Frontiers in Public Health (Oct 2015)
Co-creating an online exercise-based rehabilitation programme for people with chronic knee and hip pain based on user preferences and behavioural change techniques.
Abstract
Background: Chronic knee and hip pain in elderly people is very prevalent (1,2) and causes reduced mobility, disability and co-morbidity. Evidence-based many men guidelines recommend exercise and self-management as effective interventions (3). “Enabling Self-management and Coping of Arthritic Pain through Exercise, ESCAPE-pain” (www.escape-pain.org), is a rehabilitation programme that integrates patient self-management information and advice with an exercise regimen (4). Increased knowledge of the condition and how people can self-manage their problems, better appreciation of the role of exercise in the management of pain and positive experiences of the programme alters people’s health beliefs and behaviour (5). This results in reduced pain, improved physical and psychosocial function and well-being (4). The programme is usually delivered as face-to-face programmes in clinical departments. Unfortunately this has limited “reach” so few people benefit. An online version reach and benefit many more people. However, online programmes developed without input from potential users can produce unwanted, unusable, “high tech but low impact”, ineffective programmes with poor uptake (6). Adopting user-centred approach when design of the programme might improve the fit between human needs and the technology, improving uptake and effectiveness (7). This could be achieved by integrating persuasive technology - which considers factors influencing change in people’s attitudes and behaviour (8,9), human-centred design - which advocates consulting potential users of an intervention during the design process to produce a useful, usable product that fits their needs, improve uptake, effectiveness and satisfaction (10,11) and business modelling - which establishes the user’s context, values, beliefs and needs before designing the intervention (12). The findings are integrated to design a product users deem valuable, usable and deliverable, thereby improving uptake, effectiveness, implementation and sustainability. Using the principles of persuasive technology, human-centred design and business modelling we asked potential users what they considered important in the content and design of an online “ESCAPE-pain” programme. Their preferences were mapped onto effective behavioural change techniques (13) and used to design the online version of the programme. Methods: General and specific needs of potential users were elicited from 4 focus groups involving 24 people (5-7/group) with chronic knee/hip pain. A summary of their opinions and preferences was used to design an online programme prototype consisting of: i) general information about the ESCAPE-pain programme; ii) an overview of its content and format; iii) features such as participant testimonials, “text” coaching, etc; iv) aesthetics. From the focus group 8 people were purposely selected for semi-structured “think aloud” evaluations of the prototype, commenting on the content, aesthetics and quality of the prototype, verbalising their thoughts, difficulties, (dis)likes and suggestions (14,15). Field notes were made of user interactions (ease of use, problems, etc). Participant’s comments, opinions and preferences were compared with the behavioural change techniques taxonomy, BCTTv1 (13) and from participant preferences and known effective BCTs (16,17,18) “patient-facing” online resources were constructed. Results: Participants had many differing opinions and preferences for many aspects of the content and format of the potential online programme, which were often mutually exclusive. All participants wanted a simple, easy to navigate site with interesting, engaging images. Information needed to be succinct, unambiguous, jargon free, tailored to each individual’s needs, with the ability to print information (BCTTv1 - 4.Shaping knowledge; 5.Natural consequences). Videos of older people exercising with clear specific descriptions how to perform the exercises correctly were enthusiastically welcomed (BCTTv1 - 4.Shaping knowledge; 5.Natural consequences; 7.1Associations – cues and prompts). The facility to enter pertinent information about an exercise (number of repetitions, time, etc) to enable people to chart and monitor their progress was popular (BCTTv1 - 2.Feedback/monitoring). Some people wanted to be able to feed this back to others and receive feedback, to get some comparative overview of their situation and progression (BCTTv1 - 2.Feedback/monitoring; 3.Social support; 6.Comparison of behaviour). Support from peers and healthcare professionals (BCTTv1 - 3. Social support) via virtual communities, blogs, forums was popular with some participants, but others were sceptical about their usefulness. Endorsement by trusted, non-commercial, institutions, organisations or healthcare professionals was strongly advocated (BCTTv1 – 9.Comparisons of outcomes - credible sources). Commercially-backed websites were treated with suspicion. Based on the information generated by the focus groups and interviews, and incorporating BCTs known to be effective in changing behaviour, online resources allowing people to implement the “ESCAPE-pain” programme have been developed, user tested and will be live in January 2016. Conclusions: Using persuasive technology, human centred design and business modelling we established the features people want from an online programme to manage chronic joint pain. Combining these with BCTs known to be effective in face-to-face behavioural change programmes have enabled us to develop an online resources that will make an effective programme available to many more people to improve their pain, function, general health and wellbeing and quality of life.
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