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. Veteran Primary Care patients (n=12) who screen positive for hazardous drinking, and VA Peer Support Specialists (n=12) will be recruited to systematically review the un-modified Step Away 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 : 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. Veteran Primary Care patients (n=32) will be recruited and asked to use the modified app daily 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 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. 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.
A large number of Veteran Primary Care patients screen positive for hazardous drinking, yet the vast majority of these Veterans go untreated due to patient and structural/organizational barriers. Yet, as has been amply documented, hazardous drinking has a significant adverse impact on medical treatment success and cost-effectiveness in VHA. Implementation of a brief smartphone-based alcohol intervention coupled with a peer support component, promises to more completely address Veterans? healthcare needs with little impact on overall health care cost by making available a more robust, easily implemented (without additional MD burden), and effective alcohol intervention to the ?silent majority? who rarely seek needed alcohol treatment.
