Development and Pilot Evaluation of an Online Relapse-Prevention Program Based on Acceptance and Commitment Therapy for Chronic Pain Patients

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

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.

Methods for Human-Centered eHealth Development: Narrative Scoping Review

Background

Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes.

Objective

The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods.

Methods

We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach.

Results

In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided.

Conclusions

This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.

Online Acceptance and Commitment Therapy (ACT) interventions for chronic pain: A systematic literature review

BACKGROUND

We systematically reviewed all literature concerning online Acceptance and Commitment Therapy (ACT) interventions for chronic pain to evaluate their (1) ACT content, (2) design characteristics, (3) design rationales, and (4) adherence.

MATERIAL AND METHODS

A systematic search was performed on July 9th, 2020 in; PubMed, PsycINFO, CINAHL, and Web of Science. Search terms related to: Acceptance and Commitment Therapy, chronic pain, and eHealth. Extracted data concerned ACT content, design characteristics, adherence, and design rationales.

RESULTS

20 articles, in which 14 interventions were described, met all inclusion criteria. Adherence and design rationales were described to a limited extent in the included studies. In total, the majority provided an overview of the included ACT processes. In 10 articles it was described that the intervention was delivered via a dedicated website (n = 10), which was sometimes combined with an app (n = 3). Guidance was included in most studies (n = 19). Studies including RCT's (n = 8) reported online ACT interventions to be effective.

CONCLUSION

Online ACT interventions for chronic pain have been shown to be effective and have generally been constructed in line with ACT theory. However, the majority of studies does not provide information about the choices to optimize the fit between task, technology, and user. Considerations behind the choices for intervention features as well as design rationales could help to optimize future online ACT interventions. Additionally, consistent attention should be paid to measurement and operationalization of adherence, since this is a crucial link between content, design and effectiveness.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

Efficacy of an ACT and Compassion-Based eHealth Program for Self-Management of Chronic Pain (iACTwithPain): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic pain (CP) has serious medical and social consequences and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving their quality of life is timely. Although acceptance and commitment therapy (ACT) is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates the change in disability and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a medical TAU group.

METHODS

The eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise eight weekly self-management sessions and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyze whether the iACTwithPain intervention will present superiority in improving CP's impact and related health markers over the two other conditions, this study will follow an RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-month follow-ups. The interventions' acceptability will also be assessed.

DISCUSSION

The iACTwithPain intervention is expected to improve CP patients' psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP.

CLINICAL TRIAL REGISTRATION

This trial has been registered at ClinicalTrials.Gov (NCT04200183; 16 December 2019; https://clinicaltrials.gov/ct2/show/NCT04200183). The current manuscript comprises the first version of this clinical trial's protocol.

What makes it work? Exploring experiences of patient research partners and researchers involved in a long-term co-creative research collaboration

BACKGROUND

Exchanging experiences of patient and public involvement (PPI) can bring insights into why, how and when PPI is most effective. The aim of this study was to explore the experiences of patient research partners (PRPs) and researchers engaged in a co-creative long-term collaboration in cancer research.

METHODS

The aim and procedures of this study were jointly decided upon by PRPs and researchers. The PRPs included former patients treated for cancer and significant others of the same target group. The participants (11 PRPs, 6 researchers) took part in semi-structured telephone interviews. The interviews were analysed using qualitative content analysis by a researcher who had no prior relationships with the participants.

RESULTS

Five overarching categories were identified: Reasons for investing in a long-term collaboration, Benefits of participating, Improving the research, Elements of success and Challenges and ways to improve. Reasons for investing in the collaboration included the desire to improve cancer care and to make use of own negative experiences. Benefits of participating included a positive impact on the PRPs' psychosocial adjustment to the illness. Moreover, the researchers highlighted that working together with the PRPs made the research feel more meaningful. The participants reported that the collaboration improved the relevance and acceptability of the research. Having a shared goal, a clear but yet accommodating structure, as well as an open and trustful working atmosphere were recognised as elements of success. The PRPs furthermore emphasized the importance of seeing that their input mattered. Among the few challenges raised were the distance to the meeting venues for some PRPs and a limited diversity among participants.

CONCLUSIONS

This study identified factors essential to researchers and clinicians attempting to engage the public in research. Our results suggest that for successful patient involvement, the purpose and format of the collaboration should be clear to both PRPs and researchers. A clear but yet accommodating structure and keen leadership emerged as key factors to create a sense of stability and a trustful atmosphere. Furthermore, providing regular feedback on how PRPs input is implemented is important for PRPs to stay committed over time.

Proposal for the User-Centered Design Approach for Health Apps Based on Successful Experiences: Integrative Review

Background

Different strategies encompassed within mHealth have shown themselves to be effective for maintaining good health or controlling certain diseases. However, there is usually a very high rate of abandonment of health apps. Therefore, it would seem obvious that there is a need for involving the end users (whether they are health professionals, patients, or both) in the design process from the early stages in order to enable their needs and characteristics to be identified. In this sense, it is common knowledge that focusing on the user permits the consideration of valuable details aimed at making the correct adjustment between the patient, the technology, and the organization of attention.

Objective

The goal of the research was to propose a methodology based on the review of previous successful user experiences in setting up health apps by using qualitative techniques (focus groups and discussion groups) that includes the participation of information technology and health professionals and the patients themselves.

Methods

An integrative review was made of studies in which a qualitative methodology was employed mainly through focus and/or discussion groups for the design and development of health apps, consulting diverse databases (PubMed, Scopus, and Proquest) with the following search strategy: “mHealth AND apps AND focus group OR discussion group.” A total of 69 papers were included in the review.

Results

A proposal structured in 4 sessions of variable duration was made in which information technology and health professionals and patients take part: composing, preparing, and organizing contents (session 1); testing structure and usability (session 2); does the app fit the needs of end users? (session 3); and last testing—keep on improving (session 4). Throughout the sessions, we propose studying aspects like previous user experiences in mHealth, barriers to the adoption of mHealth, interface contents, management and browsability, usability, perceived quality, security and privacy, capacity to self-manage disease with the app, ergonomics, and glanceability, etc. Specific tools that have proved useful in previous research for measuring these aspects are presented.

Conclusions

These work sessions would be based on predominantly qualitative methodologies although, as they evolve, validated questionnaires permitting the assessment of the objectivity of certain technical aspects could be incorporated. With this proposal, a project centered on end users could be effected, responding to their needs. However, this requires validation that will be made via implementation in the development of health apps, with the subsequent measurement of results in terms of adherence and improvement in the clinical variables of the end users.

Methodological Quality of Manuscripts Reporting on the Usability of Mobile Applications for Pain Assessment and Management: A Systematic Review

BACKGROUND

There has been increasing use of mobile mHealth applications, including pain assessment and pain self-management apps. The usability of mHealth applications has vital importance as it affects the quality of apps. Thus, usability assessment with methodological rigor is essential to minimize errors and undesirable consequences, as well as to increase user acceptance.

OBJECTIVE

this study aimed to synthesize and evaluate existing studies on the assessment of the usability of pain-related apps using a newly developed scale.

METHODS

an electronic search was conducted in several databases, combining relevant keywords. Then titles and abstracts were screened against inclusion and exclusion criteria. The eligible studies were retrieved and independently screened for inclusion by two authors. Disagreements were resolved by discussion until consensus was reached.

RESULTS

a total of 31 articles were eligible for inclusion. Quality assessment revealed that most manuscripts did not assess usability using valid instruments or triangulation of methods of usability assessment. Most manuscripts also failed to assess the three domains of usability (effectiveness, efficiency and satisfaction).

CONCLUSIONS

future studies should consider existing guidelines on usability assessment design, development and assessment of pain-related apps.

Theoretical Grounds of Pain Tracker Self Manager: An Acceptance and Commitment Therapy Digital Intervention for Patients with Chronic Pain

OBJECTIVE

To report the theoretical basis and design of a novel digital Acceptance and Commitment Therapy (ACT) intervention for people with chronic pain, the Pain Tracker Self Manager (PTSM), which had promising efficacy in a recent pilot trial.

METHODS

Content development by a multidisciplinary panel of experts in psychiatry, clinical psychology, nursing and social work, with feedback from a group of patients with chronic pain and their providers. Materials included paper-based sketching of a story character, visual metaphors, and a series of stories designed to deliver the theory-based components of our behavioral intervention.

RESULTS

This development and design process resulted in 4 digitally delivered clinical modules that combine visual and verbal cues. In addition, it generated a series of novel ACT metaphors specifically tailored to patients with chronic pain: Pain: Injury vs. Threat, Life Navigation System, The Fog of Pain, and Get Rhythm. Consistent with ACT theory and the contextual behavioral science framework, PTSM utilized: perspective-taking, values clarification, acceptance strategies, and nursing and psychological care recommendations.

DISCUSSION

Reports of the design and theoretical basis of digital health interventions are highly needed to increase the rigor of their development process and more progressively advance our body of knowledge. This pilot study developed and tested a series of ACT metaphors that can be readily used by ACT clinicians working with this population.

CONCLUSION

PTSM is a novel digital ACT intervention for patients with chronic pain with features directly linked to ACT processes and theory.

An internet-delivered cognitive behavioural therapy pain management programme for spinal cord injury pain: A randomized controlled trial

BACKGROUND

Chronic pain is common after spinal cord injury (SCI) and dedicated SCI cognitive behavioural therapy pain management programmes (CBT-PMPs) have a growing evidence base to support their uptake clinically. The development of internet-delivered treatment options may overcome barriers to the access and uptake of centre-based programmes. This study examines such an approach on quality of lie (QoL), pain, mood and sleep.

METHODS

Adults with SCI pain (>3 months) were recruited and randomly assigned to the intervention or control group. The intervention comprised a six module CBT-PMP delivered once weekly. A blinded assessor determined changes in self-reported outcome measures post-intervention and at 3 months. Linear mixed models and effect sizes based on changes between groups were reported. Significance was set p < 0.05.

RESULTS

The recruitment rate was 32% (intervention n = 35, control n = 34), and the drop-out rate at 3 months was 26%. On average, participants accessed three (SD 2.1) of six modules. While no difference in QoL was reported, a significant group*time interaction was found for NRS of current pain (χ²  = 8.22, p = 0.016), worst pain (χ²  = 11.20, p = 0.004), and Brief Pain Inventory (interference) (χ²  = 6.924, p = 0.031). Moderate to large effect sizes favouring the intervention were demonstrated at each time point for the pain metrics (Cohen's d: 0.38-0.84). At 3-month follow-up, 48% of the intervention group rated themselves improved or very much improved (p < 0.05).

CONCLUSIONS

This study demonstrates the potential of an internet-delivered SCI specific CBT-PMP in reporting significant statistical and clinical benefit in pain intensity and interference. Strategies to improve engagement are needed.

Participatory Methods to Engage Health Service Users in the Development of Electronic Health Resources: Systematic Review

Background

When health service providers (HSP) plan to develop electronic health (eHealth) resources for health service users (HSU), the latter’s involvement is essential. Typically, however, HSP, HSU, and technology developers engaged to produce the resources lack expertise in participatory design methodologies suited to the eHealth context. Furthermore, it can be difficult to identify an established method to use, or determine how to work stepwise through any particular process.

Objective

We sought to summarize the evidence about participatory methods and frameworks used to engage HSU in the development of eHealth resources from the beginning of the design process.

Methods

We searched for studies reporting participatory processes in initial development of eHealth resources from 2006 to 2016 in 9 bibliographic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Emcare, Cochrane Library, Web of Science, ACM Guide to Computing Literature, and IEEE Xplore. From 15,117 records initially screened on title and abstract for relevance to eHealth and early participatory design, 603 studies were assessed for eligibility on full text. The remaining 90 studies were rated by 2 reviewers using the Mixed Methods Appraisal Tool Version 2011 (Pluye et al; MMAT) and analyzed with respect to health area, purpose, technology type, and country of study. The 30 studies scoring 90% or higher on MMAT were included in a detailed qualitative synthesis.

Results

Of the 90 MMAT-rated studies, the highest reported (1) health areas were cancer and mental disorders, (2) eHealth technologies were websites and mobile apps, (3) targeted populations were youth and women, and (4) countries of study were the United States, the United Kingdom, and the Netherlands. Of the top 30 studies the highest reported participatory frameworks were User-Centered Design, Participatory Action Research Framework, and the Center for eHealth Research and Disease Management (CeHRes) Roadmap, and the highest reported model underpinning development and engagement was Social Cognitive Theory. Of the 30 studies, 4 reported on all the 5 stages of the CeHRes Roadmap.

Conclusions

The top 30 studies yielded 24 participatory frameworks. Many studies referred to using participatory design methods without reference to a framework. The application of a structured framework such as the CeHRes Roadmap and a model such as Social Cognitive Theory creates a foundation for a well-designed eHealth initiative that ensures clarity and enables replication across participatory design projects. The framework and model need to be clearly articulated and address issues that include resource availability, responsiveness to change, and the criteria for good practice. This review creates an information resource for future eHealth developers, to guide the design of their eHealth resource with a framework that can support further evaluation and development.

Trial Registration

PROSPERO CRD42017053838; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=53838

Development of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: User-Centered Design

Background

Around the world, depression is both under- and overtreated. The diamond clinical prediction tool was developed to assist with appropriate treatment allocation by estimating the 3-month prognosis among people with current depressive symptoms. Delivering clinical prediction tools in a way that will enhance their uptake in routine clinical practice remains challenging; however, mobile apps show promise in this respect. To increase the likelihood that an app-delivered clinical prediction tool can be successfully incorporated into clinical practice, it is important to involve end users in the app design process.

Objective

The aim of the study was to maximize patient engagement in an app designed to improve treatment allocation for depression.

Methods

An iterative, user-centered design process was employed. Qualitative data were collected via 2 focus groups with a community sample (n=17) and 7 semistructured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoypes of the app.

Results

Iterative development resulted in 3 prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the clinical prediction tool, but there was a need for a personalized treatment recommendation made in conjunction with a consultation with a health professional.

Conclusions

User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool that allows users to feel hope, engage in self-reflection, and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial.

Pilot Test of an Acceptance-Based Behavioral Intervention to Promote Physical Activity During Weight Loss Maintenance

Behavioral interventions for obesity reliably facilitate short-term weight loss, but weight regain is normative. A high level of aerobic exercise may promote weight loss maintenance. However, adopting and maintaining a high level of exercise is challenging, and experiential acceptance may be important. The aim of this study was to pilot test the feasibility and efficacy of an acceptance-based behavioral treatment to promote moderate-to-vigorous physical activity (MVPA) among individuals who had recently lost weight. Adults (n = 16) who had recently lost ≥ 5% of weight were provided with a 12-week, group-based treatment. At 12 weeks, complete analyses indicated that participants had increased activity 69% (completing an average of 198.27 minutes/week of bouted MVPA, i.e., episodes of at least 10 minutes in duration). Medium-to-large effect sizes were observed for changes in process measures, including experiential acceptance. Future research to test this approach using an experimental design, a larger sample, and a longer period of observation is warranted.

A Web-Based Caring Training for Caregivers of Children with Cerebral Palsy: Development and Evaluation

OBJECTIVES

Caregivers of children with cerebral palsy (CP) have to spend a long time to take care of their children. We aimed to develop a user-friendly web-based intervention for training parents of children with CP and evaluate the process of development using modified CeHRes roadmap.

MATERIALS & METHODS

The study was conducted from September 2016 to September 2017 in Tehran, Iran. We did it in four main steps including determining the needs of users, content development, design, operational development and evaluation.

RESULTS

The website for caregiver training provided nine general topics and had the possibility that the caregivers could determine their educational priorities. Moreover, the users could share their experiences with other users and could ask questions from an expert. Ten caregivers completed a usability questionnaire after four weeks of use. The average score of 70.5 out of 100 was shown among caregivers. The average score of all statements was above three on a Likert scale between 1 and 5.

CONCLUSION

The website has the possibilities including registering caregivers of children with CP, the possibility to confirm registration with an SMS and the possibility to determine the caregiver educational priorities. It has the usability for training caregivers of children with CP.

Drivers and Barriers to Acceptance of Web-Based Aftercare of Patients in Inpatient Routine Care: A Cross-Sectional Survey

Background

Web-based aftercare can help to stabilize treatment effects and support transition after inpatient treatment, yet uptake by patients seems limited in routine care and little is known about the mechanisms of adoption and implementation.

Objective

The aim of this study was to (1) determine acceptance of Web-based aftercare and (2) explore its drivers and barriers in different subgroups of a mixed inpatient sample.

Method

In a cross-sectional design, 38.3% (374/977) of the inpatients from a broad spectrum of diagnostic groups (psychosomatic, cardiologic, orthopedic, pediatric, and substance-related disorders) filled out a self-administered questionnaire prior to discharge. Drivers and barriers to patients’ acceptance of Web-based aftercare were examined based on an extension to the “unified theory of acceptance and use of technology” (UTAUT). In total, 16.7% (59/353) of the participants indicated prior use of eHealth interventions.

Results

Acceptance (min 1, max 5) was low (mean 2.56, SD 1.22) and differed between diagnostic groups (Welch F_4,133.10 =7.77, P<.001), with highest acceptance in adolescent patients (mean 3.46, SD 1.42). Acceptance was significantly predicted by 3 UTAUT predictors: social influence (beta=.39, P<.001), performance expectancy (beta=.31, P<.001), and effort expectancy (beta=.22, P<.001). Furthermore, stress due to permanent availability (beta=−.09, P=.01) was negatively associated with acceptance.

Conclusion

This study demonstrated a limited acceptance of Web-based aftercare in inpatients. Expectations, social environment’s attitude, and negative experience with permanent availability influence eHealth acceptance. Improving implementation, therefore, means increasing eHealth experience and literacy and facilitating positive attitudes in patients and health professionals through education and reduction of misconceptions about effectiveness or usability.

Development of a Self-Help Web-Based Intervention Targeting Young Cancer Patients With Sexual Problems and Fertility Distress in Collaboration With Patient Research Partners

Background

The Internet should be suitable for delivery of interventions targeting young cancer patients. Young people are familiar with the technologies, and this patient group is small and geographically dispersed. Still, only few psycho-educational Web-based interventions are designed for this group. Young cancer patients consider reproductive health, including sexuality, an area of great importance and approximately 50% report sexual problems and fertility-related concerns following cancer treatment. Therefore, we set out to develop a self-help Web-based intervention, Fex-Can, to alleviate such problems. To improve its quality, we decided to involve patients and significant others as research partners. The first 18 months of our collaboration are described in this paper. The intervention will subsequently be tested in a feasibility study followed by a randomized controlled trial.

Objective

The study aims to describe the development of a Web-based intervention in long-term collaboration with patient research partners (PRPs).

Methods

Ten former cancer patients and two significant others participated in building the Web-based intervention, using a participatory design. The development process is described according to the design step in the holistic framework presented by van Gemert-Pijnen et al and evaluates the PRPs’ impact on the content, system, and service quality of the planned intervention.

Results

The collaboration between the research group and the PRPs mainly took place in the form of 1-day meetings to develop the key components of the intervention: educational and behavior change content, multimedia (pictures, video vignettes, and audios), interactive online activities (eg, self-monitoring), and partial feedback support (discussion forum, tailored feedback from experts). The PRPs influenced the intervention’s content quality in several ways. By repeated feedback on prototypes, the information became more comprehensive, relevant, and understandable. The PRPs gave suggestions concerning the number of exercises and pointed out texts and pictures needing revision (eg, experienced as normative or stereotypical) to increase the persuasiveness of the program. The system quality was improved by PRPs’ feedback on design, technical malfunctions, and navigation on the website. Based on feedback about availability of professional support (technical problems and program content), the organization for support was clarified, which increased service quality. The PRPs also influenced the research project on an overall level by suggesting modifications of inclusion criteria for the RCT and by questioning the implementation plan.

Conclusions

With suggestions and continuous feedback from PRPs, it was possible to develop a Web-based intervention with persuasive design, believed to be relevant and attractive for young persons with cancer who have sexual problems or fertility distress. In the next step, the intervention will be tested in a feasibility study, followed by an RCT to test the intervention’s effectiveness in reducing sexual problems and fertility distress.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 36621459; http://www.isrctn.com/ISRCTN36621459 (Archived by WebCite at http://www.webcitation.org/6gFX40F6T)

Development and Initial Evaluation of the Web-Based Self-Management Program "Partner in Balance" for Family Caregivers of People With Early Stage Dementia: An Exploratory Mixed-Methods Study

Background

People with dementia increasingly depend on informal caregivers. Internet-based self-management interventions hold considerable promise for meeting the educational and support needs of early stage dementia caregivers (EDCs) at a reduced cost.

Objective

This study aimed to (1) develop an online self-management program for EDC to increase self-efficacy and goal attainment, and (2) evaluate the program’s feasibility and report preliminary data on effectiveness.

Methods

Based on the Medical Research Council (MRC) framework for the development and evaluation of complex interventions, a stepwise approach was adopted to explore potential user needs and develop and validate the content by means of (1) focus group discussions with dementia caregivers (N=28), (2) interviews with dementia care professionals (N=11), and (3) individual think-aloud usability tests with EDC (N=2) and experts (N=2). A pilot evaluation was conducted with EDC (N=17) to test the feasibility and establish preliminary effects. Self-report measures of feasibility were completed after the completion of intervention. Self-efficacy and goal attainment were evaluated before and after the intervention.

Results

The different steps provided useful information about the needs of potential users regarding the content and delivery of the program. This resulted in the newly developed “Partner in Balance” program. At the start, system failures resulted in a high noncompleter rate (7/17, 41%), but at the end, an acceptable feasibility score of 209 (range 54-234) was found. The convenience of completing the program at home, the tailored content, and the guidance (face-to-face and online) were appraised positively. Preliminary effects on caregiver self-efficacy (P<.05) and goal attainment (T>50) were promising.

Conclusions

Adaptations were made to the program to limit the amount of system failures and prevent high noncompleter rates. As recommended by the MRC framework, confirming the feasibility and preliminary effectiveness is a valuable step toward examining the effectiveness of this newly developed intervention.

Trial Registration

Dutch Trial Register (NTR): NTR4217; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4217 (Archived by WebCite at http://www.webcitation.org/6f6B8lvRP).

Using Social Media While Waiting in Pain: A Clinical 12-Week Longitudinal Pilot Study

Background

Chronic pain places an enormous burden on health care systems. Multidisciplinary pain management services are well documented as an effective means to improve patient outcomes. However, waiting lists to access these services are long and outcomes deteriorate. Innovative solutions such as social media are gaining attention as a way to decrease this burden and improve outcomes. It is a challenge to design research that demonstrates whether social media are acceptable to patients and clinically effective.

Objective

The aim was to conduct a longitudinal pilot study to understand what aspects of research design are key to the success of running a larger-scale study of social media use in the clinical management of chronic pain.

Methods

A 12-week study examined social media use by patients on the waiting list for the Royal Melbourne Hospital Pain Management Service. Selected social media resources were suggested for use by patients waiting for an appointment at the clinic. Patients filled out measures for pain interference and pain self-efficacy before and after the study. Follow-up was conducted at monthly intervals via telephone semistructured interviews to discuss engagement and garner individual perceptions towards social media use. A social media-use instrument was also administered as part of the after-study questionnaire.

Results

Targeted recruitment refined 235 patient referrals to 138 (58.7%) suitable potential participants. Contact was made with 84 out of 138 (60.9%) patients. After a further exclusion of 54 out of 84 (64%) patients for various reasons, this left 30 out of 84 (36%) patients fitting the inclusion criteria and interested in study participation. A final study cohort of 17 out of 30 (57%) was obtained. Demographics of the 17 patients were mixed. Low back pain was the primary condition reported as leading to chronic pain. Semistructured interviews collected data from 16 out of 17 (94%) patients who started the trial, and at final follow-up 9 out of 17 (53%) patients completed questionnaires. Low specificity of the resources to one’s condition and time poorness may have been barriers to engagement.

Conclusions

Results suggest that with refinements, this study design can be implemented successfully when conducting a larger social media study. At present, comment cannot be made on what effect using social media can have on patients on hospital waiting lists, nor whether those who use social media while waiting in pain achieve better outcomes from eventual participation in a chronic pain program. Long-term follow-up should be included in future studies to answer this. Future research should focus on multicenter randomized controlled trials, involving patients in the intervention design for improved participation and outcomes and for evidence to be sound.