Barriers and facilitators to patient uptake and utilisation of digital interventions for the self-management of low back pain: a systematic review of qualitative studies

Systematic review and narrative synthesis of the experiences of individuals with chronic pain participating in digital pain management interventions

BACKGROUND

The use of digital pain management interventions has grown since the Covid 19 pandemic. The aim of this study was to systematically review and synthesise evidence from qualitative studies regarding the experiences of individuals with chronic pain participating in digital pain management interventions in primary care and community settings.

METHODS

Fourteen databases were searched, as well as citation tracking and hand-searching reference lists of included articles. The latest search was completed by 07/07/2023. Qualitative studies of patient and carer perspectives of digital pain management interventions for adults aged 18 and over with non-malignant chronic pain were included. All studies were appraised for quality using the Critical Appraisal Skills Programme Qualitative Checklist. A narrative synthesis approach was used to synthesise the findings. Normalisation Process Theory was used to understand how individuals with chronic pain make sense of digital pain management interventions and incorporate knowledge, skills and strategies learnt into their day-to-day lives.

RESULTS

Eleven studies, encompassing both digital applications for use on smartphones/ mobile devices and user-directed online modular programmes, were included in the synthesis. Three main themes and related subthemes were identified from the included studies: 1) Making sense of the digital intervention (Subthemes: Tailoring to user's needs; Human contact and support; Accessibility of the digital intervention; Personal and environmental factors affecting engagement with digital interventions); 2) Initiating and Maintaining Behaviour Change (Subthemes: Planning activity; Being active); and 3) Personal Growth (Subthemes: Gaining understanding and skills; Gaining and acting on feedback; Negotiating a new relationship with pain).

CONCLUSION

Recommendations. The key recommendations from our findings are that digital pain management interventions should provide: Specific and tailored information for individual participants.Focus on changing attitudes and behaviours and reframing perceptions of pain.Structured goal setting with prompts to review goals.Potential healthcare professional support alongside the digital intervention.Limitations of the review. To reduce bias, it would have been preferable for more than one author to independently fully analyse each paper and to identify themes and sub-themes. Instead, the identified themes and sub-themes were discussed with two other authors in the team (ES, LW) to reach a consensus view on final themes and sub-themes. One author (JS) received a Research Internship and Research Initiation Award funded by NIHR Applied Research Collaboration (ARC) Wessex (https://www.arc-wx.nihr.ac.uk/) and NHS England (https://www.england.nhs.uk/). The protocol for this review was registered with the National Institute of Health Research (NIHR) PROSPERO international database for registering systematic reviews (PROSPERO Registration Number CRD42021257768).

Embedded motivational interviewing combined with a smartphone application to increase physical activity in people with sub-acute low back pain: a cluster randomised controlled trial

BACKGROUND

Moderately vigorous physical activity (PA) may be beneficial for people with sub-acute low back pain (LBP), but may initially be painful for patients and challenging for physical therapists to facilitate.

OBJECTIVES

This study investigated motivational interviewing (MI) delivered by physical therapists and a smartphone app for increasing PA in people with LBP.

METHODS

A mixed methods cluster randomised controlled trial involving 46 adults with LBP in Melbourne, Australia. Participants attended weekly 30-min physical therapy consultations for 6 weeks. Experimental group physical therapists were taught to embed MI into consultations and patients were provided with a self-directed app. The primary outcome was accelerometer-derived moderately vigorous PA. Secondary outcomes were LBP disability (Oswestry Disability Index), functional capacity (Patient Specific Functional Scale), and self-efficacy (Pain Self-Efficacy Questionnaire). Between-group differences were analysed by ANCOVA post-intervention.

RESULTS

There was no statistically significant difference between the experimental group and control group for PA. Between-group differences in LBP disability (MD= 19.4 units, 95% CI: 8.5, 30.3), functional capacity (primary MD= -4.1 units, 95% CI: -6.9, -1.3; average MD= -3.1, 95% CI: -4.9, -1.2) and self-efficacy (MD -11.3 units, 95%CI -20.2, -2.5) favoured the control group with small to moderate effect sizes. There were low levels of overall engagement with the app.

CONCLUSION

The embedded MI intervention was no more beneficial than physical therapy alone for PA and was associated with poorer LBP disability, function, and self-efficacy. The effectiveness of embedding MI and a smartphone app into usual care for LBP was not supported.

Low back pain self-management mobile applications: a systematic review on digital platforms

OBJECTIVE

To identify and analyze the features and quality of self-management support of mobile applications available in Brazil for chronic low back pain in adults.

METHOD

A systematic review on the Apple Store® and Google Play® digital platforms. The Self-Management Support Assessment Tool scale was used to assess self-management support and the Institute for Healthcare Informatics Functionality Score scale was used to assess functionality.

RESULTS

Seventeen applications were selected, which included around seven self-management skills. The applications that met the majority of self-management support skills were Pathways, Branch, Pancea, Pain Navigator, and Curable. The Curable, Branch and MoovButh applications had the highest scores, with ten features on the functionality scale.

CONCLUSION

Some applications have the potential to complement in-person treatment in terms of validity, acceptability and clinical usefulness in pain management. However, barriers such as lack of partnership between healthcare providers and patients, limited evidence-based content, social support, cultural relevance, cost, language, security and privacy can limit their sustained use. PROSPERO Registration: CRD42022382686.

Factors influencing the use of an artificial intelligence-based app (selfBACK) for tailored self-management support among adults with neck and/or low back pain

PURPOSE

Tailored self-management support is recommended as first-line treatment for neck and low back pain, for which mHealth applications could be promising. However, there is limited knowledge about factors influencing the engagement with such apps. The aim of this study was to assess barriers and facilitators for engaging with a self-management mHealth app among adults suffering from neck and/or low back pain.

MATERIALS AND METHODS

We carried out a qualitative descriptive study among adults with neck and/or low back pain. The artificial intelligence-based selfBACK app supports tailored self-management of neck and low back pain and was used for 6 weeks. After these 6 weeks, participants were interviewed by phone.

RESULTS

Thirty-two adults (17 males) with neck and/or low back pain participated (mean age = 54.9 (SD = 15.8)). Our results show that the mode of delivery and the novelty of the selfBACK app were perceived most often as a barrier to use the app. The action plans of the app and health-related factors were perceived most often as facilitating factors.

CONCLUSIONS

This study provides insight into possible strategies to improve an mHealth service. Furthermore, it shows that adults with neck and/or low back pain are willing and ready to receive blended treatment.

Barriers and facilitators to engaging with a digital self-management programme for painful distal upper limb musculoskeletal disorders: A qualitative exploratory study

INTRODUCTION

People living with a painful distal upper limb musculoskeletal disorder (DUL-MSD) often experience pain, difficulty in doing everyday tasks and a reduced quality of life. Currently, there are challenges in the treatment of DUL-MSDs, highlighting the need to develop innovative approaches to rehabilitation. A potential solution is to develop and implement a digital self-management rehabilitation programme focussing on optimising recovery, improving function and reducing pain. Before developing this programme, we aimed to identify the barriers and facilitators to using a digital health intervention (DHI) for self-management of DUL-MSDs.

OBJECTIVE

This study aimed to investigate the potential barriers and facilitators to using a DHI with people living with DUL-MSDs and healthcare professionals (HCPs).

METHODS

A qualitative exploratory study was carried out with purposely selected participants consisting of 15 participants with DUL-MSDs and 13 HCPs. Three focus groups (FGs) and four semistructured interviews with DUL-MSD participants and semistructured interviews with 13 HCPs were conducted. FGs and interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis.

RESULTS

To address challenges in the care and management of DUL-MSDs, both HCPs and people living with a DUL-MSD welcomed the development of a DHI. This study identified several barriers and facilitators that would influence engagement with a digital intervention. Findings suggest that in developing a DHI, attention needs to be paid to digital design features, usability, tailoring, personalisation and consideration of how well usual care could be replicated digitally without direct HCP involvement.

CONCLUSION

The identified digital design features of importance to participants will inform the design of a digital self-management rehabilitation programme for people living with DUL-MSDs. Addressing the barriers and facilitators to engagement with a DHI is essential in ensuring its relevance and acceptability to those who will use it.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement and Engagement (PPIE) was integral throughout the study. PPIE members contributed to the development and planning of this study, checked and confirmed the relevance of the findings and are involved in the dissemination plans.

Protocol for the Support Application for Food PAntrieS trial: design, implementation, and evaluation plan for a digital application to promote healthy food access and support food pantry operations

Introduction

Food-insecure households commonly rely on food pantries to supplement their nutritional needs, a challenge that was underscored during the COVID-19 pandemic. Food pantries, and the food banks that supply them, face common challenges in meeting variable client volume and dietary needs under normal and emergency (e.g., pandemic, natural disaster) conditions. A scalable digital strategy that has the capacity to streamline the emergency food distribution system, while promoting healthy food options, managing volunteer recruitment and training, and connecting to emergency management systems in times of need, is urgently required. To address this gap, we are developing a working mobile application (app) called the Support Application for Food PAntrieS (SAFPAS) and will evaluate its feasibility and impact on food pantry staff preparedness, stocking, and client uptake of healthful foods and beverages in two urban United States settings.

Methods

This paper describes the protocol for a randomized controlled trial of the SAFPAS mobile application. We will conduct formative research in Baltimore, Maryland and Detroit, Michigan to develop and refine the SAFPAS app and increase scalability potential to other urban settings. Then we will test the app in 20 food pantries in Baltimore randomized to intervention or comparison. The impact of the app will be evaluated at several levels of the emergency food system, including food pantry clients (n = 360), food pantry staff and volunteers (n = 100), food pantry stock, and city agencies such as the local food bank and Office of Emergency Management. The primary outcome of the SAFPAS trial is to improve the healthfulness of the foods received by food pantry clients, measured using the Food Assessment Scoring Tool (FAST). Post-trial, we will conduct additional formative research in Detroit to prepare the app for scale-up.

Discussion

We anticipate that SAFPAS will improve alignment in the supply and demand for healthy foods among food pantry clients, food pantries, and city agencies which supply food in Baltimore. Real-time, bidirectional communication between entities across the system allows for increased situational awareness at all levels during normal and emergency operations. By conducting formative research in Detroit, we hope to increase the scalability of the SAFPAS app to additional settings nationwide.

Clinical trial registration

NCT87654321. https://classic.clinicaltrials.gov/ct2/show/NCT05880004.

Impact of digital services on healthcare and social welfare: An umbrella review

BACKGROUND

Digital services can be effective and cost-efficient options for treating non-communicable diseases, but generalizability is limited due to heterogeneous treatment effects. This umbrella review aims to evaluate the impact of digital services on population health, costs, and patient and healthcare professional satisfaction, and to identify facilitators and barriers to using digital services in healthcare and social welfare.

METHODS

The protocol of the study was registered on the 4th of September 2022 to the International Prospective Register of Systematic Reviews, PROSPERO (CRD42022355635). The review was performed using the Centre for Reviews and Dissemination, Cochrane, Ovid Medline, Scopus, and Web of Science in June 2022. The methodological quality of the included reviews was assessed. The impact of digital services was categorized as no evidence, no dominance, and mixed and positive effect. Inductive content analysis was used to identify facilitators and barriers.

RESULTS

A total of 66 studies were included in the review, 64 % of which were evaluated as high quality. Studies on the impact of digital services in social welfare were not identified. Sixty-five percent of reviews evaluated the impact of digital services on population health with mixed effects; 21 % were on costs with mixed effects; 27 % were on patient satisfaction with positive effects; and 7.6 % were on healthcare professionals' satisfaction with mixed effects. Various features, allocation, end-user support, organized services, and service development facilitated the use of digital services. Correspondingly, barriers were related to service limitations, digital competency, funding- and service strategies, resources and change management.

CONCLUSIONS

Compared to usual care, digital services had a mixed impact on population health and costs with high satisfaction in patients. Mixed healthcare professionals' satisfaction was associated with the use of digital services, and it was less studied. To ensure successful implementation and sustainability of digital services, attention must be paid to address barriers and supporting facilitators at all levels.

Patients' Experiences of Digital Health Interventions for the Self-Management of Chronic Pain: Protocol for a Systematic Review and Thematic Synthesis

BACKGROUND

Chronic pain is a highly prevalent condition that requires multidisciplinary treatment. However, in the United Kingdom, access to specialist pain clinics where patients can receive medical multidisciplinary treatment is limited, and provision varies between health boards. As such, self-management of chronic pain using digital tools has been gaining traction recently, but evidence of its effectiveness from clinical-based trials focuses mainly on quantitative outcomes.

OBJECTIVE

This systematic review aims to identify, appraise, and synthesize qualitative evidence on patients' experiences with digital health interventions (DHIs) for the management of chronic pain.

METHODS

This systematic review will consider qualitative and mixed methods studies that explore the experience of patients (aged 18 years and older) with chronic pain engaging in DHIs to manage their pain. MEDLINE Ovid, PubMed, Embase, CINAHL, PsycINFO, and Scopus databases will be searched for published studies. The systematic review will be conducted in accordance with the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines. Following the 3-step thematic synthesis methodology of Thomas and Harden, titles and abstracts will be screened by 2 independent reviewers (AM and HM), and a third reviewer (MI or FM) will resolve any conflict that arises before the full-text screening. The Critical Appraisal Skills Programme checklist tool will be used to critically appraise the included studies. The extracted data will be imported to NVivo (QSR International), where thematic synthesis will be used to derive analytical themes from the included studies.

RESULTS

Themes that encapsulate the patient experience will be identified from qualitative evidence, and these themes will shed light on the perceived benefits and disadvantages, usability, acceptability, and the overall impact digital tools can have on the lives of those with chronic pain.

CONCLUSIONS

This systematic review will identify, appraise, and synthesize the overall experience of patients engaging in DHI to manage a diverse range of chronic pain conditions. By elaborating the patient experience through qualitative analysis, the findings from this review will enhance our current understanding of the experiences of patients with chronic pain using digital tools for the self-management of their pain and highlight what person-centered elements are essential for future DHI development.

TRIAL REGISTRATION

PROSPERO CRD42023445100; http://tinyurl.com/4z77khfs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52469.

Online health information-seeking behaviours for low back pain in the United Kingdom: analysis of data from Google trends and the Global Burden of Disease Study, 2004-2019

BACKGROUND

Low back pain (LBP) is a leading cause of global disability. Timely health-seeking is crucial for early diagnosis and management of pathologies. Despite increases in internet usage, there is sparse literature regarding online health information-seeking behaviours (OHISBs) for LBP and how they correlate with the LBP disease burden in the UK.

METHODS

To examine OHISB trends, we conducted Prais-Winsten analyses on monthly search volume data from Google Trends in the UK between 1 January 2004 and 1 December 2019. Cross-correlation analyses assessed the relationship between annual LBP search volume and LBP morbidity and mortality data from the Global Burden of Disease study (2004-2019).

RESULTS

From 2004 to 2019, the trend in LBP search volume was curvilinear (β=1.27, t=5.00, p<0.001), with a slope change around the end of 2006. There was a negative linear trend (β=-0.25, t35=-1.52, p<0.14) from 2004 to 2006 and a positive linear trend (β=0.67, t108=9.17, p<0.001) from 2007 to 2019. Cross-correlations revealed positive associations between search volume and disease burden indicators for LBP such as prevalence and incidence at lags 4 and 5.

CONCLUSIONS

A rising trend in OHISBs for LBP was noted between 2004 and 2019. This trend positively correlates with incidence, prevalence and burden measures. These findings emphasise the importance of high-quality online resources to increase awareness around LBP, facilitating early diagnosis and management.

Acceptability, values, and preferences of older people for chronic low back pain management; a qualitative evidence synthesis

BACKGROUND

Chronic primary low back pain (CPLBP) and other musculoskeletal conditions represent a sizable attribution to the global burden of disability, with rates greatest in older age. There are multiple and varied interventions for CPLBP, delivered by a wide range of health and care workers. However, it is not known if these are acceptable to or align with the values and preferences of care recipients. The objective of this synthesis was to understand the key factors influencing the acceptability of, and values and preferences for, interventions/care for CPLBP from the perspective of people over 60 and their caregivers.

METHODS

We searched MEDLINE, CINAHL and OpenAlex, for eligible studies from inception until April 2022. We included studies that used qualitative methods for data collection and analysis; explored the perceptions and experiences of older people and their caregivers about interventions to treat CPLBP; from any setting globally. We conducted a best fit framework synthesis using a framework developed specifically for this review. We assessed our certainty in the findings using GRADE-CERQual.

RESULTS

All 22 included studies represented older people's experiences and had representation across a range of geographies and economic contexts. No studies were identified on caregivers. Older people living with CPLBP express values and preferences for their care that relate to therapeutic encounters and the importance of therapeutic alliance, irrespective of the type of treatment, choice of intervention, and intervention delivery modalities. Older people with CPLBP value therapeutic encounters that validate, legitimise, and respect their pain experience, consider their context holistically, prioritise their needs and preferences, adopt a person-centred and tailored approach to care, and are supported by interprofessional communication. Older people valued care that provided benefit to them, included interventions beyond analgesic medicines alone and was financially and geographically accessible.

CONCLUSIONS

These findings provide critical context to the implementation of clinical guidelines into practice, particularly related to how care providers interact with older people and how components of care are delivered, their location and their cost. Further research is needed focusing on low- and middle-income settings, vulnerable populations, and caregivers.

Mobile apps to self-manage chronic low back pain: A realist synthesis exploring what works, for whom and in what circumstances

Objective

Chronic low back pain places a significant burden on healthcare services and sufferers. Clinical guidelines state that it is a condition that requires self-management. This realist synthesis explores how a mobile app could help people to self-manage chronic low back pain.

Method

Six databases and several non-academic sources were searched. In addition, nineteen realist interviews were conducted with stakeholders. Sources were selected and appraised for relevancy, richness, and rigour. Data was coded with analytical memos making retroductive inferences. Causal explanations were presented in context-mechanism-outcome configurations to form three programme theories.

Results

Data from 57 sources was synthesised to create 16 context-mechanism-outcome configurations and presented as three refined programme theories. The findings suggest people need to feel believed before they will engage with a self-management app. For those who feel abandoned by the healthcare service, a self-management app for chronic low back pain can be a valuable source of ongoing support and reduce feelings of social isolation.

Conclusion

A self-management app, if introduced appropriately and as adjunct to care, can be an empowering tool to self-manage chronic low back pain.

Innovation

Using input from key stakeholders enhances our understanding of the hidden generative mechanisms underpinning a programme's success or failure.

Evaluación del uso de la Aplicación Renal Health por parte de los receptores de trasplante renal

Resumen Objetivo: evaluar el uso de la aplicación Renal Health por parte de los receptores de trasplante renal. Método: estudio observacional retrospectivo con una muestra compuesta por usuarios que se registraron en la sección de trasplantados renales dentro de la aplicación desde julio de 2018 hasta abril de 2021. Se recolectaron las siguientes variables: datos demográficos, ingreso de datos, tiempo de uso, registros de peso, presión arterial, glucosa en sangre, creatinina, esquemas de medicación, consultas y exámenes. Se realizó un análisis descriptivo de los datos. Resultados: Ocurrieron 1.823 descargas de la aplicación y 12,3% se registró en la sección de trasplantados, la mayoría del sudeste de Brasil (44,9%), con edad de 36±11 años y del sexo femenino (59,1%). De la muestra, 35,1% ingresó información como: creatinina (62%), peso (58,2%) y presión arterial (51,8%). La mayoría utilizó la aplicación durante un día (63,3%) y el 13,9% más de cien días. Quienes lo usaron por más de un día (36,7%), agregaron peso (69%), programación de consultas (69%), medicación (65,5%) y creatinina (62%). Conclusión: la sección para trasplantados renales de la aplicación Renal Health despertó interés en la población joven, pero mostró baja adherencia en los meses evaluados. Estos resultados ofrecen una perspectiva relevante en la implementación de tecnologías mHealth en el trasplante renal.

Avaliação do uso do aplicativo Renal Health por transplantados renais

Resumo Objetivo: avaliar o uso do aplicativo Renal Health por transplantados renais. Método: estudo observacional retrospectivo com amostra composta por usuários que realizaram cadastro na seção para transplantados renais do aplicativo de julho de 2018 a abril de 2021. Foram coletadas as seguintes variáveis: dados demográficos, inserção de dados, tempo de uso, registros de peso, pressão arterial, glicemia, creatinina, horários das medicações, consultas e exames. Realizou-se análise descritiva dos dados. Resultados: houve 1.823 downloads do aplicativo e 12,3% cadastraram-se na seção para transplantados renais, a maioria do Sudeste do Brasil (44,9%), com 36±11 anos e do sexo feminino (59,1%). Da amostra, 35,1% inseriram informações como creatinina (62%), peso (58,2%) e pressão arterial (51,8%). A maioria utilizou o aplicativo por um dia (63,3%) e 13,9% por mais de cem dias. Os que utilizaram por mais de um dia (36,7%), inseriram peso (69%), agendaram consultas (69%), medicações (65,5%) e creatinina (62%). Conclusão: a seção para transplantados renais do aplicativo Renal Health despertou interesse na população jovem, mas apresentou baixa adesão ao longo dos meses avaliados. Esses resultados oferecem perspectiva relevante na implementação de tecnologias mHealth no transplante renal.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Exploring the potential of mobile health interventions to address behavioural risk factors for the prevention of non-communicable diseases in Asian populations: a qualitative study

BACKGROUND

Changing lifestyle patterns over the last decades have seen growing numbers of people in Asia affected by non-communicable diseases and common mental health disorders, including diabetes, cancer, and/or depression. Interventions targeting healthy lifestyle behaviours through mobile technologies, including new approaches such as chatbots, may be an effective, low-cost approach to prevent these conditions. To ensure uptake and engagement with mobile health interventions, however, it is essential to understand the end-users' perspectives on using such interventions. The aim of this study was to explore perceptions, barriers, and facilitators to the use of mobile health interventions for lifestyle behaviour change in Singapore.

METHODS

Six virtual focus group discussions were conducted with a total of 34 participants (mean ± SD; aged 45 ± 3.6 years; 64.7% females). Focus group recordings were transcribed verbatim and analysed using an inductive thematic analysis approach, followed by deductive mapping according to perceptions, barriers, facilitators, mixed factors, or strategies.

RESULTS

Five themes were identified: (i) holistic wellbeing is central to healthy living (i.e., the importance of both physical and mental health); (ii) encouraging uptake of a mobile health intervention is influenced by factors such as incentives and government backing; (iii) trying out a mobile health intervention is one thing, sticking to it long term is another and there are key factors, such as personalisation and ease of use that influence sustained engagement with mobile health interventions; (iv) perceptions of chatbots as a tool to support healthy lifestyle behaviour are influenced by previous negative experiences with chatbots, which might hamper uptake; and (v) sharing health-related data is OK, but with conditions such as clarity on who will have access to the data, how it will be stored, and for what purpose it will be used.

CONCLUSIONS

Findings highlight several factors that are relevant for the development and implementation of mobile health interventions in Singapore and other Asian countries. Recommendations include: (i) targeting holistic wellbeing, (ii) tailoring content to address environment-specific barriers, (iii) partnering with government and/or local (non-profit) institutions in the development and/or promotion of mobile health interventions, (iv) managing expectations regarding the use of incentives, and (iv) identifying potential alternatives or complementary approaches to the use of chatbots, particularly for mental health.

Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field

Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.

A qualitative assessment of a text message intervention for people with low back pain

BACKGROUND

Text messages represent a simple and scalable strategy to provide self-management to people with low back pain (LBP), yet their usefulness is unknown.

OBJECTIVE

To assess the usefulness, delivery format, behaviour-change ability and potential for the TEXT4myBACK intervention to be scaled-up.

DESIGN

Qualitative study nested within a randomised controlled trial.

METHODS

64 participants of the TEXT4myBACK trial randomised to the intervention arm were invited to participate in online sessions. Participants provided feedback about the text messages received. Online sessions were conducted by two researchers until thematic saturation was achieved. Information was analysed based on framework analysis and thematic data-driven coding.

RESULTS

Of the 64 invited, 10 people participated in the sessions and thematic saturation was reached. The following themes were identified: intervention's format, barriers and facilitators for behaviour-change, effectiveness, and implementation into healthcare. The messages were considered useful and their format was well-accepted, whilst some suggested a longer duration. The messages were considered simple to read and understand yet further information about LBP and exercise would be appreciated. Some believed the intervention improved their LBP and others believed its effectiveness would depend on receiver's characteristics. Participants felt the messages helped them to increase physical activity. Provision of information, reminders, and self-awareness were some behaviour-change facilitators. Participants said the intervention could be provided by healthcare professionals either for free or through a small fee.

CONCLUSIONS

The TEXT4myBACK intervention was useful and well-accepted. It provided reminders and supported increases in physical activity. Participants provided suggestions for the intervention to be scaled-up.

Self-management programs to ensure sustainable return to work following long-term sick leave due to low back pain: A sequential qualitative study

BACKGROUND

Low back pain (LBP) is a prevalent condition frequently leading to disability. Research suggests that self-management (SM) programs for chronic LBP should include strategies to promote sustainable return to work.

OBJECTIVES

This study aimed to 1) validate and prioritize the essential content elements of a SM program in light of the needs of workplace representatives, and 2) identify the main facilitators and barriers to be considered when developing and implementing a SM program delivered via information and communication technologies (ICT).

METHODS

A sequential qualitative design was used. We recruited workplace representatives and potential future users of SM programs (union representatives and employers) and collected data through focus groups and nominal group techniques to validate the relevance of the different elements included into 3 broad categories (Understand, Learn, Apply), as well as to highlight potential barriers and facilitators.

RESULTS

Eleven participants took part in this study. The content elements proposed in the literature for SM programs were found to align with potential future users' needs, with participants ranking the same elements as those proposed in the scientific literature as the most important across all categories. Although some barriers were identified, workplace representatives believed that ICT offer an appropriate strategy for delivering individualized SM programs to injured workers who have returned to work.

CONCLUSION

Our study suggests that the elements identified in the literature as essential components of SM programs designed to ensure a sustainable return to work for people with LBP are in line with the needs of future users.

Digital health in pain assessment, diagnosis, and management: Overview and perspectives

Managing pain is essential for social, psychological, physical, and economic reasons. It is also a human right with a growing incidence of untreated and under-treated pain globally. Barriers to diagnosing, assessing, treating, and managing pain are complicated, subjective, and driven by patient, healthcare provider, payer, policy, and regulatory challenges. In addition, conventional treatment methods pose their own challenges including the subjectivity of assessment, lack of therapeutic innovation over the last decade, opioid use disorder and financial access to treatment. Digital health innovations hold much promise in providing complementary solutions to traditional medical interventions and may reduce cost and speed up recovery or adaptation. There is a growing evidence base for the use of digital health in pain assessment, diagnosis, and management. The challenge is not only to develop new technologies and solutions, but to do this within a framework that supports health equity, scalability, socio-cultural consideration, and evidence-based science. The extensive limits to physical personal interaction during the Covid-19 pandemic 2020/21 has proven the possible role of digital health in the field of pain medicine. This paper provides an overview of the use of digital health in pain management and argues for the use of a systemic framework in evaluating the efficacy of digital health solutions.

Evaluation of the use of a Renal Health application by kidney transplant recipients

OBJECTIVE

to evaluate the use of a renal health application by kidney transplant recipients.

METHOD

a retrospective, observational study with a sample composed of individuals registered in the kidney transplant section of the application from July of 2018 to April of 2021. Demographic data, data entry, time of use, weight, blood pressure, blood glucose, creatinine, medication schedules, appointments, and tests were the variables collected. Descriptive analysis of the data was performed.

RESULTS

eight hundred and twenty-three downloads of the application were identified, and 12.3% of those were registered as kidney transplant recipients, the majority from southeastern Brazil (44.9%), 36±11 years old, and female (59.1%). Of the sample, 35.1% entered information such as creatinine (62%), weight (58.2%), and blood pressure (51.8%). Most used the application for one day (63.3%) and 13.9% for more than one hundred days. Those who used it for more than one day (36.7%) recorded weight (69%), medication intake (65.5%) and creatinine (62%), and scheduled appointments (69%).

CONCLUSION

the kidney transplant recipient section of the Renal Health application generated interest in the young population, but showed low adherence throughout the assessed months. These results offer a relevant perspective on the implementation of mHealth technologies in kidney transplantation.

The Acceptance, Usability, and Utility of a Web Portal for Back Pain as Recommended by Primary Care Physicians: Qualitative Interview Study With Patients

BACKGROUND

An ever-increasing number of patients seek health information via the internet. However, there is an overabundance of differing, often low-quality information available, while a lack of health literacy makes it difficult for patients to understand and assess the quality and trustworthiness of the information at hand. The web portal tala-med was thus conceived as an evidence-based, up-to-date, and trustworthy information resource for lower back pain (LBP), which could be used by primary care physicians (PCPs) and patients during and following consultations for LBP. The current evidence demonstrates that patients with LBP could benefit from web portals. However, the use of such portals by patients remains low, thus limiting their effectiveness. Therefore, it is important to explore the factors that promote or hinder the use of web portals and investigate how patients perceive their usability and utility.

OBJECTIVE

In this study, we investigated the acceptance, usability, and utility of the web portal tala-med from the patient perspective.

METHODS

This qualitative study was based on telephone interviews with patients who had access to the web portal tala-med from their PCP. We used a semistructured interview guide that consisted of questions about the consultation in which patients were introduced to tala-med, in addition to questions regarding patient perceptions, experiences, and utilization of tala-med. The interviews were recorded, transcribed, and analyzed through framework analysis.

RESULTS

A total of 32 half-hour interviews were conducted with 16 female and 16 male patients with LBP. We identified 5 themes of interest: the use of tala-med by PCPs during the consultation, the use of tala-med by patients, its usability, added values derived from its use, and the resultant effects of using tala-med. PCPs used tala-med as an additional information resource for their patients and recommended the exercises. The patients appreciated these exercises and were willing to use tala-med at home. We also identified factors that promoted or hindered the use of tala-med by patients. Most patients rated tala-med positively and considered it a clear, comprehensible, trustworthy, and practical resource. In particular, the trustworthiness of tala-med was seen as an advantage over other information resources. The possibilities offered by tala-med to recap and reflect on the contents of consultations in a time-flexible and independent manner was perceived as an added value to the PCP consultation.

CONCLUSIONS

Tala-med was well accepted by patients and appeared to be well suited to being used as an add-on to PCP consultations. Patient perception also supports its usability and utility. Tala-med may therefore enrich consultations and assist patients who would otherwise be unable to find good-quality web-based health information on LBP. In addition, our findings support the future development of digital health platforms and their successful use as a supplement to PCP consultations.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12875-019-0925-8.

One size does not fit all: Participants' experiences of the selfBACK app to support self-management of low back pain-a qualitative interview study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for disability globally. Digital interventions are a promising means of supporting people to self-manage LBP, but implementation of digital interventions has been suboptimal. An artificial intelligence-driven app, selfBACK, was developed to support self-management of LBP as an adjunct to usual care. To better understand the process of implementation from a participant perspective, we qualitatively explored factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and the self-perceived effects, acceptability, and satisfaction with the selfBACK app.

METHODS

Using a qualitative interview study and an analytic framework approach underpinned by Normalization Process Theory (NPT), we investigated the experiences of patients who participated in the selfBACK randomized controlled trial (RCT). Interviews focused on the motivation to participate in the RCT, experiences of using the selfBACK app, and views about future intended use and potential of using digital health interventions for self-management of LBP. Participants were purposively sampled to represent diversity in age, sex, and implementation reflected by a proxy measure of number of app-generated self-management plans during the first three months of RCT participation.

RESULTS

Twenty-six participants aged 21-78, eleven females and fifteen men, with two to fourteen self-management plans, were interviewed between August 2019 and April 2020. A broad range of factors influencing implementation of selfBACK within all constructs of NPT were identified. Key facilitating factors were preferences and beliefs favoring self-management, a friendly, motivational, and reassuring supporter, tailoring and personalization, convenience and ease of use, trustworthiness, perceiving benefits, and tracking achievements. Key impeding factors were preferences and beliefs not favoring self-management, functionality issues, suboptimal tailoring and personalization, insufficient time or conflicting life circumstances, not perceiving benefits, and insufficient involvement of health care practitioners. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant.

CONCLUSIONS

The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions using digital health tools.

Patient Perspectives on Using a Smartphone App to Support Home-Based Exercise During Physical Therapy Treatment: Qualitative Study

Background

Home-based exercise is an important part of physical therapy treatment for patients with low back pain. However, treatment effectiveness depends heavily on patient adherence to home-based exercise recommendations. Smartphone apps designed to support home-based exercise have the potential to support adherence to exercise recommendations and possibly improve treatment effects. A better understanding of patient perspectives regarding the use of smartphone apps to support home-based exercise during physical therapy treatment can assist physical therapists with optimal use and implementation of these apps in clinical practice.

Objective

The aim of this study was to investigate patient perspectives on the acceptability, satisfaction, and performance of a smartphone app to support home-based exercise following recommendations from a physical therapist.

Methods

Using an interpretivist phenomenology approach, 9 patients (4 males and 5 females; aged 20-71 years) with nonspecific low back pain recruited from 2 primary care physical therapy practices were interviewed within 2 weeks after treatment ended. An interview guide was used for the interviews to ensure that different aspects of the patients’ perspectives were discussed. The Physitrack smartphone app was used to support home-based exercise as part of treatment for all patients. Data were analyzed using the “Framework Method” to assist with interpretation of the data.

Results

Data analysis revealed 11 categories distributed among the 3 themes “acceptability,” “satisfaction,” and “performance.” Patients were willing to accept the app as part of treatment when it was easy to use, when it benefited the patient, and when the physical therapist instructed the patient in its use. Satisfaction with the app was determined by users’ perceived support from the app when exercising at home and the perceived increase in adherence. The video and text instructions, reminder functions, and self-monitor functions were considered the most important aspects for performance during treatment. The patients did not view the Physitrack app as a replacement for the physical therapist and relied on their therapist for instructions and support when needed.

Conclusions

Patients who use an app to support home-based exercise as part of treatment are accepting of the app when it is easy to use, when it benefits the patient, and when the therapist instructs the patient in its use. Physical therapists using an app to support home-based exercise can use the findings from this study to effectively support their patients when exercising at home during treatment.

From hands-on to remote: Moderators of response to a novel self-management telehealth programme during the COVID-19 pandemic

BACKGROUND

In March 2020, state-wide lockdowns were declared in many countries, including Spain. Citizens were confined to their homes and remotely supported activities were prioritized as an alternative to in-person interactions. Previous data suggest that remote and self-management interventions may be successful at reducing pain and related psychological variables. However, individual factors influencing the effectiveness of these interventions remain to be identified. We aimed to investigate the psychological and motivational factors moderating changes in pain observed in chiropractic patients undertaking a novel telehealth self-management programme.

METHODS

A cohort of 208 patients from a chiropractic teaching clinic was recruited to participate in the study. Patients received telehealth consultations and individualized self-management strategies tailored for their current complaint. They were encouraged to make use of these strategies daily for 2-4 weeks, whilst rating their pain intensity, motivation and adherence. Validated questionnaires were completed online to assess catastrophizing, kinesiophobia and anxiety.

RESULTS

A total of 168 patients completed the first 2 weeks of the programme, experiencing significant reductions in all variables. Kinesiophobia emerged as a key factor influencing pain reduction and moderating the association between motivation and pain relief. In turn, adherence to the programme was associated with lower pain intensity, although moderated by the degree of motivation.

CONCLUSIONS

In the context of COVID-19, when introducing remote and self-management strategies, pain cognitions and motivational factors should be taken into consideration to foster adherence and yield better pain outcomes.

Clinical outcomes one year after a digital musculoskeletal (MSK) program: an observational, longitudinal study with nonparticipant comparison group

Background

The evidence base for the impact of digital health on musculoskeletal (MSK) outcomes is growing, but it is unclear how much digital MSK programs address pain and function in the intermediate and long term.

Methods

This observational study of digital MSK program participants versus nonparticipants (n = 2570) examined pain, function, depression, and anxiety at 3, 6, and 12 months, and health care use at 12 months. The intervention group engaged in a digital MSK program that included exercise, education, and coaching for at least 3 months. The nonparticipant group registered, but never started the program. We collected data in app or by emailed survey at 3, 6, and 12 months after registering for the program. We conducted descriptive analyses and unadjusted and adjusted regression modeling.

Results

The odds ratio of achieving a minimally clinically important difference (MCID) in pain improvement for the intervention versus the nonparticipant group was 1.97 (95% CI: 1.28, 3.02; p = .002) at 3 months, 1.44 (95% CI: 0.91, 2.25; p = .11) at 6 months, and 2.06 (95% CI: 1.38, 3.08; p = .004) at 12 months in adjusted models. The odds ratio of achieving a MCID in functional improvement for the intervention versus the nonparticipant group was 1.56 (95% CI: 1.03, 2.38; p = .01) at 3 months, 1.55 (95% CI: 1.02, 2.37; p = .04) at 6 months, and 1.35 (95% CI: 0.89, 2.06, p = 0.16) at 12 months in adjusted models. For those with moderate to severe depression or anxiety at baseline, we observed statistically significant lower odds of moderate to severe depression or anxiety at 3 months, 6 months, and 12 months for the intervention versus the nonparticipant group in adjusted models (p < .05). At 12 months, the percentage with invasive, imaging, and conservative services was higher for the nonparticipant versus intervention group by 5.7, 8.1, and 16.7 percentage points, respectively (p < 0.05).

Conclusions

A digital MSK program may offer participants sustained improvement in pain, depression, and anxiety with concomitant decreases in health care use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05188-x.

Multimorbidity and co-occurring musculoskeletal pain do not modify the effect of the SELFBACK app on low back pain-related disability

BACKGROUND

SELFBACK, an artificial intelligence (AI)-based app delivering evidence-based tailored self-management support to people with low back pain (LBP), has been shown to reduce LBP-related disability when added to usual care. LBP commonly co-occurs with multimorbidity (≥ 2 long-term conditions) or pain at other musculoskeletal sites, so this study explores if these factors modify the effect of the SELFBACK app or influence outcome trajectories over time.

METHODS

Secondary analysis of a randomized controlled trial with 9-month follow-up. Primary outcome is as follows: LBP-related disability (Roland Morris Disability Questionnaire, RMDQ). Secondary outcomes are as follows: stress/depression/illness perception/self-efficacy/general health/quality of life/physical activity/global perceived effect. We used linear mixed models for continuous outcomes and logistic generalized estimating equation for binary outcomes. Analyses were stratified to assess effect modification, whereas control (n = 229) and intervention (n = 232) groups were pooled in analyses of outcome trajectories.

RESULTS

Baseline multimorbidity and co-occurring musculoskeletal pain sites did not modify the effect of the SELFBACK app. The effect was somewhat stronger in people with multimorbidity than among those with LBP only (difference in RMDQ due to interaction, - 0.9[95 % CI - 2.5 to 0.6]). Participants with a greater number of long-term conditions and more co-occurring musculoskeletal pain had higher levels of baseline disability (RMDQ 11.3 for ≥ 2 long-term conditions vs 9.5 for LBP only; 11.3 for ≥ 4 musculoskeletal pain sites vs 10.2 for ≤ 1 additional musculoskeletal pain site); along with higher baseline scores for stress/depression/illness perception and poorer pain self-efficacy/general health ratings. In the pooled sample, LBP-related disability improved slightly less over time for people with ≥ 2 long-term conditions additional to LBP compared to no multimorbidity and for those with ≥4 co-occurring musculoskeletal pain sites compared to ≤ 1 additional musculoskeletal pain site (difference in mean change at 9 months = 1.5 and 2.2, respectively). All groups reported little improvement in secondary outcomes over time.

CONCLUSIONS

Multimorbidity or co-occurring musculoskeletal pain does not modify the effect of the selfBACK app on LBP-related disability or other secondary outcomes. Although people with these health problems have worse scores both at baseline and 9 months, the AI-based selfBACK app appears to be helpful for those with multimorbidity or co-occurring musculoskeletal pain.

TRIAL REGISTRATION

NCT03798288 . Date of registration: 9 January 2019.

At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain

ABSTRACT

Telehealth is a promising approach to support self-management with the potential to overcome geographical barriers. Understanding patient perspectives will identify practical challenges to delivering self-management strategies by telehealth. The aim of this study was to synthesize the perceptions of people with chronic musculoskeletal pain for engaging in interventions delivered using telehealth. We searched MEDLINE, Embase, CINAHL, LILACS, and PsycINFO databases. We included qualitative studies that explored perceptions or experiences or attitudes of people with chronic musculoskeletal pain engaging with telehealth. We assessed the methodological quality using the Critical Appraisal Skills Programme checklist. Meta-synthesis was guided by a thematic synthesis approach. The level of confidence of review findings was assessed using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). Twenty-one studies were included (n = 429). Telehealth comprised web-based, videoconference-based, telephone-based, video-based, and smartphone app-based programs delivered solely or combined. Chronic musculoskeletal conditions included people with knee or hip osteoarthritis, chronic low back pain, persistent pain (chronic joint pain or nonspecific chronic musculoskeletal pain), rheumatoid arthritis, and functional fatigue syndrome. The enablers for engaging in telehealth interventions were as follows: (1) "at my own pace, space, and place" and (2) empowered patient. Barriers to engaging in telehealth interventions were as follows: (1) impersonal, (2) technological challenges, (3) irrelevant content, and (4) limited digital (health) literacy. Telehealth interventions with well-designed interactive platforms, flexibility to fit patients' routine, and the broad availability of material may favor better engagement. Encouragement of self-efficacy is linked to successful telehealth-delivered self-management programs.

The Promise of Digital Self-Management: A Reflection about the Effects of Patient-Targeted e-Health Tools on Self-Management and Wellbeing

Increasingly, people have direct access to e-Health resources such as health information on the Internet, personal health portals, and wearable self-management applications, which have the potential to reinforce the simultaneously growing focus on self-management and wellbeing. To examine these relationships, we searched using keywords self-management, patient-targeting e-Health tools, and health as wellbeing. Direct access to the health information on the Internet or diagnostic apps on a smartphone can help people to self-manage health issues, but also leads to uncertainty, stress, and avoidance. Uncertainties relate to the quality of information and to use and misuse of information. Most self-management support programs focus on medical management. The relationship between self-management and wellbeing is not straightforward. While the influence of stress and negative social emotions on self-management is recognized as an important cause of the negative spiral, empirical research on this topic is limited to health literacy studies. Evidence on health apps showed positive effects on specific actions and symptoms and potential for increasing awareness and ownership by people. Effects on more complex behaviors such as participation cannot be established. This review discovers relatively unknown and understudied angles and perspectives about the relationship between e-Health, self-management, and wellbeing.

Using Intervention Mapping to Develop a Decision Support System–Based Smartphone App (selfBACK) to Support Self-management of Nonspecific Low Back Pain: Development and Usability Study

Background

International guidelines consistently endorse the promotion of self-management for people with low back pain (LBP); however, implementation of these guidelines remains a challenge. Digital health interventions, such as those that can be provided by smartphone apps, have been proposed as a promising mode of supporting self-management in people with chronic conditions, including LBP. However, the evidence base for digital health interventions to support self-management of LBP is weak, and detailed descriptions and documentation of the interventions are lacking. Structured intervention mapping (IM) constitutes a 6-step process that can be used to guide the development of complex interventions.

Objective

The aim of this paper is to describe the IM process for designing and creating an app-based intervention designed to support self-management of nonspecific LBP to reduce pain-related disability.

Methods

The first 5 steps of the IM process were systematically applied. The core processes included literature reviews, brainstorming and group discussions, and the inclusion of stakeholders and representatives from the target population. Over a period of >2 years, the intervention content and the technical features of delivery were created, tested, and revised through user tests, feasibility studies, and a pilot study.

Results

A behavioral outcome was identified as a proxy for reaching the overall program goal, that is, increased use of evidence-based self-management strategies. Physical exercises, education, and physical activity were the main components of the self-management intervention and were designed and produced to be delivered via a smartphone app. All intervention content was theoretically underpinned by the behavior change theory and the normalization process theory.

Conclusions

We describe a detailed example of the application of the IM approach for the development of a theory-driven, complex, and digital intervention designed to support self-management of LBP. This description provides transparency in the developmental process of the intervention and can be a possible blueprint for designing and creating future digital health interventions for self-management.