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. Author manuscript; available in PMC: 2024 May 12.
Published in final edited form as: Res Gerontol Nurs. 2023 May 12;16(3):108–114. doi: 10.3928/19404921-20230405-03

Improvement Opportunities for PAINReportIt® Delivered on a Wireless Tablet

Rated by Black Older Men With Low Back Pain

Dottington Fullwood 1, Sydney Means 1, Zachary L Stickley 1, Marie-Carmelle Elie-Turenne 1, Diana J Wilkie 1
PMCID: PMC10754271  NIHMSID: NIHMS1936598  PMID: 37040308

Abstract

Health care professionals and researchers can implement technology to improve older adults’ acceptability of providing health information and to better include older adults in sharing information with health providers. However, older adults’ engagement with technology remains low. This study focused on 60 Black older men (mean age = 70 years, SD = 6 years) with low back pain who completed the 13-item Computer Acceptability Scale after using the PAINReportIt® software on an Apple iPad®. On average, the sample found it acceptable to use PAINReportIt® software to share their pain or discomfort but that this was no replacement for oral dialogue with their health care provider. These findings contribute valuable information about the acceptability of using technology and indicate potential opportunities to improve PAINReportIt® software. Community interventions with acceptable tablet devices can offer new insight into collecting pain or discomfort data in populations with low presence in clinical research studies.

There is growing evidence of using technology devices, such as personal computers, laptops, tablets, and smartphones, to collect health care information from older adults (Mitzner et al., 2019; Owens et al., 2016). Technology design can play an important role in clinical research assessment of low back pain (LBP). Lack of design acceptability may overwhelm individuals and contribute to missing data. Despite the digital divide, 64% of Black American individuals are adopters of smartphones and of these individuals, approximately 75% most often search for disease-specific topics or various health information (Smith, 2014) using these devices. However, little is known about the acceptability of digital devices for reporting pain among Black older men with LBP. The purpose of the current study was to examine whether reporting pain or discomfort using an Apple iPad® (i.e., tablet) would be acceptable for community-dwelling Black older men with LBP.

BACKGROUND

The appraisal of pain during an assessment holds significant value within the pain community. Pain assessments conducted in health care settings mostly consist of time-consuming interviews between the patient and clinician that can produce multiple sources of bias and error by clinicians (Ashton-James & Nicholas, 2016; Schäfer et al., 2016; Wilkie et al., 2003). These sources result from some clinicians’ lack of comprehension about the severity of pain experienced by their patients (Schäfer et al., 2016). Although the best way to gauge an individual’s pain is to simply ask them, applying technology to the pain assessment process may improve patient health outcomes (Wilkie et al., 2003). The assessment of nonverbal indicators of pain along with self-report pain can help individuals unravel pain dilemmas.

Members of society of all ages find themselves entangled with some technological device. These devices range in all sizes and styles, from desktop computers to laptops to tablets to smartphones, that serve as communication tools. The feasibility and acceptability of these tools have shown promise in capturing real-time data in patients’ homes and outpatient clinics (Aktas et al., 2015; Girgis et al., 2018; Tutelman et al., 2018). Essentially, surveys distributed through these devices allow patients, with a simple touch of the finger, to answer questions about pain and activities of daily living. These web-based measures allow health care professionals to gather quality information from a touchscreen response compared to patients answering questions verbally or writing things down (Wilkie et al., 2003).

The promotion of independence by incorporating advances and changes in technology creates the ability for older adults to age in place. Benefits associated with the adoption of new technology will require full transparency for older adults to witness the value, as adopting new technology remains unlikely in this population (Vaportzis et al., 2017). The usefulness and usability of technology by older adults can remove inadequate feelings when enthusiasm and willingness to learn new technology results in preservation of independence and quality of life (Heinz et al., 2013). Technology research studies offer the potential to minimize challenges associated with traditional clinical and community-based interventions by placing minimal demands on participants and clinical personnel (Campbell et al., 2012; Chisolm & Sarkar, 2015).

The importance of technology in people’s lives gives rise to innovative processes of data dissemination in clinical research spaces. Research data remain limited on Black older men with or without LBP across all spectrums of health-related research. The hesitation of many Black men to participate in research stems from institutional racism, health care system discrimination, mistrust of researchers, and the perception of the research having no value (Brown et al., 2012; Campbell et al., 2012; Griffith et al., 2011; James & Harville, 2017; James et al., 2016; Schmotzer, 2012). To fill this gap, the current study relied on formative research to determine various acceptability aspects (e.g., difficulty using, screen aesthetics, clarity of instructions) of using PAINReportIt® on an iPad among Black older men with LBP in Jacksonville, Florida. The formative results will inform the appropriate content, functionality, interface, and modifications of PAINReportIt® for future computer-based interventions delivered through collaborative alignment with members from this population.

METHOD

Design and Setting

Over a 1-day period, participants with LBP completed a battery of objective procedures and subjective measures, including a computer acceptability questionnaire. Full details of the objective battery measures were the focus of a larger study that included the Short Physical Performance Battery, Back Performance Scale, and the 400-Meter Walk Test (Fullwood et al., 2022). Participants were recruited from Duval County, particularly Jacksonville, Florida. The University of Florida Institutional Review Board approved this research study (IRB# 202003284).

Inclusion and Exclusion Criteria

Inclusion criteria stipulated participants were (a) Black men, (b) aged ≥60 years, (c) experiencing LBP for ≥3 months, (d) able to use a computer, and (e) physically able to perform functional measures (e.g., engagement in low intensity physical activities, vision proprioception). Participants were excluded if they had (a) unstable angina, heart attack, or stroke in the past 3 months; (b) any signs of persistent or progressive neurological deficit; (c) history of spinal surgery; or (d) inflammatory or cardiac disease. The analytic sample included 60 Black men who were recruited over 6 weeks.

Procedure

The principal investigator (D.F.) was granted permission from YMCA® and senior housing facilities to inform participants about the study. Participants who showed interest were consented and received a $50 Visa® gift card upon completion of the study. This 1-day period comprised two parts that lasted approximately 2 hours at a teaching hospital. All enrolled participants were given the opportunity to ask questions before providing written informed consent. Participants completed the PAINReportIt®, which included the Computer Acceptability Scale (CAS) questionnaire, via an internet browser on a Wi-Fi enabled iPad.

Instruments

Previous studies have administered the CAS effectively. The CAS was designed to support efficient computer– human interface to measure how suitable and satisfactory participants find reporting pain using computer technology. The instrument comprises 13 questions with mostly dichotomous answers (i.e., yes/no). The items cover questions about the device itself, access and usability, and the appropriateness of the software application. Participants were asked to evaluate the adequacy of lighting, clarity of instructions, level of computer glare, use of the touch screen, screen colors, and enjoyment of using the tool. Specific items focused on whether the device was hard to use, whether the participant felt rushed, whether the participant believed the tool was good to use, whether it allowed them to report what they believed important, and whether they liked using the tool. All items were completed using an iPad through an internet browser. Scores for each item range from 0 to 13, with higher scores indicating greater acceptability of the PAINReportIt® delivered on the iPad. Responses were stored in a structural query language database.

Data Analysis

Analyses were conducted using the statistical software R version 4.1.0. Frequencies, means, and standard deviations were calculated to characterize the analytic sample. CAS scores and demographic variables were analyzed using likelihood ratio test of two nested models to evaluate bivariate associations. Missing data were estimated at approximately 1% and these missing observations were excluded from the analysis. Statistical significance was set a priori at the alpha level of 0.05.

RESULTS

A total of 61 Black American older adults participated in the study. Participant age ranged from 61 to 87 years, with a mean age of 70 (SD = 6) years. However, one participant failed to meet the inclusion criteria of LBP after being enrolled to participate in the first phase of the study. Thus, the final analytic sample comprised 60 Black men aged in their 60s (50%) or 70s to 80s (50%) (Table 1). Many participants had a high school diploma (n = 24; 40%) and completed vocational school or associate degree (n = 20; 33%) or college (n = 9; 15%). Many participants were single (n = 38; 63%). On a scale from 0 to 10, with 10 being pain as bad as it could be, participants had an average current pain of 6 (SD = 3) and worst pain of 7 (SD = 3) in the past 24 hours. Current household income ranged from <$10,000 (n = 11; 18%) to >$80,000 (n = 4; 7%). Most participants reported using computers either daily (n = 28; 47%) or never (n = 23; 38%).

TABLE 1.

Demographic Characteristics of Participants (N = 60)

Variable n (%) CAS Score p
Age (years) 0.49
 60 to 69 30 (50) 10 (1)
 70 to 89 30 (50) 10 (1)
Educational level 0.34
 8th grade or lower 4 (6) 9 (1)
 High school 24 (40) 10 (2)
 Vocational school/associate degree 20 (33) 10 (1)
 College or higher 9 (15) 11 (1)
 Income (USD) 0.94
 <$10,000 11 (18) 10 (1)
 $11,000 to $20,000 20 (33) 10 (1)
 $21,000 to $30,000 5 (8) 10 (1)
 $31,000 to $50,000 7 (12) 11 (1)
 $51,000 to $80,000 5 (8) 9 (1)
 >$80,000 4 (7) 10 (1)
Marital status 0.30
 Single 38 (63) 10 (1)
 Married/partnered 18 (30) 11 (1)
Computer use 0.11
 Daily 28 (47) 10 (1)
 Never 23 (38) 9 (2)
 Weekly 5 (8) 11 (1)
 Monthly 4 (7) 11 (1)
Mean (SD) (Range)
Age (years) 70 (6) (60 to 89)
Paina
 Current 6 (2.7)
 Least 5 (2.7)
 Worst 7 (2.9)
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Note. CAS = Computer Acceptability Scale; USD = U.S. dollar. Some data are missing for education (n = 3), income, (n = 8), and marital status (n = 4).

a

Measured using the pain intensity scale from the McGill Pain Questionnaire. Each pain item is scored from 0 to 3, where 0 = none, 1 = mild, 2 = moderate, and 3 = severe.

CAS scores ranged from 5 to 12, with a mean score of 10.2 (SD = 1.3) and a median of 11. Table 2 shows participants in their 70s to 80s indicated using the device was somewhat hard but able to use (63%) compared to participants in their 60s (23%). Overall, 67% of participants in their 60s found using the computer not hard at all compared to 6% of participants in their 70s to 80s. Approximately >90% of participants from each age group indicated appropriate lighting (60s: 93%; 70s to 80s: 93%), pleasing screen aesthetics (60s: 100%; 70s to 80s: 90%), they understood instructions (60s: 100%; 70s to 80s: 90%), and that the touch screen was easy to use (60s: 93%; 70s to 80s: 87%). Only 10% of each age group reported too much glare on the screen.

TABLE 2.

Affirmative Responses to Computer Acceptability Scale Questions by Age Groups

Affi rmative Responses (%)
Acceptability Scale Question All 60s 70s to 80s
1. Was using this computer too hard?
 Too hard 10 10 10
 Somewhat hard but I could use it 22 23 63
 Not hard at all 67 67 6
2. Was the lighting adequate for you to use this computer? 97 93 93
3. Was there too much glare on the computer?a 10 10 10
4. Was the color of the screen pleasing to you? 98 100 90
5. Were the instructions easy to understand? 98 100 90
6. Was the touch screen easy to use? 95 93 87
7. Were the words easy to see? 91 90 83
8. Did you feel more rushed by this way of telling your doctor or nurse about your pain or discomfort than you do when you talk with them about it?a 15 10 22
9. Did you enjoy using this computer technology as a way of telling your doctor or nurse about your pain or discomfort? 16 10 20
10. Did the computer program allow you to report ALL the information about your pain that you think is important to share with the doctor and nurse? 93 90 90
11. Did you like this computerized pain assessment to report your pain or discomfort? 90 90 83
12. Do you think that this program is a good way for people with your illness to report their pain or discomfort to their doctors or nurses? 90 90 83
13. Do you think this computer program should be available to all people who have pain or discomfort? 93 97 83
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a

Item reverse coded to calculate the total score.

Participants in the 60s and 70s to 80s age groups enjoyed taking this pain assessment for reporting their pain (90% and 83%, respectively) and thought it was an appropriate measure for reporting pain or discomfort to health care professionals (90% and 83%, respectively). Many agreed all people should have access to this computer program to share their pain or discomfort (60s: 97%; 70s to 80s: 83%). Participants thought that the assessment had adequately allowed them to report all of their information about their pain (60s: 90%; 70s to 80s: 90%).

Although many enjoyed the pain assessment for reporting pain, few participants reported that they enjoyed using this technology as a form of communication to tell a physician about their pain (60s: 10%; 70s to 80s: 20%). Approximately 10% of participants in their 60s and 22% of participants in their 70s to 80s found speaking with a health care professional about their pain with the computer device evoked a rushed feeling of communication.

Observations

Many participants, regardless of age, were more comfortable with a researcher present to complete the instruments on the iPad. Brief commentary between the researcher and participants during processing of gift cards revealed why certain questions were skipped and how familiarity of the Apple ecosystem helped them complete the surveys. Many men indicated that they skipped items that did not appear as important to their pain context, such as the screens with the many pain quality descriptors. Most men who owned Apple technology products decided to use the Apple Siri voice feature option as opposed to using their fingers on the device to provide their responses to the questions. Most participants also shared that they preferred the oral tradition of speaking with their health care provider.

DISCUSSION

This is the first study to investigate the acceptability of using technological devices for Black older men with LBP. Our study highlights that reporting pain and discomfort on an iPad for health care professionals was found to be acceptable with minor difficulty by Black older men. However, the acceptance of providing information on technological devices was not to be a replacement for oral communication with a health professional.

These findings echo previous research, suggesting persons are willing to embrace technology advances but remain clear that traditional oral dialogue is preferred when discussing health topics (Schoppee et al., 2020; Wilkie et al., 2003). The current study extends these results, suggesting community-dwelling Black older men with LBP can engage with surveys displayed on technological devices to express their pain and discomfort. However, recognition of nonverbal pain indicators in the presence of self-reported pain should remain paramount to capture an extensive frame of pain experienced from the person’s perspective.

Interactive computers with touch-screen technology have given researchers the ability to extend research by developing computer-based interventions. The acceptability of using technology to capture health data has been well documented (James et al., 2016; Mitzner et al., 2019; Owens et al., 2016; Tsai et al., 2015; Vaportzis et al., 2017). Studies have incorporated conversational avatars or designed and implemented interventions guided by information gathered from participants (Owens et al., 2016). Our sample of participants using the PAINReportIt® software on an iPad deemed the interaction highly acceptable to share self-reported pain or discomfort. This innovative tool requires minimal to no assistance for older adults. Researchers examining pain in persons with cancer and the general public demonstrated good usability of PAINReportIt® (Wilkie et al., 2003). The acceptability of this tool for communicating pain to clinicians aligned with findings from our sample. This opportunity to capture new information can provide health care professionals with new information to adjust an individual’s plan of care.

Black older men showed lack of enjoyment for using this tool to communicate with health care providers, which differed from patients with cancer and the general public with pain (Wilkie et al., 2003). This difference in findings suggests two potential explanations. First, Black communities have an embedded and unspoken oral tradition of expression using all forms of storytelling to communicate with others (Bonner et al., 2014; Bonner et al., 2021). This artform found in these spaces seems to depend on face-to-face interaction. Second, managed care protocols could have been interpreted as offering this technology as a cost-saving strategy to replace health care providers. This assumption stems from individuals suggesting insurance companies are trying to restrict access to health professionals (Fullwood et al., 2022). The attractiveness of technology seems of interest for many persons with pain or discomfort as long as the human connection with their health care provider remains intact.

The acceptability of technology in health spaces may depend on the clarity of instructions within the PAINReportIt® software. Direct observation of our participants while using the software proved essential for receiving feedback about the participant experience. Some participants commented about skipping or bypassing questions because they believed some questions had an unclear relevance to pain or discomfort. These findings were similar with other studies, noting increased clarity of instructions can lead to active participation by patients using new technology during health data collection (Tsai et al., 2015; Vaportzis et al., 2017). Revision of the instructions with detailed information explaining the relevance (i.e., value) of the questions may decrease the number of items skipped. Notably, giving better context behind questions offers patients the opportunity to understand the nature of their medical condition. These minor adjustments could lead to better collection of pivotal information for pain or discomfort and could improve the technology for all populations, especially individuals with low health literacy. Potential modification of these parameters of the PAINReportIt® software may enhance participant experience during clinical and research assessments.

Overall, participant engagement with this interactive, self-assessment tool proved positive for using the iPad. However, some participants had low confidence when interacting with the device. This lack of confidence was related more to the device itself. Notably, there are a variety of technology device suppliers, such as Android® and Microsoft®. Differences across platforms in device functions can contribute to difficulty for young and older adults comfortable with one platform versus another. Technology awareness may fail to transfer over to other devices, leading to potential frustration for participants. Many institutions conducting research online or in dedicated spaces use certain operating systems. The burden of dedicated devices will play a pivotal role for researchers using technology. For example, participants who are experienced with Apple products may have difficulty operating tasks on an Android platform device. The acceptability of using technology to capture vital health information could be increased by a query about device familiarity and tailored delivery of cross-platform development aids to help individuals acclimate to new devices.

LIMITATIONS

The current study has some limitations. First, the sample represents Black older men from only one small geographical area and does not represent Black younger men. Second, it is unknown if the acceptability would be as high if the device had been an Android or other smartphone.

CONCLUSION

Our study extends the understanding of computer acceptability for Black older men with LBP. Participants were highly accepting of providing information about pain or discomfort on the PAINReportIt® tool. However, their acceptance of the technology is not to be considered a replacement for discussing and sharing health information with their health care professional in-person. The under-reporting of pain or taking pain seriously represent calls to action during face-to-face communications.

Acknowledgments:

We salute our community scientists Mr. Charles F. Waldon and Mrs. Carol B. Thomas for championing this research project in Health Zone 1, located in Jacksonville, Florida. We would also like to acknowledge Mrs. Teresa Richardson and Merlen Mills for technical support on this project and Dr. Marco Pahor for his stewardship.

Funding:

This work was supported by the National Institutes of Aging (R33 AG056540–04S2) and National Cancer Institute (NCI U54CA233444).

Footnotes

Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.

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