Development of a Technology-Based, Interactive Intervention to Reduce Substance Use Disorder Stigma Among Medical Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall this is an interesting description of the creation of a training program for medical students to aid in the reduction of bias towards patients and others with SUD. Functional outcomes (for a future publication) will be very interesting.

 

As for this manuscript, some improvements in the description of the methods are needed. First in Section 2.1 (and lines 297-301) the authors stress the importance of iterative feedback from the multidisciplinary team and the development of the four modules (2.3 and subsections). While the team is broadly described as consisting of medical students, practicing clinicians, and experts in the fields of psychology, stigma, and addiction medicine, more detail about this team would be valuable. How many people were in each category? How were the medical students selected (self-selected, nominated by peers, chosen by administrators) and what year(s) were the students when the modules were being developed? 

 

Second, in considering how these modules would fit into the UME curriculum it would be good to know how long (in hours) does it take to run through all of the modules? How long is each module? Can each module be done separately or stopped/started as the learner needs? In testing, what percentage of learners completed all of the modules?

 

Lastly, in Section 4 Discussion the authors discuss next steps (lines 329-333). What specific pre-and post-module employment tools will be used to assess the impacts of this training? What would the follow-up interval be (6-months post completion perhaps) to see if any lasting impact on SUD bias occurred in response to training? A tool that assesses levels of empathy towards those with SUD would be interesting, as would an implicit attitude test related to those with SUD. The authors should suggest some tools that they may use and the relative merits of each.

Author Response

Overall this is an interesting description of the creation of a training program for medical students to aid in the reduction of bias towards patients and others with SUD. Functional outcomes (for a future publication) will be very interesting.

Thank you.

1. As for this manuscript, some improvements in the description of the methods are needed. First in Section 2.1 (and lines 297-301) the authors stress the importance of iterative feedback from the multidisciplinary team and the development of the four modules (2.3 and subsections). While the team is broadly described as consisting of medical students, practicing clinicians, and experts in the fields of psychology, stigma, and addiction medicine, more detail about this team would be valuable. How many people were in each category? How were the medical students selected (self-selected, nominated by peers, chosen by administrators) and what year(s) were the students when the modules were being developed?

This information has been added to section 2.1.

 

2. Second, in considering how these modules would fit into the UME curriculum it would be good to know how long (in hours) does it take to run through all of the modules? How long is each module? Can each module be done separately or stopped/started as the learner needs? In testing, what percentage of learners completed all of the modules?

This information has been added to sections 2.2 and 2.3. As mentioned, this current paper describes the development process for the intervention and next steps involve pilot testing the intervention. The percentage of learners who completed all the modules will be included as an outcome in a future publication.

 

3. Lastly, in Section 4 Discussion the authors discuss next steps (lines 329-333). What specific pre-and post-module employment tools will be used to assess the impacts of this training? What would the follow-up interval be (6-months post completion perhaps) to see if any lasting impact on SUD bias occurred in response to training? A tool that assesses levels of empathy towards those with SUD would be interesting, as would an implicit attitude test related to those with SUD. The authors should suggest some tools that they may use and the relative merits of each.

The main endpoints for the next study will be acceptability and feasibility. This study will report outcomes such as percentage of learners completing all the modules, time spent on each module, number of log-ins and log-outs, and responses on feasibility, acceptability, and engagement surveys. After completion of that study, we will then do a full-scale trial to address the impact of the intervention on student SUD stigma, relative to controls. We plan to assess stigma pre-intervention, at a 1 week, 6 month, and 12 month follow up and using validated scales such as the Social Distance Scale adapted for Substance Users (Link et al., 1987; Brown 2011), Dangerousness Scale adapted for Substance Users (Link et al., 1987; Brown 2011), and the Affect Scale adapted for Substance Users (Penn et al., 1994; Brown 2011). We will also ask free-response stigma questions. This specific information is not included in the current manuscript, as the full-scale trial will occur after pilot testing. 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors developed a SUD stigma intervention tailored to medical students. My major concerns are as follows:

1. Please clarify how many members involved in the multidisciplinary team.
2. Did the multidisciplinary team use any methods to develop the intervention, such as Delphi, focused group discussion, etc?
3. Did you pilot this intervention to a small sample of medical students? The lack of validation or piloting should be a major concerns.
4. What is the meaning of “technology-based” in the title?

Author Response

The authors developed a SUD stigma intervention tailored to medical students. My major concerns are as follows:

1. Please clarify how many members involved in the multidisciplinary team.

This information has been added to Section 2.1.

 

2. Did the multidisciplinary team use any methods to develop the intervention, such as Delphi, focused group discussion, etc?

Additional details about the methods used to develop the intervention have been added to section 2.3.

 

3. Did you pilot this intervention to a small sample of medical students? The lack of validation or piloting should be a major concerns.

The current manuscript outlines the development of the intervention and is not intended to be a validation or pilot study. As described in the discussion, the next steps are to pilot test this intervention in a small sample of medical students. We did add to section 2.3 a statement about informal, internal pilot testing that we conducted to see how long the modules would take.

 

4. What is the meaning of “technology-based” in the title?

The use of “technology-based” in this title refers to the use of an online platform (CIAS) that can be accessed online on various technological devices including smartphones, ipads, and computers. The purpose of including this specification in the title is to emphasize the divergence from traditional classroom and lecture-based education to a curriculum that is formatted to improve access and tolerability among current medical students.

Reviewer 3 Report

Comments and Suggestions for Authors

As per the attached PDF review report 

Comments for author File: Comments.pdf

Author Response

Title:

1. The title is long. Please revise to a concise title. Suggestion: “Development of a technology-based interactive intervention to reduce substance use disorder stigma among medical students”

The title has been changed to the suggested title.

Abstract:

1. Please add a clear study objective “This study aims to” and briefly state what makes this intervention unique compared to existing approaches.

We have added the following sentences to the abstract:

 

This study aims to describe the development of a technology-based, interactive SUD stigma intervention for medical students, created in collaboration with medical students, practicing clinicians, and experts in the fields of psychology and addiction medicine. This intervention is unique in its interactive application-based approach and the use of a computerized intervention authorizing system (CIAS) to guide the participant through the training.

 

2. Please add intervention overview and mention the platform used (CIAS) to provide more specificity for the key outcome results.

Intervention overview in the abstract is stated as follows:

 

The final intervention includes four interactive online modules focused on SUD education from a biopsychosocial model, stigma acknowledgment, examining patient perspectives, and application of skills.

 

We have also added the following sentences to incorporate discussion of CIAS into the abstract:

 

This intervention is unique in its interactive application-based approach and the use of a computerized intervention authorizing system (CIAS) to guide the participant through the training.

 

3. Please change the statement “future studies will examine” also avoid repeat words “tailored”

“tailored” is now only used once in the abstract. We kept the “future studies will examine” statement because this statement does outline our goals for future studies.

 

4. Add a short concluding statement to the final line about the innovation and scalability of the approach in the

The following regarding the innovation and scalability of the intervention has been added to the end of the abstract:

 

This intervention leverages the existing CIAS system to provide an interactive training that can be used as a part of medical student training and be expanded to other healthcare professionals (e.g., nurses, community health workers). Ultimately, this work will be used to drive the reduction of SUD stigma in medical settings.

 

Introduction

1. Introduction clearly establishes the significance of SUD stigma as a public health issue

Thank you.

2. consider refining the last sentence slightly to make it more impactful and to guide the reader into the methods

Thank you for your feedback. The last sentence of the introduction has been refined to:  Here, we describe the development process for a technology-based, interactive SUD stigma intervention tailored to medical students that is provided on a dynamic platform incorporating multimedia features and an interactive module where users participate in a series of “choose-your-own-adventure” type of activities.

 

Methods

1. Methods adequately describes collaboration. Please add short statement on how team members were chosen, especially medical student contributors

This information has been added to section 2.1.

 

2. Please clarify if any pilot usability testing or platform validation completed

The current manuscript describes the development of the intervention and, as described in the discussion, next steps will be to pilot test this intervention. We did add to section 2.3 a statement about informal, internal pilot testing that we conducted to see how long the modules would take.

Results

1. Results are clearly structured by module, reflecting the intervention design.

Thank you.

2. Please add % of students completing modules as quantitative measure

The current manuscript outlines the development of the intervention, and as such there is no current user data. These are items that will be available following pilot testing and a full-scale trial.  

3. Present summary of user responses if available

Please see comment above.

Discussion

1. Please focus more on how the design choices contribute to stigma reduction compared to traditional methods

We have added paragraph 2 in the discussion to address this point.

2. Strengthen discussion by comparing intervention with similar studies

We have added paragraph 2 in the discussion to address this point.

3. Please elaborate more on the study limitations, such as absence of current user evaluation data, lack of randomization

The current manuscript outlines the development of the intervention, and as such there is no current user or evaluation data, or randomization. It makes sense that these items are not available, as this intervention has just been developed and next steps are to pilot test and proceed with a full-scale trial.

4. Strong conclusion needed to summarize the study contributions and clearly say the next steps

The final two paragraphs of the discussion have been revised to emphasize the study contributions and next steps.

Reviewer 4 Report

Comments and Suggestions for Authors

The article "Addressing Substance Use Disorder (SUD) Stigma in Healthcare: Collaborative Development of a Technology-Based, Interactive SUD Stigma Intervention Tailored to Medical Students" presents a well-structured and comprehensive attempt to address stigma related to SUDs in medical education. The authors successfully highlight the pervasive nature of stigma within healthcare and its negative impact on patient outcomes, particularly in limiting access to appropriate care. They make a strong case for early intervention in medical training, arguing that shaping students’ perceptions and behaviors early may reduce stigmatizing attitudes later in their careers. The study’s premise is well-grounded in the existing literature on stigma reduction, particularly in its emphasis on integrating a biopsychosocial model of addiction.

The proposed intervention is a technology-based, interactive program that includes four modules: SUD education, stigma acknowledgment, patient perspectives, and practical application. Each module is designed to engage students in various ways, incorporating multimedia elements such as videos, self-reflection prompts, and interactive decision-making scenarios. Choosing the Computerized Intervention Authorizing System (CIAS) as a platform is practical, ensuring accessibility and flexibility for students with demanding clinical schedules.

Here are two recommendations to enhance the article.

First, while the authors discuss the importance of tailoring the intervention to medical students, they do not adequately justify why this population was chosen over other healthcare professionals, such as nurses or social workers, who also play crucial roles in addiction care. A more thorough comparison of existing stigma reduction interventions for different healthcare professionals could have strengthened the rationale for focusing exclusively on medical students.

Second, the authors acknowledge potential bias within the development team, noting that individuals who voluntarily participated in this project may have been predisposed to support stigma-reduction efforts. However, they do not suggest any strategies to mitigate this limitation. Including perspectives from individuals who initially held more stigmatizing views on SUDs could have provided a more balanced approach to developing the intervention.

Author Response

The article "Addressing Substance Use Disorder (SUD) Stigma in Healthcare: Collaborative Development of a Technology-Based, Interactive SUD Stigma Intervention Tailored to Medical Students" presents a well-structured and comprehensive attempt to address stigma related to SUDs in medical education. The authors successfully highlight the pervasive nature of stigma within healthcare and its negative impact on patient outcomes, particularly in limiting access to appropriate care. They make a strong case for early intervention in medical training, arguing that shaping students’ perceptions and behaviors early may reduce stigmatizing attitudes later in their careers. The study’s premise is well-grounded in the existing literature on stigma reduction, particularly in its emphasis on integrating a biopsychosocial model of addiction.

Thank you.

The proposed intervention is a technology-based, interactive program that includes four modules: SUD education, stigma acknowledgment, patient perspectives, and practical application. Each module is designed to engage students in various ways, incorporating multimedia elements such as videos, self-reflection prompts, and interactive decision-making scenarios. Choosing the Computerized Intervention Authorizing System (CIAS) as a platform is practical, ensuring accessibility and flexibility for students with demanding clinical schedules.

Here are two recommendations to enhance the article.

1. First, while the authors discuss the importance of tailoring the intervention to medical students, they do not adequately justify why this population was chosen over other healthcare professionals, such as nurses or social workers, who also play crucial roles in addiction care. A more thorough comparison of existing stigma reduction interventions for different healthcare professionals could have strengthened the rationale for focusing exclusively on medical students.

To strengthen the rationale for focusing on medical students, we have added to paragraph 2 of the introduction. Additionally, in the discussion, we have added mention of the roles different healthcare professionals, such as nurses, social workers, medical assistants, and community health workers and acknowledged that they could also benefit from their own tailored SUD stigma interventions. We plan to do future needs assessments of these groups.

 

2. Second, the authors acknowledge potential bias within the development team, noting that individuals who voluntarily participated in this project may have been predisposed to support stigma-reduction efforts. However, they do not suggest any strategies to mitigate this limitation. Including perspectives from individuals who initially held more stigmatizing views on SUDs could have provided a more balanced approach to developing the intervention.

Thank you for this feedback. Several sentences have been added to paragraph 3 of the discussion to address this point.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed all my concerns. I have no more comments.