Assessing a peer-led pain and wellness self-management program with older adults

Abstract

Background and Objectives

In 2021, the National Council on Aging developed the Self-Management Curriculum for Wellness and Pain Relief (NCWPR), a peer-based pain self-management program that provides person-centered pain management strategies, credible information on pain management methods and medications, and safe practices for the use of OTC drugs. This study describes a larger-scale, controlled intervention study of the NCWPR implemented to demonstrate its efficacy and readiness for more rigorous translation studies of the NCWPR’s impact on participants.

Research Design and Methods

This intervention efficacy study enrolled 90 adults (50 years and older) in a pre-/post-intervention design with a baseline control. Eight cohorts took the workshop series and were surveyed pre-study, 6 weeks post-control, on completing the curriculum, and 6 weeks later.

Results

Of 34 practices, therapies, or activities in the curriculum, participants showed robust, statistically significant increases in engagement and uptake on 23 following the curriculum, which was largely retained in the follow-up survey 6 weeks later. Participants showed statistically significant increases in knowledge around medications and sources of information about pain management, improved self-reported health, and a diminished experience of pain in daily life.

Discussion and Implications

The NCPWR fills an important gap for community-dwelling older adults who are living with pain but still able to engage in exercises at home as well as other professional therapies available in behavioral, traditional, or alternative medical care. It is accessible, peer-based, non-clinical, and able to be provided with minimal training to trainers.

Innovation and Translational Significance:

This study describes the implementation of a peer-based pain and wellness self-management course with low barriers to entry and delivery by non-clinical personnel that provides older adults with knowledge, practices, and tools to address pain on their own. The main aim was to stimulate the uptake of practices and therapies that reduce pain and identify resources for pain self-management in social networks (e.g., pharmacists, providers). We demonstrated the feasibility of providing senior centers and other venues with an accessible, evidence-based intervention that can be deployed virtually or in-person, requires little training to facilitate, is inexpensive, and emphasizes empowering participants.

Background and objectives

Chronic pain is among the most commonly experienced conditions in the United States and worldwide, increasing in incidence and intensity with age. Chronic pain among adults 50 years and older is associated with significant suffering, disability, and social isolation, resulting in increased costs to health care systems (Domenichiello & Ramsden, 2019). Pharmacologic treatment of chronic pain in older adults is usually only partially effective and is often limited by side effects, including urinary retention, constipation, bleeding, and risk of falls, as well as interaction effects between prescribed and non-prescribed medications (Pickering et al., 2024; Schwan et al., 2019). Notable recent increases in the rate of death by drug overdose among older persons (Spencer et al., 2024) signal an enhanced potential for adverse drug events related to polypharmacy or unintentional overdose. For persons with dementia, side effects may also include respiratory depression and delirium (Liao et al., 2021). Among other complicating factors limiting medical treatment for pain are age-related physiological changes, cognitive impairments, multimorbidity, and personal beliefs about pain and treatment (Reid et al., 2015). Chronic pain negatively impacts function and quality of life and increases social isolation and health care costs (Dahlhamer et al., 2018). Cognitive behavioral therapy (CBT) has been found to help reduce pain-related distress and improve self-efficacy for managing pain, but older adults may face barriers to accessing CBT treatment including financial (lacking insurance), geographic (transportation and distance), attitudinal (personal beliefs about pain), and systemic (lack of available providers) factors (Ehde et al., 2014).

Pain self-management programs have shown promise in improving the physical functioning and daily activities of older adults, especially if the program is tailored to participants’ individual problems and goals (van Het Bolscher-Niehuis et al., 2016). However, dominant models such as the Stanford Chronic Pain Self-Management Program and others based on it (Darnall et al., 2024; LeFort et al., 2015) can require lengthy leader training and other resources, and in 2021 the National Council on Aging (NCOA) began working with Dr Michelle Fritsch, a pharmacist and geriatric clinician specializing in pain management to create a complementary, simpler, portable program for managing pain. The resulting “Self-Management Curriculum for Wellness and Pain Relief” (NCWPR) is a peer-based pain self-management program that requires no more than 2 hr of asynchronous training of peer trainers and can be implemented effectively in virtual or in-person settings with 10-to-12 persons at a time. The program utilizes existing evidence to provide person-centered pain management strategies optimizing health, functioning, and quality of life; credible information on pain management methods, over-the-counter (OTC) remedies, side effects of certain OTC medicines and prescribed pharmaceutical medications to prevent accidental misuse; safe practices for the use of OTC drugs in pain self-management; and relaxation strategies, mindful movement and reliable sources for information about pain relief. The NCWPR is a community-based lifestyle and behavior change program that uses a flexible approach to engagement, with both online and face-to-face activation available to participants.

A key element in the NCWPR’s design is peer leadership. Support groups have been shown to play a valuable role in managing pain safely, and peer support offers a valuable way for people with chronic health conditions to learn to live with and manage the complexities of their condition day to day, giving them the confidence, knowledge, and support to do this (Farr et al., 2021). A study of a peer-led chronic pain self-management program in rural New York found that participants reported significant improvement in pain disability, depression, and pain self-efficacy immediately after program completion, with most improvements sustained six months after program completion (Pullyblank et al., 2022). A randomized controlled trial with nursing home residents showed that upon completion of a peer-led intervention, there was a significant increase in pain self-efficacy and reduction in pain interference among participants that was sustained in the 3-month follow-up (Tse et al., 2021).

The NCWPR’s central features

The NCPWR is designed to be accessible, available, and relatively simple to implement with persons of any background and with minimal program leader experience. The central features are:

Iterative workshop

The NCWPR provides a workshop structure of six weekly sessions for 90 minutes each with an instructor who is trained in delivering the curriculum. Participants are provided with a downloadable version of the curriculum for home use, with the option of having a physical workbook mailed to them.

Non-clinical

The NCWPR is a non-clinical intervention that may be delivered by anyone who is trained with a leader guide and self-directed instructional video that can be completed asynchronously and reviewed as necessary, including peers who are experiencing the same kinds of pain as the participants.

Peer-based learning

The NCWPR utilizes a “peer-based” pedagogy delivered to groups of eight to 10 individuals at a time. Peer-based learning is a powerful tool for adults that creates a cohort-learning process with opportunities for mutual support that may reduce anxiety or other barriers that can inhibit learning (Farr et al., 2021; Tse et al., 2021).

In-person or virtual

The NCWPR may be provided in both virtual and in-person formats. Peer- and cohort-learning effects may be obtained in both circumstances, while the alternative of an in-person or virtual experience enhances the accessibility of the curriculum for participants. Individuals with transportation or travel barriers may prefer a virtual format, while the in-person format can benefit those who do not have access to the internet or personal space to do the curriculum at home.

Modular presentation

The NCWPR is divided into six stand-alone, non-cumulative modules. In this format, each module is a course unto itself, and missing one session should not diminish the benefits of the next one. The modules are titled (1) “My Life, My Choice, My Action”; (2) “Options, Options Everywhere: Where Do I Begin?”; (3) “Is That Tiny Print Important?”; (4) “What Else Can I Take? What Are the Risks?”; (5) “The Role of Prescription Medications”; and (6) “Your Pharmacy: A Place for Trusted Information.” Each module addresses an area of pain management, including therapies, home exercises, medical treatment, mental health solutions, over-the-counter medications, prescription pain medications, and how to utilize pharmacists as a source of valuable information about medications and pain relief. Each module has a similar structure, breaking down the new knowledge and practices into smaller portions that are more easily assimilated by participants. In this structure, the modules undertake different activities (instruction, practice, activities, and questions) in blocs of 10–20 min, blending educational information about treatments, therapies, and medication; learning and practice of stretching and other exercises; activities built around cases or scenarios; and time for questions and exchange of information among participants and the facilitator.

Piloting the NCWPR

One of the goals of the NCPWR was to address the growing need for more resources that focus on medication management and address pain. Pain is a major driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity (IOM, 2011).

We believe this program can meet the Administration for Community Living’s criteria for recognizing “evidence-based programs” funded through the Older Americans Act Title IIID and other discretionary funding. Testing the curriculum began with a pilot study conducted from November 2021 through March 2022. The pilot was implemented with 32 participants across three sites in Florida, Washington, and Illinois. Results showed participants increasing their knowledge of pain and pain management, reporting decreases in pain after completing the program, and engaging in behavioral changes that included incorporating stretching and relaxation techniques into daily regimes, getting more restful sleep, and cleaning out old, expired medicines from their cabinets. Based on this experience, the NCOA has implemented a larger-scale, controlled intervention study of the NCWPR to demonstrate the curriculum’s efficacy and readiness for more rigorous translation studies of the NCWPR’s impact on participants, the results of which are reported herein.

Research design and methods

Functional constraints among stakeholders, timing, and sample size ruled out utilizing a randomized control trial or other group comparison designs. To maximize the number of participants, we used a pre/post intervention design with a baseline control to survey participants prior to the intervention, immediately after, and 6 weeks later. A condition of enrollment was that participants had a regular experience of pain that was disruptive to daily life, but we could not know what their baseline exposure had been to pain treatment or therapies. In order to prevent the study from representing a carry-over of disparities that may exist due to prior exposure to pain treatment, we provided a common “control document” from the National Institutes of Health that reviewed common pain management therapies that one might hear from providers in pain care. To mitigate the priming effect of such exposure, we allowed a 6-week period for the control to weaken (or “wash out”), after which participants were baselined and enrolled in the workshops. Figure 1, study consort, shows the process of outreach, screening, and enrollment, from 325 persons interested in the study to the eventual 90 who enrolled.

Figure 1.

Consort diagram.

The study treated each workshop group as a “study cohort.” The cohorts were convened by three different organizations: Weber Moore Partners, LLC; Oasis St Louis; and Rush University Senior Care (Chicago). Weber Moore and Oasis St Louis recruited participants for virtual cohorts held online over Zoom. Rush recruited one virtual cohort and one in-person cohort. Eligibility criteria were (1) 50 years or older, (2) experiences physical pain that interferes with their daily quality of life, (3) English-speaking, (4) able to commit to an 18-week study, (5) completes and passes a comprehension screener, (6) for virtual participants, able to participate via teleconference over the internet on a mobile device or computer for the 6-week workshop period, and for in-person participants, able to attend workshop physically for the 6-week workshop period.

Following consent, 90 participants fully enrolled by completing the study pre-survey. During the consent process participants chose among available opportunities to experience the curriculum, resulting in eight study cohorts ranging from 9 to 17 participants per cohort, with a mean of 11.25 and mode of 11. Removing the one high outlier (17), the other seven cohorts ranged from eight to 12, with a mean of 10.4. Six of the cohorts were run virtually from September 2023 through January 2024, with another virtual cohort from December 2023 through April 2024 and a final, in-person cohort from at the Rush University Senior Care Center in Chicago, Illinois January 2024 through May 2024.

Each cohort took place independently in the following sequence:

1. Pre-survey, week 1: Participants take a pre-survey that collects baseline information on the sample.

2. Baseline control phase, weeks 1–6: Following the pre-survey, participants are provided with printed materials available in the public domain at the National Institute on Aging, addressing pain self-management (https://www.govinfo.gov/app/details/GOVPUB-HE20-PURL-gpo183683). The materials reflect the current standard of information a person would receive from a physical therapist, physician, licensed clinical social worker, licensed nurse, or senior center staff. Participants were asked to review the materials and consider how to apply the information in their daily lives.

3. Post-control survey, week 6: Participants receive an invitation to take a brief post-control survey.

4. NCOA workshop, weeks 7–12: Participants join a weekly workshop session with other cohort members and a trainer.

5. Post-workshop survey, weeks 12–13. Participants receive an invitation to take a brief post-workshop survey.

6. Follow-up period, weeks 13–18: No new intervention materials or activities.

7. Follow-up survey, weeks 18–19: Participants are invited to complete the final follow-up survey.

Survey structure and measures

The pre-survey collected participant demographics and other characteristics, self-reported quality of life, emotional and behavioral health background before the trial, attitudes and beliefs about bodily control and management, activities of daily life, attitudes about over-the-counter (OTC) and opioid medications, a self-reported inventory of pain incidence and prevalence across a dozen body sites, and to whom they turn for information about pain management. Some of these items also continued through the post-control, post-workshop, and follow-up surveys. With these baseline measures, the study tested for significant differences among the trial cohorts.

Specific items related to knowledge, attitudes, and pain management practices or therapies were included in the post-control, post-workshop, and follow-up surveys. Practices and therapies are actions that a person can take to help manage the pain they experience. Some items, like stretching, can be done on one’s own, while others, such as mental health counseling and traditional or alternative medical therapies, require one to seek professional help. To measure change at the individual level across these indicators, we adapted the “stages of change” [SOC] model of health behavior to capture how participants assessed the practices promoted in the curriculum, whether they tried them out or not, and which practices might become part of the participants’ regular routines. The SOC tracks the uptake of a new practice from a lack of awareness or concern with the practice (“pre-contemplation”) to considering the practice (“contemplation” and “preparation”), taking up the practice (“action”), and sustaining utilization over time (“maintenance”). The SOC has proven adaptable to a number of behavioral circumstances, including tobacco, alcohol, and other substance abuse; other addiction behaviors; weight control; exercise acquisition; prevention; and school bullying (Prochaska et al., 1992). For the current study of the uptake of pain self-management practices from the NCPWR, our 5-point adaptation of the SOC scale is provided in Table 1.

Table 1.

Stages of change applied to the NCOA curriculum outcomes.

Stage	Meaning	Adaptation for trial: 5-point scale
Pre-contemplation	The subject is not thinking about the risk or issue, or there is no explicit way to change behavior.	1 = I did not think about trying this.
Contemplation	The subject can express the risk or problem, but they may not be sure what to do about it or what the alternatives are.	2 = I thought about this but did not try it out.
Preparation	The subject is considering alternatives or even trying them out.	3 = I tried this out, but it’s not for me.
Action	The subject has committed to a course of action.	4 = I am trying this out currently.
Maintenance	The subject has routinized the new behavior; it has become part of their regimen or daily life.	5 = This has become part of my pain management routine.

Results

The study enrolled 90 individuals across eight cohorts, with an overall retention rate of 82% from pre-survey to follow-up. Almost four-fifths (79%, n = 71) of participants completed all four surveys. Attrition accounted for most of the missing data, with other missing data resulting in lower paired ns for difference of means tests among the more medically or technically complicated items tested. Paired difference of means tests were used for the main SOC results on the 30 practices and therapies discussed in the curriculum, with the pairs varying from a low of 55 to 73 (with two outliers at 42 and 47, acceptance and commitment therapy, and transcranial stimulation) in the post-control to post-workshop period and 55 to 71 (with five outliers, from 42 to 54) in the post-control to follow-up phase (acceptance and commitment therapy, transcranial stimulation, cognitive behavioral therapy, hypnosis, and biofeedback).

 

Sample

Table 2 provides the sample demographics. In terms of gender, participants were predominantly female (77 of 90, 87.5%), and in terms of race, predominantly White (57, 65.5%) and Black or African American (24, 27.6%). The preponderance of White and Black female participants was related to a few statistically significant distributional differences throughout the sample, but in the main sample, there were few patterns that would affect the implementation of the trial. Difference of means tests were run across all basic demographics, other characteristics, and by cohorts, and overall, there were no systematic, demographic, or cohort-related differences in the sample. Where any statistically significant differences were found, they involved only a few participants who made the difference:

Table 2.

Sample demographics (N = 90).

Age group	N	%
50–54	1	1.1
55–59	8	8.9
60–64	9	10.0
65–70	26	28.9
71–74	25	27.8
75–79	12	13.3
80–84	5	5.6
85 and older	4	4.4
Gendera
Male	9	10.2
Female	77	87.5
Non-binary	1	1.1
I would prefer not to say	1	1.1
Orientationb
Bisexual	1	1.1
Gay or lesbian	1	1.1
Straight	82	93.2
I would prefer not to say	4	4.6
Race
American Indian, Alaska Native, or Native American	1	1.2
Asian	1	1.2
Black or African American	24	27.6
White	57	65.5
Multiracial	4	4.6
Latino Ethnicity
No	83	95.4
Yes	4	4.6
Veteran
No	82	94.3
Yes	5	5.8
Gross income (monthly)
Less than $1,000	6	6.8
$1,000–$1,499	8	9.1
$1,500–1,999	8	9.1
$2,000–2,499	12	13.6
$2,500–2,999	7	8.0
$3,000–3,499	1	1.1
$3,500–$3,999	3	3.4
$4,000–4,499	5	5.7
$4,500–4,999	5	5.7
$5,000 or more	8	9.1
I would prefer not to say	25	28.4
Living situation
By myself	56	63.6
With a spouse or domestic partner	19	21.6
With grown children	5	5.7
With other family members	3	3.4
With a spouse and children or other family members	5	5.7

^aNo (zero) Black participants were male; all were female.

^bMale participants tended to be White. All men in the study reported straight orientation. Women included four identifying as bisexual, lesbian, or prefer not to say.

• Gender: Black participants were all female. Eight of nine male participants were White.

• Sexual orientation: All male participants (n = 9) were straight, while other orientations were distributed among female participants, non-binary persons, and other genders.

• Veterans: Three of five veterans in the sample were in Cohort 3, a small outlier in the larger sample.

• Social drivers of health: Black participants were statistically significantly more likely to report being worried that their food would run out before they had money to purchase more, and/or that they did not have adequate money for housing or utilities payments.

• Medical mistrust: Black participants agreed or strongly agreed at a highly statistically significant level with the statement that “Health care organizations have sometimes done harmful experiments on patients without their knowledge.” This pattern reflects the history of unethical medical experimentation with African Americans, most notably the Tuskegee Syphilis Study in the United States.

• Use of marijuana for pain relief: White participants were more likely to report having used marijuana for the management of pain.

• Use of aspirin with additives: White participants were more likely to report having used aspirin with additives (e.g., Excedrin) compared to other participants.

Cohort comparison

Difference of means tests by study cohort were performed across all 30 performance indicators in the post-control, post-workshop, and follow-up surveys. There were no statistically significant differences on any indicator by any cohort at any stage of the study. The consistency of outcomes between cohorts and the consistency of results in learning, adoption, and retention across phases of study indicate that the workshops delivered consistent outcomes regardless of training leader, setting, or study timing. The value of the program is durable across cohorts.

Incidence, prevalence, and acuity of pain

In the study’s pre-survey, participants reported living with diverse and acute pain on a regular basis, among several types and sites for pain: hand, shoulder, back, neck, foot, joint (general), knee, hip, spine, arthritis, headache, and other sources of pain. Back pain (73%), arthritis (69%), and knee pain (53%) were the most commonly reported sources of pain. Almost all participants (97%) reported two or more sources/sites for pain, while over four-fifths (82%) reported two to six sources/sites for pain. Over half the participants reported living with pain at all sources/sites (except for headaches, at 39%) for 15 or more days in the last month. Pain was disruptive of daily life at a consistent but not totalizing level, with 27% of participants reporting that their pain causes “somewhat” or “a lot” of disruption for “learning, remembering or concentrating” and 50% for “socializing with friends or others outside the home.”

Participants reported that they have been seeking alternatives for pain management and that pain, no matter how prevalent, is not controlling their lives. Only one-fifth (20.7%) of participants expressed satisfaction with the ways they manage pain, while four-fifths (81.8%) were thinking about the goals they would like to achieve in reducing pain. Almost half (46%) were not sure about what to do with their pain. Over half to two-thirds have been discussing pain or seeking guidance or advice from friends (67.4%) and talking to professionals (60.2%) about what to do for pain management, but only a quarter (25.8%) say that pain has totally taken control of their lives.

SOC and self-management measures

Progress on the SOC measures

The modified SOC measures were used to ask participants about 30 practices or therapies recommended in the pain management control and the NWPCR. These were provided in five categories: mental health options (cognitive behavioral therapy, music therapy, acceptance and commitment therapy, hypnosis, and distraction); medical and professional services (occupational therapy, massage therapy, biofeedback, transcranial magnetic stimulation, swimming or water aerobics, electric nerve stimulation, heating and cooling, spinal manipulation and chiropractic, and physical therapy); alternative medical practices (meditation and/or mindfulness, relaxation techniques, Tai Chi or Qigong, yoga, and acupuncture), prevention (healthy weight or losing weight; physical activity; limiting alcohol, tobacco, and caffeine; and improving sleep quality); and pain management and consultation (discuss OTC drugs with pharmacist, change how one uses OTC drugs, clean out expired medications, discuss medications with health care providers, topical therapies, cannabis products, and joining a pain support group).

Participants were surveyed on the SOC measures three times: to establish the post-control baseline in week 7 (“PC” in Tables 3 and 4), after workshops in week 13 (“PW” in the tables), and 6 weeks following the end of the workshops in week 18 (“FU” in the tables). Table 3a–e provides the results for all 30 items measured on the SOC scale. On all 30 measures, change was positive from the PC to PW phase, with 19 showing two-tailed t-test results at p < .05 or lower. The FU survey, 6 weeks after the workshop ended, showed similar results, with learning and perspectives on the curriculum items largely maintained in spite of an expected drop-off in retention, with 18 of the items at p < .05 compared to their PC baseline. Cohen’s d measures are provided for statistically significant changes (p < .05) and show moderate (0.50–0.80) to moderately strong (>0.80) effect sizes for most items. The period between the workshop’s conclusion and the follow-up survey (not shown in Table 3) resulted in an expected drop-off in the impact measured immediately after the workshops. However, among the 30 items, only three showed statistically significant drop-off or “wash-out” levels during the PW-FU phase that was statistically significant. The rest were slight and not statistically significant.

Table 3.

NCPWR indicators for change, paired t-tests.

Variables	PC to PW						PC to FU
	N	Means		D (PW-PC)	95% CI	Cohen’s d	N	Means		D (FU-PC)	95% CI	Cohen’s d
		PCa	PWa					PC	FUa
(a) Mental health optionsa
Cognitive behavioral therapy	56	2.16	3.25	1.09***	0.62, 1.56	0.79	54	2.17	2.69	0.52*	0.08, 0.96	0.36
Music therapy	60	2.48	3.47	0.98***	0.58, 1.39	0.65	57	2.35	2.98	0.63**	0.20, 1.07	0.40
Acceptance and commitment therapy (ACT)	47	2.55	3.34	0.79**	0.30, 1.27	0.51	43	2.33	3.23	0.91**	0.34, 1.48	0.59
Distraction	61	3.05	3.84	0.79***	0.39, 1.18	0.53	57	3.09	3.61	0.53*	0.10, 0.95	0.34
Hypnosis	56	1.46	1.66	0.20	−0.05, 0.44		53	1.28	1.53	0.25	−0.13, 0.50
(b) Medical and professional servicea
Occupational therapy	59	1.49	2.02	0.53**	0.21, 0.84	0.49	60	1.45	1.87	0.42*	0.05, 0.78	0.39
Biofeedback	57	1.67	2.25	0.58***	0.28, 0.88	0.48	54	1.56	1.93	0.37	−0.02, 0.76
Massage therapy	64	2.44	3.03	0.59**	0.24, 0.94	0.46	62	2.39	2.76	0.37*	0.01, 0.73	0.27
Transcranial magnetic stimulation	42	1.14	1.43	0.29	−0.03, 0.60		46	1.11	1.28	0.17	−0.02, 0.36
Swimming or water Aerobics	67	2.15	2.60	0.45**	0.18, 0.71	0.33	63	2.02	2.46	0.44**	0.14, 0.75	0.33
Electric nerve stimulation	55	1.73	1.98	0.25	−0.01, 0.52		57	1.68	1.86	0.18	−0.10, 0.45
Heating and cooling	64	3.59	3.88	0.28	−0.03, 0.59		60	3.55	4.15	0.60**	0.22, 0.98	0.46
Spinal manipulation or chiropractic medicine	63	1.78	1.98	0.21	−0.06, 0.47		61	1.82	1.98	0.16	−0.03, 0.36
Physical therapy	68	3.15	3.38	0.24	−0.11, 0.58		64	3.14	3.38	0.23	−0.15, 0.62
(c) Alternative medical practicesa
Meditation and/or mindfulness	68	2.85	3.71	0.85***	0.51, 1.19	0.61	64	2.84	3.30	0.45**	0.13, 0.78	0.30
Relaxation techniques	68	3.37	4.06	0.69***	0.35, 1.03	0.61	62	3.47	3.94	0.47*	0.09, 0.84	0.37
Tai chi or Qigong	61	1.97	2.39	0.43**	0.12, 0.73	0.35	59	2.03	2.34	0.31*	0.04, 0.57	0.25
Yoga	63	2.41	2.70	0.29*	0.05, 0.52	0.22	61	2.46	2.72	0.26	0.00, 0.52
Acupuncture	69	1.71	1.88	0.17	−0.04, 0.39		63	1.59	1.71	0.13	−0.06, 0.31
(d) Preventiona
Keeping a healthy weight or losing weight	72	3.83	4.19	0.36**	0.11, 0.61	0.35	66	3.80	4.20	0.39**	0.15, 0.64	0.38
Physical activity such as walking, stretching, or exercise	73	4.12	4.40	0.27*	0.05, 0.50	0.31	67	4.09	4.40	0.31**	0.11, 0.51	0.33
Limiting or eliminating alcohol, tobacco, and/or caffeine	67	3.42	3.82	0.40	−0.01, 0.81		59	3.31	3.85	0.54*	0.13, 0.96	0.34
Sleeping well, sleeping enough, or improving sleep quality or restfulness	70	4.14	4.36	0.21	−0.02, 0.45		65	4.11	4.26	0.15	−0.08, 0.39
(e) Pain Management and Consultationa
Connecting with a pharmacist to discuss OTC and other medications that help relieve pain	67	1.73	2.97	1.24***	0.82, 1.66	0.91	62	1.76	2.90	1.15***	0.73, 1.56	0.85
Changing how I use OTC products based on the materials I have received	63	2.48	3.75	1.27***	0.78, 1.76	0.89	59	2.54	3.75	1.20***	0.68, 1.73	0.82
Cleaning out old or expired medications	64	3.27	4.09	0.83***	0.40, 1.25	0.57	60	3.28	4.18	0.90***	0.52, 1.28	0.62
Meeting with healthcare provider to discuss all my medications, including prescription medications	69	3.30	3.80	0.49*	0.03, 0.96	0.33	65	3.40	3.55	0.15	−0.27, 0.58
Using topical therapies (creams and gels)	70	3.59	3.87	0.29*	0.04, 0.54	0.23	66	3.62	3.88	0.26	0.00, 0.51
Using cannabis products	67	1.73	1.84	0.10	−0.06, 0.27		61	1.69	1.87	0.18**	0.07, 0.29	0.15
Joining a pain support group	66	1.73	1.76	0.03	−0.37, 0.43		60	1.77	1.98	0.22	−0.15, 0.59
(f) Self-management of painb
In the last 6 weeks, I have been able to deal more effectively with my overall pain management.	75	3.13	3.75	0.61***	0.42, 0.81	0.72	71	3.11	3.92	0.80***	0.58, 1.03	0.91
In the last 6 weeks, I have set specific goals for pain management, prevention, or treatment.	76	3.39	3.83	0.43***	0.22, 0.65	0.51	71	3.38	3.87	0.49***	0.26, 0.73	0.54
In the past 6 weeks, I have been able to achieve the goals I set for pain management, prevention, or treatment.	74	2.93	3.47	0.54***	0.32, 0.76	0.60	70	2.93	3.44	0.51***	0.30, 0.73	0.55
In the last 6 weeks, I have been discussing the topic of pain management in general with friends, peers, and family members.	75	3.29	3.63	0.33*	0.07, 0.60	0.35	70	3.23	3.43	0.20	−0.07, 0.47

Note. CI = confidence interval; FU = follow-up; OTC = over-the-counter; PC = post-control; PW = post-workshop; SOC = stages of change.

^aMeasured using the SOC scale: 1 = I did not think about trying this; 2 = I thought about this but did not try it out; 3 = I tried this out, but it’s not for me; 4 = I am trying this out currently; 5 = This has become part of my pain management routine.

^bMeasured using the agreement scale: 1 = Strong Disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly Agree.

^* p < .05.

^** p < .01.

^*** p < .001.

Table 4.

Quality of life and attitudinal measures: PC to PW.

Variables	N	PC	PW	D (PW-PC)
Health and mental well-being (5-point scale, 1 = poor, 5 = excellent)
Self-rated health	77	2.97	3.61	0.64***
Self-rated mental health	76	3.20	3.87	0.67***
Level of social support	77	3.19	3.71	0.52***
Experience of pain recently
Wong-Baker Pain Scale (0–10, 0 = no pain, 10 = worst pain)	76	4.53	4.00	−0.53**
Attitudes about OTC drugs (1–5 agreement scale, 1 = strongly disagree, 5 = strongly agree)
OTC medications are safer than prescription pain relievers.	77	2.71	2.74	0.03
OTC medications are not strong.	77	2.62	2.22	−0.40***
Generic or store-brand OTC pain medications are not as strong as the major brands.	77	2.43	2.06	−0.36**
OTC medications are not addictive.	77	2.53	2.06	−0.47***
OTC medications do not have stigma.	74	3.07	3.01	−0.05
It is ok to use more than recommended dosage of OTC medications.	75	1.76	1.35	−0.41***

Note. OTC = over-the-counter; PC = post-control; PW = post-workshop.

^* p < .05.

^** p < .001.

^*** p < .001.

The overall drop-off in the 6 weeks following the end of the workshops is reflected in the smaller effect sizes and lower levels of statistical significance in the PC-FU measure compared to the PC-PW results, as shown in Table 3a–e. At the same time, shifts in patterns of interest in or uptake of the practices or therapies occurred throughout the follow-up period, which can be seen in fluctuations in impact when comparing the PC-PW and PC-FU results. Four of the practices/therapies that reflected significant change in the PC-PW period washed out by follow-up (biofeedback, yoga, discussing medications with healthcare providers, and use of topical creams). Three (heating/cooling, limiting use of alcohol and tobacco, and use of cannabis products) show significant changes in the PC-FU that were not present at that level in the PC-PW phase immediately after the workshop. Finally, the “prevention” category was alone in showing increased effect sizes in the PC-FU measurement that were not present in the PC-PW phase surveyed just after the workshops concluded. This fluctuation indicates continued consideration and activation by participants in the follow-up period, at the same time as the effects on many of the items were decreasing.

These changes are robust and show, on average, increased thinking about, and utilization of, the practices indicated in both the workshop and control document along the stages of change model. Effect sizes were largest for items in the “pain management and consultation” category, particularly regarding learning about and managing OTC pain relievers. These were items that participants had little familiarity with prior to the study—they had lower mean scores, relatively, at PC. The NCPWR provides information and learning about OTC pain relievers and other medications that may be new to the participants or help them see the use of the OTC products in a new way. “Mental health options” and “alternative medical practices” showed the next highest effect sizes, with moderate effects occurring on all but one item. The category of “medical and professional services” showed mixed results, in which three of the nine items showed positive results that were statistically significant and had 95% confidence intervals—these items were more well-known therapies that have lower activation costs and often can be initiated outside of the context of medical insurance. The other items (“transcranial magnetic stimulation,” electric nerve stimulation, etc.) may require more self-education, provider visits, and insurance approvals.

Self-management of pain

In addition to the SOC questions, participants were asked at all three survey points about their self-management of pain and goals regarding pain self-management, which are reported in the last sub-table of Table 3f. Three of the four items are reported with robust change and effect sizes. These items asked participants to report their agreement or disagreement along a 5-point scale in which 1 = strongly disagree, 2 = disagree, 3 = neither, 4 = agree, and 5 = strongly agree. All four items showed statistically significant change in the PC-PW phase, though only three remained in the PC-FU analysis. At the same time, for participants who completed the follow-up surveys, the PC-FU effect sizes increased for two items, indicating a strong and lasting effect on participant self-assessment of their own capacity to “deal more effectively with my overall pain management” and setting “specific goals for pain management, prevention or treatment.”

Adjustment for false positives

Testing the curriculum with 34 indicators runs a higher risk of Type I error, in which we accept false positives and fail to reject null hypotheses. To test for this risk, we used the Benjamini-Hochberg Process for all 34 items tested in Table 3 at both the PC-PW and PC-FU phases of the study. The Table 3 results across SOC and self-management categories show 23 of 34 items at p < .05, which includes a 7.5% chance of false positives according to the Benjamini–Hochberg formula. Using the formula and reducing the false positivity parameter to 5% risk, we decrease the significant results from 23 to 22 items in the PC-PW phase and from 23 to 20 in the PC-FU phase. Finally, reducing the false positivity parameter to 2.5%, we decrease the significant results from 22 to 19 items in the PC-PW phase and from 20 to 14 in the PC-FU phase. In each false positivity parameter, except for the PC-FU phase at 2.5%, over half of the indicators retain their statistical power at p < .05. Even with a modest risk of false positives, the intervention is associated with moderate to moderately strong changes in participant contemplation and uptake of new self-management practices for pain.

Quality of life and attitudinal changes

In addition to providing information and introducing new practices for pain self-management, the NCPWR also emphasizes the importance of credible knowledge about drug treatments—both prescribed—and over-the-counter pain medications. To understand if or how the workshop affected participants’ knowledge about pain medications, perspectives on pain self-management, and general sense of well-being, the study surveys included measures of quality of life, pain, and attitudes about OTC treatments. The results on the “quality-of-life” questions (including self-reported health, mental health, and emotional support) are reported in Table 4 for the PC to PW period, emphasizing the change due to the workshops compared with the attitudes on these measures after exposure to the NIH control materials. The results for the PC to PW phase are robust, positive, and statistically significant—and this repeats across the other phases of the study from pre-survey through follow-up (not shown). Not only did the participants develop new behaviors and attitudes about self-management of pain but also they reported feeling better after participating in the study across all phases, and those changes were sustained over the entire 18 weeks of the study.

In terms of the everyday experience of pain, participants were provided with the Wong-Baker FACES Pain Rating Scale, which uses pictures of faces that illustrate increasing levels of physical pain, ranging from 0 = no pain to 10 = worst pain (Keck et al., 1996; Kim & Buschmann, 2006). Participants were asked to select the “face” that best expresses the level of pain they tend to experience. This assessment tool is typically used in healthcare settings to assess pain levels and monitor pain management effectiveness. The results showed a statistically significant decrease from post-control (4.53) to post-workshop (4.00), indicating an overall decrease in how participants characterized their pain, with 95% confidence intervals well above zero on the low end. The study measured attitudes surrounding OTC drug use on the 5-point agreement scale (1 = strongly disagree to 5 = strongly agree), using questions created by NCOA staff for the initial pilot study. Four of the six OTC drug indicators showed a statistically significant improvement in knowledge of the proper use of OTC medications for pain relief, and for these, 95% confidence intervals are above zero at the lower end. Overall, the workshop was impactful in shifting the way participants view and use OTC medications.

Discussion and implications

Discussion

The NCPWR shows promising results in helping older individuals living with pain learn about and experiment with new practices that improve their experience of pain in two main ways. Analysis of participant responses reveals statistically significant, moderate to moderately strong changes on over half of the SOC indicators and even stronger changes on the items about pain self-management. Drop-off on the SOC scale in the 6 weeks after the training is modest. Some notable clusters of items that include higher and stronger effect sizes are present for “pain management and consultation” related to OTC medications and consultation with pharmacists and providers. Four of the five “mental health options” surveyed showed statistically significant, moderate effect sizes from PC to PW on four items, with only a slight drop-off through follow-up on three of the items. “Alternative health practices” that can be done on one’s own, including meditation and relaxation, also show moderate effects in the PC to PW phases, with three of the four alternative health items showing small but statistically significant changes across the whole study period (PC to FU). These are areas that the NCPWR might seek to enhance in future implementation and translation, reflecting, on the one hand, things that the participants can do on their own (consultation with pharmacist, meditation and relaxation, cleaning out old cabinets of medicines) and other options that reflect growing evidence of the stressors and mental health burden facing American adults as they age (Vani Agarwal et al., 2024). Improved responses on several quality-of-life items (including the Wong-Baker scale and better self-reported health, mental health, and social support indicators) and changing beliefs about managing pain and goal-setting around pain and wellness indicate that the NCPWR may have beneficial attitudinal impacts, helping participants believe they can improve their experience of pain through the curriculum’s self-activated practices and therapies. Finally, participants leave the workshop series with improved knowledge about OTC pain medications, prescription medications, and the utility of pharmacies and pharmacists as easily accessible sources of new information on pain management and pain medication.

The NCPWR was created to fill a gap left by the dominant model of pain self-management, which is limited by cost, duration, and reading levels. In this gap, the NCPWR is a complement to the Stanford Chronic Pain Self-Management Program, providing a similarly high level of training but in a peer-based format that is less formal and intense. While barriers to activation in pain self-management may also include the daunting intensity of many programs and workshops, the NCPWR provides a “zero class” that can serve as an introductory program before participating in other evidence-based programs (Jiang et al., 2015). It fills a gap in the availability of simple, self-activating, experiential, and non-clinical practices that ordinary people can learn over a few weeks and continue practicing independently.

The NCPWR’s uniqueness is not in the practices or interventions it emphasizes, but rather in the ease of implementation and a peer-based workshop structure that delivered the material in manageable pieces for participants who could assimilate the information with others—watching and listening to them in the workshops even when they were virtual. The isolation experienced by many individuals in pain contributes to a sense of powerlessness (Berglund et al., 2015; Gillsjö et al., 2020; Schofield, 2007). Prior to the COVID-19 pandemic, social isolation among older adults was a major public health issue, gaining international recognition as being detrimental to quality of life and premature mortality. As social beings, our social relationships (both quality and quantity) largely impact our health and well-being, as well as risk for illness and death. The negative ramifications of social isolation and low social connectivity have been equated to the health risks of high blood pressure, physical inactivity, obesity, or smoking cigarettes (Holt-Lunstad et al., 2010). The NCPWR’s peer-based workshop structure breaks the isolation and enhances the prospect that one can exercise some control or agency over pain.

Limitations

The benefits of the NCPWR as reported in this study are limited by design factors, including its convenience sample, short duration, and reliance on self-reported data. Results cannot be generalized beyond this intervention study. The building of an evidence base for dissemination will require further trials and translation of the program.

Observational design

The study used a pre/post intervention design that can only measure change along a metric before and after an intervention. In order to strengthen our capacity for inference regarding the workshops’ efficacy in helping participants to contemplate and try out new practices, we used two processes. First, we established a baseline control to mitigate differences among participants who were extremely knowledgeable about pain management and those who were not. The baseline control established a common benchmark to measure the impact of the workshops, which delivered much of the same knowledge but with the opportunity to learn and practice with peers, in a process led by a peer, in an accessible format, and in a brief period of time (6 weeks). Second, we added a follow-up measurement 6 weeks after the conclusion of the workshops. The follow-up showed that the impact of the workshop experience continued at levels substantially higher than at baseline control. Knowing that the full washout of the intervention experience may be longer than 6 weeks allows the program’s developers with a benchmark to begin work on supplemental workshop programming to extend its impact and provide refresher curricula for persons with some experience in self-management of pain.

Intervention modality

The study results cannot speak to any potential differences between delivering the curriculum in a virtual or in-person setting. With seven of eight cohorts receiving the curriculum virtually, over Zoom, the results certainly suggest that the workshops are effective in the virtual modality. Results comparing the in-person cohort to the virtual cohorts showed no systematic difference between the in-person and virtual cohorts. Studies with other, brief pain self-management programs using telehealth and telephone support to self-directed programs have shown promise (Scriven et al., 2019; Sheth et al., 2022). However, any advantage to either a virtual or in-person modality is beyond the scope of the study and must be investigated in a different study.

Sample and representation

The results of this study are limited to the sample in the study. The sample was recruited by convenience, “first-come first-served,” through the contact lists of the Rush and Oasis collaborating partners, NCOA’s network of senior centers, and recipients of newsletters and other pools of potential candidates. Self-selection biases in the sample are enhanced by exposure to individuals who are already involved in senior centers or other programming for older adults. In this study, the response to outreach was overwhelmingly female, which is reflected in 87.5% of the sample being female. Probable reasons involve some of the known gender disparities in social participation and pain management among women and men. Senior center participation in the United States is more heavily female than male (Kadowaki & Mahmood, 2018). Globally, older women tend to have higher levels of participation in community activities, though the motivations of men to social participation are less well known than for women (Ong et al., 2024). Regarding pain, research review has found that men are less likely to seek support for pain, due to a “stoic” approach that favors masculinized norms of strong bodies and self-reliance (Samulowitz et al., 2018).

In addition to an underrepresentation of men in the study, the sample is overwhelmingly White (65.5%) and Black or African American (27.6%), and underrepresents other racial and ethnic minorities, including Latiné or Hispanic and Asian or Pacific Islander communities. Black or African Americans are slightly over-represented compared to population norms in the metropolitan areas where we recruited (Chicago and St Louis), but the small sample size prevents meaningful comparisons between White and non-White participants, limiting generalizations to this specific sample and as establishing proof-of-concept for a multimedia (virtual or in-person), peer-based curriculum and a baseline indication of the curriculum’s impact on participants. Further study in specific ethnic and racial communities, as well as with men in general, will be needed to understand the acceptability and impact of the curriculum in other settings.

Self-reported data

The study is based on self-reported responses that are subject to social desirability biases and the ordinary issues of memory or recall that individuals of all ages contend with. Participant screening addressed issues of cognitive acuity and memory loss, seeking to control for memory loss or cognitive decline that many persons face in older age. The distribution of responses to the questions for incidence, prevalence, and acuity of pain indicated that the sample is not skewed in significant ways. The questions about pain and disruption of daily life show that memory and cognitive issues are the least disruptive: only 11.2% reported “a lot” of disruption due to memory or cognition, while almost two-thirds reported “not at all” (36%) or “a little” (32.6%).

Conclusion

Notwithstanding the limitations noted, the NCPWR was associated with statistically meaningful changes in pain self-management behaviors and strategies beyond formal clinical settings. It has the potential to be replicated across multiple community-based settings due to its trialability, low barriers to entry, modular format, and theory-based intervention design. Its effectiveness in a virtual setting indicates high levels of scalability and may be a very appropriate introductory self-management program for older adults whose experience with pain is notable but not completely debilitating. Longer-term study of the NCPWR may also examine questions of the long-term benefits of lower intensity curricula initiated earlier in life, before daily pain management becomes an issue requiring higher levels of professional and programmatic attention.

Funding

This work was supported by funds from Kenvue, Inc.

Conflict of interest

The authors report no conflicts of interest.

Data availability

The study was not a clinical trial and was not pre-registered. Data sharing may be subject to restrictions by the funders; please contact the National Council on Aging (NCOA). Analytical methods and results are available by request to the corresponding author. Survey instruments may be available by request to the corresponding author, along with descriptions of statistical methods used and, when necessary, coding in Stata SE, v17. The authors utilized the STROBE checklist for cross-sectional studies to check for appropriate utilization and description of study methods.

Ethical approval

The study was submitted to the New York Academy of Medicine (NYAM) Institutional Review Board (IRB), which is the IRB of record for TRX Development Solutions (NCOA’s research partner) under Federalwide Assurance #FWA00027581. The project was approved under expedited review.