Acceptability of Internet-based interventions for problem gambling: a qualitative study of focus groups with clients and clinicians

To date, research in the utility and impact of Internet-based interventions (IBIs) in the treatment of mental health issues, particularly for depression and anxiety [1, 2], have shown positive effects. There is interest in seeing this success replicated in the field of addictions [3‐5], including problem gambling [6‐8].

Problem gamblers report several barriers to treatment including feelings of shame and embarrassment, stigma, denial, and a desire to solve the problem on their own [9, 10]. Treatment cost, availability, and effectiveness are also commonly cited barriers [9‐11], as well as geographical and time constraints [10]. Treatment delivery through IBIs can mitigate the negative impacts of these barriers. A recent scoping review of IBIs for problem gambling [6] concluded that they are a promising direction in preventing and treating problem gambling, as well as in reducing barriers to accessing professional help. Though highly valuable, these findings offer little explanation as to how users, typically healthcare providers and their clients, perceive and engage with IBIs.

Acceptability is increasingly acknowledged to be an important domain to consider in the design, implementation, and evaluation of healthcare interventions, including Internet-based interventions (IBIs). Most healthcare interventions are complex in nature. Developers are constantly faced with the challenge of designing effective interventions that maximize the resources available to deliver optimal clinical outcomes [12]. With the release of the first World Health Organization guideline on digital health interventions (DHIs) earlier this year, the role of digital health in health system strengthening and universal health coverage was highlighted [13]. IBIs and DHIs are often used interchangeably in the literature, however, DHI is a broader term encompassing both IBIs and non-internet computer-based interventions. Despite the collective recognition of its value, “digital health has also been characterized by implementations rolled out in the absence of a careful examination of the evidence base on benefits and harms [13].” In its list of evidence-based recommendations, the guideline identified acceptability as a facilitator to successful uptake and implementation. This finding is supported by recent research evaluating the design, implementation, and impact of DHIs [14‐17]. Despite this, research assessing the acceptability of IBIs is very limited.

Heeding the recommendations advanced in the WHO guideline [13], we conducted a series of focus groups with clinicians and clients of a problem gambling treatment clinic in Toronto, Canada. We used the definition of acceptability provided by Sekhon and colleagues [12], which described it as “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention.” The authors reasoned that assessing the acceptability prior to participation in the intervention can highlight aspects that can be modified to increase acceptability, and thus uptake [12].

Focus group objectives were two-fold: 1) to gain a better understanding of the barriers experienced by gamblers in accessing treatment, and 2) to understand how clients and clinicians perceive IBIs for problem gambling. The focus groups were a part of a larger multi-stage mixed methods study exploring the feasibility of an online treatment service for problem gambling. Findings informed the design, implementation, and evaluation of a pilot IBI for problem gambling that concluded in June 2019.

We explored the concept of acceptability of IBIs for problem gambling through semi-structured focus groups with clients and clinicians. In health services research, focus group methods are useful in examining patient experiences and exploring the attitudes and needs of healthcare professionals [18]. Focus groups enable participants to become an active part of the design process. As end users, gaining the perspectives of clients and clinicians is a crucial part to successful intervention design in healthcare settings [12, 19, 20]. Data saturation was reached after the second focus group with each end user group.

In this study, we aimed to understand the factors that shape the acceptability of IBIs for problem gambling among end user groups (‘If this service existed, would you use it? Why or why not?’); and to identify factors that can increase the acceptability of IBIs for problem gambling (‘What would you like to see in this type of service?’). From the focus groups, we learned that it is important to recognize the motivations behind the choice to use IBIs in order to understand the factors that influence and increase the acceptability of IBIs for clients and clinicians. Our findings are thus reported in this order.

Although IBIs have been around for nearly two decades, evidence suggests a slow uptake of IBIs into clinical settings [16]. Increasing the acceptability of IBIs among end users may increase uptake [13]. Understanding acceptability alone is not enough to ensure successful uptake, however it can significantly impact overall effectiveness [12, 13, 16, 19, 24]. However, to date, research on IBIs has been largely focused on treatment outcomes in assessing effectiveness. While this is important, it offers little insight on how end users interact with interventions. This study is a step towards addressing this gap in the design and implementation of IBIs in health services. To do this, we used the theoretical framework of acceptability developed by Sekhon and colleagues [12], which recognized acceptability as a multi-construct concept. The assessment of perceived or prospective acceptability, another feature of the TFA, offers intervention developers the opportunity to design and implement an intervention that is informed by its target users.

One of the strengths of the study is in its juxtaposition of client and clinician perspectives. In general, clinician perspectives were more homogeneous reflective of healthcare professionals sharing the same practice and values. In comparison, client narratives were more heterogeneous descriptive of diverse experiences and individual preferences. Although both user groups reported similar experiences, each group also had unique concerns. For example, during the focus groups, clinicians repeatedly voiced the importance of clarifying the barriers experienced by clients seeking treatment and the utility of IBIs in addressing these barriers. The client focus groups were able to provide rich insight into the nature of the barriers they have experienced or are currently experiencing in accessing professional help. This was a strength of our study design as it allowed for the examination of each group’s perspectives adjacent to the other. Through this model, we were able to yield meaningful patterns across each end user group. Additionally, we were able to maximize the benefits associated with the use of focus groups in qualitative data collection, particularly its unique value in inciting group dynamics [22].

Clinicians and clients alike worried about the possibility of IBIs being a gateway to unintended use, such as Internet gambling. Although Internet gambling is a possible negative consequence of an IBI that should be monitored during intake and in each session, it should be noted that none of the participants in the client groups reported participating in Internet gambling. Involvement in Internet gambling should be taken into account when considering the client’s suitability for participating in IBIs, but it is not known if it should be an exclusion criterion. Whether online or Internet gambling can affect treatment outcomes for IBIs, and to what extent, warrants further investigation, perhaps in a sample of problem gamblers who only gamble online.

Concerns that IBIs would replace face-to-face treatment was repeatedly voiced by focus group participants from both end user groups. Although it was clarified in the beginning of each focus group that the purpose of the study was to investigate a “proof of concept,” participant responses often referred to a service that would replace current programming. This resulted in the facilitators repeatedly reminding participants, more so in the clinician groups, that the purpose of the study was to explore the feasibility of an online treatment service as an expansion of services to reach new clients who are heretofore not coming into treatment, rather than one that would replace existing face-to-face services. Nonetheless, some therapists may have been worried about losing their job to IBIs and exhibited signs of apprehension, which is consistent with the literature [25‐27]. On the other hand, clients reported a strong preference for IBI run by therapists, rather than self-help resources. The literature remains inconclusive on the preference for IBIs by clients or clinicians, warranting further investigation.

On top of the intricacies involved in the design of IBIs in healthcare, the problem gambling population is unique and complex. Comorbidity with other psychiatric disorders is common [28, 29]. During the focus groups, some clients self-reported comorbid problem gambling and depression or anxiety problems. Two clients shared that their depression was making it difficult for them to attend treatment. It is therefore not surprising that an integrated approach to treatment was highly desired by the clients. These client perspectives are consistent with the results of a randomized controlled trial that examined the clinical efficacy of a computer-based psychological treatment for comorbid depression and substance use, which suggest that interventions that target both issues simultaneously can lead to better outcomes [3].

Researchers aiming to design effective interventions are faced with composite challenges. The findings from the focus groups are instrumental in understanding how best to approach the design of a problem gambling intervention. By asking end users probing questions focused on how they intend to interact with the intervention, we learned the specific factors that influence their decision to use IBIs. We also gained an understanding of the nature and extent of their past experience with Internet-based tools and resources for treatment, and how this influences their current treatment decisions. The clients and clinicians that participated in the focus groups offered various service user and clinical perspectives that may not be captured in the literature on IBIs. These perspectives are an important element of intervention studies that are complex in nature and comprise several interacting components for both treatment providers and treatment recipients. An intervention that meets both client and clinician needs and is considered acceptable, is more likely to guarantee the best treatment outcomes [12, 13, 16, 19, 26].

The study sample was not evenly distributed as the clinicians outnumbered the clients who participated in the focus groups. This may be attributed to challenges recruiting among problem gamblers that have been observed by other researchers [30]. The majority of clients that were eventually recruited were clients at the Problem Gambling Services at CAMH comprised of service users who may be more motivated or engaged with mental health services. Additionally, all of the clients who participated in the focus groups were adults living in urban areas in one province in Canada. As a result, the narratives from problem gamblers living in rural areas may not have been captured. Research drawing upon a representative sample of problem gamblers in Canada is needed. To reduce participant burden, the research team made conscious efforts to minimize the need for participants to provide any personal information, including demographic information. Methodological limitations must also be mentioned. Focus groups, by tapping into interpersonal communication and group dynamics, offer a unique opportunity to explore issues that are not well understood or have received little attention in the past. However, focus groups also pose unique challenges for participants who may not be assured confidentiality in a group setting, may feel reluctance to discuss sensitive topics in a group, or may be affected by common issues related to focus groups like groupthink or response bias [21]. Ultimately, the objectives of the focus groups were met as can be determined from the data collected, which provide insight into the acceptability of IBIs for clients and clinicians.

This study provides insight into the factors that influence the acceptability of IBIs among end users, including access, usability, high quality technology, privacy and security, and professional guidance. Acceptability is an important factor in the overall effectiveness of IBIs. Gaining an understanding of how end users perceive IBIs and why they choose to use IBIs can be instrumental in the successful and meaningful design, implementation, and evaluation of IBIs. Findings from the focus groups have implications for others developing IBIs for problem gambling and other similar issues.