Table 2.
Summary of qualitative feedback and associated changes to the ACCEPT intervention manual
| Sub-theme | Feedback | Illustrative Quote | Changes |
|---|---|---|---|
| I. General suggestions for improvement | |||
| Length of first session | • Both FGD participants and providers expressed concern with the length of the first session and recommended shortening the session | P: “I’m not clear as to whether – this was one phone conversation?” | • A sixth intervention session was added so that all intervention sessions stayed between 30–45 min |
| I: “This was one phone call yeah. So what do you all think about that?” | • The educational section was shortened, the 80th birthday exercise was moved to the 2nd session, and the Quicksand exercise was moved to the 3rd session | ||
| P: “That’s too long.” [PWH/FGD participant] | |||
| Rapport-building | • FGD participants expressed concern with the lack of rapport-building incorporated in the first phone call | “This reminded me of going to a doctor’s appointment where you get about 2 min of hi, how you are doing and then we are in the meat and potatoes man. We got meat and potatoes for 20 min and then I’m out of here. That’s what it reminded me of.” [PWH/FGD participant] | • Additional rapport-building was added to the beginning of the first session; participants are asked to briefly share about themselves |
| “Check-ins” | • FGD participants suggested including more regular check-in’s, particularly in the educational section, to ensure comprehension | “Keep engaging them. I think it’s one of the things I did like on this last one you asked her a question.” [PWH/FGD participant] | • To assess for understanding and sustained attention, we incorporated additional “check-ins” into the intervention that vary from inquiring about reactions to an activity to asking for specific examples from the participant’s own life or asking the participant to explain educational content in their own words |
| “More check-ins.” [PWH/FGD participant] | |||
| Health literacy | • Providers expressed concern regarding participants’ literacy levels and ability to comprehend the educational content | “I don’t know if you guys will require your participants to have a particular literacy level, but I do have some patients who can’t read at all.” [Provider/IDI participant] | • We added an inclusion criterion related to literacy (8th grade level) using the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) |
| • All content of the workbook was reviewed to ensure an eighth-grade literacy level | |||
| Managing comorbidities | • FGD participants and providers expressed concerns regarding the management of participants’ mental health comorbidities | “I find that many of our patients have serious mental health problems caused either by having the diagnosis of HIV or because of trauma that they’ve had.” [Provider/IDI participant] | • Alternative metaphors/exercises were added throughout the manual in the event that a participant finds an activity too triggering |
| • FGD participants suggested including more educational content on managing other physical health comorbidities (e.g., diabetes) | • A brief education section on how mindfulness-based skills can be applied to physical health comorbidities (e.g., diabetes) was added | ||
| Tailoring | • FGD participants and providers emphasized the importance of tailoring the intervention to participants | “Just be willing to adapt, adapt, adapt.” [Provider/IDI participant] | • Alternative metaphors/exercises were added throughout the manual |
| • Interventionists were trained on how to tailor the intervention to participants using basic MI skills (e.g., summarizing, active listening) | |||
| “Intervention” | • Some FGD participants and providers expressed concern with the term “intervention,” stating that it may be too stigmatizing | “I mean you draw pictures of three family members showing up at your door to do the intervention because you have this deep problem that everyone can see but you.” [PWH/FGD participant] | • The term “intervention” was replaced with the phrase “our time together” to emphasize the framing of the intervention as a journey |
| II. Car journey metaphor | |||
| Overall impression | • The car journey was generally well-liked and perceived as an accurate metaphor for the goal of the intervention | “I like the analogy or the comparison to the car. It’s pretty clear, you know what the intention is from that.” [PWH/FGD participant] | • No changes were made |
| III. Education section | |||
| Sustaining attention | • Both providers and FGD participants expressed concern that participants would have difficulty sustaining attention throughout the entire first session, including during the educational content | “Because a lot of people, at least a lot of the patients that I know, will tune out after – after reading a few sentences.” [Provider/IDI Participant] | • We reduced the length of the first call by including a sixth session |
| • We changed the format of the education section to be more conversational by asking about participants’ knowledge of a topic prior to providing an explanation or definition | |||
| • We formatted the educational content as bullet points and interventionists were trained to use a teach-back method to facilitate comprehension | |||
| Additional education | • FGD participants and providers requested several additional educational components, including but not limited to: more education on STIs, self-care, medication adherence, and interactive toxicity beliefs | “And teaching over and over and over is something we always do especially about HIV, and you know, the goal is to take your medication every day. Don’t miss any doses. The importance of the possibility they can develop a resistance to the ERT if they do miss doses, the importance of regular pharmacy refills, we don’t want any interruption in treatment.” [Provider/IDI participant] | • To prevent substantially increasing the length of the education section, or extending beyond the scope of this intervention, we added the following: |
| • Brief education on other STIs and how mindfulness-based skills can be useful for other areas of one’s life (e.g., managing stress) | |||
| • A footnote containing references regarding interactive toxicity beliefs was added to the treatment manual | |||
| Standard drink explanation | • FGD participants requested more concrete examples during the explanation of a standard drink | “I would like to see the alcohol ounces be more relatable.” [PWH/FGD participant] | • Interventionists now use a handout that provides concrete comparisons of a standard drink to commonly consumed containers of alcohol (e.g., red solo cup, bottle of wine) |
| IV. 80th birthday exercise | |||
| 80 is too old | • Several FGD participants and providers noted that it may be challenging for participants to fantasize about their 80th birthday given their HIV status and other health-related comorbidities | “Yeah, I’m thinking 80 years old might as well be a kingdom. It’s not even a fantasy of mine.” [PWH/FGD participant] | • We slightly modified the exercise by asking participants to think about any celebration of their life, such as an 80th birthday party or retirement party |
| “80 is a milestone within itself.” [PWH/FGD participant] | |||
| Too personal too soon | • Some FGD participants expressed concern that the 80th birthday exercise was too personal for the first phone session | “Yes, it’s too much. Picture like this, your first call is you’re dealing with an infant. You’re trying to shove a hamburger down his throat. Just feed him liquids right now. So they could absorb the meat when it gets to the meat time. [PWH/FGD participant] | • We moved this exercise to the second phone session to allow for more rapport-building prior to introduction of the activity |
| V. ABCs/Self-Monitoring | |||
| “Antecedent” | • A majority of FGD participants and providers disliked the term “antecedent” as it was considered too academic and not commonly known to this population | “Well, I don’t like the word antecedent, even though I know what it means but I don’t think that’s a common word for most people. So I just don’t like it.” [PWH/FGD participant] | • We replaced the term “antecedent” with “Any thought, feeling, or situation that occurs before your drink.” |
| • This modification allowed us to maintain the acronym ABCs while providing a clearer description of the self-monitoring activity | |||
| Self-monitoring phone app | • Both FGD participants and providers expressed interest in the use of a phone-based app as an option for collecting self-monitoring data | “I think some people would have an easier time doing it on their phone or computer.” [PWH/FGD participant] | • We tested an app in which participants could input what happens before, during, and after they drink, however further development of the app was considered beyond the scope of the developmental grant |
| “You can put an app in there and would be better or at the bar. I can whip my phone out.” [PWH/FGD participant] | |||
| VI. Quicksand metaphor | |||
| Overall impression | • This metaphor was generally well-received by both FGD participants and providers | “I think it’s good. People understand it. It’s very relatable. Some people they feel like their life they’ll even say it’s like quicksand. Things just start happening and I try to fight it, and it gets worse. So, I think it will be very relatable to people.” [Provider/IDI participant] | • We did not make any changes to the exercise except moving it to the third session to reduce the length of the first session |
FGD focus group discussion, IDI in depth interview, PWH person with HIV