Accepted for/Published in: JMIR Research Protocols
Date Submitted: Apr 15, 2025
Date Accepted: Aug 31, 2025
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BEhavioral Nudges to Enhance Fidelity in Telehealth Sessions (BENEFITS): Protocol for developing and pilot testing a telehealth tool to improve CBT implementation
ABSTRACT
Background:
The proliferation of telehealth offers a unique opportunity to integrate strategies from behavioral economics (BE) into the telehealth infrastructure to improve clinician fidelity to cognitive behavioral therapy (CBT).
Objective:
We will develop and evaluate “Tele-BE,” a novel telehealth infrastructure that nudges and incentivizes clinicians to use core structural CBT components. We focus on structural CBT components as they align with practices most likely to benefit from BE strategies, are delivered regardless of diagnosis, and represent CBT competencies independently associated with improved patient outcomes.
Methods:
We will refine our Tele-BE prototype in collaboration with clinicians and supervisors (target end-users; Aim 1). We will work closely with our web development team to field test and iteratively refine Tele-BE using rapid cycle prototyping to optimize the user experience and refine our specific BE strategies (Aim 2). The revised Tele-BE platform will be tested in a 12-week open trial with 30 community mental health clinicians randomized to Tele-BE or telehealth as usual (Tele-AU). The trial will include 2 patients per clinician (60 patients in total). All sessions will be recorded and coded for CBT fidelity. Clinicians and patients will complete questionnaires at Weeks 1, 5, 9, and 12 and qualitative interviews at post. Primary outcomes will be CBT structural component fidelity, measured through coding of recorded sessions; secondary outcomes include target implementation mechanisms (intentions and their determinants: attitudes, norms and self-efficacy), measured via mixed methods, and overall CBT fidelity (Aim 3). Using data from the trial, we also will examine acceptability and feasibility of Tele-BE from patient and clinician perspectives, as well as any potential ethical issues identified with Tele-BE use (Aim 4).
Results:
The study received NIMH funding in June 2024. Recruitment for Aim 1 started in October 2024. As of March 2025, we recruited 6 participants in the initial development stage. Recruitment is ongoing and we anticipate Aim 1 will be completed in May 2025 at which point we will prepare for study activities in Aim 2. We aim to have all study collected by the end of 2026. Per the terms of our grant award, we will submit de-identified study data collected in Aims 3 & 4 to the NIMH Data Archive for participants who consent to data sharing.
Conclusions:
Outcomes will provide insight into the utility of a behavioral economics-informed telehealth platform to increase clinicians’ use of core structural components of CBT to improve overall CBT fidelity and patient outcomes. It also will inform future confirmatory trials. Clinical Trial: Clinical Trials Registration Number: NCT NCT06601062. Registered 9/17/2024, https://clinicaltrials.gov/study/NCT06601062
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