The drug treatments with the greatest empirical validity are those involving cognitive behavioral interventions (CBIs) [1]. Some authors argue that the success of such interventions is related to the use of specific techniques, such as exploration of the positive and negative consequences of substance use (decisional balance); self-monitoring, or diary of use, where situations of high risk for drug use can also be identified; elaboration of strategies to anticipate and face situations of risk and craving; and training in social abilities [2-4].

A recent meta-analysis of the effectiveness of Internet-based interventions based on cognitive behavioral therapy demonstrated a large effect size (0.83, n=3960) as compared with other modalities, including psychoeducation (0.46, n=6796) [5]. On the other hand, it has been reported that the principles and techniques of CBIs focused on reduction in alcohol and tobacco use lend themselves more easily to adaption to an Internet-based format [6].

Web-based interventions allow complex treatments to be delivered with consistency and minimal demands on staff time and training resources. Moreover, computerized programs may be less threatening, provide greater anonymity [7,8], and reduce the effects of stigma, allowing individuals to seek information in relative privacy [9]. The expansion of the Internet offers new treatment opportunities for a large number of individuals at a relatively low cost; they may be particularly useful in rural or remote settings, where access to psychotherapy for substance use disorders may be limited, and they may thus help to broaden the availability of treatment [10-15]. Current Web-based programs differ in the level of therapist support provided and the use of tools that require or not a response from the user. The level of support can vary from nonassistance (self-help) to having some level of therapist contact by email or telephone; the latter has shown results superior to those of total self-help programs [5,16-18].

During the last decade, several Web-based interventions have been developed and validated in the mental health field [5]. Those for substance abuse, however, have focused mainly on alcohol [19-21] and tobacco [22,23]. There are few validated Web-based interventions to address drug abuse [24-27] and even fewer that address substance abuse and depression together even though comorbidity is highly frequent [28,29].

Web-based interventions developed in Latin America are very limited and focus on smoking [30], heavy drinking [31,32], and depression [33,34]. Given the 560 million people worldwide who speak Spanish, 40 million of whom live in the United States, there is a pressing need for Web-based interventions in this language [35].

Approximately 3.3 billion people around the world use the Internet, among them 345 million in Latin America, with a growth of 1808.4% in the past 15 years [36]. According to the Mexican Internet Association [37], there are approximately 53.9 million Internet users in the country, 46% of whom are aged 13-24 years. Although there are no specific studies of the use of the Internet for health care, it has been documented that health-related pages occupy the eleventh place among Web searches as a whole [38].

There are few publications that describe the process of developing a Web-based intervention, the selection of strategies required, or the limitations involved in starting it up [39]. Such information could help to provide better interpretations of data on the effectiveness of Web-based programs, aid in the design of outreach strategies to target populations, and suggest avenues for further research [40]. It could also testify to the complexity of designing such programs in a Latin American context, where they have seldom been attempted and where there is still a degree of resistance to their use.

The purposes of this paper are therefore to describe the development process of the Web-based Help Program for Drug Abuse and Depression (Programa de Ayuda para Abuso de Drogas y Depresión, PAADD, in Spanish) [41] in Mexico and to describe its final structure and functioning, which includes the participation of a counselor.

The PAADD was developed in an interactive multistage process that involved design, testing, and redesign tasks, following international recommendations for the development of eHealth strategies and ethical standards for Web-based interventions [42].

A total of 9 health professionals from Mexico City, State of Mexico, and the states Morelos, and Baja California agreed to participate. Inclusion criteria were that (1) they worked in an addiction treatment center; (2) they had at least a year of experience working in substance abuse treatment using cognitive behavioral strategies; (3) they had experience using the Internet; and (4) they were regular email users. Each was asked to invite patients under treatment (n=20) to give their opinion of the PAADD. The inclusion criteria for the patient group were that (1) they were adults; (2) they had received a minimum of 4 treatment sessions for abuse of psychoactive substances during the previous 6 months; (3) they could read and write; (4) they had experience using the Internet; and (5) they were regular email users.

All participants (both health professionals and patients) responded to a questionnaire about their Internet usage and received an instruction guide for usability test. The checklist for the health professionals focused on evaluating the role of the counselor (usefulness of strategies, contents, and message system), whereas that for patients focused on their perspective about language and ease of use.

This procedure was approved by the Research Ethics Committee of the Ramón de la Fuente Muñiz National Institute of Psychiatry. All participants were volunteers and signed an informed consent form with the understanding that the data might be used in research. All information obtained in this program is confidential and available only to members of the research team. The questionnaires, forms, and other documents were identified by a numeric code that avoids the identification of participants.

The usability test was based on a selection of tasks and pages according to the guidelines proposed by Dumas and Loring [49]: (1) frequently used tasks; (2) tasks that are basic to the general program; (3) tasks that are critical because they affect other parts of the design, even though they may not be frequently used; (4) tasks in which problems are anticipated; (5) tasks that test the structure and components of the design; and (6) the time available for the evaluation.

The tests carried out by the health professionals consisted of navigating the PAADD, following a list of specific actions, and reporting on their experience. The tests by patients were carried out at the centers where they were receiving treatment. A member of the research team accompanied them and recorded their commentaries and suggestions.

The group included 5 women and 3 men with an average age of 30.25 years (SD 5.33). All participants had a master's degree in psychology of addiction and had an average of 5 years of experience using the CBI approach to treat persons with problems of substance abuse. All participants were regular users of the Internet, with an average daily use of 6.1 hours, the majority from their home and workplace.

The main suggestions from the health professionals focused on the content and format but not on the structure of the program, for instance, recommendations to change the color scheme, page layout, font size, arrangement of functions, inclusion of confirmation messages at the end of activities, avoiding the use of technical language and “read more” links, providing short introductory texts for every task, and creating more visible help buttons with specific explanations and tips. They found the functionalities easy to learn, although they indicated that some were not intuitive at first glance. They suggested providing feedback about every activity and including more activities and exercises within the program, as well as more tips on how to end substance abuse. They also suggested the possibility of including testimonials from persons who had benefited from the program (see Table 2).

The user group included 16 men and 4 women, 60% of them single, with an average age of 29.6 (SD 9.1) years. In this group 70% (14/20) had completed high school, 15% (3/20) an undergraduate degree, and 15% (3/20) elementary school; 65% (13/20) were employed, 20% (4/20) did not work, and 15% (3/20) were students. All participants were regular users of the Internet, with an average daily use of 3 hours, the majority from home (85%) and the rest using their cell phone and/or at Internet cafes.

Users suggested a more dynamic design with images and colors, clearer, more concrete instructions, inclusion of empathetic, reflective feedback, and also a chart showing the names and appearance of different drugs. The majority said it was important to be able to modify the weekly goal and clarify the sequence of activities in the program (see Table 3).

The observations and suggestions of users and health professionals were compiled into a document that served as a guide for development of a new version of the PAADD, which was in turn put through an evaluation process.

This paper describes the development and results of the usability test of PAADD, a Web-based intervention with the participation of a counselor, the first of its kind in Latin America that is designed to reduce substance use and depressive symptoms. The development of the program was systematic and rigorous. It began with a review of the literature on brief interventions and incorporated the opinions of experts in addiction treatment as well as 2 types of end users, following a procedure similar to that reported by Morrison et al [50]. The result of the process was a Web-based program that contains the key elements of a CBI, with a user-friendly design, simple instructions, and intuitive and time-efficient functions.

The translation of cognitive behavioral strategies to the concrete activities of the PAADD was complex and time consuming. Van Voorhees et al [51] note that a focus on detail is necessary to achieve good results in this type of process. Likewise, a multidisciplinary approach considering different points of view leads to more satisfactory results [52]. The detailed description of the process of designing a Web-based program is an important contribution, given that there is no specific method for the creation of this intervention modality [50]. This study can therefore serve as a guide to others interested in this field.

An important characteristic of the PAADD is that it includes the participation of counselors who provide feedback according to the motivational interviewing techniques. This element is intended to strengthen adherence, as it has been shown that the inclusion of health professionals has a positive influence on retention and motivation of participants in such programs [53,54].

In the usability test, drug users commented that the PAADD was professional and clear. Many felt that the information presented within the modules was relatively easy to follow, comprehensive, and of good quality. A few participants reported at times feeling impatient to receive the next module. The majority of users commented positively on the content of the program and felt that they could benefit from it. In their view, it helped principally with improved self-awareness of their pattern of drug use. They reported that the PAADD encouraged them to think about self-management techniques, how to monitor their thoughts and feelings, and how to regulate their behavior and consumption patterns. These observations suggest that the design process was successful; it resulted in a program that is easily usable by persons who wish to end their substance use and who present depressive symptomatology.

The PAADD may have advantages over traditional face-to-face therapies because of its low cost, wide accessibility, anonymity, and independence of time and distance factors. It may be a good alternative for persons not receiving treatment owing to factors such as physical distance from available services, lack of qualified providers, socioeconomic condition, and stigma, although these potential benefits will have to be verified in specific studies.

In future efforts it will also be important to consider that the initial investment for the design of a Web-based intervention can be high and that it is necessary to perform a cost-benefit analysis to document the viability of the project. It should also be kept in mind that technologies are developing rapidly; in order to provide increased availability and accessibility, it is necessary to plan from the beginning the possibility of using the program on diverse types of devices, such as mobile phones and tablets, and not just on computers.

Because PAADD is not an open-access program, it will also be necessary to design a dissemination strategy that would include training of counselors and to promote the use of PAADD in specialized treatment centers. This will allow to document adoption and implementation in real-life scenarios.

The lack of forums or chat functionalities for users to interact with each other may be a limitation in this program because having contact with others in the same situation can be a source of support. It is also possible that the small number of users participating in the usability test limited the number of opinions regarding improvements to the program. Such limitations have been reported in similar studies [53,54].

Data from the usability test indicate that the PAADD has the necessary features to support users in their process of reducing drug use. If this is corroborated in effectiveness studies, the program could be used as an alternative to treatment as usual.