Understanding Engagement Experiences in an Adapted Digital Cognitive Behavioral Intervention for Lower-Income Adults With Eating Disorders With Binge Eating and/or Purging: A Qualitative Analysis of Barriers and Facilitators

Objective: This study explored the experiences of lower-income adults in accessing and engaging with an adapted digital guided self-help cognitive behavioral intervention for binge and/or purge-type eating disorders. This study sought to inform future adaptation of evidence-based eating disorder interventions to improve accessibility, acceptability, and engagement among this population. Method: Participants (N = 9) were adults with public insurance or no insurance coverage who endorsed ≥ 6 binge eating episodes, ≥ 6 vomiting episodes, and/or ≥ 6 laxative/diuretic episodes in the past 3 months, had a BMI ≥ 18.5 kg/m², with annual household income ≤ 200% of the federal poverty level. Participants completed 4 weeks of intervention usability testing, followed by a semi-structured interview examining barriers and facilitators to intervention engagement. Interviews were analyzed using inductive qualitative thematic analysis. Results: Participants identified barriers and facilitators related to intervention accessibility, acceptability, and engagement. Barriers included psychosocial and structural stressors, treatment readiness, and concerns about representation and intervention fit. Facilitators included feeling understood and supported, perceived symptom improvement, and hopefulness. Participants emphasized the importance of tailoring interventions to individual identity and lived experience. Discussion: Findings highlighted the need for continued adaptation of digital interventions to better meet the specific needs of lower-income individuals with eating disorders. Incorporating flexibility, representation, and personalization may enhance engagement and support more equitable access to care. This study increased representation of the lived experiences of this underrepresented population and contributed to ongoing efforts to reduce disparities in eating disorder treatment through expanded access to evidence-based care.