Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer

Abstract

Background: Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent's life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary.

Objective: Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer.

Methods: We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app.

Results: Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete.

Conclusions: A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.

Figure 1

Pain Squad app title screen.

Figure 2

Screenshots of Pain Squad app assessment functionality showing the visual analogue slider scale (top left), the selectable body-map (top right), a multiple-choice question (bottom left), and a free-text question (bottom right).

Figure 3

Screenshots of Pain Squad reward system showing compliance-based promotion scheme (left), and videotaped acknowledgement of the adolescent’s compliance with completing pain assessments (right).

Figure 4

App prototype home screens: the Gum Shoe home screen depicting a detective case file (left), and the Pain Squad home screen depicting the desk of a law enforcement officer (right). Tapping "Start Survey" or "Start Case" begins the pain assessment. Tapping "Accomplishments" or "Rewards" allows review of rank and access to videotaped acknowledgements.

Figure 5

Screenshots of Pain Squad app visual analog scales showing before (left) and after (right) verbal and numerical rating anchors were added.

Figure 6

Screenshots of Pain Squad app "body map" showing before (left) and after (right) body parts were combined as recommended by adolescents.

Figure 7

Screenshots of Pain Squad app "body map" showing before (left) and after (right) specificity of selectable pain location was improved.