"A tool in a toolbox": patient engagement with a gamified and personalised approach bias modification app to reduce harmful alcohol consumption - a qualitative study.

backgroundApproach Bias Modification (ApBM) is a recommended adjunctive intervention during residential treatment for Alcohol Use Disorder (AUD), and there are also promising findings for ApBM as an adjunctive intervention for people in outpatient treatment. ApBM can be delivered via smartphone apps, yet little is known about how people interact with and interpret ApBM apps. We adopted an ‘evidence-making intervention’ approach to qualitatively explore experiences of an AUD ApBM app, to guide implementation in real-world settings. Whilst evidence-based research is mostly concerned with whether trials show that ApBM reduces approach bias and relapse/alcohol use, evidence-making research is concerned with how things like trial design, measures, contexts, and narratives of participants shape our understanding of ApBM’s effectiveness.

methods20 participants (12 men, 8 women; mean age 52.1 years) from two randomised controlled trials of a personalised and gamified ApBM app (10 outpatient, 10 residential rehabilitation) completed semi-structured phone interviews exploring their experiences with the app, its perceived effects, and its alignment with other treatment options. Common themes were identified using thematic analysis.

resultsParticipants engaged with the app in several ways, with four primary themes identified. The first, context and structure of app use (part of daily routines), with preferred times of day and locations for use, to support habit formation. Second, gendered responses to gamification elements shaped participant engagement with the intervention, with male participants framing it more as a game, and females tending to describe it as monotonous. The third theme encompassed participants’ multiple perceptions of how the app works, including as: a craving distraction tool; reinforcing recovery goals and life beyond alcohol use; assisting with countering the effects of environmental alcohol-related triggers; and affecting subconscious processes. The fourth theme related to participants’ feelings that the app was complementary to other addiction treatment and support.

conclusionsParticipants interpreted and applied ApBM in ways that went beyond the primary intentions of the app, with most perceiving it as a useful supplement to other forms of AUD support. These findings highlight the importance of exploring user experiences and incorporating consumer feedback in future app design to improve the implementation of this brief, convenient, low-cost intervention.

trial registrationThe Outpatient project was prospectively registered with ClinicalTrials.gov on November 11, 2021, registration number NCT05120856 https://clinicaltrials.gov/ct2/show/NCT05120856 . The Rehabilitation project was prospectively registered with the Australian New Zealand Clinical Trials Registry on September 15 2022, registration number ACTRN12622001245785 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12622001245785 .