A Geospatially Customizable Culturally Tailored Just-in-Time Adaptive Intervention for Violence-Affected People...

Posttraumatic stress, along with comorbid mental health challenges and hazardous alcohol use, disproportionately affects people living with HIV. The drivers of these stressors are both intraindividual, rooted in early life adversity and firsthand violence exposures, and contextual, often place-based. Imparting effective coping skills and distinguishing between changeable and unchangeable stressors can improve stress management in the short term, with cascading effects on key HIV continuum of care end points, such as antiretroviral therapy adherence. However, problem- and emotion-based coping skills, delivered via traditional linear in-person group modalities, may falter in the moment. To address this, we adapted the evidence-based Living in the Face of Trauma intervention into an iOS- and Android-native app, featuring daily diary-triggered coping skills recommendations, self-guided Living in the Face of Trauma psychoeducational sessions, and a customizable geofencing function.

This mixed methods study aimed to examine the acceptability, feasibility, and user experiences of NOLA (New Orleans, Louisiana) Gem, focusing on user interaction costs relative to geographic ecological momentary assessment (GEMA) alone and refining future optimization options.

People living with HIV (N=32) were recruited across New Orleans and initially randomized 1:1 to treatment (NOLA Gem + GEMA) versus control (GEMA) for 21 days. Feasibility was assessed via enrollment and attrition rates. At the immediate postassessment, participants completed acceptability and usability measures and a brief structured usability interview. Analyses included descriptive statistics, bivariate logit modeling, and synergistic human-large language model deductive coding.

In total, 30 participants (n=22 in the GEMA + NOLA Gem treatment arm) completed the pilot, representing 94% (n=29) of baseline enrollees. Acceptability was very high across the board: 100% (n=30) of users considered NOLA Gem "very" or "somewhat" successful in addressing their daily lives, with 91% (n=28) endorsing increased calm and emotional well-being. In addition, 50% (n=11) of NOLA Gem users were "extremely likely" (Net Promoter Score=10/10) to recommend the app to friends. Eight (27%) GEMA and GEMA + NOLA Gem users reported privacy concerns. Eleven (50%) NOLA Gem users received geofencing alerts; perceptions of this feature's helpfulness were mixed. No statistically significant sociodemographic or clinical predictors of disparate acceptability or increased privacy concerns were found. No additional frictions were evidenced by GEMA + NOLA Gem versus GEMA users. Qualitatively, NOLA Gem users praised the just-in-time mindfulness, breathing, problem-solving skills delivery, and broader stress control and self-insight benefits. A subset of users pointed out the burdensome length and sometimes inconvenient timing of the daily diaries. Recommendations for next-generation personalization included user-specific dynamic daily diary and geofencing prompt tailoring.

Our small pilot study demonstrated high NOLA Gem acceptability and feasibility, as well as a rich and beneficial user experience among people living with HIV, with clear and actionable opportunities for improvement.