The effectiveness of an electronic pain management programme for the working population with chronic pain: study protocol for a randomized controlled trial

The working population comprises the largest portion of people in Hong Kong society and is defined as adults aged from 15 to 64 years [1]. This group of people helps society to function. However, some of them continue to work despite experiencing pain.

Pain affects all age groups. It is defined as ‘an unpleasant and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ [2]. Chronic pain is pain that persists for more than 3 months in an individual [3]. Pain is highly prevalent in the Hong Kong population. Studies have revealed that the prevalence of chronic pain ranges from 34.9% to 87.4%, and is high in people aged 18–64 years [4‐6]. For the working population in particular, the prevalence of pain is 71.6% [4]. Common pain sites included the neck, bilateral shoulders, back, and extremities [4‐6]. Mild to moderate pain intensity has been reported [4, 6]. The pain situation in the Hong Kong population is more serious than that in western countries. The prevalence of pain is reportedly 19% in the United States and 24.9% in Germany with mild intensity [7, 8], levels that are far below that in Hong Kong.

Pain can bring physical discomfort to sufferers and affect them psychologically. Depressive mood and anxiety have been found to be associated with the presence of pain [9, 10]. Patients with chronic pain develop and experience significant levels of depression and anxiety. Stress levels are also related to the presence of chronic pain [11‐13]. Psychological stress and stress factors are associated with chronic non-specific neck–arm pain. Pain duration also influences a person’s stress level [12]. According to a longitudinal study, people who suffer from musculoskeletal pain and stress at the same time exhibit poorer working performance and ability [11]. In addition, chronic pain contributes negatively to the quality of life of patients. Surveys have revealed that chronic pain patients with multiple pain sites and pain-related difficulty in engaging in activities are likely to have a lower quality of life [14, 15]. Chronic pain patients have a lower quality of life than those who suffer from acute pain or no pain [16]. One survey focusing on the pain situation of the Hong Kong Chinese population showed that people with higher pain intensities exhibited higher levels of depression and anxiety and a lower quality of life [6].

People often use self-initiated treatments to manage their pain, including taking analgesics, exercising, and resting [17]. Instead of visiting accident, emergency, or outpatient departments, people either self-initiate treatments or use over-the-counter medications to treat their pain [5, 17]. Some even apply multiple treatments such as physiotherapy and traditional Chinese medicine [17, 18]. In addition, they perceive good effects from their self-initiated treatment [17]. Pain services are scarce in Hong Kong. Patients stay in their communities and see general practitioners or primary specialists before visiting pain specialists [18]. Therefore, to manage their pain and especially to meet their preference for pain self-management, it is essential to establish alternative means of targeting the working population. Promoting and enhancing self-efficacy in pain management may be the way to equip the working population with the knowledge and skills to manage their pain.

Self-efficacy is an important measure for determining whether patients can manage their health conditions [19]. Bandura’s self-efficacy theory of behavioural change is a classical model used to explain people’s perceptions and ability to actively participate in activities [20]. Self-efficacy is ‘people’s domain-specific perceptions of their ability to perform the actions necessary to achieve desired outcomes’ [21]. The self-efficacy theory of behavioural change explains how people’s beliefs and expectations contribute to their behaviour. People have their expectations when they engage in activities. When they engage in behaviours, they expect certain outcomes [20]. This leads them to actively participate in activities to achieve expected outcomes. Health promotion and disease prevention can be integrated with the self-efficacy theory of behavioural change [22]. Improving self-efficacy can modulate people’s health behaviour, and the maintenance of health behaviour can be promoted when people gain better control over their health problems. Health studies adopting the self-efficacy theory of behavioural change have demonstrated improvements in self-efficacy when managing chronic illnesses such as osteoarthritis, symptoms of heart failure, and obesity [23‐25].

Therefore, in this study the self-efficacy theory of behavioural change will be adopted as the conceptual framework, taking advantage of eHealth, and an electronic pain management programme (ePain) will be designed as the intervention. eHealth is ‘the use of information and communication technologies for health’ [26]. The benefits of using eHealth include an increase in efficiency; enhancements in quality; patient empowerment, encouragement, and education; the exchange of information and communication; and overcoming of the barriers to obtaining health services [27, 28]. With the advancement and advantages of eHealth, people can obtain health education information from the Internet without the limitations of geography and time [29]. Web-based programmes have shown success in enhancing the disease knowledge and self-management abilities of patients with type 2 diabetes, fibromyalgia, and chronic pain [30‐32]. There is currently no electronic pain management system that has been tailor-made for the working population and that is in the Chinese language. An electronic pain management programme can meet the demands and service needs of the working population with chronic pain, especially when the population is well equipped with the knowledge to access the Internet and use electronic devices.

Different studies using web-based programmes have demonstrated satisfactory results for their targeted populations [31, 32]. Using web-based programmes to administer health education to the public has become a trend due to the efficiency of this approach in getting in touch with and delivering information to participants [27]. As information technology develops more quickly, both hardware and software will greatly facilitate the spread of information to the public.

This study will adopt the self-efficacy theory of behavioural change to develop an intervention. ePain will provide step-by-step illustrations of pain knowledge and interventions for participants to improve their pain situations. People like to use self-initiated treatments to relieve pain [17]. ePain will provide information about different types of self-initiated treatments, including their correct use. Therefore, this study will use ePain to examine the improvement in the pain self-efficacy of the participants, which previous studies have yet to consider as a primary outcome [30].

The participants in ePain will benefit from improved pain self-efficacy and decreased pain intensity. They will be able to learn and understand pain as they go through the chapters. ePain will introduce various pharmacological and non-pharmacological interventions. The participants will be able to plan and choose their preferred pain relief methods. As psychological distress is associated with pain, the participants will experience lower levels of psychological distress. The anticipated effects of pain management can be sustained; ePain is an electronic pain management programme that will be available on the Internet for the public to access and it will be a cost-effective intervention.

One limitation of the study is the small size of the sample, which could limit the generalizability of the study. The calculation of the effect size is preliminary, based on a previous intervention study on pain intensity. Because there is no information about pain self-efficacy, our estimate of the size of the sample that will be required to determine a significant effect may be an underestimate or an overestimate. However, the optimal sample size can be calculated from the preliminary findings of the study after an accurate estimate is obtained of the standard deviation and the standardized effect size of the primary outcome variable ‘pain self-efficacy’. Another limitation of the study is the selection bias. Participants need to have access to the Internet or to have an electronic device to access the Internet to join the study.

This study will be the first in Hong Kong to examine the effectiveness of an electronic pain management programme that targets the working population. The programme will suit people’s work–life schedules and facilitate how they learn about and plan for pain management. Furthermore, ePain will contain Chinese cultural content that fits the needs of the Chinese population. Indeed, ePain will demonstrate a mix of the East and the West.

The study will attempt to improve the pain self-efficacy; pain intensity; levels of depression, anxiety, and stress; and quality of life of the working population. As an electronic pain management programme, ePain may offer an intervention that improves the pain and psychological status of the working population. Pain education materials can be delivered efficiently through the Internet. The contents of ePain will be tailor-made for the pain situations of the working population and be suitable for pain education. The results of the study will demonstrate how e-learning can help to improve the pain situations of the working population.