Author: Tang, Shuk Kwan
Title: The effectiveness of an electronic pain management programme (ePain) for working population with chronic pain : a randomized controlled trial
Advisors: Tse, Mimi (SN)
Leung, Sau Fong (SN)
Fotis, Theofanis (SN)
Degree: Ph.D.
Year: 2021
Subject: Pain -- Treatment
Chronic pain -- Treatment
Hong Kong Polytechnic University -- Dissertations
Department: School of Nursing
Pages: xxix, 277 pages : color illustrations
Language: English
Abstract: Background : The prevalence of pain is high in the working population. Persistent pain becomes a chronic condition. The working population either bears their pain to work, or takes a sick leave. Their work performance can be affected. It can cause work loss, in terms of both working days and money. Pain services are inadequate to satisfy the demand. The long wait times in out-patient clinics means that pain sufferers must wait for a long period before an appointment. Pain causes both physical disturbance and psychological distress to individuals. An extended duration of pain predicts the presence of depression, anxiety, and stress. People living with chronic pain report a lower level of quality of life, as their physical activity levels are affected. Pain self-efficacy acts as a contributor to mediate the negative effects of chronic pain. People with higher pain self-efficacy would decrease pain avoidance behaviours and depression. Based on the self-efficacy of behavioural change, building up pain self-efficacy means that chronic pain sufferers believe in their ability to manage their pain and attain a better pain situation. Members of the working population with self-care ability have the capacity to self-manage their pain to improve their pain self-efficacy, gain relief from the negative effects of pain, and enhance their quality of life. Pain management programmes are used to empower participants with self-management skills and reduce their pain severity and disability. Aerobic exercise, cognitive coping skills training, pain acceptance and normal activity, progressive muscle relaxation and imagery, and ergonomic and posture training are included. These programmes are mainly delivered through face-to-face and group-based sessions. The sessions are often held during office hours and overlap with working hours. Members of the working population may not be available to attend all sessions. eHealth is an alternative method and solution to tackle the difficulties involved in attending face-to-face sessions. The advancement of information technology allows participants to join programme anywhere and at any time, with an electronic device and network. Internet-based pain programmes should be used to deliver pain management education to the working population in order to reduce their pain and address the difficulties involved in attending pain management programmes in person. There is a lack of studies examining how Internet-based studies affect pain severity in chronic pain sufferers and in the Chinese population. Previous groundwork found a high prevalence of chronic pain in the Hong Kong working population. They preferred accessing the Internet and healthcare professionals to deliver pain management education. An electronic pain management programme (ePain) was developed to tackle their pain problems. The self-efficacy theory of behavioural change was adopted as the theoretical framework for the main study. Aims and objectives : The study aimed to develop, implement, and evaluate the effectiveness of an electronic pain management programme (ePain) for members of the working population with chronic pain. The study's primary objective was to develop and evaluate the effectiveness of ePain to decrease pain severity in the working population with chronic pain. The secondary objective was to evaluate the effectiveness of ePain in members of the working population suffering from chronic pain in the improvement of pain self-efficacy, pain interference, levels of depression, anxiety and stress, and quality of life. Methods and outcome measures : ePain was developed in a systematic and evidenced-based approach. A systematic review was conducted to identify effective non-pharmacological interventions for pain management. The essence of online learning, including self-paced learning, learner control, and self-directed learning, was integrated into the development of ePain. The issue of data security was considered. An expert panel was formed to validate the ePain contents. The expert panel rated the content as having good relevancy. Five workers with chronic pain were recruited to conduct a usability test of ePain. The usability test received a satisfactory score, implying that participants perceived it to be a positive user experience and accepted ePain. Strategies to ensure treatment fidelity were applied during the ePain development phase. The study was a double-blinded randomised controlled trial. Participants were recruited by snowball sampling, including social media, distributing recruitment pamphlets in community centres, and sending invitations to companies. A total of 319 members of the working population who lived with chronic pain were randomised to either the intervention group or the control group. Participants were aged from 15 to 65, performed a formal job during the seven days before the study or worked for pay or profit during the seven days before the study, were able to read and understand traditional Chinese, had experienced non-cancer chronic pain for at least three months, had a pain score of one or above in the Chinese version of the Brief Pain Inventory (BPI-C), and had a computer or mobile phone to access ePain. The intervention group participants received ePain, while the control group read a pain education pamphlet. Participants' levels of pain severity and pain interference were recorded by the Chinese version of Brief Pain Inventory (BPI-C); pain self-efficacy were measured by the Chinese version of the Pain Self-Efficacy Questionnaire (PSEQ-HK); depression, anxiety, and stress were measured by the Chinese version of the Depression Anxiety Stress Scale (DASS-21); and quality of life was measured by the Hong Kong version of the World Health Organization Quality of Life Instruments (WHOQOL-BREF (HK)). Data were collected at baseline, interim evaluation (T1) at Week 3, post-intervention evaluation (T2) at Week 6, and follow-up evaluation (T3) at Week 12. Demographic data and pain-related sick leave information were collected at baseline. Feedback from the intervention group participants was collected to explore the usefulness and user experience of ePain. Changes in participant knowledge level were measured by the frequency of pages viewed and quiz results. Generalized Estimating Equation (GEE) was used to analyse the changes in outcomes between the intervention and control groups, within group (time) effects, and the intervention effects (group x time). Pairwise analysis comparing the outcomes between time points by groups was conducted. The primary analysis was intention-to-treat (ITT) analysed data from T0 to T2 to reduce bias resulting from a participant dropout rate.
Results : A total of 319 participants joined the main study, with 160 participants in the intervention group and 159 participants in the control group. A majority of participants were female (77.4%), with a mean age of 43.64, without chronic illness (69.3%) and not taking long term medications (77.7%). The demographic characteristics did not present significant differences at baseline. At baseline, the mean score of pain severity of all participants was 4.16 (SD = 1.90), pain self-efficacy was 41.56 (SD = 12.23), and pain interference was 3.74 (SD = 1.92). The total participants' mean scores of total score of depression, anxiety, and stress was 12.86 (SD = 8.63), depression was 12.82 (SD = 9.59), anxiety was 11.68 (SD = 8.38), and stress was 17 (SD = 9.62). For quality of life, the mean score of overall quality of life was 3.23 (SD = 0.65), overall health and well-being was 2.30 (SD = 0.75), physical health domain was 13.33 (SD = 2.32), psychological domain was 11.62 (SD = 1.58), social relationships domain was 12.41 (SD = 3.03), and environment domain was 11.98 (SD = 2.50). At baseline, there were no significant differences noted between the mean scores of pain severity, pain self-efficacy, pain interference, anxiety, stress, and all quality of life domains in the intervention and control groups. When comparing the two groups over time, from T0 to T2 of the pain-related outcomes in the GEE analysis, there were no significant differences found. Statistical significances were noted for pain severity (p = 0.002) and pain interference (p = 0.04) at T1. The intervention group presented significant effects on the pain severity from T0 to T1 (p = 0.001) and from T0 to T2 (p = 0.000). There was significant difference in pain interference from T0 to T2 (p = 0.000). The control group did not present any significant effects in any pain-related outcomes in the GEE analysis. In the GEE analysis for psychological outcomes, no significant findings were presented when comparing the results between groups over time and between time points by group from T0 to T2. Significant effect was presented in overall health and well-being from T0 to T2 when comparing results between the intervention group and control group (p = 0.04). In pairwise comparison in the intervention group, significant effects were found in overall health and well-being (p = 0.02) from T0 to T1. The control group showed significant effects in overall health and well-being from T0 to T1 (p = 0.003) and from T0 to T2 (p = 0.001). The participants' knowledge level demonstrated improvements with a high passing rate (96.2%) in 53 participants who completed the quizzes. The participants reported satisfaction with ePain's usefulness and user experience. Their feedback was divided into four categories: enhancing pain knowledge and management, positive learning experience of pain management, positive user experience from the technical aspects of ePain, and suggestions for improving ePain. Discussion : There were 319 participants randomized in the study. In the intervention group, there were 160 participants in the intervention group and 159 participants in the control group. After the baseline assessment, the intervention group participants started ePain and the control group participants received a pain education pamphlet. The outcomes measured were the levels of pain severity, pain self-efficacy, pain interference, depression, anxiety, stress and quality of life. They were assessed at baseline (T0), interim evaluation at Week 3 (T1), post-intervention evaluation at Week 6 (T2) and follow-up evaluation at Week 12 (T3). The results were compared between groups and time points from T0 to T2 by GEE. The strengths of ePain were demonstrated in the protocol development and characteristics of the intervention. ePain was developed in a systematic way. The intervention built with self-efficacy theory of behavioral change. An online survey was conducted to determine the prevalence of pain in the working population, the source of information for pain management and the preferred contents in ePain. The contents of ePain were validated by an expert panel with good relevancy. A usability test was conducted and high level of satisfaction was resulted. The outcomes did not show significant results in the pain severity, pain self-efficacy, pain interference, depression, anxiety, stress and quality of life when comparing between the intervention group and control group from T0 to T2. The insignificant results may relate to several reasons. The duration of the intervention may be inadequate to improve the pain severity, pain self-efficacy, pain interference, depression, anxiety, stress and quality of life. The low response rate of the evaluations at T2 may bound the observations of the outcomes. Limitations were identified from the study. There were dropouts of participants across time points and caused low response rate of 29.2% at T2. The low response rate was comparable to other Internet-based programmes without incentives. The low response rate contributed to the missing data. GEE was adopted in the study and no imputation was conducted. Member of the working population without a computer or mobile phone and Internet access were unable to join the study. The participants recruited mainly comprised of the professionals and clerical staff. The effects of ePain might not be demonstrated in the blue collars. The contents of ePain focused on the physiological interventions for pain relieve. The psychological support for pain should be included in future studies. Conclusion : The results demonstrated that ePain was ineffective at reducing pain severity; improving pain self-efficacy; decreasing pain interference, levels of depression, anxiety, and stress; and enhancing quality of life in the working population with chronic pain. The pain knowledge level increased in the intervention group. ePain equipped intervention group participants with pain and self-management knowledge. The intervention group participants noted a positive user experience of ePain, finding it to be useful to their situation. Their positive feedback and learning experiences motivated them to continue managing their pain, and their pain situation would continue to improve. There were reasons contributing to the insignificant results, including participants' dropout, research method and intervention. Suggestions and recommendation for the limitations and future studies were discussed.
Rights: All rights reserved
Access: open access

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