Adaptations of an online cognitive-behavioral therapy intervention for binge type eating disorders in publicly-insured and uninsured adults: a pilot study

Background: Publicly-insured and uninsured individuals—many of whom are marginalized because of race/ethnicity, ability status, and/or other social identities—experience barriers to accessing evidence-based interventions (EBIs) for eating disorders (EDs). Additionally, EBIs have not been developed with or for diverse populations, exacerbating poor treatment uptake. Mobile technology is well-positioned to bridge this gap and increase access to low-cost, culturally-sensitive EBIs. Methods: This study leverages a user-centered design approach to adapt an existing coached cognitive-behavioral therapy-based digital program and evaluate its usability in a sample of 11 participants with (sub)clinical binge type EDs who are publicly-insured (n = 10) or uninsured (n = 1). Participants were primarily non-Latinx White women (n = 8). Two semi-structured interviews occurred with participants: one to assess treatment needs and the other to obtain program-specific feedback. Interviews were coded using inductive thematic analysis. Results: Interview 1 feedback converged on three themes: Recovery Journey, Treatment Experiences, and Engagement with and Expectations for Online Programs. Participants endorsed facing barriers to healthcare, such as poor insurance coverage and a lack of trained providers, and interest in a coach to increase treatment accountability. Interview 2 feedback converged on three themes: Content Development, Participant Experiences with Mental Health, and Real-World Use. Participants liked the content but emphasized the need to improve diverse representation (e.g., gender, body size). Conclusions: Overall, user feedback is critical to informing adaptations to the original EBI so that the intervention can be appropriately tailored to the needs of this underserved population, which ultimately has high potential to address critical barriers to ED treatment. Trial registration: This study was reviewed and approved by the Institutional Review Board (IRB) at the University California, San Francisco (IRB #22-35936) and the IRB at Washington University in St. Louis (IRB ID 202304167).