Table 4.

Preferred features of a mental health app that addresses chronic pain among nondigitally native adults.

Theme				Representative quote
Tools
	Features
		Participants were interested in having access to a variety of tools including education about chronic pain neuroscience, mindfulness exercises to help manage pain, strategies to improve pain coping and acceptance, pain and mood tracking capabilities, and gentle physical exercise. They appreciated immediate, 24/7 access to management tools.	“I think it’s probably going to be some kind of a help [to have a] mindfulness activity to help control and manage pain.” (56-year-old female) “Give me a summary of how my week was...pain, mood—both depression and anxiety—which I’m sure part of my anxiety is from the pain. Yeah.” (66-year-old female) “Last night I had trouble sleeping because of my lower back, and it’s progressively getting worse. I have injections next week and so on, and I’m really looking forward to them. But in the meantime—getting up in the middle of the night and just saying, ‘My back hurts, maybe there’s this app I can check out.’ Could be interesting.” (51-year-old male)
	Mood tracking
		Participants were interested in periodic, brief, self-report assessments to track their mental health over time (eg, 4 questions as opposed to 16 questions). Participants preferred self-reporting their mood, as opposed to the app using passively collected data to infer their mood (eg, with call logs, step count, and GPS data). Participants would be more motivated to complete self-assessments if the results are used to tailor suggestions of additional tools for them. Participants voiced mixed sentiments regarding whether they would want their health care team to see responses to their self-reported mental health assessments.	“If it asked, ‘Hey, how was your week? Did you have any kind of issues that you need to talk about?’ And then if you’re honest with the app, then maybe it can touch base a little bit sooner.” (48-year-old male) “[Passive data collection to infer mood] is a little creepy.” (66-year-old female) “It can be a double-edged sword. For example, if you answer incorrectly, ‘Do you feel like harming yourself?’ Is somebody [from your healthcare team] going to say, ‘Wait a minute, there are specific laws that say we have to take action and you have to be under care now.’ If it’s chronic pain, that’s different. But if it’s mental health, there’s a big stigma with it.” (51-year-old male)
	Other tracking feature
		Participants were interested in a feature to track associations between their pain symptoms, mental health symptoms, physical activity and life events, and engagement/tasks completed within the app. Their goal from this complex tracking feature would be to identify what app tools and general behaviors were helpful to reduce their symptoms. Some participants would also want to show this data to their health care team.	“Yeah, maybe my activity level is higher. Maybe my emotional level is better. I would think tracking all of those things that correlate directly to my pain level would be good...Something where you can really see the results of the app working with you or for you would be good, but I think it would feel a little disconnected without also tracking any kind of pain scale.” (56-year-old female)
	Methods to encourage sustained engagement
		Participants expected they would be motivated to sustain engagement with the app if they were instructed to set goals and had pending tasks on a to-do list, if the app helped them track their tasks completed and corresponding symptom improvement, and if the app suggested new features for them to try. They were generally not in favor of using access to new features as a reward/motivator for continued engagement. Participants were also in favor of a free trial period of paid content before deciding whether to purchase the app (or an upgrade). There was a slight preference for a content-limited trial rather than a time-limited trial (eg, 2-4 weeks).	“Is there stuff that you could add that you’re working on in the next week, or maybe things that you didn’t fully complete?” (60-year-old male) “Suggest a tool, something that’s actually useful as opposed to a gold star. Yes. Yes.” (53-year-old female) “Yeah. Having a trial and then going to paid content after the trial—that would determine for me, ‘How well is this working?’” (60-year-old female)
User design
	Onboarding
		Participants requested a clear explanation regarding how the app can help with chronic pain and mental health (eg, coping and management strategies, rather than a focus on pain severity reduction).	“I am confused, and I don’t know how this is going to work. Yeah, I guess my knees and my back are preventing me from exercising. Is that what you’re talking about? Mental and physical health going together?” (66-year-old female) “I guess...intervene in letting pain take over. I think by checking in or doing mindfulness things, you could possibly alleviate chronic pain.” (56-year-old female)
	Tone
		Some participants thought an overly cheerful, personal tone presented by a cartoon-like avatar was less suitable for older adults and felt artificial. Similarly, participants had mixed opinions on the use of emojis throughout the app experience.	“These kinds of issues, we don’t want to make light of them, and I think a [cartoon-like chatbot avatar] kind of makes it a little childish. If this was geared toward children and teens, ok. But for adults, I think it needs to have something a little more serious... I think I would be more comfortable with more of a question-and-answer screen—more like journal prompts than a text conversation.” (60-year-old female) “For me, [emojis are] very unnecessary. [They’re] infantile. I mean, but I’m old. So a lot of this stuff is goofy now, that wouldn’t be goofy to other people. If a kid is using it, they might like that.” (69-year-old female) “I think an emoji is like putting an expression to a sentence. So I think it’s amazing.” (52-year-old female)
	User flow
		Participants generally preferred for the app to initially guide them through a structured curriculum (such as for a duration of 8 weeks) but to also allow for self-guided exploration through the app, if desired.	“It seems like once you become familiar with what it is, self-guided would definitely be preferable.” (56-year-old female) “I think eight weeks would be good because it takes a significant amount of time to change habits or incorporate new habits.” (54-year-old female)
Timing of interactions
	Notifications to prompt engagement
		Most participants preferred to initiate engagement with the app on their own, but many participants were also welcoming or at least accepting of occasional notifications to encourage engagement if relevant. Most participants expressed that once or twice daily notifications would be acceptable, and some participants preferred an even greater frequency of notifications. For once daily notifications, evening check-ins were more often preferred to morning check-ins. Participants voiced varied preferences regarding the option for notification frequency to be adaptive based on their engagement. Some participants were in favor of pausing notifications (eg, for 3-7 days), while others did not want a pause in notifications unless they were specifically asked first.	“If it recognizes that you struggled, and if you’re honest with the app, then maybe it can touch base a little bit sooner.” (48-year-old male) “[Check-ins twice a day] is okay with me because I don’t do anything. I’m in pain, I don’t work, and all I do is go back and forth to the doctors.” (55-year-old female) “Like, you could say, ‘Dismiss for three days,’ or however long it is. Or let’s say you’re going on vacation, you could set a time limit to dismiss for seven days or however long it needs to go. Give me the option to click that button, then I can go from there.” (49-year-old female) With regards to pausing notifications: “Don’t forget about me now. Everybody else in the world does. And don’t give up on me. I look at that as giving up on me. Don’t do that. Don’t leave me.” (62-year-old female)
General app preferences
	Improved awareness
		While most participants were aware of apps designed to address mental health, many participants were unaware of apps that address chronic pain. They were also unclear as to “how an app can help with pain.”	“I had no idea there were any [apps to help manage pain]. I’m wondering what [a pain app] can do because I have no clue.” (61-year-old male)
	Other stressors to address
		Participants also suggested additional stressors that should be addressed by an app that aims to improve mental health and chronic pain. These stressors commonly included other health concerns, finances, and low motivation. Mobility limitations, shame, attention issues, frustration, loneliness, time pressures, and work were also suggested.	“It could be other health challenges. You could have something related other than just pain.” (53-year-old female) “Finances play a big part of everything you do because if you don’t have it, you can’t do it.” (55-year-old female)