Introduction
Methods
Design
Participants
Procedure
Data analysis and theoretical framework
Coding framework | Core constructs of NPT |
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How people understand and view the benefits versus disbenefits of selfBACK and decide whether it is appropriate for them to use Motivation and willingness to commit to self-management activities | Coherence (Sense-making work; enrolling with / embedding selfBACK): development of an individual and collective understanding of the new intervention when faced with operationalizing it |
Willingness to “buy into” selfBACK and whether it is a legitimate means to promote self-management of LBP Issues relating to the support provided to use of selfBACK and level of engagement of HCPs involved with selfBACK | Cognitive Participation (Relational work; engaging with or integrating selfBACK): relational work to build and sustain engagement with a new intervention |
Ease of use, accessibility and appropriateness of selfBACK Resources, training, workload and technical support Perceived quality and trustworthiness of selfBACK content and function | Collective Action (Operational work; utilizing and engaging in use of selfBACK): investment of effort and resources to enact the new intervention |
How people judge the new selfBACK and the self-monitoring work that accompanied uptake of the selfBACK Ability to match an individual’s needs | Reflexive Monitoring (Appraisal work; maintaining/sustaining engagement with selfBACK): evaluation of the impact of the new intervention on individuals and groups along with any reconfigurations suggested |
Codes falling outside the NPT framework | |
Inherent personal attributes such as personal physical or cognitive abilities that could promote or inhibit use of selfBACK |
Ethical considerations
Results
Participant number | Sex | Age | Country | Number of SM plans generated |
---|---|---|---|---|
1 | M | 31 | Denmark | 2 |
2 | M | 61 | Denmark | 2 |
3 | M | 21 | Denmark | 2 |
4 | F | 22 | Norway | 3 |
5 | M | 40 | Norway | 3 |
6 | F | 35 | Denmark | 4 |
7 | M | 74 | Denmark | 5 |
8 | F | 57 | Denmark | 6 |
9 | F | 39 | Denmark | 9 |
10 | M | 59 | Norway | 9 |
11 | F | 56 | Denmark | 9 |
12 | M | 23 | Norway | 10 |
13 | F | 57 | Norway | 11 |
14 | F | 58 | Denmark | 11 |
15 | F | 25 | Denmark | 12 |
16 | M | 78 | Denmark | 12 |
17 | M | 47 | Norway | 12 |
18 | M | 63 | Denmark | 13 |
19 | M | 48 | Denmark | 13 |
20 | M | 56 | Norway | 13 |
21 | F | 31 | Norway | 13 |
22 | M | 35 | Denmark | 14 |
23 | M | 29 | Denmark | 14 |
24 | F | 70 | Denmark | 14 |
25 | M | 38 | Norway | 14 |
Findings
Level of embedding is associated with personal preferences, beliefs, and level of information (coherence)
”I understand that the manual therapy treatments only help if you also do something yourself. So I’ve been doing strength training for the last 5–10 years.” (participant 25 – male, 38).
“I’m against medications, so I don’t do any and I won’t have any. I don’t believe medications are any good, so instead I had to figure out how to get rid of my low back pain.” (participant 24—female, 70).
Integration depends on perceived level of support and understanding of app features (cognitive participation)
“Yes, a bit like an exercise partner who asks ‘hey, shouldn’t we go work out today?’ and then you actually might get going. Where on the other hand, if you were on your own, you might forget about it or take the easy way out.” (participant 22 – male, 35).
“My workday ended, I had had a long day, I think I was at the university around 4.30 or 5 pm. Then I had to read something, then I had to sign something, and then I had to use my civil registration system number to log in to the app, and then he had to show me the app, and then there was the wristband, and then I had to look around and see what the app could do, and then… then, ‘here you are, go home and use it’. I mean, that was not enough.” (participant 2 – male, 61).
Engagement depends on perceived fit of the app, time consumption, trustworthiness, and functional issues (collective action)
“It [updates] was great because then new exercises appeared. And they impacted some different things, I felt. That was good.” (participant 3 – male, 21).
“It’s just 20 min. You can spare that in the evening. That’s a… a nice feeling of doing at least something productive. You’re able to allocate 20 min per day or at least a couple of times per week.” (participant 22 – male, 35).
“I’m so tormented by my knee, if I have to lie down to perform some of the exercises, I can hardly get back up. I have to roll onto the other foot and find a piece of furniture to pull myself up by because my knee is so weak. So the exercises for my low back pain, I’m not able to perform them as long as my knee is in such a bad condition.” (participant 10 – male, 59).
Perceived effects, acceptability, satisfaction, and sustained engagement and self-management (reflexive monitoring)
“It’s been so effective that I actually forgot my visit to the physiotherapist […] I thought, that’s a really great sign. I hadn’t experienced that in several years; if 6 weeks went by instead of 4, then I experienced a significant impairment of my back. So now, just within this half-year or 4 months, I’ve been in this project, I’ve rescheduled. Now we try 6–7 weeks between visits.” (participant 19 – male, 48).
“I’m not feeling the same kind of pain anymore. I don’t feel sorry for myself in the same way I used to […] it has meant that I’m more aware that my own effort has a large effect on how my back will feel going forward.” (participant 18 – male, 63).
”Well, you’re able to follow exactly how you’re doing in reaching your goal. Compared to just thinking to yourself ‘I have to walk this much today’ then you’re able to follow how far you are from achieving that goal, in percentages. I think that’s positive!” (participant 9 – female, 39).
“The things you have to do on your own at home, that’s more bothersome, because the other things [group training], I have to leave [the house] for that. […] I also have an exercise bike at home, it’s been years since I used it last! And that’s the thing about being on your own, it’s a struggle. (participant 16 – male, 78).
“I was hard up, I mean I couldn’t… I live in a new first-floor apartment and the car is parked just outside, and even walking the few steps down and out to the car was an overcoming for me. I was very passive and could barely walk.” (participant 7 – male, 74).
“It hasn’t been good enough for me that it was purely an app. I mean, I missed being followed up.” (participant 2 – male, 61).
“I actually think it works really well. Because I think the persistent reminder of getting you to understand that it’s important you keep doing something despite pain works really great in the app.” (participant 11 – female, 56).
Option to self-regulate time points for notifications e.g. prompt for physical activity exactly when the participant thought it was needed |
Option to see one’s weekly progress in pain symptoms from the answers to the tailoring session questionnaire |
Option to “star mark” favorite exercises |
Option to watch exercises performed from different angles to enhance understanding of correct performance |
Guidance on tweaking exercises rather than fully replacing exercises |
Option to rule out all exercises that required for example weight on knees or wrists |
Data outside the coding framework
Discussion
Methodological considerations
Implications for practice and future research
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As most participants were satisfied and perceived benefits from implementing selfBACK, our findings should support clinicians in exploring patients’ interest in using selfBACK or similar apps for self-management of LBP as an adjunct to usual care.
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Self-management of chronic pain, including LBP, is a key treatment strategy, but something many patients struggle to achieve. Although self-management of LBP with selfBACK was supposed to work as an adjunct to usual care, this was achieved by some but for others, not integrating HCP follow-up limited implementation. HCPs remain key players in supporting self-management behavior [50], and we suggest incorporating solutions that allow users and HCPs to share the app content and monitor progress. Having the opportunity to discuss app content and features with the HCP should be incorporated in future, similar apps. Building on experiences from the selfBACK RCT, a clinician dashboard to facilitate co-decision making is currently in development [51].
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In this study, we have reported on implementation of the selfBACK app from a participant perspective only, but as key players in supporting self-management, it is vital we also aim to understand the perspective of HCPs. Future research should explore HCPs’ barriers for use of the selfBACK and similar apps, as well as means and incentives to overcome identified barriers. In continuation, clinical practice barriers relating to provision of digital interventions, and organizational and systemic healthcare system barriers should be targeted.
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Digital health interventions have been suggested as essential for overcoming future challenges of limited resources in the healthcare sector. Despite the potential value, there is only limited research to support cost-effectiveness. We recommend future research focus on the economic impact of selfBACK and other digital interventions on patients’ healthcare utilization and need for social services or workers compensation.