The prevalence of chronic pain, including chronic cancer pain in adults, is estimated to be between 18% and 21%, with severe repercussions for all aspects of the lives of those affected, their families, and society [1-3]. Chronic pain affects patient-perceived health status and psychological functioning; decreases energy levels; and hinders engagement with physical, emotional, cognitive, and social activities [3-6]. These impacts can strain familial and social relationships and affect work performance [7]. Living with chronic pain often involves increased medical expenditures and detrimentally affects one’s financial well-being [3,6]. In addition, the wait for services is not without added consequences to these repercussions, with long wait time (12-30 months) being associated with further deterioration in pain-related interference, psychological distress, and pain acceptance [3,8-10].

In Canada, adults with chronic noncancer pain face a persistent insufficiency of publicly funded resources, with the gold standard multidisciplinary pain treatment facilities being unable to meet the high clinical demand [1,2,11]. Since 2019, the Canadian Task Force has reaffirmed the necessity to implement equitable and innovative ways to deliver health interventions in a timely manner in the public network [12,13]. Web-based self-management programs that include exercise, sleep hygiene, pacing, and a healthy lifestyle are endorsed as part of the therapeutic considerations and recommendations for chronic noncancer pain management [14]. These programs have shown an impact on patients’ pain intensity, pain interference [15,16], anxiety [15,17], depression [17,18], stress [18], catastrophizing, and self-efficacy [19].

The lack of accessible and reliable unguided web-based self-management programs tailored to French-speaking individuals with chronic noncancer pain is a significant yet solvable health services gap. Over the years, individuals with lived experience, organizations, and researchers have stressed the relevance and importance of actively involving patient partners in the health intervention development process [20-25]. Therefore, a novel French web-based self-management program for chronic noncancer pain developed in collaboration with individuals with lived experience could meet the specific needs of French-speaking individuals [26].

This study aims to (1) assess the feasibility and acceptability of the Agir pour moi (APM) self-management program and trial procedures and (2) explore preliminary outcomes in individuals living with chronic noncancer pain.

We conducted a mixed methods sequential explanatory study consisting of a single-arm, pre- and postintervention trial, followed by qualitative, semistructured interviews with adults experiencing chronic noncancer pain and awaiting services from a center of expertise in chronic pain management [27-29]. We registered the trial at ClinicalTrials.gov (NCT05319652) and followed the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) and guidelines for reporting nonrandomised pilot and feasibility studies [30,31].

The University Hospital Centre (CHU) de Québec-Université Laval Research Ethics Board approved the study (#2023-6312).

A total of 7 individuals with lived experience of chronic pain, 5 health care professionals with experience and expertise in chronic pain management, 3 medical students, and 1 graphic designer contributed to the program’s codevelopment. We engaged in web-based, phone, or email conversations over a period of 1.5 years. All knowledge users could contribute to various aspects of program development, including its identity (eg, colors, logo, and name), structure (eg, lesson sequence, content organization, and navigation), content (eg, self-management strategies, theoretical content, and testimonials), and learning modalities and behavior change techniques (eg, personal plans, reflective activities, and interactive scenarios). These knowledge users were not further involved across the duration of the trial, but individuals with lived experience initially guided the team toward reducing the questionnaire burden to a minimum for the participants.

We recruited participants from the center of expertise in chronic pain management waitlist at the CHU de Québec-Université Laval. This center provides superspecialized services intended for complex chronic pain cases requiring a technical platform and multidisciplinary team. Most individuals referred to such centers experience significant impairments, including high pain levels interfering with their daily life, moderate to extremely severe depression, and pain-related sleep disturbance. Most of them take prescription analgesic medication and have already consulted different types of health care professionals [2].

Using the center’s assigned priority level, between June and August 2022, we sent 500 invitation letters to adults (aged >18 years) with chronic noncancer pain (for >3 months) unlikely to receive services within the next 6 months. Interested individuals were to email us to set an eligibility interview, confirming that they understood French, had access to a computer and high-speed internet, had not started a new treatment for pain within the last 1 month and agreed to notify us before starting a new one, were available for the duration of the study, and were able to provide informed consent. We excluded individuals who participated in a chronic pain self-management program within the last year or those who were scheduled for surgical treatment within 6 months. Following the assessment for eligibility, a research team member explained the study procedures and recorded verbal informed consent.

The codevelopment of the APM self-management program (thereafter APM or the program) is detailed [32] and available in the study by Marier-Deschenes et al [33]. Briefly, we designed a cognitive behavioral therapy (CBT)–centered, web-based self-management program that would enable participants to develop their self-management skills autonomously (eg, goal setting), practice suggested self-management strategies (eg, pacing), and sustain new behaviors (eg, respect of limits). Despite the diverse nature of our targeted population, the proposed self-management strategies to explore and develop are mostly universal, spanning areas such as managing thoughts and emotions, gradually resuming physical activity, practicing pacing, and adopting good sleep hygiene. The program is self-guided (ie, unguided) in that it provides the same information as face-to-face programs offered in tertiary pain clinics but without therapeutic support from health care professionals [34]. It is structured around weekly lessons over an 8-week period with content that encompasses 26 different behavior change techniques [35] and a downloadable personal plan (Table 1).

The program incorporates a variety of media, including photos, infographics, interactive scenarios, tables, audio recordings, and videos. All content is fully narrated, with short audio clips accompanying written information in each lesson, ensuring accessibility in both formats. Interactive exercises such as quizzes, drag-and-drop questions, and real-life scenarios enhance understanding.

Participants were encouraged to set and track their own weekly objectives related to the topic in their personal plan, which serves as our learner’s workbook. This plan features reflective, observational, monitoring, problem-solving, and action-planning activities.

Participants were advised to allocate 60 to 90 minutes weekly for program activities. They had the flexibility to divide the lessons into multiple short sessions; completing each lesson in 1 sitting was not necessary. While participants were encouraged to follow the program sequentially, all 8-week content was readily accessible.

Following the program poses minimal health risks. The program incorporates low-intensity activities, such as stretching exercises, which might cause temporary discomfort when resumed. However, the risks associated with physical inactivity, including the development or worsening of chronic illnesses, outweigh those of gradually resuming physical activity.

We addressed our study’s main objectives by integrating the quantitative and qualitative results, drawing on all relevant data. We opted for 2 approaches: a weaving approach through the narrative and 2 joint displays presenting categories and associated quotes explaining the quantitative data [53,54].

From the 500 invitations sent, 74 (15%) individuals expressed interest, of which 65 (13%) were confirmed eligible. Of these 65 eligible individuals, 63 (97%) consented to participate (Figure 1). A total of 9 (12%) of the 74 participants were ineligible due to unavailability during summer, current services from a pain clinic or rehabilitation center, lack of belief in program helpfulness, absence of computer access, low literacy level, and being unreachable. Response rates were 70% (44/63) at postintervention and 56% (35/63) at 3-month follow-up. A total of 15 (24%) of the 63 participants exited the study for reasons mostly unrelated to the intervention. Missing data were attributed to connectivity problems with the REDCap platform.

Participants were almost exclusively White (61/63, 97%) and female (44/63, 70%), with a mean age of 54 (range 24-75) years. On average, participants experienced chronic pain symptoms for 12 (SD 13.6) years, and most (34/63, 54%) had chronic musculoskeletal pain (Table 3).

Among the 63 participants, 38 (60%) completed the Acceptability eScale. The average total score for these participants was 25.2 out of 30 (acceptability threshold=24). In Table 4, we have presented the integrated results of the quantitative and qualitative phases. The mean score for each of the 6 items from the Acceptability eScale is listed in the first column. Each item score ranges from 1 to 5, with higher scores reflecting higher acceptability. The interviews revealed a consistent theme: a program that is globally acceptable, easy to use, and engaging. Interviewees felt they could opt for what worked for them once they had experienced it completely. They would keep most of the program as is, with some potential minor improvements.

Of the 63 participants who consented to the study, 46 (73%) started the program, 29 (46%) finished at least 6 weeks’ lessons, and 26 (41%) completed all the lessons (Table 5).

Participants generally followed the lessons in order. Among the 19 noncompleters who did not withdraw from the study, 10 (53%) wrote back to us after receiving the email reminder. These participants provided personal reasons for not following the program according to schedule, including sickness or mental health issues among close relatives, the death of a parent, estate management, and increased symptoms. Including participants who withdrew from the study, 21 (33%) out of 63 participants were not connecting weekly or stopped at some point for reasons external to the study or the intervention. Reasons related to the program included having already applied the proposed strategies and having trouble connecting. Of the 63 participants, 5 (8%) needed help logging in independently (n=3, 60% only required information by email and n=2, 40% received phone support and succeeded with a step-by-step explanation but did not connect afterward).

Interviewees mentioned other factors potentially undermining the engagement in completing the program. Interviewees highlighted that timing and pain acceptance played an essential role in their perseverance or lack thereof. For example, understanding that no specific cause for her pain issue might ever be found was a turning point in a participant’s proactivity:

For some interviewees, occasional or regular coaching would have been necessary to sustain motivation, answer questions, and revise their personal plan. Of the 63 participants, 2 (3%) mentioned their need for support and feedback:

There are participants who related less to parts of the program because their activity level was not adequately represented:

Furthermore, interviewees described factors mostly contributing to their engagement in completing the program. They expressed a connection to the program’s content and felt more hopeful, supported, and less alone listening to the multiple integrated testimonials of individuals with lived experiences applying the strategies:

Moreover, a participant living far from a major urban area highlighted the appeal of these short videos:

On the one hand, interviewees thought the weekly connection and review of personal objectives supported their motivation and helped them stay focused:

On the other hand, it might have been too much for some individuals:

There is a fine line between what feels like a comprehensive program and what feels like an overwhelming task for unsupported participants. While most interviewees showed interest in all the presented topics and perceived the lessons’ sequence as logical, gradual, and positive, specific strategies within these lessons might have lacked appeal to some participants. A suggestion was made that participants could start with their most appealing lessons after covering the pain education section. While we invited everyone to complete the tasks in order, the content was freely available and one could decide to skip parts of the program if desired.

Through the interviewee discourse, we could distinguish microlevel engagement, including the number of lessons they have followed, from macrolevel engagement, referring to the depth of involvement with the behavior change process, such as applying strategies consistently in a real-world setting [55,56]. Behavior change could be challenging, with participants facing expectations from others and their own. However, the program provided them with a better understanding of why it is beneficial to do so, and some participants made it a priority. Getting into the habit of doing something sometimes required broader or prior changes such as setting boundaries with the extended family. The notion of beginning with the easiest tasks was mentioned to underscore the initial challenge of implementing a strategy. Interviewees described the integration of certain habits into their routine as gradual, sometimes evolving over several months, without the participants realizing it. Over 5 months after finishing the program, interviewees described what they continued to apply and how some strategies became part of their routine:

We observed an indication of improvements over time in self-efficacy, pain interference, depression, and pain catastrophizing between baseline and postintervention (Table 6). The results of the linear model corrected for the individual (treatment effects) are presented in Table 7. In addition, 24 (56%) out of 43 participants reported some level of improvement on the Patient Global Impression of Change Scale after the intervention.

From a qualitative perspective, 14 (93%) out of 15 interviewees reported a different set of effects 5 to 7 months later. These effects included, among others, shorter and less frequent pain attacks, better management of pain, higher sense of control, less comparison with life before pain, improved psychological state, more patience, less frustration and irritability, forgiveness toward oneself, higher activity level, more self-care, and increased social life.

In Table 7, we have presented the integrated results of the quantitative and qualitative phases, with the overarching theme that the various effects observed were potentially influenced by macrolevel engagements.

The effects of the lifelong task of self-management might become noticeable over time. A participant mentioned recognizing these effects several months after completing the program:

Therefore, conducting the interviews 5 to 7 months after program completion was deemed appropriate.

This paper described a pilot, mixed methods study assessing feasibility and acceptability and exploring the preliminary outcomes of a new self-directed, web-based program for chronic pain among adults awaiting superspecialized services. Collaborating with patient partners experiencing diverse types of pain was a key strategy enabling us to align the program closely with the varied needs and expectations of our wide-ranging audience. We opted for a simple yet attractive layout, providing clear instructions and features to aid those with attention and concentration challenges.

Chronic noncancer pain affects individuals in different ways and to different degrees. Those awaiting tertiary services in Canada experience severe impairments and present with a poor biopsychosocial profile [2]. To specifically recruit these individuals who are not yet patients at the center of expertise in chronic pain management, we could not directly reach out to them. The hospital’s archives had to send them invitation letters. Estimating the response rate in such a specialized context proved challenging because we lacked a benchmark for our expectations. However, a study by Thiblin et al [57], which involved a comparable internet-administered, CBT-based self-help intervention, achieved an 11% enrollment rate by sending out 509 invitation letters. Considering the documented high dropout rates in similar trials [19,58], we anticipated that 500 invitations would suffice to ensure a minimum of 30 participants responding to questionnaires at all 3 time points. Our enrollment rate for a 3-month recruitment period was similar to or better than those of studies recruiting in tertiary pain treatment facilities [59,60]. The consent rate among potentially eligible adults was acceptable. However, because 4 (6%) out of 63 participants exited the study for surgery purposes and 3 (5%) others for significant changes in their medication, we might need to reconsider how we address these eligibility criteria during the phone interview. Furthermore, considering there are between 1000 and 1500 individuals awaiting services from the center of expertise and that they all would not meet our eligibility criteria, our response rate, although similar to those observed in other studies, would require conducting a future full trial across multiple centers.

Our study yielded comparable data collection results to other web-based intervention pilot trials with approximately 50% (35/63) of response at 3-month follow-up [61,62]. While studies with higher financial incentives (US $25-$80 per assessment) during visit assessments or initial motivational interviews had better response rates [60,63-66], we purposefully chose to stay as close as possible to real life where no incentives are offered. We received no negative feedback on the number or length of questionnaires. However, sending email reminders to participants who did not log in or complete the questionnaires at the appropriate time was suboptimal. Making phone calls in addition to email reminders might have provided us with reasons for disengagement and ensured participants received the reminders.

Some interviewees highlighted that the log-in process was not intuitive, leading us to consider modifying this aspect before conducting a full trial. The log-in was essential to the research project but is not part of APM itself and will not apply in real life. Once logged in, accessing APM at their most convenient time and place was a significant asset for our participants, consistent with patients’ preferences [21].

APM’s codevelopment with health care professionals and people with lived experience of chronic pain allowed a tailored approach to this population’s needs and preferences in a web-based self-management program [32]. The interviewees’ description of APM aligned with the acceptability score as a globally acceptable, easy-to-use, and engaging program. We based our 24 (80%) out of 30 threshold score for the Acceptability eScale based on the study by Tariman et al [38], suggesting that 80% of the highest possible summary score indicates good program acceptability. However, a score <24 would not automatically deem the program unacceptable. We must examine individual item scores to assess specific program weaknesses. All items scored ≥4 (≥80%) out of 5, as show in Table 4, indicating no significant flaws requiring major modifications. Minor improvements we could make include adding testimonials from highly active individuals with chronic pain who learned to pace themselves and mentioning that lessons are preferably followed in order but can also be explored based on personal preferences after completing week 1. APM effectively promoted behavioral change, guided participants in taking action, and served as a reference in the longer term.

While participants’ weekly lessons’ level of completion was lower than anticipated, it was consistent with what had been observed in other feasibility and pilot studies [62,67-69] and could be explained mainly by reasons external to the study. Our qualitative results alleviated concerns about potential flaws and did not point toward questioning the participant’s appeal to the program. Overall, we are confident that the program and trial procedures are both feasible and acceptable.

We explored pre- and postintervention effects as preliminary indications of potential changes in self-efficacy, pain intensity and interference, anxiety, depression, and catastrophizing. Findings yielded relevant results, but these should be interpreted cautiously.

Nevertheless, the qualitative interviews pointed in the same direction as our preliminary quantitative findings. Furthermore, these aligned with the results of a meta-analysis suggesting that following internet-delivered, CBT-centered interventions for chronic pain can lead to small significant improvements in pain interference and intensity, depression, anxiety, self-efficacy, and catastrophizing, with greater treatment effects in anxiety, pain interference, and intensity in guided compared to unguided interventions [34]. Therefore, depending on their perceived importance of change and self-efficacy, individuals with chronic pain may require additional support in reaching readiness to make sustainable changes.

Because we still did not know precisely what clinical, intervention, and study characteristics positively impacted the effects of unguided CBT-based self-management programs for chronic pain, APM offered several self-management strategies [70]. However, we did not expect participants to implement all of them once they completed the program. Participants used this program as a toolbox, as mentioned by an interviewee.

No adverse events were reported throughout the course of this study.

This study has some limitations. First, we cannot make definitive statements regarding APM’s effects without an appropriate control group, randomization process, and sample size. Indeed, we neither designed nor appropriately powered this feasibility trial to test a specific hypothesis [36]. Furthermore, while the participants presented various pain conditions, most of the female participants were White, as this is the case in similar trials [18,71,72], and were all attached to a single center. Recruitment strategies of a future randomized controlled trial should focus on attracting a broader representation of individuals with chronic pain in terms of gender, ethnicity, and health care institutions. In Quebec City, where our study was conducted, <10% of the population identified as members of a visible minority group in 2021. Expanding our research to cities with greater ethnic diversity could enhance our sociodemographic data and improve the relevance of our findings. Shifting to web-based recruitment methods might allow us to create tailored invitation messages for specific demographic groups, using a casual design and images, instead of overwhelming potential participants with excessive written information. In our feasibility study, we had to use standardized letters to recruit participants from the waitlist of the center of expertise in chronic pain management. We acknowledge the need to adopt more flexible parameters for future large-scale studies. Furthermore, we might adjust our eligibility criterion, not limiting participation to those awaiting specialized services. This broader criterion could yield a more diverse sample, aligning with our aim to reach a wider demographic. However, we are mindful of the potential impacts on adherence and user satisfaction this broader criterion might pose. Nevertheless, these adjustments reflect our dedication to conducting a comprehensive and inclusive trial, ultimately contributing to a more nuanced understanding of chronic pain management. This may lead us to unforeseen modifications in our program.

Despite widespread internet access in Canada, disparities in internet speed, affordability, and digital literacy persist. APM, being exclusively web-based, poses a limitation in reaching individuals from remote regions and Indigenous communities as well as those in low-income households, older adults, and individuals with disabilities. These groups are disproportionately affected by the digital divide in Canada, making it challenging for them to access our program.

This study provides an initial understanding of APM’s potential benefits for this group of individuals with chronic pain awaiting specialized services. Through the interviews, we acknowledged we had not captured the effects on the temporal aspect of pain, such as shorter and less frequent pain attacks, which were crucial for some participants. Therefore, we could consider adding measures capturing these aspects in a future trial.

Developing a web- and evidence-based, patient-centered, free-of-charge, user-friendly, and French self-management program for chronic noncancer pain represents a potential response to the clearly expressed needs of individuals with this condition. Although the literature increasingly emphasizes the importance of personalization in eHealth, our limited financial resources hindered us from incorporating advanced features. We deliberately chose to focus on fundamental aspects and prioritize what we could offer and support in the long term, establishing the groundwork for a web-based program that could potentially evolve. As a result, the current version did not include personalized features, but it was still perceived as usable and useful. It will be essential to document how the program’s implementation makes it possible to respond quickly and more equitably to some of the needs of patients waiting for services or who live far from large centers. APM is currently being used without restrictions in other French-speaking regions and countries. Anyone can use it freely, but a potential hurdle faced when using it abroad pertains to adapting to the accents in testimonial videos and Quebec-specific expressions.

The study findings provided preliminary evidence that the APM program and research methods were both feasible, as suggested by perceived acceptability and engagement. Furthermore, it provided preliminary indications of potential improvements in self-efficacy, pain intensity, interference, depression, and catastrophizing. The study yielded essential results to undertake a future complete trial.