Mobile technology and task shifting to improve access to alcohol treatment services in Mozambique

May combine two claims.

Language was the most commonly discussed adaptation, and for some patients, providers had to translate into the local language, adding time and complexity to the app session.

“In terms of adaptations, participants most commonly discussed language.”

• Also stated in: § App appropriateness · plain

  “For some patients, providers had to translate into the local language, adding time and complexity to the app session.”

• AssumptionRests on an assumption: The app is in Portuguese to match the national language, but 11 local languages are used throughout the country.
• AssumptionRests on an assumption: Portuguese may be a second language for both providers and patients, and some providers may not speak the same local language as their patients.

Classified as probably not a substantial claim. May combine two claims.

The app was a good match for providers to do SBIRT/MI, provided a guide or script, and was highly relevant due to the high rate of unhealthy alcohol use cases.

“Participants for the most part indicated that the app was a good match for them to do SBIRT/MI.”

• Also stated in: § App appropriateness · plain

  “They felt the app provided a guide or script for the intervention.”

• Also stated in: § App appropriateness · plain

  “Participants also thought that the app was highly relevant to their work because of the high rate of UAU cases.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The app provides for an efficient session because of the automated calculation of the screening tool and its structured resources.

“Several participants noted that the app provides for an efficient session because of the automated calculation of the screening tool and its structured resources.”

May combine two claims.

Qualitative analysis identified themes for acceptability (efficiency, experience, design/content), appropriateness (patient-provider rapport, match with SBIRT process and goals, adapting to local needs), and feasibility (time pressures and wifi connection).

“Below, quantitative results are presented along with the themes identified for each of the three inductively coded qualitative categories: 1) Acceptability (efficiency, experience, design/content), 2) Appropriateness (patient-provider rapport, match with SBIRT process and goals, adapting to local needs, and 3) Feasibility (time pressures and wifi connection).”

May combine two claims.

Participants were mostly satisfied with the app content and felt it helped with patient interactions, with useful visual displays and screens facilitating discussion about readiness to change and behavior change plans.

“Participants were mostly satisfied with the app content and felt it helped with patient interactions.”

• Also stated in: § App acceptability · plain

  “Several participants identified screens with useful visual displays that can be used with the patient, including screens that show images of the amount of alcohol used by the patient, recommended drinking levels, and the connections between alcohol and physical health.”

• Also stated in: § App acceptability · plain

  “Screens that facilitated a discussion about readiness to change as well as behavior change plans also increased acceptability.”

May combine two claims.

Some participants noted less acceptable factors: too small letters on the screen, slowness of the app, difficulty of patients being able to accurately express quantity of drinking, and questions that felt repetitive or too numerous.

“Though, some participants noted factors that were less acceptable, including too small letters on the screen, slowness of the app, difficulty of patients being able to accurately express quantity of drinking, and questions that felt repetitive or too numerous.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The app added time to already busy workflows for some providers, and feasibility would depend on the work flow.

“Related to time pressures, participants felt that feasibility “would depend on the work flow” (Participant 10).”

• Also stated in: § App feasibility · plain

  “The app added time to already busy workflows for some providers, as illustrated here: The app is good, but if some aspects were improved, such as minimizing questions and time. Looking at the flow because for us who do everything in our health units, it is complicated to have to be with a patient for an hour or an hour and a half(Participant 14).”

May combine two claims. The quote only partly states this claim.

Participants reported a good user experience with the app, which they attributed to its organization and practice after training.

“Participants generally reported that the app provided a good user experience.”

• Also stated in: § App acceptability · plain

  “Participants felt that the application was well organized which contributed to the positive user experience.”

• Also stated in: § App acceptability · hedged

  “A few participants noted that they practiced using the app after training which increased its appeal over time.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Participants reported that using a standardized tool like the app enhanced patient comfort and provider legitimacy, and that ensuring data security was important for rapport.

“Participants also expressed that when patients observe that they are using a standardized tool to deliver the intervention, patients feel more comfortable and that perhaps the app also provides legitimacy as a task-shared worker in the eyes of the patient.”

• Also stated in: § App appropriateness · plain

  “Several participants also noted that it was important for maintaining rapport to be sure the patient understood that their data and answers were secure within the app and that privacy protections were in place.”

May combine two claims.

Participants, particularly those in rural areas, lack strong network connections and depend on data packages that are not always available.

“Regarding internet connections, participants, especially those located in rural areas, do not have strong network connections and rely on data packages that are not available at all times.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Constructive feedback indicated that although the app enhanced the efficiency of screening and diagnosis, the number of questions and prompts was at times tedious.

“Constructive feedback indicated that although the app enhanced efficiency of screening and diagnosis, the number of questions and prompts was at times tedious.”

May combine two claims.

The vast majority of participants agreed that the mSBIRT app was acceptable, appropriate, and feasible.

“Our results showed that the vast majority of participants agreed that the mSBIRT app was acceptable, appropriate, and feasible.”

• Also stated in: § Conclusions · plain

  “Nonspecialized providers found the mSBIRT app to be acceptable, appropriate, and feasible.”

May combine two claims.

Providers appreciated the improved standardization of the intervention and thought it matched well with the SBIRT process they had learned in training without the app.

“Providers additionally appreciated the improved standardization of the intervention and thought it matched well with the SBIRT process they learned in training without the mSBIRT app.”

May combine two claims.

Increased efficiency, experience, and design/content were all related to providers' views of the acceptability of mSBIRT.

“Increased efficiency, experience, and design/content all related to providers’ views of acceptability of mSBIRT.”

May combine two claims.

The mSBIRT app can be used offline for parts of the intervention and synchronizes when service is available, but it must connect to the network at the start of a session to match data with the server and supply information from previous sessions.

“While the app can be used offline during some parts of the intervention and will synchronize when service is available, it must connect to the network to match data with the server at the start the session to provide useful information from previous sessions (e.g., change in alcohol use).”

May combine two claims.

Providers perceived the app to facilitate screening procedures and to make the intervention more efficient.

“Providers perceived the app to facilitate screening procedures, making the intervention more efficient.”

May combine two claims.

Providers in Mozambique shared concerns about maintaining rapport and about the importance of introducing the app to patients that were similar to those in the original mSBIRT study conducted in the US.

“While we found that providers in Mozambique shared similar concerns about maintaining rapport and the importance of introducing the app to patients as in the original mSBIRT study conducted in the US (O’Grady et al., 2019), they often mentioned patients’ satisfaction with the tablet and app.”

• cites O’Grady et al., 2019 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Inter-rater reliability was not calculated because the main purpose was to yield concepts and themes rather than finite coding agreement, consistent with accepted qualitative conventions.

“According to accepted conventions in qualitative methods, inter-rater reliability was not calculated because our main purpose was to eventually yield concepts and themes, rather than finite coding agreement (McDonald et al., 2019).”

• cites McDonald et al., 2019Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Interviews were recorded, transcribed verbatim, and translated into English for coding.

“Interviews were recorded and then transcribed verbatim and translated into English for coding.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study received IRB approval from the Mozambican Ministry of Health and the last author's institution.

“This study received IRB approval from the Mozambican Ministry of Health (Protocol # CIBS/FM/HCM/64/2017) as well as the last author’s institution (Protocol #7485).”

Classified as probably not a substantial claim. May combine two claims.

The 12-item quantitative survey consisted of three validated scales (Acceptability of Intervention Measure, Intervention Appropriateness Measure, Feasibility of Intervention Measure) measured on a 5-point Likert scale.

“The 12-item quantitative survey consisted of three validated scales (Acceptability of Intervention Measure, Intervention Appropriateness Measure, Feasibility of Intervention Measure)(Weiner et al., 2017) measured on a 5-point Likert scale (1 = completely disagree, 5 = completely agree).”

• cites Weiner et al., 2017 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

All participants invited to the qualitative study participated.

“All participants invited to the qualitative study participated.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Qualitative analysis used Thematic Analysis.

“Qualitative analysis used Thematic Analysis (Braun & Clarke, 2021).”

• cites Braun & Clarke, 2021 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Thematic Analysis generally followed phases outlined by Nowell et al., 2017, including familiarizing with data, generating initial codes, searching for themes, and reviewing, defining, and naming themes.

“Thematic Analysis generally followed phases outlined by Nowell et al., 2017, including familiarizing ourselves with the data, generating initial codes, searching for themes, and reviewing, defining, and naming themes (Nowell et al., 2017).”

• cites Nowell et al., 2017 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Interviewers had previous interactions with participants from other research activities currently underway.

“Interviewers have had some previous interactions with participants from other research activities currently underway (e.g., trainings, app technical support, other data collection).”

Classified as probably not a substantial claim.

Qualitative interview participants were purposively selected because they were trained in SBIRT and used the mSBIRT application.

“Qualitative interview participants were purposively selected because they were trained in SBIRT and used the mSBIRT application.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Deductive coding was first used based on established definitions of acceptability, appropriateness, and feasibility; then the team searched for, identified, named, and selected representative quotations for themes within each category.

“In this process, deductive coding was first utilized based on established definitions of acceptability, appropriateness, and feasibility. Then, once data was deductively coded into each one of these larger categories (e.g., feasibility), the team searched for themes within each coded category, identified and named these themes (e.g., time pressures) and selected representative quotations for each”

May combine two claims.

Although task-shifting has increased availability of mental health services, there is limited system capacity to bring evidence-based interventions for unhealthy alcohol use to scale.

“While this strategy has increased availability of mental health services, there is limited system capacity to bring evidence-based interventions for UAU to scale (Halsted et al., 2019; Suleman et al., in press; Wainberg et al., 2020).”

• cites Halsted et al., 2019 sourceNot checked yet

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• cites Suleman et al., in pressNot checked yet

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• cites Wainberg et al., 2020Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Mozambique is the fourth poorest country in the world, with half the population below the poverty line and 70% living in rural areas with limited healthcare access.

“Mozambique is the fourth poorest country in the world where half of the population lives below the poverty line and 70% live in rural areas with limited healthcare access (World Bank, 2016; Pasquali, 2020; Schwitters et al., 2015).”

• cites World Bank, 2016Not checked yet

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• cites Pasquali, 2020Not checked yet

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• cites Schwitters et al., 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Instrument translation into Portuguese and cultural adaptation used WHO-recommended methods, including forward and backward translation by bilingual experts, cognitive pre-testing with 10 providers, and consensus finalization.

“Instrument translation into Portuguese and culturally adaptation used methods recommended by the WHO (WHO, n.d.), including forward and backward translation by bilingual experts, cognitive pre-testing with 10 PTs and PCPs, and finalization of language through consensus.”

• cites WHO, n.d.Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

The study draws from recent recommendations in the implementation science literature on characterizing implementation outcomes for behavioral intervention technology.

“The study draws from recent recommendations in the implementation science literature on characterizing implementation outcomes for behavioral intervention technology (Hermes et al., 2019).”

• cites Hermes et al., 2019 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Unhealthy alcohol use is a major public health challenge, particularly in low- and middle-income countries where disease burden per liter of alcohol consumed is greater than in high-income countries.

“Unhealthy alcohol use (UAU), defined as a continuum of behaviors from risky or harmful use (exceeding recommended daily, weekly, or per occasion amounts) to alcohol use disorder, is a major public health challenge, particularly in low- and middle-income countries (LMICs) where disease burden per liter of alcohol consumed is greater than in high-income countries (Rehm et al., 2009).”

• cites Rehm et al., 2009 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The first author conducted initial theme identification, which was then reviewed and finalized by the full qualitative analysis team through discussion.

“The first author conducted the initial identification of themes which were then reviewed and finalized by the full qualitative analysis team through discussion.”

May combine two claims.

Evaluations of trainings for primary care practitioners and psychiatric technicians show effective knowledge transfer for the SBIRT/MI intervention and strong intentions to deliver its core components with fidelity.

“Evaluation of these trainings for PCPs and PTs show effective knowledge transfer for the SBIRT/MI intervention and strong intentions to deliver its core components with fidelity (Wainberg et al., 2021).”

• cites Wainberg et al., 2021 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

A recent study found that among approximately 500 patients screened for mental health and substance use, 16% had likely substance use disorder.

“A recent study showed that of approximately 500 patients screened for mental health and substance use, 16% were identified with likely substance use disorder (Wainberg et al., 2021).”

• cites Wainberg et al., 2021 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

From 2010 to 2014, the number of psychiatric technicians grew from 66 to 241, allowing Mozambique to increase mental health coverage from 60 districts (44%) to all 135 districts (100%).

“From 2010 to 2014, the number of PTs grew from 66 to 241 allowing Mozambique to increase coverage from 60 (44%) to all 135 (100%) districts in the country (dos Santos et al., 2016).”

• cites dos Santos et al., 2016 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Analysis used an iterative process with preliminary qualitative analysis, follow-up interviews with 6 of the original 15 interviewees for participant checking and additional in-depth questions, and data saturation.

“Analysis used an iterative process where preliminary analysis of the qualitative data was conducted and then follow up interviews were completed with 6 of the original 15 interviewees to conduct participant checking and ask additional in-depth questions about topics that arose during the initial interviews in order to reach data saturation (Saunders et al., 2018).”

• cites Saunders et al., 2018 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The three-person analysis team consisted of the first and second authors (PhD-level social and clinical psychologists and faculty trained in qualitative methods) and a bilingual research assistant trained in qualitative coding.

“The three-person analysis team consisted of the first and second author, PhD-level social and clinical psychologists respectively, who are also faculty members at academic medical centers and trained in qualitative methods, as well as a bilingual (Portuguese/English) research assistant trained by the study team in qualitative coding.”

Classified as probably not a substantial claim.

The WHO mhGAP Guidelines recommend using Screening, Brief Intervention, and Referral to Treatment (SBIRT) to reduce unhealthy alcohol use.

“The WHO Mental Health Gap Action Programme Guidelines (mhGAP)(Dua et al., 2011; WHO, 2008a) recommend using Screening, Brief Intervention, and Referral to Treatment (SBIRT) (Babor & Higgins-Biddle, 2001) to reduce UAU.”

• cites Dua et al., 2011 sourceNot checked yet

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• cites WHO, 2008aNot checked yet

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May combine two claims.

Resources and infrastructure to treat unhealthy alcohol use in Mozambique are limited, with 75-90% of people with behavioral health issues receiving no care due to provider scarcity and geographic distribution.

“However, resources and infrastructure to treat UAU in Mozambique are limited; 75–90% of people with behavioral health issues receive no care because of provider scarcity and geographic distribution (Demyttenaere et al., 2004; dos Santos et al., 2016; Dua et al., 2011).”

• cites Demyttenaere et al., 2004 sourceNot checked yet

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• cites dos Santos et al., 2016 sourceNot checked yet

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• cites Dua et al., 2011 sourceNot checked yet

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May combine two claims.

Mobile health technology is a promising but understudied tool to support providers and supervisors under task-shifting models.

“Mobile health technology is a promising but understudied tool to support providers and supervisors under task-shifting models (Naslund et al., 2019; Triplett et al., 2021).”

• cites Naslund et al., 2019 sourceNot checked yet

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• cites Triplett et al., 2021 sourceNot checked yet

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Classified as probably not a substantial claim.

The World Health Organization recommends task-shifting, in which non-specialists are trained to deliver brief evidence-based interventions with expert clinical supervision, to overcome the global shortage of mental health specialists.

“One of the key strategies recommended by the World Health Organization (WHO) to overcome the global shortage of mental health specialists involves “task-shifting,” wherein non-specialists (e.g., community health workers) are trained to deliver brief evidence-based interventions with expert clinical supervision (WHO, 2016).”

• cites WHO, 2016Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study used a sequential exploratory mixed-methods design with greater weight given to qualitative data (QUAL → quan).

“This study used a sequential exploratory mixed-methods design where more weight was given to the qualitative data (QUAL → quan)(Creswell et al., 2003).”

• cites Creswell et al., 2003Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Meta-data about provider usage of the app can be used to monitor the length and content of sessions and to identify deviations in expected delivery that can prompt corrective feedback.

“For example, meta-data about provider usage of the app can be used to monitor length and content of sessions and identify deviations in expected delivery (e.g., amount of time spent on each screen) that can prompt corrective feedback.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

The provider-facing mHealth approach for supporting task-shifted workers may be applicable to other therapeutic approaches and evidence-based practices.

“Our provider-facing mHealth approach for supporting task-shifted workers may be applicable to other therapeutic approaches and evidence-based practices.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A script was included at the beginning of the survey and interview reminding providers that their responses would be anonymous and not used to evaluate professional merit.

“To preemptively address this possibility, a script was included at the beginning of the survey and interview that reminded providers that their responses would be anonymous and not used in any way to evaluate professional merit.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The quantitative questions were self-administered via redcap on the tablets, and this method may have selected for providers most comfortable with and approving of technology.

“Finally, the quantitative questions were self-administered via redcap on the tablets. It is possible that this method selected for providers most comfortable with and approving of technology.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In most African countries, less than 1% of the national budget is allocated to behavioral health services.

“In most African countries, less than 1% of the national budget is allocated for behavioral health services (Rathod et al., 2017).”

• cites Rathod et al., 2017Not checked yet

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May combine two claims.

The parent study is in early stages of app implementation and providers had been using the app in the field for only several months.

“The parent study is in early stages of app implementation and providers have only been using the app for several months in the field.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Exposure to wars, food insecurity, poverty, and other social determinants is highly prevalent in low- and middle-income countries and negatively affects people's behavioral health.

“Exposure to wars, food insecurity, poverty, and other social determinants are highly prevalent in LMICs and negatively affect people’s behavioral health (Lund et al., 2018).”

• cites Lund et al., 2018 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

A synthesis of qualitative studies of health workers' perceptions of digital interventions found that increased efficiency fundamentally changed how health workers provided care.

“A synthesis of qualitative studies that examined health workers’ perceptions of using digital interventions found that increased efficiency fundamentally changed the way health workers provided care (Odendaal et al., 2020).”

• cites Odendaal et al., 2020Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The mostly positive endorsement of the app could suggest that social desirability biases were at play.

“Yet, the mostly positive endorsement of the app could suggest social desirability biases at play.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the context of task-shifting, the app may have increased providers' feelings that they appear more legitimate in conducting UAU interventions, which may in turn increase provider satisfaction and patient confidence in the intervention.

“It appeared that in the context of task-shifting, that the app may have increased providers’ feelings that they appear more legitimate in conducting UAU interventions, which may lead to greater feelings of satisfaction for the provider and increased confidence in the intervention for the patient.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Using mHealth has the potential to greatly improve fidelity and clinical performance in the delivery of UAU interventions and to monitor adoption by providers under real-world conditions.

“Using mHealth has the potential to greatly improve fidelity and clinical performance in the delivery of UAU interventions and monitor adoption by providers under real world conditions.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In Mozambique, a religious insurgency in the province directly north of Nampula, the site of this study, has escalated, displacing over 674,000 civilians, many of whom relocated to Nampula, and killing 2,000 civilians.

“In Mozambique, a religious insurgency in the province directly north of Nampula, the site of this study, has escalated. Over 674,000 civilians have been displaced, many of whom have relocated to Nampula, and 2,000 civilians have been killed (Goldbaum et al., 2021).”

• cites Goldbaum et al., 2021Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A qualitative study in rural Nepal found that although providers tended to have low digital literacy, they supported including mobile health technology to facilitate services.

“A qualitative study in rural Nepal also found that although providers tended to have low digital literacy, they supported inclusion of mobile health technology to facilitate services (Angdembe et al., 2017).”

• cites Angdembe et al., 2017 sourceNot checked yet

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May combine two claims.

The app's need for network connection at session start may create feasibility challenges for some participants and require that providers understand online and offline functions.

“This may present challenges for some participants in terms of feasibility and making sure providers understand online and offline functions.”

May combine two claims.

Technology that capitalizes on task-shifting models to expand alcohol treatment services and increase reach in low- and middle-income countries shows great promise, though it is nascent.

“While nascent, technology that capitalizes on task-shifting models to expand alcohol treatment services and increase reach in LMICs shows great promise.”

May combine two claims.

Community health workers in low- and middle-income countries are frequently paid little or no salary, and providers are often given increased responsibilities without compensation for the additional work.

“CHWs in LMICs are frequently paid little or no salary and often providers are tasked with increased responsibilities and not compensated for the additional work (Bhardwaj et al., 2020).”

• cites Bhardwaj et al., 2020 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Concerns about loss or damage of devices and lack of network connection are challenges frequently documented in other studies in low- and middle-income countries.

“Concerns about loss or damage of devices and lack of network connection are challenges frequently documented in other LMIC studies (Bhardwaj et al., 2020; Merchant et al., 2020).”

• cites Bhardwaj et al., 2020 sourceNot checked yet

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• cites Merchant et al., 2020 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Acceptability of technology-based interventions may facilitate implementation in low- and middle-income countries, in contrast to high-income settings where providers and patients may be more wary.

“Acceptability of technology-based interventions may facilitate implementation in LMICs in contrast to high-income settings where providers and patients may be more wary (Mohr et al., 2010).”

• cites Mohr et al., 2010 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Human-centered designs are known to increase the acceptability and relevance of technology.

“This approach is consistent with human-centered designs known to increase acceptability and relevance of technology (Triplett et al., 2021).”

• cites Triplett et al., 2021 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Because nonspecialized providers work for the public health system in which the implementation study is integrated, social desirability could have influenced their responses to the quantitative surveys and qualitative interviews.

“Moreover, because nonspecialized providers work for the public health system in which this implementation study is being integrated, social desirability could have influenced their responses to the quantitative surveys and qualitative interviews.”