Using Mobile Technology to Address the Trauma Mental Health Treatment Gap

IDeA-CTR-Using Mobile Technology to Address the Trauma Mental Health Treatment Gap in Primary Care: Developing Implementation Protocols for Primary Care

BounceBack Now (BBN) is a self-help, trauma-focused mental health mobile application (app) with automated assessment with treatment guidance and in-app evidence-based treatment support for depression, post-traumatic stress disorder (PTSD), sleep difficulties, and anxiety. BBN contains many of the necessary components to promote self-management of these conditions. Investigators will evaluate the app's feasibility and acceptability among under served participants (e.g., African Americans and participants with lower socioeconomic status) with trauma histories in an integrated primary care (IPC) setting. There are two specific aims: 1) to develop educational materials for patients and behavioral health providers for BBN in IPC, and 2) to conduct a pilot trial of BBN for participants with trauma histories in an IPC setting. For Aim 1, focus groups with behavioral health providers and participants will be conducted to obtain feedback about BBN and training materials. For Aim 2, a feasibility study with 15 participants will be conducted to identify and address any procedural issues and to refine the protocol before conducting the full-scale study.

Study Overview

• Status: Completed
• Conditions: Post Traumatic Stress Disorder
• Intervention / Treatment: Behavioral: Aim 1 Participant Focus Groups; Behavioral: Aim 1 BHP Focus Groups; Behavioral: Aim 2: BounceBack Now (BBN) for Trauma Informed Care Deployment; Behavioral: Aim 2 : Participant Focus Group; Behavioral: Aim 2: BHP, Provider, Staff and Admin Focus Groups

Detailed Description

BounceBack Now (BBN) is a Trauma Focused Mobile Application. After consent, a behavioral health provider (BHP) will assist the participant in downloading BBN onto their smartphone device. The current BBN structure contains a brief assessment and multiple treatment components for disorders that are frequently associated with traumatic event exposure. A brief assessment based on the Kessler 6 will be completed and based on this assessment, the participants are then guided to treatment recommendations with an interactive rationale for each treatment. Education/explanations are provided in written, spoken, and animated video formats. Given that each of these treatments may be beneficial for patients with subsyndromal or very minor symptoms, all participants are able to see and interact with all treatment components, but it is anticipated that BHPs will provide recommendations for the sections that will be most beneficial. The treatment components are each based on effective in-person interventions. These include behavioral activation (depression), Written Exposure Therapy, and Expressive Writing (PTSD), Cognitive Behavioral Therapy for Sleep, and Relaxation/Mindfulness (stress/anxiety). The corresponding app sections are titled Activate, Write, Sleep, and Coping Tools, respectively. Each of these sections contains education components and there is a separate education component for the app overall that can be found through the coping tools page.

Aim 1: Develop educational materials for patients and Behavioral Health Providers (BHPs) for BBN in integrated primary care (IPC) settings. Investigators will present the educational materials and BBN in focus groups. These focus groups may be conducted virtually (i.e., zoom call) or in-person. The focus group will last 30 - 60 minutes. Focus groups will address acceptability, feasibility, and usability of the materials and the education materials and the app.

Focus groups will be audio recorded and a transcript will be prepared. Information obtained from the focus groups will be used to refine the patient and provider educational materials before we implement Aim 2 activities.

Aim 2: Conduct a pilot trial of BBN for participants with trauma histories in an IPC setting. A primary care provider at one of the two approved clinic locations will do a standard "warm handoff" referral to a behavioral health provider (BHP) if the patient is determined to have a behavioral health issue. The BHP will ask the patient about interest in participating the app study. If so, informed consent will be obtained and the participant screened using the Adverse Childhood Experience (ACE) screener to identify individuals at risk for trauma related conditions. Participants who screen positive on the ACE (>=3 points) will be invited to participate in further data collection for the study. A clinical assessment will be conducted, and a treatment assigned according to the standard of care specific to the mental health conditions of the participant. A brief explanation of BBN will be provided using the patient education material created under Aim 1. Certain features of the app will be suggested for use (e.g., journal, sleep intervention) according to participant need. The application is entirely self-paced, but a minimum use at least once a week is recommended.

Participants will complete a baseline survey online or through an investigational team member. Participants will continue to meet with their BHP as determined by the standard of care interactions, and, if deemed appropriate the BHP will highlight features contained in BBN for participant to use in between appointments. Follow-up phone calls will be scheduled for 2 week and 6 weeks after the initial visit to complete follow-up surveys, either online or administered by the investigative assistant over the phone. At the 6-week follow-up phone call, usability of the app will be assessed using the 18-item mHealth App Usability Questionnaire (MAUQ). Acceptability will be measured using the 20-item User Burden Scale. Additionally semi-structured interviews will be completed at that time or scheduled for an alternate date. The BHPs will complete a 5-item questionnaire about their comfort-level with integrating mental health apps into clinic care.

Addressing Needs of African American and Low-Income Patients:

The participating clinics primarily serve African American or low income patients. Race/ethnicity and income information will be collected through electronic health record data. The needs of these two patient population groups will be met by recruiting participants primarily from these two population groups for both aims to ensure their perspectives will be reflected in the patient education materials and by obtaining feedback through the individual interviews conducted at the end of the study.

• Study Type: Observational
• Enrollment (Actual): 29
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Nebraska
    • Omaha, Nebraska, United States, 68104
      • Nebraska Medical Center-Fontenelle Clinic
    • Omaha, Nebraska, United States, 68131
      • Nebraska Medical Center-Midtown Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 19 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

Participants with a trauma related disorder and behavioral health providers (BHPs) which are Clinical staff, providers and administration

Description

Inclusion Criteria:

Behavioral Health Providers:

• 19 years and older

Participants:

• 19 years and older
• Newly referred to a behavioral health provider at the Fontanelle or Midtown Clinic
• Own a smart phone

Exclusion Criteria

Behavioral Health Providers:

• 18 years and younger

Participants:

• 18 years and younger
• Referred to a behavioral health provider in the past year
• Does not own a smart phone
• Score 2 points or lower on the Adverse Childhood Experience screening
• High suicidality based on a clinical assessment by the behavioral health provider
• Having neurocognitive conditions either assessed by a primary care provider or diagnostic code for neurocognitive condition found in the patient note or Electronic Health Record (EHR)

Study Plan

How is the study designed?

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
BounceBack Now (BBN) Participants Aim 1; Participants who are receiving care at one of the designated integrated care clinics.	Behavioral: Aim 1 Participant Focus Groups; At the beginning of the focus group the patients will be asked to download BBN on their smartphone device with the assistance of the research team, if they have not already done so. A basic tutorial of the BBN and the developed educational materials will be conducted/reviewed with the participants. After the tutorial and education has been provided the participants will be asked to try some of major features of the app. Then, they will be asked to review the patient education materials. They will be asked to discuss strengths and weaknesses of the materials. They will be also asked whether there is any content missing from the education material.
BounceBack Now (BBN) Behavioral Health Provider Aim 1; Behavioral Health Providers who serve as a BHP at one of the designated integrated care clinics.	Behavioral: Aim 1 BHP Focus Groups; At the beginning of the focus group the BHPs will be asked to download BBN on their smartphone device with the assistance of the research team, if they have not already done so. A basic tutorial of the BBN and the developed educational materials will be conducted/reviewed with the BHPs. After the tutorial and education has been provided the participants will be asked to try some of major features of the app. Then, they will be asked to review the patient education materials. They will be asked to discuss strengths and weaknesses of the materials. They will be also asked whether there is any content missing from the education material.
BounceBack Now (BBN) Participants Aim 2; Participants who are receiving care at a designated integrated care clinic	Behavioral: Aim 2: BounceBack Now (BBN) for Trauma Informed Care Deployment; Brief explanation of BounceBack Now (BBN) will be provided. Participants will be directed to areas of the application that are congruent with treatment focus identified during their standard of care appointment. Participants will complete a baseline survey by either going online or being contacted by a member of the investigational team. The investigative assistant will contact all participants in 2-3 days to help the participant navigate the BBN and complete the baseline survey, if needed. The participant will continue to meet with their behavioral health provider (BHP) as determined by the standard of care interactions. BHP will highlight features contained in BBN for participant to use in between appointments. Follow-up phone calls will be scheduled for 2 weeks and 6 weeks after initial visit. During these phone- calls the participant will be contacted by a member of the investigational team to complete follow-up surveys.; Behavioral: Aim 2 : Participant Focus Group; Semi-structured interviews will be conducted with Participants to assess the feasibility, acceptability, and usability of BBN.
Bounce Back Now (BBN) Aim 2 BHPs, Clinical Staff, Providers, and Administration; Clinical staff, Behavioral Health Providers, Providers, and Administration staff who can provide feedback pertaining to the factors that contribute to app deployment in an integrated care setting.	Behavioral: Aim 2: BHP, Provider, Staff and Admin Focus Groups; Semi-structured interviews will be conducted with BHPs, Clinical Staff, Providers and Administration They will ask questions to BHPs, Clinical Staff, Providers and Administration about feasibility, acceptability, and usability of BBN and overall clinical protocol.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Aim 1: Evaluation of Educational Materials	Educational Materials that have been developed related to using a trauma related mobile app will be evaluated by focus groups comprised of Patients and BHPs. The participants will be asked to use a think aloud approach using semi-structured interviews in order to determine the acceptability, usability and feasibility of the materials using questions developed to evaluate these items assessed during the focus group.	5 months
Aim 2: Feasibility	Feasibility will be assessed using semi-structured interviews. BHPs, Clinical Staff, Providers, Administration and Patients will complete semi-structured interviews guided by the Integrated Promoting Action on Research Implementation in Health Services Framework.	8 months
Aim 2: Acceptability: App Use	Acceptability will also be measured by the number of patients who have downloaded and used the app for the duration of the 6 week study time-frame.	8 months
Aim 2:Usability	Patient usability of the app will be assessed using the 18-item mHealth App Usability Questionnaire (MAUQ). In this questionnaire each item is rated from 1 - strongly disagree, 2 - disagree, 3 - somewhat disagree, 4 - neither agree nor disagree, 5 - somewhat agree, 6 - agree, 7 - strongly agree. Scale Max= 126. Scale Min= 18 To determine the usability of an app, calculate the total and determine the average of the responses to all of the 18 statements. The higher the overall average, the higher the usability of the app.	8 months
Aim 2: Patient Burden	Patient acceptability, patients will complete the 20-item User Burden Scale at both follow-up visits. The scale has shown good overall inter-item reliability, convergent validity, and concurrent validity. The User Burden Scale (UBS) is a 20-item instrument used to assess perceived burden from digital health technologies across domains such as difficulty of use, time, physical demand, privacy, guilt, and financial burden. Each item is scored from 0 (Not at all) to 4 (Extremely), with total scores ranging from 0 (minimum) to 80 (Maximum). Higher scores indicate greater burden.	8 months

Collaborators and Investigators

• Sponsor: University of Nebraska
• Investigators: Principal Investigator: Margaret R Emerson, DNP, APRN, University of Nebraska

Publications and helpful links

General Publications

• Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, Cording E, Tomson D, Dodd C, Rollnick S, Edwards A, Barry M. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012 Oct;27(10):1361-7. doi: 10.1007/s11606-012-2077-6. Epub 2012 May 23.
• Zhou L, Bao J, Setiawan IMA, Saptono A, Parmanto B. The mHealth App Usability Questionnaire (MAUQ): Development and Validation Study. JMIR Mhealth Uhealth. 2019 Apr 11;7(4):e11500. doi: 10.2196/11500.
• Stetler CB, Damschroder LJ, Helfrich CD, Hagedorn HJ. A Guide for applying a revised version of the PARIHS framework for implementation. Implement Sci. 2011 Aug 30;6:99. doi: 10.1186/1748-5908-6-99.

Study record dates

Study Major Dates

• Study Start (Actual): August 3, 2022
• Primary Completion (Actual): March 22, 2024
• Study Completion (Actual): March 22, 2024

Study Registration Dates

• First Submitted: May 3, 2022
• First Submitted That Met QC Criteria: May 9, 2022
• First Posted (Actual): May 16, 2022

Study Record Updates

• Last Update Posted (Estimated): September 9, 2025
• Last Update Submitted That Met QC Criteria: August 18, 2025
• Last Verified: June 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Trauma and Stressor Related Disorders; Mental Disorders; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
• Other Study ID Numbers: 0178-21-EP

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No