A Randomized Control Trial of Multimedia Interventions to Improve Pain Education among Veterans with Chronic, Non-Cancer Pain

Abstract

Purpose Pain is one of the most common reasons Veterans consult with their primary care providers and is one of the most prevalent symptoms reported by returning Veterans (Gironda et al., 2006). Cosio and colleagues (2012) developed and implemented the aPain Education Schoola to address an identified need for patient pain education within the VA. Past findings indicate that Veterans who elected to complete the program reported a statistically significant difference in pain intensity, readiness to adopt a self-management approach, experience of pain, and depressive symptoms, but failed to show a change in knowledge acquisition (Cosio & Lin, 2013). Additional studies have found improvement in knowledge acquisition with audience response technology (Simmons et al., 2015); patient satisfaction (Watson et al., 2014); and provider satisfaction with this particular program (Watson et al., 2015). One of the earliest studies investigating multimedia for use in educating patients about patient-controlled analgesia found the intervention made a significant difference in pain knowledge, produced better outcomes in pain relief, and received the endorsement of patients on its usefulness (Chen, Yeh, & Yang, 2005). Several other studies in health education (fall prevention, Hill et al., 2009; laparoscopic cholecystectomy, Wilhelm et al., 2009; COPD, Stellefson et al., 2009; and cancer pain, Capewell et al., 2010) have been conducted which provide support for the use of DVD-based interventions. The most recent venture in multimedia-based education and noncancer pain is its application to improve readiness to self-manage joint pain (Elander, Robinson, & Morris, 2011). The current study explored how a patient pain education intervention translated into multimedia, such as DVD, a booklet, or both, in a randomized control trial. Primary outcome measures of the current study were whether the use of multimedia promoted a decrease in pain intensity and an increase in readiness to adopt a self-management approach among Veterans with chronic, non-cancer pain. Secondary outcomes included whether Veterans who participated in a low-intensity pain education intervention would increase in factual pain knowledge; experience decreases in intractable pain; demonstrate positive changes in their attitudes or beliefs about their own pain problem; and demonstrate a decrease in depressive symptoms. Methods A total of 120 Veterans with mixed, idiopathic (back, neck, extremity, head, and fibromyalgia), chronic pain voluntarily participated in a multimedia-based, patient pain education program at a Midwestern VA Medical Center between 3 January 2017a-1 October 2018. A third of the sample were given a DVD (N = 40), a third was given a booklet (N = 40), and a third was given both (N = 40). Veterans will be recruited from the pain clinic during the weekly patient intake orientations. Veterans must not have been able to attend the face-to-face intervention due to a conflict in their schedule and must have had access to a DVD player. The DVD was a 3-disc set which included the 13 edited classes filmed in the face-to-face Pain Education School. Each clip on the DVD from each discipline (30a-45 minutes each) shared information about chronic, non-cancer pain from their perspective, what treatments are available in their service, and how to access their respective clinics. The booklet included the same written materials given to Veterans who participated in the face-to-face intervention. Participants were asked to complete the pre-intervention assessment, which included the Numeric Rating Scale, the Readiness Questionnaire, the Patient Pain Questionnaire, the Pain Information and Beliefs Questionnaire, and the Patient Health Questionnaire. Participants were then instructed to review the materials within the next three monthsa time. After three months, the Veterans were mailed their post-intervention assessment which included the same battery of measures. Three follow-up reminder calls were made, duplicate questionnaires were mailed, and return envelopes were provided to improve response rate. Upon completion of each assessment, Veterans received a gift card. Veterans were allowed to keep the education materials given as part of the low-intensity intervention. The primary outcome analysis was a 3 x 2 repeated measures (RM) multivariate analyses of variance (MANOVA), with aIntervention Arma as the between-subjects factor and aTimea as the within-subjects factor. The dependent variables were the primary outcome variables of pain intensity and readiness to adopt self-management approach, and the secondary variables of pain knowledge, pain experience, factual knowledge, attitudes and beliefs, and depressive symptoms. SPSS was used for all outcome analyses. Results Of the 120 Veterans who were enrolled in the study, twenty-one (17.5%) of the participants were female; and 99 (82.5%) were male. Fifty-nine (49.1%) were African American; 51 (42.5%) were Caucasian; 8 (6.7%) were Latino; and two (1.7%) were identified as Other races. About 63% returned the post-assessment via mail; while 37% did not. Response rates are approximately 60% for most research and is the goal of researchers and editors of journals (Fincham, 2008). Among completers versus non-completers, there were no significant baseline differences in arm of intervention (p = 0.491) or sex (p = 0.730), but African American participants (73%) were the most likely to complete both assessments and Other races were the least (p = 0.023). There were no significant differences in demographics or baseline scores among the arms of the intervention (ps > 0.127), except those who were given the DVD were in more agreement with strategies of conservative pain management when compared to those who were also given the book (p = 0.003). There were no significant differences in demographics or baseline scores between sexes (ps > 0.079) or among races (ps > 0.062). There was no significant interaction effect of aIntervention Arm x Time,a Wilksa lambda = 0.743, F(14,134) = 1.535, p = 0.107, which indicates that the three arms of multimedia were no significantly different on their impact on the dependent measures aforementioned. There was a significant main effect for aTime,a Wilksa lambda = 0.726, F(7,67) = 3.608, p = 0.002, n2 = 0.274. A significant univariate main effect was obtained for the primary measures of pain intensity (now) from baseline (5.24 +/- 2.238) to post-treatment (5.82 +/- 2.285), F(1,73) = 6.272, p = 0.014, n2 = 0.079; but not for readiness to adopt self-management approach, F(1,73) = 1.519, p = 0.222. Significant univariate main effects were also achieved for secondary measures of factual knowledge from baseline (25.95 +/- 2.196) to post-treatment (25.38 +/- 2.148), F(1,73) = 4.868, p = 0.031, n2 = 0.063; and depressive symptoms from baseline (1.59 +/- 1.601) to post-treatment (2.25 +/- 1.819), F(1,73) = 11.274, p = 0.001, n2 = 0.134. There was no significant main effect found for pain knowledge, F(1,73) = 1.683, p = 0.199; pain experience, F (1,73) = 2.861, p = 0.095; and attitudes and beliefs, F (1,73) = 1.178, p = 0.281. Conclusions Healthcare organizations consider the expenses being saved when using multimedia versus face-to-face interventions, such as medical and resource costs, but also the value of pain, suffering, and loss in QOL of Veterans. It can also reduce costs due to absenteeism and lost work days (Chen et al., 2005). Other advantages of using multimedia include having no time or spatial limits and learning can occur according to individual needs and progress. The current study assessed the effects of multimedia used in pain education interventions on a wide range of pain measures among Veterans with chronic, noncancer. The current findings suggest that the use of multimedia had significant, moderate negative effects on pain scores and factual knowledge, and a large negative effect on depressive symptoms. This is surprising since the materials used are based on a face-to-face intervention that made significant improvements on all the measures (Cosio & Lin, 2013; Simmons et al., 2015). The current study underlines the potential negative aspects to using multimedia, such as imprecision, confusion, boredom, tiredness, and feelings of excessive involvement (Antonietti & Giorgetti, 2006). Thus, the use of multimedia should not replace any personal interaction from providers and should only be considered to support additional learning.