Usability and Acceptability of a Mobile App for the Self-Management of Alcohol Misuse Among Veterans (Step Away): Pilot Cohort Study

Abstract

Background Alcohol misuse is common among Operation Enduring Freedom and Operation Iraqi Freedom veterans, yet barriers limit treatment participation. Mobile apps hold promise as means to deliver alcohol interventions to veterans who prefer to remain anonymous, have little time for conventional treatments, or live too far away to attend treatment in person. Objective This pilot study evaluated the usability and acceptability of Step Away, a mobile app designed to reduce alcohol-related risks, and explored pre-post changes on alcohol use, psychological distress, and quality of life. Methods This single-arm pilot study recruited Operation Enduring Freedom and Operation Iraqi Freedom veterans aged 18 to 55 years who exceeded National Institute on Alcohol Abuse and Alcoholism drinking guidelines and owned an iPhone. Enrolled veterans (N=55) completed baseline and 1-, 3-, and 6-month assessments. The System Usability Scale (scaled 1-100, ≥70 indicating acceptable usability) assessed the effectiveness, efficiency, and satisfaction dimensions of usability, while a single item (scaled 1-9) measured the attractiveness of 10 screenshots. Learnability was assessed by app use during week 1. App engagement (proportion of participants using Step Away, episodes of use, and minutes per episode per week) over 6 months measured acceptability. Secondary outcomes included pre-post change on heavy drinking days (men: ≥5 drinks per day; women: ≥4 drinks per day) and Short Inventory of Problems–Revised, Kessler-10, and brief World Health Organization Quality of Life Questionnaire scores. Results Among the 55 veterans enrolled in the study, the mean age was 37.4 (SD 7.6), 16% (9/55) were women, 82% (45/55) were White, and 82% (45/55) had an alcohol use disorder. Step Away was used by 96% (53/55) of participants in week 1, 55% (30/55) in week 4, and 36% (20/55) in week 24. Step Away use averaged 55.1 minutes (SD 57.6) in week 1 and <15 minutes per week in weeks 2 through 24. Mean System Usability Scale scores were 69.3 (SD 19.7) and 71.9 (SD 15.8) at 1 and 3 months, respectively. Median attractiveness scores ranged from 5 to 8, with lower ratings for text-laden screens. Heavy drinking days decreased from 29.4% (95% CI 23.4%-35.4%) at baseline to 16.2% (95% CI 9.9%-22.4%) at 6 months (P<.001). Likewise, over 6 months, Short Inventory of Problems–Revised scores decreased from 6.3 (95% CI 5.1-7.5) to 3.6 (95% CI 2.4-4.9) (P<.001) and Kessler-10 scores decreased from 18.8 (95% CI 17.4-20.1) to 17.3 (95% CI 15.8-18.7) (P=.046). Changes were not detected on quality of life scores. Conclusions Operation Enduring Freedom and Operation Iraqi Freedom veterans found the usability of Step Away to be acceptable and engaged in the app over the 6-month study. Reductions were seen in heavy drinking days, alcohol-related problems, and Kessler-10 scores. A larger randomized trial is warranted to confirm our findings.

Contrasting a Mobile App With a Conversational Chatbot for Reducing Alcohol Consumption: Randomized Controlled Pilot Trial

“…The Step Away app was originally developed in 2013 and has undergone 4 major revisions based on user input and recommendations. A finding that has emerged frequently from research on Step Away is that the app’s ability to provide self-monitoring and tailored feedback to the user is a key driver of utilization [ 43 , 59 , 60 ], which has resulted in the feedback feature being prominent and well-developed. This was the first version of the bot, and, like many first versions, it had some unforeseen limitations.…”

“…We also had limited time to undertake this study and our 12-week follow-up period may have been insufficient for differences between interventions to emerge. Previous research with Step Away showed that participants continued to reduce their alcohol intake at 6 months [ 43 ] and that 45% of participants were still actively engaged at the 6-month follow-up. A 12-month follow-up would provide a more detailed picture of how users remain engaged with the interventions over time and how this engagement is related to improvement.…”

“…Although engagement with Step Away has been shown to be relatively high with a recent study of the app in a veteran sample showing that approximately 40% of participants were still engaged with the app at 6 months [ 43 ], use of the treatment steps or other modules was found to be relatively low [ 43 ]. In an attempt to increase intervention engagement, we developed a chatbot version of Step Away that incorporates the app modules into a chat-delivered intervention, which we postulated could result in higher use and engagement over the Step Away app.…”

The current evidence for substance use disorder apps

“…In an interesting study, Malte et al [10 ▪ ] examined the feasibility and acceptability of the ‘ Step Away’ app among 55 war veterans with excessive alcohol use (82% met DSM-5 criteria for AUD). Step Away includes self-monitoring, normative feedback, goal-setting, craving self-management, and social support.…”

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“…In most of their studies evaluating usability measurements at the prototype stage, research conducted in research [14] conducted usability testing on mobile applications for the health sector with 55 veteran respondents who had various characteristics from age, gender, skin colour, education, marital status, income, and the degree of propensity to alcoholism. Measurements were carried out for six months with a SUS value of 69.3 (SD 19.7) for the 1st month and 71.9 (SD 15.8) for the third month.…”