A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment

Abstract

Background:

The use of tracking technology in substance use research can uncover the role of contextual factors, such as social networks and environmental cues, in triggering cravings and precipitating return to use. Few studies have explored the opinions of individuals in substance use treatment related to tracking technology.

Methods:

We conducted 30 semi-structured interviews with individuals in substance use treatment facilities in Connecticut and Georgia. Interviews were not limited to individuals with any specific substance use disorder. Interviewers described a hypothetical study involving ecological momentary assessment and global positioning system tracking to examine place-based predictors of substance use. Participants were invited to share reactions to this description. We used thematic analysis to identify themes in participant perceptions of this hypothetical research study.

Results:

Most participants shared positive opinions about study participation and expressed little to no concern about the tracking components. Participant concerns focused on the security of their information and the potential burden of responding to study questions. Participants largely understood the importance of study participation for promoting greater understanding of substance use and identified potential therapeutic effects of study participation on their own recovery.

Conclusions:

Individuals in substance use treatment expressed little concern with research studies or interventions incorporating mobile-tracking elements. Future studies should explore the responsible use of tracking elements in recovery support interventions.

Keywords

qualitative ecological momentary assessment Global Positioning System tracking substance use

Introduction

Substance use disorders (SUD) are widespread, chronic conditions affecting over 20 million Americans.¹ Recovery and remission from SUD are challenging. Recovery is defined as a “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”² Meanwhile, in one meta-analytic study, remission is “defined as not meeting diagnostic criteria for abuse or dependence for a minimum period of six months.” This study suggests that 55% or fewer of individuals with any SUD who work toward remission achieve it.³ Among the challenges to SUD recovery and remission are triggers of cravings to use again.

Theoretical models of addiction, such as Marlatt and Gordon’s cognitive behavioral model, have suggested that certain people and places can act as personalized triggers for cravings and return to use.^4,5 Few previous studies have used global positioning system (GPS) tracking in concert with ecological momentary assessment (ie, the use of mobile devices to administer frequent surveys on real-world experiences) to measure the real-time exposure to such triggers or their subsequent effects on return to use. This combination of tracking technology provides an opportunity to look at the duration and frequency of exposure to triggers and other aspects of the “environmental context” on recovery and return to use.⁶

In contrast to the relatively newer and more uncommon use of geographic ecological momentary assessment described above, ecological momentary assessment (without GPS tracking) has been widely used to understand short-term triggers of substance use, identifying such predictors as negative affect, cravings and craving intensity, stress, and physical pain/discomfort, while also highlighting the role of the built environment on triggers and use.^7
-13 More recent research validates the use of geographic ecological momentary assessment in particular to understand the role of contextual factors such as the built environment in chronic health conditions in real time.^10,14,15 We operationalize tracking technology as encompassing both active data collection methods (such as self-report via ecological momentary assessment) as well as passive ones (such as GPS tracking of location data). To our knowledge, researchers have not explored in depth the attitudes and perceptions of people in SUD treatment on the use of such tracking technology, especially GPS tracking, for research purposes. Charron et al¹⁶ recently found high levels of acceptability for different sensing technologies, but did not examine attitudes toward more active methodologies (ie, ecological momentary assessment). To this end, we conducted semi-structured qualitative interviews with individuals in treatment for a variety of SUD. Interviews assessed participant reactions to the use of GPS tracking and ecological momentary assessment in a hypothetical research study that would explore how contextual predictors and triggers relate to return to use.

Methods

The methods used in this research study have been described in other published research.¹⁷ We repeat our description of those methods here.

Participants and Venue

Researchers recruited a convenience sample of 30 participants on-site through SUD treatment programs in South Central Connecticut (n = 15) and northeastern Georgia (n = 15). These locations were selected because they were to serve as the primary recruitment areas for a larger prospective cohort study akin to the one described to participants for their feedback. Both programs offered outpatient treatment and ongoing educational and recovery support groups; the program in Georgia also offered inpatient treatment. Members of the research team presented the research study at the beginning or end of treatment groups, sharing that individuals would be interviewed about their experiences with substance use and substance use treatment and given the opportunity to provide feedback on a hypothetical research study. No flyers were distributed as all interviews were conducted on-site at the treatment organization. Afterward, interested individuals approached or were brought to the members of the research team for informed consent and participation in the interview. To participate in this study, participants needed to: (1) be 18 years of age or older, (2) be enrolled in a SUD treatment program for any type of substance, and (3) speak English. Inclusion was not limited based on the treatment modality or specific SUD. Interviewers screened interested individuals to ensure that they met the eligibility criteria.

Data Collection

Semi-structured, individual interviews were conducted by trained research staff in private rooms; only research staff and the participant were present during interviews. Interviews were conducted in September and October of 2019.

The research team developed the interview guide, which was reviewed by community partners, namely key staff from each of the recruitment venues. The research team then pilot tested the interview guide internally through mock interviews before use. The interview guide was developed following principles of grounded theory as an epistemological approach,^18,19 exploring participant perceptions without seeking to test a specific hypothesis, and asked participants about their attitudes (eg, feasibility, acceptability, perceived barriers, perceived benefits) toward participation in a research study using mobile phones to examine contextual predictors of substance use. Participants were asked for opinions about a hypothetical study, in which they were not currently enrolled, which involved once-daily surveys about substance use and additional assessments delivered when they visit places identified by participants as associated with prior or current use (see Supplemental Material for Interview Guide).

Interviews lasted approximately an hour. We did not collect demographic information from participants to maintain their confidentiality; this was largely due to the fact that the recruitment site in Georgia was small and located in a rural area, so the research team believed that refraining from collecting demographic data would encourage participation and participant comfort in sharing their experiences without fear of being identified through demographic details.

We established a recruitment target of 30 interviews (15 per location) based on research showing that this number is sufficient for achieving saturation.^20,21 The research team engaged in ongoing discussions throughout data collection to address any potential challenges in conducting interviews and eliciting rich participant responses. Through these discussions, in which the interviewers provided summaries of participant responses, we determined that a sufficient level of thematic saturation in responses had been reached after 30 participants.

Each participant received $40 for their participation. This study was approved by a joint external Institutional Review Board (Hummingbird).

Data Analysis

Interviews were audio recorded and transcribed using Trint (www.trint.com) and reviewed for accuracy by the research staff. Names of people and places were redacted to protect confidentiality. Transcripts were uploaded to NVivo version 12.6.0²² for coding and analysis. Research staff reviewed all transcripts and generated a preliminary coding scheme identifying themes related to study participation attitudes. Three researchers independently coded 2 transcripts, met to compare results and resolve discrepancies, and edited the coding scheme to clarify categories. Researchers then recoded the same transcripts using the revised scheme and met again to compare the results. Following this, researchers coded the remaining transcripts, with at least 2 researchers coding each one. Intercoder reliability was conducted throughout the coding process to ensure consistent application of codes across coders and was 88.8% at final coding.

After coding, we used thematic analysis as an analytic methodology²³ to organize participant responses to questions about participating in the year-long hypothetical research study, generating themes inductively. We classified participants’ general attitudes toward GPS tracking as positive, neutral, ambivalent, or negative. We employed a thematic matrix, a common technique used in thematic analysis, to organize excerpts into the themes presented below, determine how common themes were across participants, and to compare themes across study sites and by the valence of participant attitudes regarding the study (ie, positive, neutral, ambivalent, negative).

All interviewers and coders were trained and/or experienced in qualitative research methodology. A full reflexivity statement is included as part of the Supplemental Material for this article.

Results

We identified themes related to participant concerns about study participation and the benefits they thought might result. As part of the latter, we identified a subtheme related to the perceived therapeutic potential of participation in the research study. We present these themes and related quotes in detail below. We observed no difference in themes by study site.

Attitudes Toward GPS Tracking

Most participants within this study expressed positive or neutral attitudes toward the GPS-tracking element of the study.

I wouldn’t mind ‘cause I really don’t go nowhere. Like I said, a lot of the places that I got drugs from were out of town and I’d bring them back into town. So, really, I don’t go past a lot of those places anymore. (Participant 7)

Participants mentioned that they had no concerns about GPS tracking because they were not using substances anymore, explaining that they were okay with GPS tracking because they “have nothing to hide at this point” (Participant 17).

Other participants shared that they were okay with GPS tracking because they felt that the tracking would be beneficial to them, holding them accountable for their recovery should they return to locations where they experience triggers or cravings: “I think it will be good. Because there are certain places you go you don’t need to be. And just by you being there, it could make you relapse” (Participant 12).

While the majority of participants in our sample expressed positive or neutral views of GPS tracking, a subset expressed some level of discomfort. Often, these participants expressed the perception that research staff would be following them in real time.

Oh no I don’t like it. My location is always turned off, not that I am going anywhere bad but I don’t like it. Why am I answering to you anyway? Yeah, I don’t, I mean you wouldn’t like, like if you was at home like you don’t need to know where my home is. Like I understand I am in the program, so I have to. You see what I am saying? It is uncomfortable feeling. (Participant 4)

In some cases, these concerns could be alleviated by providing information about confidentiality safeguards.

Finally, participants expressed indifference or ambivalence to the tracking features of the study because “it happens already.”

I know it happens already you know it happens a lot because my phone tells me all the time, “What did you think about Firehouse Subs?” It’s like how do you know that? How do you know I was here? I know it happens I just have to trust that Google is doing the right thing with it I guess. But I’m not happy about it. (Participant 11)

They’re already doing it. No, nothing, nothing new. It’s already been happening. . . You can run, but you can’t hide. (Participant 24)

Study Concerns

Participants expressed 2 main concerns about participating in the research study: concerns related to privacy or the security of collected information and concerns related to the burden of participation in the study.

To start, participants expressed no concerns about participating in the study, but did so in a way that indicated that this could change should they return to use. For example, Participant 18 presented their lack of concern as “I’m not doing anything that I’m not supposed to.” Similarly, as previously shared, Participant 17 stated “I have nothing to hide at this point.” These 2 quotes have similar messages. The second quote suggests that the participant feels comfortable participating because they do not feel the need to hide anything. The first quote suggests that the participant feels comfortable participating, but leaves a question of whether they would continue to feel comfortable participating if they were not doing what they are “supposed to do.” This suggests that while there are no concerns currently, this opinion might change if the participant returns to use, something Participant 2 explicitly stated in reference to the GPS-tracking component:

As being pretty much 100% sober now, barely any chance of slipback, I don’t mind it. But if like say y’all are doing it to help people that are coming into treatment, it would be a little less appealing because if there’s still a chance of me slipping back into my old, or going to mess up this day or that day, I wouldn’t want to think somebody’s tracking me going to wherever I go to get my drugs or anything like that. I know plenty of people that that sketches out.

Meanwhile, a subset of participants wanted guarantees of confidentiality and protection of their personal information. When the interviewer highlighted the language from the informed consent for this study, these participants described wanting extra measures to ensure their information would be properly protected. Participant 22 stated:

This feels like—I have to come up with an entirely other contract. You know, guarantees. . . What would that look like? That the information being collected, isn’t for like spying on people, that there was no legal involvement. You know, that no legal authorities were wanting to be involved. No government authorities [have the] right to intrude. That kind of thing.

Participant 22 later added, “I have a lawyer friend and I want to send [the informed consent].”

In addition to the above concerns about confidentiality and data security, participants commonly expressed concerns about the amount of time they would need to commit to participation in the study, specifically the ecological momentary assessment portion.

Just uh be mindful of you know people’s schedules a little bit and stuff like that. Not really so much their schedule you know what I mean. Maybe like when they get around certain places they are frequenting all the time you’ll send em’ that survey. Just not sending them a whole bunch of [surveys]. (Participant 9)

In addition to the general burden of responding to daily survey questions, participants were concerned about being able to fit study participation in with other priorities, such as work or treatment. Participant 2, for example, was fine with participating in the study “unless drug court told me I couldn’t.” Participant 20 was concerned about the potential conflict of study participation with their employment: “I would have to stop and jot down stuff where, where I’m at, when I’m working, stuff like that. So I don’t know how that would work.” This participant felt that they could be overtaxed with the time they were expected to contribute to participation, namely completion of the ecological momentary assessment, and communicated that even brief surveys while they were at work crossed a boundary for them.

Study Benefits

Balancing out study concerns, participants shared potential ways in which the study could benefit themselves or others. While compensation was mentioned by a few participants as an effective incentive for participation, participants noted the potential positive impact of the study on themselves. For example, as Participant 25 highlighted: “It’s not about the money. I mean, the money is nice. That’s cool. But you get to learn more about yourself in the process of you learning about us.”

Meanwhile, other participants saw study participation as a way to potentially support others in recovery.

I know on the news it says a lot about people overdosing and dying from drugs and stuff like that. But it would be really good just to have more advocates for recovery, and people that are even thinking about it. Like, show them how good it can really be, you know? I could put ten pictures up at one point in time and look like a poster child for meth. I was so beautiful and then it was so bad. And just having real people, like, just compassionate people about helping others and not judgmental. So I think it’s real good that you guys are doing this study. (Participant 6)

This quote highlights the importance of conveying to potential participants, as much as possible, how researchers plan to use the information they garner through the research study. This was something that participants explicitly asked about in these interviews. Participant 8 asked who the research team would report to, though they later shared they would participate regardless: “I would be willing to do it regardless, even if you did report to authorities. I was just curious.”

Therapeutic Potential

As suggested above, participants identified ways in which they thought participation in this kind of study, and both the tracking features specifically, would be beneficial to them in their recovery process.

I think this right here would be really good for a lot of people, because, as long as you can convince them that that confidentiality won’t be broken, a lot of people that I’ve seen—because like I said, I’ve been through this recovery process before—they need someone that they can say this to, and say yes I got high, no I didn’t want to be here. And I think that would help them a lot, being able to open up. And even if it is just to an app, being able to write it out, or text it, or say it, or whatever. I believe that would help people. And as you speak it, when you say it out loud, sometimes it makes it more real. (Participant 8)

Participants shared that they saw the ecological momentary assessment portion as a means to share, express, or reflect on one’s experiences, much like a journal.

It would help me like in my choice process like better clarifying people to talk to, different ways to cope with certain things that may arise. (Participant 3)

Because it’ll make them more aware. When I’m sure like you said if you’re gonna send a survey out after they leave these certain places or from being with these certain people, they might not realize the potential for relapse when they’re around these people but when they leave and they actually have to look at the survey, it’s possible that they could be like well I was feeling this way or I did think about this when I was around them. So it might bring awareness to people. (Participant 14)

Other participants thought the daily surveys could be reassuring in other ways, providing a demonstration that someone cares how they are feeling and is listening to them.

I think that’s amazing. That’s so sweet. Just to even say, how is your day? How are you feeling? You know. Some people don’t have it, I guess as good, as others, you know. So probably just getting that text could turn somebody’s day around, you know? (Participant 29)

Finally, participants thought that the place-based ecological momentary assessments could be useful if converted into an ecological momentary intervention.

Like me, for me, for instance, like I go to the gas station to get cigarettes and I get gas once a week, of course. But I just like to see, “OK, I see you’re at the gas station. Didn’t you buy cigarettes yesterday?” Something like to discourage. . . you know? Or, “Did you see you’re right next door to a package store? Be careful.” You know, that type of thing. (Participant 19)

. . .if I was to like fall off and knowing I’m not supposed to be in that area. It would be good to get a call from somebody saying, “Yo, you’re not supposed to be here. Get back where you belong.” You know, it’d helped me stay grounded and focused. You know. And like my sister wanted me to do that, too, come to think about it. Because she was like, you know, there’s areas up here that we’re not supposed to be, but, you know, we go. (Participant 16)

Discussion

Based on our interviews, we found that participants were mostly unconcerned with the use of tracking elements in research and intervention. Participant concerns focused on maintaining confidentiality and the burden of collecting information for research. Additionally, participants saw several benefits to participating in research incorporating tracking elements, both for themselves and others who use substances. Participants identified potential for therapeutic benefits of participation in studies involving tracking, including opportunities for self-reflection and feelings of accountability. Finally, participants suggested additional opportunities for the ecological momentary assessment and GPS-tracking elements of research to be converted to recovery support interventions.

Our findings that participants were mostly unconcerned with the use of tracking elements in research and intervention are supported by high rates of feasibility and acceptability of both ecological momentary assessment^9,24
-26 and GPS tracking^16,27 in similar populations of people who use substances. Participant concerns around confidentiality²⁸ and the time and effort burden of data collection have been documented elsewhere among people who use drugs.^16,29,30

Similarly, perceived participant benefits related to study participation, including increased self-worth and social support along with decreased substance use, have also been observed elsewhere.³¹ To our knowledge, this is the first study discussing specific perceived benefits to participation in studies using ecological momentary assessment and GPS tracking among people who use substances. The components that participants identified as therapeutic (ie, opportunities for self-reflection, feelings of accountability) have been hypothesized to support decreases in substance use and maintenance of recovery.^32
-36

Participants suggested additional opportunities for the ecological momentary assessment and GPS-tracking elements of research to be converted to recovery supportive ecological momentary interventions. Such interventions have been explored in other studies³⁷ and have been likened to the increased promise seen in other just-in-time adaptive interventions for SUD.^38,39 Future research by this team will explore the development of an ecological momentary intervention utilizing GPS tracking to send location-specific support messages, similar to what was described by participants of this study.

Limitations

The study has a number of limitations. Social desirability bias may have influenced participant responses, both because these interviews covered sensitive topics, such as substance use, and because participants may have felt swayed to respond positively to questions about the research study when posed by research staff, especially since questions about tracking technology were presented toward the end of the interview after some rapport had been built between the interviewer and the interviewee. That said, this does underscore the importance of establishing trust and rapport within any research relationship, particularly when researchers are using potentially intrusive methods and/or exploring sensitive topics. Another limitation is that, given the small settings in which interviews were conducted, we did not collect demographic information from participants to maintain confidentiality. As such, we were unable to explore how the themes that emerged varied by participant characteristics such as age, gender, race/ethnicity, socioeconomic status, history of carceral involvement, or drug of choice. Moreover, given our use of a convenience sample, participant motivation to participate in research studies like the ones described may vary in important ways from the larger population of people in substance use treatment. Additionally, participant attitudes may have changed over the 4 years since this study was conducted, especially as a factor of increased use of digital technology after the COVID-19 pandemic. Finally, participant responses were based on a hypothetical research study experience; we plan to conduct similar interviews as part of an ongoing study like the one described here to determine how these findings compare to the experience of actual research participants.

Implications

This study has a number of implications for both research on and interventions for substance use. First, people in substance use treatment generally endorsed high rates of acceptability toward participating in research on their substance use that uses ecological momentary assessment and GPS tracking. This level of acceptability could likely have been increased further by proactively addressing participant concerns about confidentiality and burden of participation. Their concerns, overall, were few; this is promising for scholars who want to pursue research using GPS-tracking technologies to support individuals in recovery. The overall lack of concern among participants about research-tracking features should not be construed as a reason to relax measures safeguarding participant confidentiality. Instead, greater attention to safeguards is needed for digital information given the increasing frequency and public awareness of cyberattacks and the greater sensitivity of the information collected in substance use research. Protection of participant confidentiality is an especially relevant topic, given the recent push for sharing research data in repositories, which requires the establishment of even greater safeguards.

Further research using both qualitative and quantitative methods should explore how the willingness to participate in research studies and interventions using GPS tracking or ecological momentary assessment varies by factors such as specific SUD, treatment modality, drug of choice, and sociodemographic characteristics. Additionally, our finding that participants’ lack of concern was related to and prefaced by currently being in recovery implies that individuals with low recovery self-efficacy may be less willing to agree to participate in studies with tracking components and that research participants may be less inclined to continue participation if they return to use. We are examining both of these as part of an analysis within the ongoing study described hypothetically in these interviews. Moreover, it is possible that framing these components as “sensing” instead of “tracking” could alter participants’ level of approval as the term “tracking” may have a negative connotation. Future research should explore how the framing of these components relates to subsequent levels of acceptability.

Second, research should explore the potential therapeutic effects of participation in studies, especially longitudinal and qualitative studies, which involve elements of accountability and/or self-reflection. Those elements that demonstrate some level of benefit in outcomes analysis should be considered in future research as potential intervention components. We are building on the research presented in this article with an ongoing set of studies developing and testing a geographic ecological momentary intervention to be used independently and in conjunction with substance use treatment programs. This research will explore the independent effects of ecological momentary assessment and ecological momentary intervention on a variety of outcomes.

Conclusions

Ecological momentary assessments and GPS tracking are both described as highly acceptable among individuals in substance use treatment. Participant concerns can be easily addressed by detailing safeguards for confidentiality and clarifying the burden of data collection on the participant. Participant benefits of such tracking features, including the therapeutic potential of ecological momentary interventions, should be explored further.

Supplemental Material

sj-docx-1-saj-10.1177_29767342231218514 – Supplemental material for A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment

Supplemental material, sj-docx-1-saj-10.1177_29767342231218514 for A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment by Adam Viera, PhD, MPH, Ashlin Ondrusek, BA, Cecil Tengatenga, MA, Erin McBurney, MPH, John Lauckner, MPH, Emma Tran, MPH, Jessica Muilenburg, PhD, Trace Kershaw, MPhD and Carolyn Lauckner, PhD in Substance Abuse

Supplemental Material

sj-docx-2-saj-10.1177_29767342231218514 – Supplemental material for A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment

Supplemental material, sj-docx-2-saj-10.1177_29767342231218514 for A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment by Adam Viera, PhD, MPH, Ashlin Ondrusek, BA, Cecil Tengatenga, MA, Erin McBurney, MPH, John Lauckner, MPH, Emma Tran, MPH, Jessica Muilenburg, PhD, Trace Kershaw, MPhD and Carolyn Lauckner, PhD in Substance Abuse

Footnotes

Author’s Note

Adam Viera and Trace Kershaw are also affiliated with Center for Interdisciplinary Research on AIDS, New Haven, CT, USA.

Author contribution

AV led the development of the interview guide along with coding and analysis of the data, and drafted and finalized the manuscript. AO was integrally involved in analysis and in writing up the findings in the Results section. CT and EM coded and analyzed all the data. JL and ET coordinated and oversaw administration of the surveys at the two locations and contributed meaningfully to preliminary analysis of the data. TK and JM oversaw the overall design of the project, obtained the funding, and established the relationship with participating treatment organizations. CL guided the data analysis process and provided extensive feedback during manuscript development. All authors participated in drafting and finalizing the interview guide and reviewed and provided feedback on this manuscript.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was made possible through funding from the National Institues for Health, National Institute for Alcoholism and Alcohol Abuse (NIAAA): R01AA025954 (PIs: Kershaw, Muilenburg) and F31AA028992 (PI: Viera).

Compliance,Ethical Standards,and Ethical Approval

Institutional Review Board’s approval was not required.

ORCID iDs

Adam Viera

Emma Tran

Supplemental Material

Supplementary material for this article is available online at the SAJ website

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