) | 4.50 (0.8) | 1.75 (1.4) | “You can isolate and identify specific triggers.” [Peer-013] | “A lot of reading and less interacting in this step.” [Peer-012] | |||
Strategiese | 4.00 (1.2) | 1.93 (1.3) | 4.00 (1.0) | 1.57 (1.1) | 4.00 (1.4) | 2.29 (1.5) | “Good variety of strategies.” [Patient-003] | “Seemed aimed at heavy drinkers.” [Patient-008] | |||
Support personsf | 3.81 (1.0) | 1.41 (0.7) | 3.63 (1.1) | 1.56 (0.9) | 4.00 (1.1) | 1.25 (0.5) | “Actually putting in the number and email of the person.” [Peer-001] | “Prompt user to check in with someone every day.” [Peer-006] | |||
Remindersg | 3.60 (1.1) | 1.60 (1.1) | 3.29 (1.1) | 1.71 (1.3) | 4.33 (0.6) | 1.33 (0.6) | “Different ways to personalize reasons for change (eg, photos of loved ones).” [Patient-003] | “More text space to provide reasons for change.” [Patient-010] | |||
High riskh | 3.75 (0.9) | 1.33 (0.8) | 3.67 (0.8) | 1.00 (0.0) | 3.83 (0.9) | 1.67 (1.0) | “Allows me to see what time I am more at risk to drink.” [Peer-009] | “Provide link to supports as way to deal with high-risk times.” [Patient-013] | |||
Moodsi | 3.94 (0.7) | 1.34 (0.6) | 3.86 (0.7) | 1.14 (0.4) | 4.00 (0.7) | 1.50 (0.7) | “Keeps weekly track of fluctuations in mood.” [Patient-011] | “More information regarding graphs.” [Patient-010] | |||
New activitiesj | 4.23 (0.8) | 1.54 (0.9) | 4.40 (0.9) | 1.40 (0.9) | 4.13 (0.8) | 1.63 (0.9) | “Easy to customize. Allows you to plan ahead for a high-risk time.” [Peer-013] | “Expand to track activities taken up instead of drinking.” [Patient-010] |
aNTotal sample=21, NPatients=11, NPeers=10.
bNTotal sample=18, NPatients=9, NPeers=9.
cNTotal sample=17, NPatients=8, NPeers=9.
dNTotal sample=14, NPatients=6, NPeers=8.
eNTotal sample=15, NPatients=8, NPeers=7.
fNTotal sample=16, NPatients=8, NPeers=8.
gNTotal sample=10, NPatients=7, NPeers=3.
hNTotal sample=12, NPatients=6, NPeers=6.
iNTotal sample=16, NPatients=7, NPeers=9.
jNTotal sample=13, NPatients=5, NPeers=8.
Descriptive statistics were calculated for quantitative items from the daily surveys and the follow-up interview. Textual data from the open-ended questions of the daily surveys and the follow-up interviews were analyzed using techniques for rapid qualitative analysis recommended by Hamilton [
When asked, “Will the app help veterans reduce the amount they drink or how often they drink?,” 22 of the 23 participants answered affirmatively. When asked, “How likely are you to continue using Step Away?,” 15 of the 23 participants indicated plans to continue using the app or said they would continue to use it if it were available on their personal phone. Patient participants noted the benefits for increasing their access to care and ability to monitor their drinking over time:
It would help. Not a lot of people are in an area where there’s availability for help. It’s helped me already.
It's good because you can put in the exact number of drinks and track your progress. I think I personally drank less while using it.
Peer participants also noted the benefits of the app for reducing a patients’ drinking, although they added that this would depend on another person keeping the patient accountable for using it:
If they have a solid support system that reminds them of using the app it would be helpful.
Yes, it will hold them accountable and help them. As long as they’re reminded to use it, it would help.
Regarding facilitators to their engagement with Step Away, participants noted the (1) reminders on high-risk times and situations; (2) encouraging rewards for reaching one’s drinking goals; (3) personalized feedback, particularly around the financial costs and health consequences of alcohol use; (4) ability to customize one’s drinking goal and other features of the app; and (5) measurement capabilities, such as the app’s ability to track one’s drinking and progress toward their drinking goal (see
Facilitators and barriers to engagement with Step Away.
Themes | Sample quotations | |
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Reminders on high-risk times and situations | “[I like that it] provides education and awareness of risky situations and times of drinking.” [Patient-005]; “I like that it reminded me when I was coming up on a time I was going to drink.” [Peer-006] |
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Encouraging rewards for reaching drinking goals | “Rewards for milestones reached were helpful. Sometimes veterans don’t know what to do for themselves as a reward instead of drinking. Typically, they would go out and have a drink.” [Peer-001] |
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Personalized feedback regarding financial costs and health consequences of alcohol use | “Information about amount of money spent on alcohol was useful” [Peer-004]; “Good information in terms of caloric impact of my drinking and how alcohol may be affecting my problems with weight control.” [Patient-013] |
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Ability to customize one’s drinking goal and various app features | “It allowed me to set up a schedule to be notified; it engaged me and helped me be involved…it made it more personalized.” [Patient-008]; “I like that it gives a choice of moderation. That makes it helpful for people who might not want to fully quit but still want help.” [Peer-011] |
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Measurement capabilities (eg, ability of app to track drinking and progress toward goals) | “If you want to change something, measure it. [The app] helps vets pay attention to what they’re doing and keep track of progress so they have an idea of what they need to change.” [Patient-010) |
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Key features appeared hidden or were insufficiently highlighted: The “Get Help” feature; more options for customization | “I tend not to click on help icons. One reason is because I typically don’t find the answer I’m looking for and another is because I did not feel the need to use the feature.” [Patient-010] |
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Concerns that some aspects of the interface could limit user engagement: Not user-friendly for elderly patients (eg, small font size); “Text heavy”—not enough visuals and graphics. | “It was hard to read. It would be nice if they could be magnified for people with older eyes.” [Patient-013]; “I don’t think it would be helpful for vets who are actively drinking. Too much reading.” [Peer-004] |
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Privacy concerns insufficiently acknowledged | “Trust issues with government and VA. Fear of breach of confidentiality. Those who are new to sobriety might be overwhelmed.” [Peer-002]; “Provide a rationale as to why we are putting contacts in, for example, including that [providing personal information] typically helps people for reasons x, y, and z; otherwise it could be triggering.” [Patient-005] |
The qualitative interviews yielded themes to enhance engagement and effectiveness of Step Away with the veteran population (see
Following the analyses, 2 meetings with the steering committee were convened. The first meeting (daylong) was held in person, with remote members attending by phone. Committee members downloaded Step Away to their iPhones or a study-provided iPod Touch to review the app before the meeting. During the meeting, a demonstration of Step Away’s content and functionality was given by the lead author. Participant feedback and other summary findings were then reviewed, and the suggested modifications to Step Away were discussed and operationalized. Committee members were asked to evaluate the suggested modifications according to 3 criteria:
Following this meeting, a list of proposed changes to Step Away to create a veteran version of the app was drafted by the lead (DMB) and senior authors (PLD) and emailed to committee members. Members rated each of the proposed changes in terms of whether it was (1)
The lead and senior authors had a series of meetings to review the progress on the planned changes, discuss and edit wireframes of the changes, and conduct beta testing of the initial versions of the revised app. To solicit feedback on specific content that was being considered for inclusion in the app, a meeting was convened with members of the Veteran and Family Engagement Council at the local facility. This council assists with the development and implementation of projects and initiatives at the facility to ensure that the perspectives of veterans and their family members are incorporated. After all the changes to Step Away were completed and beta tested by the lead author and an RA, a second meeting of the steering committee was convened by phone. Before this meeting, an initial version of the repurposed app—
The goal of this study was to use the M-PACE model to repurpose the Step Away mobile intervention system for US veterans. In particular, we sought to create a version of the app that would enhance engagement and effectiveness with veterans in primary care who screened positive for hazardous drinking, many of whom are in mid-to-late life [
One strength of the app from the perspective of participants was the personalized feedback provided via the
One potential barrier to engagement with Step Away was both the size and the amount of text throughout the app’s modules. Small font size may be particularly salient for the target population, given that many veterans treated in primary care in VHA are mid-to-late life and may have visual impairments [
In addition to modifying Step Away to address the characteristics of the veteran population and increase its usability, other changes involved alterations to the
The design of this study included a number of strengths, many of which are inherent to the M-PACE model. Specifically, we used a mixed-methods approach to data collection to obtain comprehensive feedback from key consumers (veteran patients and peer providers) on the unmodified app. Drawing on the principles of community-based participatory research [
Among the study limitations, the patient feedback was based on a sample from a single VA Health Care System, which may not generalize to the perceptions of veterans in other clinics and geographical regions. This limitation was somewhat countered by soliciting feedback from peer providers across multiple geographical regions in the United States. Furthermore, a minority of both the patient and peer providers who were contacted about the study agreed to participate; for patients, this may reflect the fact that many veterans who screen positive for alcohol use problems are not interested in receiving help. Consequently, feedback from these highly self-selected groups may not be representative of the larger samples of veterans and providers who could conceivably use the app. A larger sample size of both patients and peer providers may also have been advantageous. However, a substantial portion of the participant feedback involved qualitative data, and sample sizes of 10 or more are often sufficient for reaching thematic saturation and conducting group comparisons in qualitative research [
We used the M-PACE model to repurpose the Step Away mobile intervention system to target the characteristics, needs, and preferences of veterans who are identified in primary care settings as engaging in hazardous drinking. We envision the approach outlined here as a generalizable method that other researchers can follow to systematically tailor an mHealth tool to maximize engagement and effectiveness of an app with a patient population for which the app was not originally designed. Ultimately, the use of Stand Down may serve as an innovative, low-cost means of overcoming barriers to access and engagement in alcohol use treatment among veteran primary care patients. Our preliminary study of this app would benefit from a follow-up study in a larger population and involving patients across multiple VA medical centers.
Modifications to Step Away to create a veteran version of the app (“Stand Down: Think Before You Drink”).
alcohol use disorder
Alcohol Use Disorder Identification Test for Consumption
iPhone Operating System
Method for Program Adaptation through Community Engagement
mobile health
research assistant
Veterans Affairs
Veterans Health Administration
This work was supported by a Department of Veterans Affairs Health Services Research and Development grant awarded to DMB (PPO 16-305). CT and KH were supported by Senior Research Career Scientist Awards from the Department of Veterans Affairs Health Services Research and Development (RCS-00-001 and RCS-14-141, respectively). The views expressed are those of the authors and do not necessarily reflect those of the VHA.
PLD is the primary owner of Here & Now Systems, LLC—the company that developed the Step Away mobile app as well as the veteran version of this app (Stand Down: Think Before You Drink). There are no other conflicts to report.