Psychological Services

Psychological Services Customizing a Clinical App to Reduce Hazardous Drinking Among Veterans in Primary Care Daniel M. Blonigen, Brooke Harris-Olenak, Jon Randolph Haber, Eric Kuhn, Christine Timko, Keith Humphreys, and Patrick L. Dulin Online First Publication, November 8, 2018.

CITATION Blonigen, D. M., Harris-Olenak, B., Haber, J. R., Kuhn, E., Timko, C., Humphreys, K., & Dulin, P. L. (2018, November 8). Customizing a Clinical App to Reduce Hazardous Drinking Among Veterans in Primary Care. Psychological Services. Advance online publication.

Customizing a Clinical App to Reduce Hazardous Drinking Among Veterans in Primary Care

Daniel M. Blonigen Department of Veterans Affairs Palo Alto Health Care System,

Menlo Park, California, and Stanford University School of Medicine

Brooke Harris-Olenak and Jon Randolph Haber Department of Veterans Affairs Palo Alto Health Care System,

Menlo Park, California

Eric Kuhn, Christine Timko, and Keith Humphreys Department of Veterans Affairs Palo Alto Health Care System,

Menlo Park, California, and Stanford University School of Medicine

Patrick L. Dulin University of Alaska–Anchorage

Within the Veterans Health Administration (VHA), 15–30% of patients seen in primary care are identified as hazardous drinkers, yet the vast majority of these patients receive no intervention. Time constraints on providers and patient-level barriers to in-person treatment contribute to this problem. The scientific literature provides a compelling case that mobile-based interventions can reduce hazardous drinking and underscores the role of peer support in behavioral change. Here, we describe the benefits of using a clinical app–Step Away–to treat hazardous drinking among VHA primary care patients as well as an approach to customizing the app to maximize its engagement and effectiveness with this population. We highlight the value of integrating use of Step Away with telephone support from a trained VHA peer support specialist. This type of integrated approach may provide the key therapeutic components necessary to generate an effective and easily implemented alcohol use intervention that can be made available to VHA primary care patients who screen positive for hazardous drinking but are unwilling or unable to attend in-person treatment.

Keywords: Veterans Health Administration, primary care, hazardous drinking, smartphone application, peer support

Hazardous drinking is defined as a pattern of alcohol consumption that places an individual at risk for adverse health consequences, even though the individual may not meet criteria for a diagnosis of alcohol use disorder. Globally, hazardous drinking negatively impacts medi- cal treatment, increases the likelihood of chronic medical conditions, and increases health care utilization and costs (Whiteford et al., 2013).

Among U.S. military veterans, alcohol is the most widely used psy- choactive substance and carries the greatest clinical burden on the Veterans Health Administration (VHA; Fuehrlein et al., 2016). Im- portantly, within the VHA, 15–30% of veterans who are seen in primary care are identified as hazardous drinkers, yet the vast majority of these patients go untreated (Bradley et al., 2017).

Daniel M. Blonigen, Health Services Research and Development Center for Innovation to Implementation, Department of Veterans Af- fairs Palo Alto Health Care System, Menlo Park, California, and De- partment of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Brooke Harris-Olenak and Jon Randolph Haber, Health Services Research and Development Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System; Eric Kuhn, National Center for PTSD, Dissemination and Training Division, Department of Veterans Affairs Palo Alto Health Care System, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Christine Timko and Keith Humphreys, Health Services Research and Development Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Patrick L. Dulin, Department of Clinical and Community Psychology, University of Alaska–Anchorage.

This work was supported by a Department of Veterans Affairs Health Services Research and Development grant awarded to Daniel M. Blo- nigen (PPO 16-305). Christine Timko and Keith Humphreys were supported by Senior Research Career Scientist Awards from the De- partment of Veterans Affairs Health Services Research and Develop- ment (RCS-00-001 and RCS-14-141, respectively). The views ex- pressed are those of the authors and do not necessarily reflect those of the Veterans Health Administration. Patrick L. Dulin is the primary owner of the company that developed the Step Away smartphone system. The authors acknowledge the late Dr. Theodore Jacob, who contributed substantially to the conceptualization and design of the integrated intervention and the approach to customization described here.

Correspondence concerning this article should be addressed to Daniel M. Blonigen, Health Services Research and Development Center for Innova- tion to Implementation, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152), Menlo Park, CA 94025. E-mail:

Psychological Services In the public domain 2018, Vol. 1, No. 999, 000


Rapid growth in the use of smartphones and development of clinical applications (apps) to address health concerns provide new opportunities for delivering cost-effective and user-friendly ser- vices to veterans engaging in hazardous drinking. This approach reduces a range of treatment barriers. For example, for veterans who live in rural settings and/or have geographical barriers to obtaining in-person treatment, use of an app to manage drinking obviates the need for appointments and the travel time and ex- penses associated with such appointments. In addition, for veterans who experience self-stigma over their drinking problems or treatment-resistant attitudes, a clinical app can remove these bar- riers by offering a private, self-directed option for exploring drink- ing patterns.

Evidence on the effectiveness of alcohol use treatment when delivered on a mobile platform is accumulating. For example, in a randomized controlled trial, residential treatment patients using the Addiction Comprehensive Health Enhancement Support System app reported significantly fewer risky drinking days than controls (Gustafson et al., 2014). The VHA has been a pioneer in the development of smartphone technologies. For example, it devel- oped a clinical app for hazardous drinking and posttraumatic stress disorder (PTSD), called VetChange (Hoffman et al., 2015). This app is based on the VetChange web program that is evidence based. However, the app itself has received no research attention. Moreover, at present, the VetChange app provides only a limited subset of interventions from the web program. Most notably, it lacks a comprehensive drinking assessment and norm-based feed- back, which are gold standard components of brief interventions for hazardous drinking (Bradley et al., 2017).

The PTSD focus and limitations of VetChange suggest that it is not yet comprehensive enough to serve as a standalone, self- directed alcohol use intervention for wide-scale use. In addition, other clinical apps such as the Addiction Comprehensive Health Enhancement Support System were designed to improve continu- ing care engagement for those already engaged in in-person treat- ment. Consequently, there is a need for a standalone clinical app for veteran primary care patients who want to reduce or stop their drinking and may benefit from intervention but are unwilling or unable to engage in in-person treatment. The main purpose of this paper is to describe Step Away, a smartphone-based intervention system for treating hazardous drinking.

Step Away: A Smartphone-Based Intervention System for Hazardous Drinking

The Step Away program has involved more than 7 years of development aimed at producing a comprehensive smartphone- based alcohol use intervention system. It was designed for indi- viduals who want to reduce or stop their drinking but are unwilling or unable to engage in in-person treatment. The app serves as a standalone intervention in that it provides a comprehensive assess- ment of an individual’s drinking patterns, norm-based feedback, and evidence-based tools and strategies for managing drinking. A focus of early development was to adapt empirically supported cognitive and behavioral interventions for alcohol use disorders for use in a smartphone context. Development was guided primarily by a motivational enhancement theoretical framework (Miller & Rollnick, 2013). As such, Step Away interacts with the user in a nonjudgmental, facilitative manner without overt pressure to stop

drinking. For example, Step Away allows a user to choose mod- erate drinking or abstinence as a goal. The system also borrows strategies from relapse prevention and the community reinforce- ment approach (see Dulin, Gonzalez, King, Giroux, & Bacon, 2013).

A study of Step Away’s prototype was performed with adult participants (n � 28) with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition, alcohol use disorder who were at least minimally motivated to change their drinking (Gonzalez & Dulin, 2015). The prototype was compared with a web-based brief motivational intervention with empirical support (the Drinker’s Checkup) that was supplemented with bibliotherapy (n � 26). Over the 6-week trial, the prototype group showed a large increase in percentage of days abstinent and significant decreases in per- centage of heavy drinking days and drinks per week (i.e., Cohen’s d ranged from .80 to 1.1). Multilevel modeling results, controlling for confounds, indicated that both interventions resulted in signif- icant decreases in percentage of heavy drinking days and drinks per week. However, only the prototype group experienced statis- tically significant increases in percentage of days abstinent. Fur- thermore, greater utilization of the prototype over the course of the study was associated with better drinking outcomes both within and between participants. In addition, participants experienced significant decreases in cravings over time while they utilized the prototype. Participants were also less likely to drink in response to a craving cue if they used one of the specific strategies it provided to manage a craving (Dulin & Gonzalez, 2017).

The Step Away Mobile App

Data regarding system usage and participants’ ratings of the usability of the prototype informed the current version of Step Away, which can be downloaded as an app on a personal smart- phone. The core of this app is largely the same as the prototype; however, features of the prototype that participants reported as not helpful and those that were rarely utilized were removed—for example, a module on productive communication strategies, which required users to access an external website, was accessed by only 5% of users and was reported as being too text heavy; a drink monitor feature, in which users could immediately record when they were drinking, was used by less than 10% of users and rated as comparatively less helpful than other features. Other changes to the system were to streamline its navigability to enhance usability. For instance, the prototype required users to independently seek out their weekly feedback by going to a particular icon. The current version of Step Away prompts them once a week with an alert that automatically takes them to their weekly progress toward their goals. This modification from the prototype version is key, given that feedback on progress toward goals was reported by participants as being highly useful in helping them to change their drinking (Giroux, Bacon, King, Dulin, & Gonzalez, 2014).

The current version of Step Away contains 10 modules that are oriented toward four overarching goals (Here & Now Systems, LLC, 2014): (a) enhance awareness of drinking and drinking- related problems; (b) establish and monitor progress toward a drinking goal; (c) manage triggers and other problems using in- the-moment tools; and (d) connect users with other types of support. The first module involves an assessment of alcohol use and a presentation of personalized feedback. Assessment feedback


provides baseline alcohol consumption, severity of alcohol-related problems, and the financial cost associated with different contexts in which alcohol is used. Next, Step Away helps the user set personal goals, provides self-monitoring tools, notes when per- sonal goals are or are not met, and follows the user’s own prefer- ences. In this regard, assessment and norm-based feedback is provided to users over time, including progress toward goals, ongoing craving triggers, and moods experienced over the prior week. To address the unpredictability of cravings, various modules also provide in-the-moment coping tools such as mindfulness training, pleasant activity scheduling, and contacting a supportive person (for additional details, see Table 1).

Because the acceptability and benefits of the changes to the prototype version of Step Away have yet to be validated, naviga- bility of the current Step Away system and utility of the currently recommended coping tools are key areas for future research. Such research could also explore the acceptability of adding other tools

(e.g., recommending physical activities) and resources (e.g., infor- mation on Alcoholics Anonymous) to the app. In addition, because Step Away was designed primarily for use with individuals who are motivated to reduce or stop their drinking, it is important to test the acceptability and effectiveness of Step Away among veterans who are mandated to alcohol use treatment by the criminal justice system.

Customizing Step Away to Maximize Its Engagement and Effectiveness With VHA Primary Care Patients

Differences between veterans and the general population sam- ples on which Step Away’s prototype was tested underscore the value of evaluating and possibly modifying the app to fit the unique needs and characteristics of the veteran population. For example, relative to the general population, the incidence and rate of comorbidity between hazardous drinking and PTSD are higher

Table 1 Description of the Components of the Step Away Program and Their Intended Purpose and Features

Components Purpose/feature

Module 1, Drinkers Profile

• Assessment and personalized feedback on an individual’s alcohol use relative to age-specific norms: • Initial assessment and feedback based on past week quantity and frequency of drinking. • Assessments include Short Index of Problems, Drinking Motives Questionnaire, and Short Alcohol Dependence

Questionnaire. • Drinking feedback (psychoeducation): Compare drinking with gender and age-based drinking norms, peak blood-

alcohol level, intoxication affects, cost of drinking in terms of money and calories, and positive and negative drinking experiences.

Module 2, Goal Setting

• Users are prompted to choose abstinence or moderation as a goal: • If moderation is chosen, users are provided with input on the likelihood of success based on their alcohol dependence

severity. • Factors to consider when deciding to change drinking are presented. • Guidance regarding goal setting is provided to the user based on dependence level.

Module 3, Rewards • Users are encouraged to set up rewards in advance of meeting their drinking goal: • Users are prompted to reward themselves when results of daily interviews indicate the goal was met (e.g., 30 days of

no drinking). • A rewards list is provided or user can add their own.

Module 4, Cravings • Users are provided with information on alcohol cravings and evidence-based coping strategies to manage cravings. • Psychoeducation is provided in each section of the module and the user must select a cognitive strategy to cope with top

triggers (e.g., urge surfing). Module 5, Strategies • Users are provided with behavioral strategies for relapse prevention, which are tailored to whether moderation or

abstinence was selected as the goal: • Timing (e.g., delay drinking; sip drinks; count your drinks; space your drinks) • Approach (e.g., choose high-quality drinks; say no to drinking games and shots) • Consumption (e.g., eat when you drink; do not drink when you are tired, hungry, or thirsty) • Communication (e.g., tell others about new drinking limits)

Module 6, Supportive Others

• Emphasizes that having support from close friends and family is key to changing drinking. • Provide ongoing, immediate connectivity and option to send weekly feedback reports to supportive others • Text alerts to supportive others during high risk times and events (initiated by user).

Module 7, Reminders • Users are asked to consider how life will improve with changes to drinking and are asked to write their top three reasons. • Users are encouraged to create verbal and visual reminders of why they want to change drinking (e.g., photos of loved

ones). Module 8, High-Risk

Times • Provides alerting and alternative activities for users during high risk for drinking times. • Users are alerted when a high-risk time is approaching. High-risk times are based on previous assessments. • Users can add additional high-risk times/dates over time.

Module 9, Moods • Users are provided with information on moods and drinking, feedback on current depression and stress levels, and management suggestions.

• Mood assessment: Provides results for mood and stress level in comparison with norms. • Recommends behavioral activation and seeing mental health provider if depressive symptoms are severe. • Mood tracking daily and helpful suggestions for lifting your spirit during weekly check-in.

Module 10, New Activities

• Discusses the importance of replacing drinking with nondrinking activities. • It provides numerous activity categories and provides users an option to enter their own custom activity. • The user is provided with functionality to schedule the activities into their smartphone calendar and to generate an alert

when it is time to do that activity.


among veteran primary care patients (Fuehrlein et al., 2016). Thus, engagement may be maximized by reference to trauma-based triggers for drinking that are common among veterans. In terms of age, most veterans seen in primary care are in mid- to late life; however, development and testing of Step Away have been limited to adults aged 18–45 years (Dulin, Gonzalez, & Campbell, 2014; Gonzalez et al., 2015). Thus, it may be necessary to adapt the app to enhance its usability for an older population (e.g., larger font; less text; Kuerbis, Mulliken, Muench, Moore, & Gardner, 2017). Finally, it may be important to modify the look and feel of clinical apps that were originally developed for civilians to be sensitive to military and veteran culture. For example, use of military-themed images, links to veteran resources, and videos of other veterans describing their drinking and treatment experiences may enhance veterans’ engagement with app content.

Peer-supported mobile health. Peer-supported delivery of clinical apps such as Step Away can also help to maximize patients’ engagement with the evidence-based tools offered by these apps. For example, peer support specialists (PSS) are indi- viduals who are in recovery from mental illness and/or addictions and are trained to provide services to those who are currently struggling with such disorders. The importance of peer support for engagement in mental health care is particularly salient for military populations (Reif et al., 2014). Furthermore, research on mobile technologies is still in its infancy, and such technologies are not yet considered standard of care in alcohol use treatment. Thus, there is an ethical argument to using clinical apps to enhance, rather than replace, interventions delivered by care providers (Torous & Rob- erts, 2017).

There is growing evidence to support the value of integrating peer support into substance use and mental health disorder treat- ment (Reif et al., 2014). Such evidence underscores the potential value of integrating peer support with use of Step Away in the treatment of hazardous drinking among veterans. However, future studies, perhaps using focus groups (Ray, Kemp, Hubbard, & Cucciare, 2017), are needed to determine best practices for com- bining peer support and app usage. Specifically, it is unclear what are the optimal roles for a PSS in this integrated intervention. Potential roles that a PSS could fill to promote a patients’ engage- ment in an app-based intervention such as Step Away are orien- tation to the app, technical support to use the app, increasing motivation to use the app, monitoring veterans’ progress toward recovery goals, providing supportive accountability, and coaching on how to apply intervention content to real-life problems (Mohr, Cuijpers, & Lehman, 2011; Ray et al., 2017).

With Step Away, a PSS could fill a pragmatic role in terms of assisting a patient with how to complete specific modules, quickly accessing in-the-moment tools to cope with cravings, and navigat- ing the app content. In addition, a PSS could play a more personal role by providing emotional support, which is critical for substance use disorder recovery (Reif et al., 2014). Furthermore, a PSS could assist patients with individualizing Step Away content by helping them understand how the skills learned from the app can be applied to the patient’s unique triggers, risk factors, and life circumstances. In terms of the method of delivering peer support to veterans who are using the Step Away app, telephone support may be a practical means of combining the two components of the integrated intervention. The barriers and facilitators to this method of delivery could also be assessed in focus groups.

Findings from a recent survey of 232 VHA primary care mental health integration providers highlight the potential value of inte- grating peer support with veterans’ use of Step Away. Providers who indicated that a PSS worked in their primary care clinic (n � 47) were asked to rate on a 5-point scale how helpful it would be to have a PSS support patients’ use of clinical apps (1 � not at all, 2 � slightly, 3 � moderately, 4 � very, 5 � extremely). A majority (57%) reported that a PSS would be either very helpful or extremely helpful for this purpose (E. Kuhn, personal communi- cation, December 22, 2017).

Future Research

At present, more data are needed regarding the efficacy, barri- ers, and facilitators of the Step Away app and how best to cus- tomize this app for the veteran population. For example, future research will need to determine how to adapt Step Away to maximize engagement with VHA primary care patients without diluting the app’s effectiveness. The Method for Program Adap- tation through Community Engagement may be useful in this regard because it was designed to elicit comprehensive feed- back from stakeholders regarding recommended changes to an evidence-based intervention (Chen, Reid, Parker, & Pillemer, 2013). Following adaptation of Step Away, it will be necessary to determine the acceptability and utility of integrating peer phone support with patients’ use of the app. To this end, focus groups and mixed-methods research (i.e., qualitative and quan- titative assessments) can help to assess the feasibility and perceived benefits of the telephone contacts as well as identify and address any perceived barriers and facilitators to this inte- grated approach. Finally, the effectiveness of the integrated intervention and its implementation potential within primary care settings will need to be established prior to wider dissem- ination of the intervention.


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Received June 27, 2017 Revision received June 12, 2018

Accepted June 22, 2018 �


  • Customizing a Clinical App to Reduce Hazardous Drinking Among Veterans in Primary Care
    • Step Away: A Smartphone-Based Intervention System for Hazardous Drinking
      • The Step Away Mobile App
      • Customizing Step Away to Maximize Its Engagement and Effectiveness With VHA Primary Care Patients
        • Peer-supported mobile health
      • Future Research
    • References


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