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Abstract

Objective

The purpose of the current study was to describe the initial stages of co-designing a smartphone app that delivers wellness-enhanced contingency management (WECM) to individuals with stimulant use disorder (StUD). WECM integrates the principles of contingency management with a Wellness Model that helps individuals build self-directed wellness habits to sustain long-term recovery.

Method

In collaboration with a Community Advisory Board, interviews and focus groups with individuals with lived experience were conducted to collect information about smartphone access, comfort with technology, experiences with health-related smartphone apps and financial incentives, as well as the perceived feasibility and acceptability of the WECM app. Descriptive and thematic analyses were conducted to characterize the obtained data.

Results

Outcomes from interviews and focus groups indicated that some individuals faced barriers related to smartphones and had varied experience using smartphone apps to support their health/wellness and substance use recovery. Overall, participant feedback on the feasibility and acceptability of the three core features of the WECM app: (1) wellness psychoeducation, (2) financial incentives for healthy habits, and (3) financial incentives for stimulant abstinence, was positive.

Conclusion

Findings from the current study and valuable input provided by CAB members are presently being used to inform the design of the WECM app to ensure it meets the needs of individuals with StUD. This study adds to the limited research employing a co-production model in the development of CM interventions and serves as a preliminary step toward our long-term goal of co-producing a WECM smartphone app for StUD.

Keywords

Contingency management digital smartphone application stimulant use wellness

Co-producing a wellness-enhanced contingency management smartphone application for individuals with stimulant use disorder: A community-based approach

The use of stimulants, a class of drugs that includes cocaine, methamphetamine, ecstasy, and prescription stimulant medication has risen considerably in recent years. Between 2015 and 2022, fatal overdoses involving stimulants increased from 12,122 to 57,497 deaths per year.¹ Stimulant use disorder (StUD) is characterized by continued use of amphetamine-type substances, cocaine, or other stimulants leading to clinically significant impairment or distress and can range from mild to severe.² It is estimated that StUD affects approximately 5 million people in the United States and 35 million people worldwide.

Several factors are likely implicated in the increased use of stimulants and stimulant-involved overdose deaths. The co-use of stimulants and opioids has risen nationally over the past 20 years, with notable increases in co-use observed in the Northeast and Midwest.³ Overdoses involving a mixture of substances, including stimulants, has increased and many of these overdoses involve drug poisoning in which a person unknowingly consumes a substance tainted with another substance. The proliferation of illegal fentanyl and fentanyl analogs has contributed to stimulant-involved overdoses; the proportion of fatal fentanyl overdoses that involved stimulants increased from less than 1% in 2010 to 32% in 2021.⁴

Treatment and recovery options for StUD are limited relative to other substance use disorders (i.e. opioid use disorder). Unlike opioid use disorder, there are no FDA-approved medications for the treatment of StUD.⁵ Pharmacotherapy involving off-label medications is sometimes used to treat StUD with varying levels of success.⁶ The absence of an FDA-approved medication to treat StUD likely contributes to the challenges individuals with StUD face sustaining long-term recovery. Psychosocial interventions have demonstrated some success treating StUD but the most effective intervention, contingency management (CM), is not widely available in community-based treatment programs. One potential way to increase access to evidence-based treatment of StUD is to adapt interventions, like CM, for digital delivery.

The wellness model

Traditional addiction recovery programs frequently focus primarily on abstinence and symptom management, but long-term recovery success is strongly linked to holistic wellness, recognizing the habits and routines important for achieving and sustaining personal balance and abstinence. The Wellness Model provides a holistic framework that extends beyond physical health to encompass eight interconnected dimensions of wellness (emotional, physical, intellectual, social, spiritual, occupational, financial, and environmental).^7,8 The Wellness Model framework was developed by and for people with lived experiences of mental health and substance use challenges and been used to help people sustain long-term recovery.^9,10 Growing evidence suggests that a comprehensive, whole-person approach is essential for sustained recovery success.^11,12 Recognizing all eight dimensions of wellness helps individuals to focus on strengths and areas of imbalance to develop new habits and routines that promote stability and long-term recovery. By addressing all dimensions of wellness, people living with substance use disorders, including StUD, can be supported to create new habits and routines that support sobriety and help manage stressors impacting relapses.^9,10

The Wellness Model framework is critical to understanding recovery, as many individuals living with substance use diagnoses have a history of trauma, instability, or chronic stress, which can make them vulnerable to relapse if underlying distress is not addressed.¹⁰ By promoting self-care, purpose, and stability, the Wellness Model framework helps reduce these risks. Self-care strategies, including mindfulness, nutrition, and regular physical activity, have been shown to reduce cravings and emotional distress.¹³ A sense of purpose is critical for long-term recovery. Stable living and working environments reduce relapse risk. Studies confirm that access to safe housing, financial stability, and structured daily routines are essential for maintaining recovery.¹⁴ Focusing on self-care, goal-setting, and structured support systems, the Wellness Model approach mitigates underlying stressors, which may reduce the likelihood of relapse.

A strength-based, wellness-focused approach to substance use recovery can foster a sense of agency and promote long-term self-sufficiency.¹⁵ The Wellness Model provides a structured framework to help individuals build self-directed wellness habits. Studies on resilience and recovery indicate that long-term engagement in wellness-promoting activities (such as physical activity, social connection, financial planning) reduces stress and prevents recurrence of substance use.¹¹ Programs that emphasize goal setting, skill-building, and holistic health and wellness may lead to better long-term outcomes than traditional abstinence-only models.¹⁶ By shifting from deficit-based interventions to strength-based wellness strategies, individuals develop self-sustaining habits that support lifelong recovery and well-being.

Recovery is a whole-person process

Recovery from addiction can be an overwhelming process. Although addiction treatment has largely focused on helping people stop using substances, behavioral changes above and beyond the cessation of substance use have not been as extensively addressed. Individuals in recovery often face chronic stress, social isolation, financial strain, and occupational barriers that impact their ability to sustain progress. Social isolation is one of the strongest predictors of relapses. Studies have found that individuals with strong social networks and peer support report higher rates of sustained recovery.¹⁷ Financial strain is another major challenge. Economic insecurity can increase stress, trigger coping through substance use, and reduce access to treatment resources.¹⁸

Occupational barriers often persist post-treatment. Employment is strongly linked to recovery outcomes, with stable work associated with increased self-efficacy and reduced relapse rates.¹⁹ A wellness-based approach addresses these challenges by ensuring individuals are supported beyond abstinence, helping them build meaningful connections, financial security, and occupational fulfillment as part of their recovery journey. Studies show that when individuals experience improvements in social, occupational, and emotional wellness, they are more likely to stay engaged in their recovery.²⁰ Recovery-oriented models emphasize quality of life as a key predictor of sustained recovery.²¹ Social wellness contributes to motivation—having a sense of belonging and purpose within a community is associated with higher recovery engagement and well-being.²² Occupational wellness fosters self-determination—engaging in meaningful work has been linked to increased self-esteem, motivation, and decreased relapse risk.²³

In addition, engagement in habits and routines that support emotional wellness activates resilience. Studies highlight the role of emotional regulation and self-awareness in maintaining long-term recovery.²⁴ Anecdotal observations of research team members reveal that when individuals see improvements in their daily habits and routines across many of the dimensions, they are more likely to stay motivated and engage in behaviors that support sobriety.

Contingency management

Given the number of people impacted by StUD, the identification and dissemination of effective psychosocial treatments is critically important. Interventions grounded in behavioral economic theory (i.e. CM) have shown particular success at treating stimulant use. Among psychosocial interventions, CM has the strongest evidence base for the treatment of StUD.²⁵ CM is an evidence-based intervention grounded in principles of behavioral economics and operant conditioning. Within behavioral economic theory, stimulant use, as choice behavior, is a function of: (a) overvaluation and preference for immediate, certain, powerful stimulant reinforcers, (b) undervaluation of delayed, probabilistic, non-stimulant reinforcers, (c) undervaluation of long-term negative outcomes of stimulant use, (d) low constraints on the availability of stimulants, and (e) high constraints on the availability of alternative activities. CM involves the contingent delivery of incentives based on objectively verified behavior change. When applied to stimulant use, the primary behavior change being sought is stimulant abstinence. That is, financial incentives (vouchers or prizes) are delivered to individuals when they provide biochemically verified abstinence via the submission of a drug screen that is negative for stimulant use. If the individual submits a drug screen positive for stimulants, they do not receive any incentives. The mechanism underlying this approach is the delivery of positive reinforcement for a desirable behavior change (i.e. stimulant abstinence).

Historically, CM interventions for StUD have been designed to promote stimulant abstinence. Although important, the cessation of stimulant use must be accompanied by other behavioral changes for an individual to maintain long-term recovery. Basic research has revealed that access to non-drug reinforcers is critical for shifting responding away from substance use to healthier, substance-free behaviors. Targeting the development of healthy behaviors such as attending counseling appointments or employment has been an effective adjunct to abstinence-focused CM.^26,27

The integration of the Wellness Model with CM can serve as a structured approach to promoting behavioral changes beyond the initiation of stimulant abstinence. The Wellness Model framework can help people with StUD identify areas of imbalance across the eight dimensions of wellness and select healthy habits they want to establish in their daily lives to improve their overall wellbeing. CM can then be used to positively reinforce consistent performance of these healthy habits via the delivery of financial incentives. This structured approach could help individuals struggling with stimulant use focus on building habits that bolster wellness, increase quality of life, promote recovery engagement, and improve quality of life.

Need for a community-engaged approach

Despite the evidence supporting CM interventions for individuals with StUD, few CM interventions have been co-produced with community members with lived experience of stimulant use (or substance use broadly) and treatment.²⁸ Co-production involves seeking input from community members with lived experience at every step of the intervention development process. This process can help to inform the design of intervention components so that they meet the needs of the population for whom the intervention is being developed. Community members with lived experience can provide unique insights to research teams during the intervention development process that may help to increase the social validity of the intervention, decrease barriers to intervention uptake, and ultimately, improve the product. One approach that has been employed in the substance use intervention literature is the use of a Community Advisory Board (CAB). CABs are a group of individuals with lived experience with substance use or substance use treatment (as patients or providers) who collaborate closely with the research team on a study or project. Members of the CAB offer feedback and ideas to researchers at every step of the project to enhance social validity.

Despite the evidence supporting CM for StUD, many individuals encounter barriers to accessing CM treatment.²⁹ Digital delivery of interventions for StUD has emerged as a modality that may increase access to effective, evidence-based treatment to individuals who do not have access to in-person clinics that provide CM interventions. Recently, Mulhner et al. (2023) developed a digital therapeutic for individuals with moderate to severe methamphetamine use disorder.³⁰ The app-based intervention included counseling, therapeutic tasks, remote drug testing, medical oversight, and CM. The CM component included incentives for negative drug screenings and completion of assigned tasks such as completing surveys (mood, craving, meth use), educational modules, and challenges to engage in healthy behaviors. Participants received $0.50 contingent on timely completion of tasks via a cash transfer app. The completion of surveys and educational modules was monitored by the app, but it is unclear if participant engagement in healthy behaviors was verified by the app. There are several smartphone apps on the market that deliver digital interventions that include CM (e.g. Affect Therapeutics, DynamiCare, CHESS health). However, none of them have an explicit focus on the role of holistic wellness in recovery. Existing digital apps that employ CM focus primarily on the initiation of abstinence. No current market offerings provide psychoeducation on the importance of wellness in recovery from StUD despite the growing empirical support for a whole-person approach to recovery. Furthermore, none of the existing apps allow individuals to receive financial incentives for engagement in healthy habits tailored to the individual's wellness and recovery.

The long-term goal of this project is to co-produce a wellness-enhanced contingency management (WECM) smartphone app for StUD designed to decrease stimulant use and increase healthy habits that support recovery using input from a CAB and individuals with lived experience with stimulant/substance use. The purpose of the current study is two-fold: (1) to describe the process of designing the WECM smartphone app using a co-production approach, and (2) to report outcomes from interviews and focus groups conducted with individuals with lived experience to help inform the design of the WECM smartphone app.

Methods

Community-Based Co-Production (CBCP) is a collaborative research and development approach in which the target population and key stakeholders actively participate in the design, implementation, and refinement of an intervention. This model aligns with co-production principles and prioritizes shared decision-making, lived experience expertise, and iterative feedback loops to ensure that solutions are culturally relevant, practical, and widely accepted.³¹ This approach was selected because in our experience a top-down approach to intervention development often results in limited engagement, usability barriers, and reduced effectiveness. Given the complexity of recovery and the varied wellness habits that support pursuing and sustaining recovery, a co-production model is critical to ensuring that the WECM app is grounded in the real-life challenges, strengths, and preferences of the individuals it was designed to support. To ensure contextual relevance, the study engaged a CAB that included diverse stakeholders with lived experience in recovery and peer support throughout the project. This collaborative process involved:

Identifying key wellness habits and priorities based on experiences, needs, and feedback.

Co-creating the research protocols for collecting data that reflect the lived experiences of users to help inform the design of the WECM app.

Gathering feedback to consider usability, accessibility, feasibility, and sustainability so that the design of the WECM app minimizes potential barriers to engagement.

By leveraging lived expertise and community input, we believe the co-production process will enhance the acceptability, relevance, and long-term impact of the WECM app, making it a user-driven, wellness-centered recovery tool.

Research team

The research team consisted of two individuals with doctorates employed as researchers at an R1 academic institution (M.D. and P.S), one individual enrolled in a doctoral program at that institution (L.N.), and one individual enrolled in a master's program at that institution (V.T.). All research team members identified as women and had varying levels of research experience. M.D. had 13 years of research experience, P.S. had 30 + years of research experience, L.N. had 1 year of research experience, and V.T. had 1 year of research experience.

Community engagement and stakeholder involvement

To ensure alignment with the tenets of a co-production approach, community members were actively involved throughout all stages of this project. As a first step in the co-production process, we established a CAB made up of five individuals with lived experience with substance use. The last author had prior relationships with these individuals through their work on other CABs and from the local substance use recovery network. The first author reached out to each potential CAB member via email to provide an overview of the project and to invite them to serve on the CAB. All five individuals who were contacted expressed interest in serving on the CAB and did so for the duration of the project (1 year). CAB meetings were held once per month for the project's duration. Most meetings were conducted via zoom for purposes of convenience, but two meetings (at the mid-way point and end of the project) were held in person. During their tenure, members of the CAB worked collaboratively with the research team to help:

Provide information to researchers on the nuances of recovery and wellness in recovery

Identify healthy habits that support recovery within each of the Wellness Model's eight domains and how habits can be verified via smartphone technology

Refine components of the proposed WECM smartphone application

Develop and revise interview and focus group questions

Formulate participant inclusion/exclusion criteria for interviews and focus groups

Identify potential recruitment sites for interviews and focus groups

Provide information to researchers about the populations served by recruitment sites

Connect researchers to administrators of recruitment sites

Facilitate, organize, and oversee research team visits to recruitment sites

Distribute participant compensation

See Table 1 for description of meeting activities. In addition to CAB members input, we solicited feedback on the components of the WECM intervention from community members with lived experience with substance/stimulant use and substance use treatment providers via interviews and focus groups.

Table 1.

CAB meeting activities.

Meeting	Activities
1	Introductions, PI provided overview of project goals and CAB member expectations and compensation
2	PI presented initial draft of Wellness Habit Framework, CAB identified new health habits and verification methods to add to framework
3	PI presented draft of focus group questions, CAB provided preliminary feedback on focus group procedures, participant compensation, and potential recruitment sites
4	PI presented revised focus group questions, CAB provided feedback on revised focus group procedures, recruitment flyer, and screening process
5	PI solicited additional feedback form CAB about recruitment, screening, and data collection processes
6	PI presented final recruitment, screening, and enrollment processes. CAB approved processes and the group discussed finalized recruitment sites
7	PI provided study update/data collection update. Group discussed people's healthy skepticism of smartphone apps related to individualization, maintenance, and potential future use of non-monetary incentives
8	PI provided study/data collection update. Group discussed when, in the treatment timeline the WECM app might be most helpful
9	PI provided study/data collection update. Group discussed concerns about the use of saliva-based drug tests

Data collection

The research team worked alongside the CAB to develop the key topics addressed in interviews and focus groups. Interview questions were co-designed to gain information about participant access to smartphones/data/Wi-Fi, participant smartphone usage, comfort with technology, preferences for intervention delivery, familiarity with and interest in wellness, familiarity with and interest in financial incentives for behavior change, and the perceived feasibility of WECM app features. Additionally, specific questions about features of the proposed app (WECM) were posed to participants. Participants could elect to skip questions during interviews (see Supplemental Material A).

Focus group questions were co-designed to gather information about participants’ experiences with and barriers to using health-related smartphone apps, feedback on the feasibility and acceptability of the proposed app (WECM), interest in financial incentives, and the effectiveness of incentives (i.e. appropriate incentive amounts). Participants could elect to skip questions during focus groups (see Supplemental Material B).

Participants were recruited using purposive sampling. Electronic recruitment flyers with study details, inclusion criteria, and contact information were distributed by the research team and CAB members to individuals who were believed to fit the desired characteristics. The research team identified three community sites at which participants were recruited. Recruitment flyers were distributed at these sites to inform individuals of the dates and times interviews would take place. Participants were recruited primarily from two community sites (Sites 1 and 2) in a predominantly Black, historically under-resourced, urban area. Site 1 provided substance use treatment/behavioral health services and housing/residential support to women and mothers. Site 2 was a drop-in wellness center serving individuals with substance use/behavioral health challenges, most of whom were unhoused. Services available at Site 2 included the provision of meals, clothing, employment support, and peer recovery support. Site 3 was a substance use treatment program in a suburban community.

Prior to participation in the study, an eligibility screening was administered to each interested individual by a member of the research team. Individuals were deemed eligible if they met all the following inclusion criteria: (1) having current/past challenges with stimulant/substance use or being a treatment provider/family member of an individual with current/past challenges with stimulant/substance use; (2) aged 18 or older; (3) primary spoken language was English. Eligibility screenings were either conducted via phone call or in-person directly before interviews. Participants provided verbal consent for the interview and received a copy of the consent form. The Rutgers University Institutional Review Board approved all consent procedures (Pro2024001154). Research team members had no prior relationships with study participants.

The research team visited Sites 1 and 2 for one day per site, to administer individual interviews in-person with eligible participants. Two research team members (M.D. and L.N.) conducted interviews concurrently at Site 1. One research team member (M.D.) conducted interviews at Site 2. Interviews with the two participants recruited from Site 3 were conducted via Zoom by one research team member (L.N.). At the start of each interview, a member of the research team opened a Qualtrics link that contained the interview questions on their laptop computer. During the interview, the research team members read each question aloud while the question was displayed on the screen. Interviews lasted between 20 and 30 min and no other individuals were within hearing distance of interviews except for young children who accompanied their mothers to interviews. Participants were given a $35 gift card as compensation for participation in the interviews.

Twelve randomly selected participants who responded “yes” to the last question of the interview (“Are you interested in participating in a focus group?”) were contacted to invite them to attend a focus group. Based on participant availability four focus groups were conducted with three, three, four, and two participants, respectively. Participants provided verbal consent for the focus groups. All focus groups were hosted on Zoom videoconferencing software and were recorded for data collection purposes. Focus groups were conducted by three research team members (M.D., P.S., and L.N.). During focus groups, a research team member read each question aloud and invited participants to share their responses or thoughts with the group. Focus groups lasted between 1 and 2 h. Audio recordings of focus groups were provided to a commercial transcription company to generate written transcriptions for each focus group. One members of the research team (P.S.) wrote notes during focus groups to support subsequent transcription. Participants were given a $75 gift card as compensation for participation in focus groups.

Overview of core WECM app features

Before each interview and focus group, a member of the research team explained the purpose of the interview or focus group (i.e. to inform the design of the WECM app). The research team member also briefly described three core features of the proposed WECM app to participants. All participant questions following the explanation of app features were answered by a member of the research team. The three core features of the proposed WECM app were developed in collaboration with and based on feedback from the CAB before data collection. The three features are described below:

Wellness psychoeducation. The first core feature of the WECM app is teaching users about wellness and its impact on long-term recovery, as well as guiding users to identify healthy habits they want to establish or increase to help support their recovery. The Wellness Model will serve as the guiding framework for 10 educational modules designed to help participants: (a) examine their overall wellness in the eight dimensions, (b) identify current areas of strength and areas for growth, and (c) select meaningful, healthy habits they want to strengthen or improve.^8–10 At the end of Module 10, users will be guided to select 1–3 specific healthy habits they want to work on when incentivization begins. The incentive features of the WECM app will not be accessible to users until the modules have been completed and target healthy habits have been selected.

Incentives for healthy habits. The second core feature of the WECM app is incentives for the target healthy habits users select at the end of Module 10. Users will have the opportunity to log their target healthy habits and once verified by the app, they will earn incentives. Given the novelty and technological complexity of objectively verifying healthy habits via smartphone, users will be guided to select 1–3 target healthy habits depending on the verification methods needed for each habit. Some examples of verifiable data include:

Health data from smartphones (e.g. sleep data, walking/exercise data). Most commercially available smartphones collect user sleep and exercise data (i.e. Apple Health) as a part of their factory settings.

GPS data from smartphones that verifies users’ location and duration at addresses in the community (e.g. medical appointments, support groups, counseling sessions, religious services, educational classes, paid or volunteer employment) when they log their healthy habit.

Incentives for stimulant abstinence. The third core feature of the WECM app is incentives for stimulant abstinence. Saliva-based drug testing will be remotely monitored via video calls that are prompted via WECM app notifications.

Incentives for healthy habits and stimulant abstinence will be delivered via the user's personal cash-transfer smartphone app or a reloadable smartcard.

Data analysis

Data collected from interviews were analyzed via Qualtrics and descriptively summarized by calculating percentages of participant responses to interview questions. Data collected from focus groups (i.e. written transcripts) were analyzed using an, inductive, systematic, bottom-up thematic analysis approach, following techniques for multiple reviewers. Given that these data are formative, and their purpose is to inform the preliminary development of a smartphone app prototype, rather than achieve a complete understanding of a given phenomenon, we did not assess for saturation. Transcripts and identified themes were not shared with participants during the data analysis process. In the first step of the thematic analysis, members of the research team (M.D., M.S., L.N., V.T.) read each transcript and developed an initial coding framework through an inductive review of the transcripts.³² Team members (M.D., M.S., L.N., V.T.) independently read the transcripts and generated preliminary codes by identifying meaningful segments of text related to the research questions. These codes captured patterns in participants’ language, experiences, and perspectives. Following this initial coding phase, the team met to review and refine the codes. Through discussion, overlapping or redundant codes collapsed, and clearer operational definitions were developed to ensure consistency in application. The refined codes were then grouped into broader categories, from which key themes were generated. These themes represented shared patterns of meaning across the data. To ensure rigor and consensus, three team members (M.D., L.N., V.T.) re-read the transcripts using the finalized coding scheme and selected potential representative quotations for each theme. The team met to discuss their respective findings and considerable overlap in representative quotations for each theme was observed, lending support to the operational definitions of each key theme. A list of potential quotations was developed collaboratively, with team members discussing excerpts that best illustrated the core ideas within each theme. Finally, the two senior team members (M.D., M.S.) met to discuss and select the final quotations. Any disagreements that came up during discussions of key themes and representative quotations were resolved via consensus. The consolidated criteria for reporting qualitative research (COREQ) were completed (see Supplemental Material).

Results

Interviews

Demographic information

A total of 50 participants were interviewed. No repeat interviews were conducted. Out of the 50 participants who completed interviews, 42 participants (84%) reported current or past challenges with stimulant use. Six participants (12%) reported current or past challenges with (non-stimulant) substance use. Two participants (4%) reported no current or past challenges with stimulant use or substance use but identified as substance use treatment providers. All participants completed interviews in their entirety. Demographic information are listed in Table 2. Most participants lived in transitional housing or were renting an apartment or home. More than 70% of participants identified as women and more than 60% of participants identified as Black or African American.

Table 2.

Participant demographic information.

Variable	n	%
Highest Level of Education	50	100
Some high school, no diploma	9	18
High school graduate, or equivalent	18	36
Some college, no degree	12	24
Trade/technical/vocational training	3	6
Associate's degree	5	10
Bachelor's degree	3	6
Current Work Status	50	100
Working full-time	10	20
Working part-time	6	12
Student	2	4
Unemployed	17	34
Retired	3	6
Disabled, unable to work	10	20
Other	2	4
Current Housing Situation	50	100
Own home	3	6
Rent home/apartment	17	34
Living with family/friends	2	4
Transitional housing	21	42
Shelter	2	4
Homeless (street, car, etc.)	4	8
Other	1	2
Gender Identity	50	100
Gender non-conforming/Genderqueer	1	2
Man	12	24
Woman	37	74
Race	50	100
Asian or Asian American	1	2
Black or African American	31	62
Hispanic or Latino	2	4
Two or more races	3	6
White	11	22
Other identity not listed here	2	4
Hispanic/Latinx Ethnicity	2	4
Colombian	1	2
Other	1	2

Access to smartphone, data, Wi-Fi and smartphone usage

Most participants reported that they have Android smartphones, a data plan for their smartphone, and regular access to Wi-Fi (see Table 3). Over 90% of participants reported using their smartphone multiple times per day for communication, entertainment, social media, productivity, and health and wellness. Fewer than half of participants reported downloading a smartphone app for substance use recovery and slightly more than half reported downloading a smartphone app for health and wellness.

Table 3.

Access to smartphone, data, Wi-Fi and smartphone usage.

Access to smartphone, data, and Wi-Fi	n	%
Do you currently own a smartphone?	50	100
Yes	43	86
No	7	14
Is your smartphone an Android or iPhone?	43	86
Android	36	84
iPhone	7	16
Do you have a data plan for your smartphone?	43	86
Yes	39	91
No	4	9
Do you have regular access to Wi-Fi to use your smartphone?	44	88
Yes	33	75
No	11	25

Smartphone Usage	n	%
How often do you use your smartphone?	44	88
Multiple times a day	40	91
Once a day	1	2
A few times a week	1	2
Rarely	1	2
Never	1	2
How frequently do you use smartphone applications?	43	86
Multiple times a day	34	79
Once a day	4	9
A few times a week	3	7
Rarely	1	2
Never	1	2
What types of applications do you typically use on your smartphone?	44	88
Communicating with people	37	84
Social media	30	68
Entertainment	35	80
Health and wellness	26	59
Productivity	29	66
Other	1	2
Have you ever downloaded a smartphone app for substance use recovery?	47	94
Yes	20	43
No	27	57
Have you ever downloaded a smartphone app for health and wellness?	47	94
Yes	32	68
No	15	32

Comfort with technology and preference for intervention delivery

Approximately half of participants reported feeling very comfortable using technology (n = 24, 48%). When asked about their preference for intervention delivery for substance use recovery, most preferred a combination (60%) of smartphone and in-person interventions. When asked what factors would influence their decision to use a smartphone app for managing substance use, 80% (n = 35) of participants endorsed convenience, 57% (n = 25) endorsed privacy, 47% (n = 21) endorsed effectiveness, 45% (n = 20) endorsed ease of use, and 36% (n = 16) endorsed cost.

Familiarity with and interest in wellness and financial incentives for behavior change

Almost all participants said they would be interested in learning more about different types of wellness in recovery from a smartphone app (see Table 4). Over 90% of participants said wellness and healthy habits are very important in substance use recovery and most indicated that they were definitely interested in using a smartphone app that delivers financial incentives to help quit substance use, as well as to support their wellness.

Table 4.

Familiarity with and interest in wellness and financial incentives for behavior change.

Familiarity with and interest in wellness	n	%
Are you familiar with the concept of wellness in the context of substance use recovery?	50	100
Yes	44	88
No	6	12
Would you be interested in learning more about different types of wellness from a smartphone app?	49	98
Yes	47	94
No	3	6
How important do you believe wellness and healthy habits are in substance use recovery?	50	100
Very important	47	94
Somewhat important	0	0
Not important	0	0
I don't know	3	6
Familiarity with wellness, interest in financial incentives for behavior change	n	%
Are you familiar with programs that use financial incentives for promoting wellness habits and reducing substance use?	50	100
Yes	24	48
No	26	52
Would you be interested in using a smartphone application that delivers financial incentives to help you quit substance use?	50	100
Definitely interested	35	70
Somewhat interested	14	28
Not interested	1	2
Would you be interested in using a smartphone application that uses financial incentives to help you build habits that support your health and wellness?	50	100
Definitely interested	42	84
Somewhat interested	7	14
Not interested	1	2

Perceived feasibility

Two questions were posed to better understand participants’ perceptions of the feasibility of WECM app features. When asked if they thought a smartphone app could effectively assist them in quitting substance use, 35% (n = 17) of participants responded “Yes, very much so” and 46% (n = 22) responded “Yes, somewhat.” When asked if they thought a smartphone app could effectively assist them in increasing healthy habits and wellness, 58% (n = 29) responded “Yes, very much so” and 34% (n = 17) responded “Yes, somewhat.”

Specific intervention questions

Over 95% of participants reported interest in a smartphone app that provides reminders to do things that support health and wellness (see Table 5). Almost all participants expressed interest in a smartphone app that offers financial incentives for abstinence and would be willing to submit drug screens three times per week remotely to receive incentives. Similarly, over 90% of participants expressed interest in smartphone app that delivers financial incentives for healthy habits and notably, most would be willing to allow the app to track their GPS location to verify engagement in healthy habits. One open-ended question was posed to solicit ideas from participants for potential features or functionalities of smartphone app designed to promote wellness habits and reduce substance use. Participants provided a variety of suggestions including reminders, 24/7 support, methods for maintaining consistency, resources for nutrition, technological training, a 12-step recovery component, connection to legal support, educational content, medication assistance, virtual appointments with providers, connection to local resources, progress tracking, empowerment strategies, peer support, sleep resources, access to online meetings, goal setting, and video educational content.

Table 5.

Specific intervention questions.

Item	n	%
Would you be interested in a smartphone application that gives reminders to do things that support your health and wellness?	50	100
Yes	48	96
No	2	4
Would you be interested in a smartphone app that offers you the opportunity to receive financial incentives for substance abstinence?	49	98
Yes	48	98
No	1	2
Would you be willing to submit drug screens 3x per week remotely (via a smartphone app) to receive those financial incentives?	48	96
Yes	48	98
No	1	2
Would you be interested in a smartphone app that offers you the opportunity to receive financial incentives for healthy habits that support wellness (such as going to a medical appointment or taking a walk)?	50	100
Yes	47	94
No	3	6
Would you be willing to allow a smartphone app to track your GPS location to verify that you did those healthy habits (such as going to a medical appointment or taking a walk)?	50	100
Yes	43	86
No	7	14

Focus groups

Results from the thematic analysis of focus group data revealed seven themes: Smartphone: Wellness, Smartphone: Challenges, Smartphone: Support, Approval/Suggestion, Financial Incentives, Incentive Amount: Abstinence, and Incentive Amount: Healthy Habit. See Table 6 for operational definitions and representative quotations.

Table 6.

Focus group themes, definitions, and quotations.

Theme	Operational definition	Quotations
Smartphone: Wellness	Statements endorsing the value or utility of smartphone features related to physical, occupational, spiritual, social, financial, emotional, environmental, or intellectual wellness	"I also do twice a day Bible meditation. It's like an app for women. It's Bible related but it's more spiritual. I use that in my prayer, like, in the morning and at night. I'm not too big on religion, but it's very spiritual, and it definitely helps me emotionally and mentally."
		"I actually use the step counter, because I like to walk a lot to keep myself fit and healthy."
Smartphone: Challenges	Statements about challenges related to smartphone functionality, maintaining access to smartphone, accessing Wi-Fi, having sufficient data, or having sufficient internet speed/connection	"I just recently got Wi-Fi, but I do have a government phone, but I do pay for my data every month, and I’ve been having a lot of problems. Like, I would pay for unlimited data and then they would—I would just have a problem that my data would shut off."
Smartphone: Support	Statements endorsing the value or utility of smartphone features that provide reminders, notifications, alarms, and calendars.	"Yeah, I think that would be really, really helpful. Instead of—like, all of these apps that help you, for instance, I use Google Calendar. I put all my doctor's appointments in there. I put all my notifications to help me take my medication as prescribed. It helps me. It gives me more purpose and motivation."
Financial Incentives	Statements endorsing financial incentives (broadly)	"Especially at this stage of recovery, the early stages, I think that a financial incentive is big. I think, too, because I’m telling you, at this stage, like I said, some of us can’t even get internet, pay that bill. We struggle. The early stages, you’re struggling. Some of us can’t work for whatever reason. Some are on a fixed income. Some are just struggling, so the financial incentive is big, but at the same time, as you’re walking up and gearing your mind to the options that will present you some money, it's [one of those] options. That's what's going to stick in the long run, so I could see it being overall beneficial, but I do think that the financial incentive is a major part of how you get people in this stage of recovery really locked and loaded to even participate, but I think it's awesome because now I know, if I can get such-and-such amount for a clean urine, I’m going to keep this urine clean. You know what I mean? So, I think it's good. I think that that's a great incentive."
		"I can’t speak for everybody, but me, yeah, no, I think it would be really, really helpful, and then maybe after I do a lot of it and for me to get compensation, then like I said before, I think it would make me more motivated to stay clean if I had all these resources and information."
Approval/Suggestion	Statements endorsing technology delivery of recovery support, endorsement of the WECM app concept that researchers presented, or additional suggestions for the WECM smartphone app concept.	"Technology is everything right now, and what I like about that is, no matter where I am, I could reach out, get on my phone, open the app, be able to use it whenever I need it, whereas to like maybe if I’m with my son or something like that and we’re extremely busy, I can’t make the meeting, or something similar to that, but I think anything beneficial to my recovery is something that I would definitely use."
		"If I had an app on my phone, I think I’d be more apt to pay attention to my recovery a little bit more.”
Incentive Amount: Abstinence	Statements endorsing a specific payment amount for abstinence/negative drug screens	"I agree with that. I think $15 to $20 sounds reasonable. I think also, like [name of other focus group participant] was saying, it's just enough where, if you do do it a few times a week, you have something and you have something to look forward to, putting a little money away or doing something for yourself each week. I think that's reasonable without going like too overboard."
		"That would be good, so if you start doing it from like 5 to 10 and then maybe the second one, if you pass the second one, you might go to 10 to 20 if you pass (talk over 0:35:05), so I would start off small to give them something to look for."
Incentive Amount: Healthy Habits	Statements endorsing a specific payment amount for engaging in healthy habits	“The walk should be like one or two dollars. Going to the doctor, now, we could go with five dollars.”

Theme 1: Smartphone: Wellness

Focus group participants endorsed the use of smartphone apps for health and wellness. Several participants noted that they used apps related to several different dimensions of wellness including physical exercise apps (i.e. step counter), religious apps, meditation apps, and apps for managing their healthcare.

Theme 2: Smartphone: challenges

Many participants described difficulties around their access to Wi-Fi and cellular data due to data usage limitations on their government-issued smartphones. Several participants reported that they frequently run out of cellular data before the end of the month resulting in slow operating speed or limited usability of their smartphone. Keeping track of their monthly data allotment and fear of exceeding data limitations were major concerns expressed by participants.

Theme 3: Smartphone: Support

Participants widely endorsed the utility of smartphone features that enhance organizational capacity. Several participants expressed that reminders/notifications and calendar features on their smartphones help them to manage their daily lives, remember appointments, and stay on track in their recovery.

Theme 4: Approval/suggestion

Participant responses to researcher descriptions of the WECM app and digital recovery tools broadly were positive. Participants noted that having an app on their phone aimed at helping them maintain abstinence and increase their wellness could facilitate access to and engagement with recovery-related content when they are out in the community.

Theme 5: Financial incentives

Overall, participants strongly endorsed the use of financial incentives to support both abstinence and the development of healthy habits. Some participants noted that they experienced financial challenges following discharge from substance use treatment programs. They described that in the early stages of recovery, especially when resources are limited, financial incentives could be valuable in promoting continued abstinence and the development of healthy habits. Participants also noted that the financial incentives would serve as additional motivation to remain abstinent and engage in healthy habits that support their recovery.

Theme 6: Incentive amount: abstinence

Participants provided a range of suggested values for financial incentives for negative drug tests ranging from $10 to $25 per test. One focus group participant suggested that incentive amounts be increased with each negative submission.

Theme 7: Incentive amount: Healthy habits

Participants also provided a range of suggested values for financial incentives for healthy habits ranging from $1 to $5 per habit. Most participants endorsed $2–$3 per habit. In one focus group, a participant suggested that incentive amounts differ based on the effort involved in performing the habit (i.e. $1 for a walk and $5 for attending a doctor's appointment).

Data collected from interviews and focus groups provided critical insight to the research team about the individual challenges and circumstances of our participants. An important take-away from these results is that every person's recovery is unique, and thus, recovery support should be individualized. As such, the WECM app will be designed to allow users to identify healthy habits to establish or increase based on the wellness dimensions they seek to bolster their personal wellness goals.

Discussion

The purpose of the current study was to describe the process of designing the WECM smartphone app using a co-production approach and to report outcomes from interviews and focus groups conducted with individuals with lived experience to help inform the design of the WECM smartphone app. Descriptive data were summarized and thematic analysis was used to describe and distill participant responses to better understand their experiences with smartphones, technology, apps, barriers to using health-related apps, preferences for intervention delivery, and knowledge of and interest in wellness and financial incentives in the context of substance use recovery. Prior to interviews and focus groups, research team members briefly described the three core features of the proposed WECM app to participants. WECM's core features were developed in collaboration with and based on feedback from the CAB and included wellness psychoeducation, incentives for healthy habits, and incentives for stimulant abstinence. Overall, participant feedback on the feasibility and acceptability of the three core features of the WECM app was overwhelmingly positive.

Integrating findings into app development

Data obtained from interviews and focus groups is currently being used to inform the design of the WECM app. Findings related to participants’ access to smartphones, data, Wi-Fi, and usage suggest several technological considerations for app development. Results from interviews indicate that most study participants owned Android phones, not iPhones. As such, the WECM app will be designed to be compatible with both operating systems, while prioritizing the development of the Android version first. Next, only half of interview participants reported using apps to support substance use recovery or health and wellness suggesting that outreach may be critical to WECM app uptake. It may be important to collaborate with community treatment providers to make individuals with StUD aware of the WECM app when it becomes available.

Participants provided strong endorsement of the utility of smartphone features that enhance organizational capacity. Reminders, notifications, and calendars were frequently mentioned during both interviews and focus groups. One focus group participant remarked, “Notifications really help me out and keep me focused.” Based on these findings, the WECM app will incorporate several features to enhance organizational capacity including frequent reminders to users to engage in healthy habits, notifications that prompt users to submit drug screens on the appropriate days, and a calendar feature that will allow users to proactively schedule when, and on what days, they will engage in their healthy habits.

Many participants expressed challenges related to smartphones, specifically around Wi-Fi access and cellular data usage. As such, the WECM app will be designed to limit the amount of cellular data needed to use it. Several participants reported challenges posed by “government phones” with respect to data usage limitations and not having consistent access to high-quality Wi-Fi. To reduce the cellular data needed to operate the WECM app when not connected to Wi-Fi, users will be able to choose to consume the educational content about wellness in WECM modules in text-based format or video-based format. When a smartphone is not connected to Wi-Fi, accessing text-based content uses less cellular data than streaming video content. Providing users a choice of how they want to consume educational content could help to mitigate concerns about data usage.

With respect to comfort with technology and preference for intervention delivery, the obtained data suggest that most participants would be open to using a smartphone app to support recovery. Over 70% of participants who completed interviews expressed a preference for smartphone app-based interventions for substance use or a combination of smartphone and in-person intervention which suggests that individuals with StUD, for whom the WECM app is being designed, may be willing to use it to support their recovery alone or in conjunction with in-person support. However, only half of participants reported feeling very comfortable using technology suggesting that it may be important for the WECM app to include an embedded how-to tutorial to teach users how to use the app and a button that would allow them to access assistance. It may also be important for the app to be intuitive enough that individuals who provide recovery support (i.e. peer support specialists, clinicians) with basic smartphone skills can help users navigate the app. There is evidence that individuals with substance use disorders prefer to be introduced to and guided to use apps for substance use by clinicians.³⁴

Most participants were familiar with the concept of wellness in recovery and expressed interest in learning more about wellness from a smartphone app. Participants also strongly endorsed the use of financial incentives to support both the development of healthy habits and abstinence. These findings provide support for the three core features of the WECM app: wellness psychoeducation, financial incentives for healthy habits, and financial incentives for stimulant abstinence. Furthermore, participants endorsed technological delivery of recovery support and endorsement of the WECM app concept that researchers presented. Participants noted that having an app on their phone aimed at helping them improve wellness and maintain abstinence could facilitate access to and engagement with recovery-related content when they were in the community. One participant remarked:

Technology is everything right now, and what I like about that is, no matter where I am, I could reach out, get on my phone, open the app, be able to use it whenever I need it, whereas to like maybe if I’m with my son or something like that and we’re extremely busy, I can’t make the meeting, or something similar to that, but I think anything beneficial to my recovery is something that I would definitely use.

With respect to feasibility, over 80% of interview participants thought a smartphone app could very much or somewhat assist them in quitting substance use. Over 90% of interview participants thought a smartphone app could very much or somewhat assist them in increasing healthy habits and wellness. Overall, participants expressed broad support for the proposed WECM app and the digital delivery of recovery tools. These results provide additional support for the development and utility of digital interventions for substance use recovery, like the WECM app, that can be delivered via smartphone.

When asked about incentive amounts for negative drug test submissions, most focus group participants endorsed incentive amounts between $10 and $25 per test, and one participant suggested that incentive amounts increase with each negative submission. These findings align with prior research that indicates that low magnitude incentives (a few dollars) are not likely to be effective at supporting abstinence and that increasing incentive amounts (i.e. an escalating schedule) could be beneficial. Most focus group participants endorsed incentive amounts of $2–$3 for engaging in a targeted healthy habit. Participants also expressed support for differential incentive amounts based on the effort required to perform healthy habits. The obtained data will directly inform the incentive values and payment structure in the WECM app.

Limitations

Despite its contributions, there are several limitations of the current study worth noting. One major limitation of the current study is the study sample. We conducted interviews with 50 participants and 12 of those 50 participants completed focus groups. Of the 50, only 84% of participants reported previous or current challenges with stimulant use. Although this constitutes much of the sample, a sample consisting entirely of individuals with reported challenges with stimulant use would have been preferable given that the WECM app will be designed specifically for individuals with StUD. Additionally, 74% of study participants identified as women which is not representative of the larger population of stimulant users. Research indicates that stimulant misuse is more prevalent in men than women across all types of stimulants.³³ Therefore, findings from the current study may not be generalizable beyond our sample. It will be important, in future work, to ensure that the design of the WECM app meets the needs of the broader population of individuals with StUD (e.g. men, rural populations). Future researchers seeking to collect qualitative data from individuals with lived experience to help inform the design of digital recovery tools should ensure that their participant sample is sufficiently representative of the target population for whom the app is intended.

A second limitation is that knowledge gained from interviews and focus groups is reliant on participant self-report which may not always align with their behavior. Thus, these findings should be considered in light of the limitations of self-reported data. A third limitation of the current study is that we failed to ask participants about their access to cash-transfer apps to receive incentives which could be an important factor in uptake and implementation.

Finally, a notable limitation of this study is that CAB members did not participate in the generation of key themes and illustrative quotations from the collected qualitative data. The thematic analysis of focus group data occurred after the conclusion of the project period, and it is possible that CAB member input during the data analysis process may have resulted in the identification of different key themes. That said, to ensure continued alignment with the tenets of CBCP, the next steps of this project will be completed in close collaboration with CAB members. Specifically, the research team will meet regularly with CAB members during the app development process to obtain ongoing feedback about user design, aesthetics, and feature functionality. Once the prototype has been created, CAB members will serve as alpha testers to gather information about the experience of using the app in their daily lives. Following the alpha testing period, CAB member feedback will be used to refine and improve the WECM app. Prototype testing can help to identify how well ideas generated during the early stages of co-production translate into application.³⁵ Finally, the CAB will provide guidance and insight to the research team when designing rigorous, empirical evaluations of the WECM app prototype.

Implications for practice and policy

Findings from the current study provide several considerations for both practice and policy. One major consideration that has not been well addressed in the literature is that many individuals who might benefit from digital recovery tools may not have consistent access to Wi-Fi or sufficient cellular data to use the digital tools as intended. When faced with limits on cellular data, some individuals may need to prioritize certain smartphone-based tasks and allocate their data usage for critical daily activities. For example, communicating with family members to facilitate daily logistics or interfacing with clinicians, medical providers, social service providers, or criminal justice agencies to support medical or recovery needs might take precedence over using a digital recovery tool when access to Wi-Fi and cellular data are limited. Digital health apps indeed have the potential to expand access to evidence-based care that may not be available to individuals in their local community. However, many individuals still face significant barriers to accessing digital health tools and researchers who develop these tools should consider these barriers during the design process.

Participants expressed positive opinions about the three core features of the WECM app suggesting that app uptake and acceptability may be strong but practical constraints on the use of financial incentives exist. The availability of funding for stimulant-focused CM interventions has grown over the past several years but is still limited based on location and insurance status as well as regulatory hurdles. Although government and payor support for using financial incentives to help people achieve stimulant abstinence has steadily increased, the use of financial incentives to help people develop healthy habits that support long-term recovery has no real-world precedence. The closest parallel to this approach are the wellness-based programs that many private health insurance companies offer to their members. These programs provide members financial incentives or rewards for completing health screenings, attending routine medical appointments, exercising regularly, and engaging in other behaviors that support wellness and prevent disease. The existence of such programs suggests that the use of financial incentives to promote behavioral changes that result in long-term health and wellness is a rational and potentially financially solvent approach. Sustained funding support for an app like WECM will require not only a strong foundation of empirical support but also recognition that long-term recovery requires behavioral shifts beyond abstinence.

Conclusion

This study adds to the limited research employing a co-production model in the development of CM interventions and serves as preliminary step toward our long-term goal of co-producing a WECM smartphone app for StUD designed to decrease stimulant use and increase healthy habits that support recovery using input from a CAB and individuals with lived experience. There is increasing recognition of the importance of a whole-person approach to substance use treatment.^11,12 Symptom management and abstinence, the foci of most treatment programs, are important aspects of recovery but the development of habits and routines that support overall wellness are critical for sustained, long-term recovery. By combining a traditional CM intervention (financial incentives for stimulant abstinence) with an explicit focus on overall wellness, the WECM app could help to facilitate the widespread behavioral changes necessary for sustained recovery from StUD.

Supplemental Material

sj-pdf-1-dhj-10.1177_20552076261426320 - Supplemental material for Wellness-enhanced contingency management for stimulant use: A formative qualitative study

Supplemental material, sj-pdf-1-dhj-10.1177_20552076261426320 for Wellness-enhanced contingency management for stimulant use: A formative qualitative study by Meghan A Deshais, Lindsey Norton, Villana Tkac, Vince Digioia-Laird and Margaret Swarbrick in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076261426320 - Supplemental material for Wellness-enhanced contingency management for stimulant use: A formative qualitative study

Supplemental material, sj-docx-2-dhj-10.1177_20552076261426320 for Wellness-enhanced contingency management for stimulant use: A formative qualitative study by Meghan A Deshais, Lindsey Norton, Villana Tkac, Vince Digioia-Laird and Margaret Swarbrick in DIGITAL HEALTH

Supplemental Material

sj-docx-3-dhj-10.1177_20552076261426320 - Supplemental material for Wellness-enhanced contingency management for stimulant use: A formative qualitative study

Supplemental material, sj-docx-3-dhj-10.1177_20552076261426320 for Wellness-enhanced contingency management for stimulant use: A formative qualitative study by Meghan A Deshais, Lindsey Norton, Villana Tkac, Vince Digioia-Laird and Margaret Swarbrick in DIGITAL HEALTH

Footnotes

Acknowledgements

We would like to thank the members of our Community Advisory Board, Arielle Estes, Jacynth Pelland, Lasheema Sanders-Edwards, Robin Shorter, and Vincent DiGioia-Laird, for their invaluable contributions to this project.

ORCID iDs

Meghan A Deshais

Margaret Swarbrick

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Rutgers, The State University of New Jersey, Center of Alcohol & Substance Use Studies.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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