CONTENT VALIDATION OF A MOBILE APPLICATION FOR SELF-CARE OF CHRONIC NON-SPECIFIC LOW BACK PAINABSTRACT
Objective: to describe the content validation process of a mobile application for self-care of chronic non-specific low back pain for health professionals.
Method: this is a methodological study conducted in Florianópolis, Santa Catarina, Brazil. The judges were selected between February and April 2023 by the Lattes Platform through the Fehring inclusion criteria. The adapted Health Education Content Validation instrument was used. The judges’ agreement was analyzed by the Content Validity Index and the reliability by Cronbach’s alpha and Intraclass Correlation Coefficient. The binomial test was performed to verify the proportion of agreement. An agreement rate of ≥ 0.78 was considered.
Results: a total of 11 expert judges in the subject area participated, achieving an overall Content Validity Index of 0.84. Cronbach’s alpha coefficient was 0.97 and the Intraclass Correlation Coefficient was 0.973. The results indicated good internal consistency of the instrument and excellent reliability between the scores attributed by the judges. The binomial test showed agreement between the judges.
Conclusion: the overall Content Validity Index among the judges demonstrates that the “Lower back self-care” application prototype is reliable and valid, and after being improved based on suggestions from experts and scientific literature, has the potential to stimulate self-care among health professionals for chronic non-specific low back pain and contribute to clinical practice.
DESCRIPTORS: Low Back Pain; Self-Management; Internet; Validation Study; Technology; Methodological Research in Nursing; Nursing
RESUMEN
Objetivo: describir el proceso de validación de contenido de una aplicación móvil de autocuidado del dolor lumbar crónico inespecífico para profesionales de la salud.
Método: estudio metodológico realizado en Florianópolis, Santa Catarina. La selección de jueces se realizó entre los meses de febrero y abril de 2023 por la Plataforma Lattes, siendo seleccionados utilizando los criterios de inclusión de Fehring. Se utilizó el instrumento adaptado de Validación de Contenidos Educativos en Salud. La concordancia de los jueces se analizó mediante el Índice de Validez de Contenido y la confiabilidad mediante el alfa de Cronbach y el Coeficiente de Correlación Intraclase. Se realizó la prueba binomial para verificar la proporción de concordancia se consideró una tasa de concordancia ≥ 0,78.
Resultados: Participaron 11 jueces expertos en el área temática, alcanzando un Índice de Validez de Contenido global de 0,84. El coeficiente alfa de Cronbach fue de 0,97 y el Coeficiente de Correlación e Intraclase fue de 0,973. Los resultados indicaron buena consistencia interna del instrumento y excelente confiabilidad entre las puntuaciones asignadas por los jueces. La prueba binomial mostró acuerdo (concordancia0 entre los jueces.
Conclusión: el Índice de Validez de Contenido general entre los jueces demuestra que el prototipo de la aplicación “Autocuidado Lumbar” es confiable y válido y, luego de ser mejorado con base en sugerencias de expertos y literatura científica, tiene potencial para estimular el autocuidado de los profesionales de la salud con dolor lumbar crónico inespecífico y contribuir a la práctica clínica.
DESCRIPTORES: Dolor de la Región Lumbar; Automanejo; Internet; Estudio de Validación; Tecnología; Investigación Metodológica en Enfermería; Enfermería
RESUMO
Objetivo: descrever o processo de validação de conteúdo de um aplicativo móvel para autocuidado da dor lombar crônica inespecífica para profissionais de saúde.
Método: estudo metodológico realizado em Florianópolis, Santa Catarina. A seleção dos juízes foi realizada entre os meses de fevereiro e abril de 2023 pela Plataforma Lattes, sendo selecionados através dos critérios de inclusão de Fehring. Utilizou-se o instrumento de Validação de Conteúdo Educativo em Saúde adaptado. A concordância dos juízes foi analisada pelo Índice de Validade de Conteúdo e a fidedignidade por meio de alfa de Cronbach e Coeficiente de Correlação Intraclasse. O teste binomial foi realizado para verificação da proporção de concordância. Foi considerada uma taxa de concordância de ≥0,78.
Resultados: participaram 11 juízes especialistas na área temática, atingido o Índice de Validade de Conteúdo global de 0,84. O coeficiente alfa de Cronbach foi 0,97 e o Coeficiente de Correlação e Intraclasse com 0,973. Os resultados indicaram boa consistência interna do instrumento e uma confiabilidade excelente entre os escores atribuídos pelos juízes. O teste binomial mostrou concordância entre os juízes.
Conclusão: o Índice de Validade de Conteúdo geral entre os juízes demonstra que o protótipo do aplicativo “Autocuidado lombar” é confiável e válido e após ser aperfeiçoado com base nas sugestões dos peritos e da literatura científica tem potencial para estimular o autocuidado de profissionais de saúde com dor lombar crônica inespecífica e contribuir para a prática clínica.
DESCRITORES: Dor Lombar; Autogestão; Internet; Estudo de Validação; Tecnologia; Pesquisa Metodológica em Enfermagem; Enfermagem
INTRODUCTION
Low back pain is a significant public health problem that entails high costs for the health system and society. It can be defined as pain or discomfort in the spine between the costal margins of the 12th rib and the gluteal folds. It leads to disability, loss of productivity, absenteeism and job changes1-3. It is highly prevalent among health professionals, particularly nurses1.
It is characterized as non-specific when it is not possible to identify a specific nociceptive source4. It also causes psychological symptoms, such as pain catastrophizing, fear of movement and mental problems3. Emotional factors play an important role in the severity of low back pain and disability, which reinforces its multidimensional nature2,5. Therefore, it is essential that interventions not only address pain relief, but also consider biopsychosocial and spiritual aspects to improve the quality of life of these people5.
Self-care involves strategies and skills that an individual uses to manage and monitor their own health or the ability of an active, responsible, informed and autonomous individual to live with the medical and emotional consequences in partnership with healthcare providers4. In this sense, Information and Communication Technologies (ICT) represent great potential in the healthcare area. They play a role in supporting diagnosis, promoting better clinical outcomes through changes in behavior and adherence, in the autonomy of digital therapeutics and in education about diseases. However, they are little explored and achieving sustained clinical improvements and long-term results is a challenge6. The adoption of digital solutions, such as mobile applications (apps), increases accessibility, provides personalized resources and reduces costs7. They have become important tools to promote the health of people living with low back pain, assisting them in self-care and managing their condition with practical functions, such as health education, symptom tracking and social support7,8.
Some systematic reviews (SRs) have highlighted the use of apps and their effectiveness in low back pain treatment. They may be an option for low-income countries, however language barriers and internet dependency are identified challenges9. In addition, studies have revealed moderate to low evidence that self-management programs have had positive short-term impacts on reducing pain and improving functionality in patients with chronic low back pain10,11. However, the sustainability of these results in the long term remains uncertain, highlighting the need for more rigorous clinical trials and follow-up studies10. The simultaneous use of mobile health interventions and conventional care has been shown to be more effective than conventional care alone in reducing pain and disability in patients with low back pain12. Although health apps for self-management of low back pain have potential, the heterogeneity between studies indicates the need for more specific and high-quality research focusing on personalized approaches.
Overall, smartphone apps for low back pain self-management vary in quality, with most lacking specific self-management support and robust behavior change features13,14. Therefore, improvements in design and greater focus on effectiveness are needed in this area.
It is clear that applications must be based on scientific evidence and undergo a rigorous validation process to ensure the quality and effectiveness of these technologies and establish confidence in their ability to serve their intended purpose with quality data and information. Content validation is a process which assesses its representativeness by adequately addressing the universe it is intended for, and the participation of experts in the development and validation is essential to avoid inaccurate results or biased measures15.
The evaluation of these tools is a necessity to improve the quality of information through more dynamic and coherent metrics that can measure their strengths and weaknesses. Therefore, the objective of this study was to describe the content validation process of a mobile app for self-care of non-specific chronic low back pain (CLBP) for health professionals.
METHOD
Study type
This is a methodological study employing a qualitative and quantitative approach with technological evaluation to validate the content of a mobile application prototype for self-care of non-specific CLBP entitled: “Lower Back Self-Care”.
Mobile application development
The application prototype content was based on a SR11 and a technological prospecting of applications, as well as websites, technical books, manuals and technical standards, which provided the basis for its technical-scientific content.
The app development was based on the theoretical framework of instructional design, and includes the following stages: analysis, design, development, implementation and evaluation, which feedback into each other at the end of the process, generating a continuous and cyclical chain. A literature review was conducted in this study phase (conception), the screens of the app prototype were constructed and its content was submitted to the judges for analysis of relevance, intermediate validations and revisions related to the content. After execution (implementation and evaluation), the app will be implemented with all its functionalities and a general evaluation will be conducted (usability, semantics and face).
The app content involved skills for self-management of low back pain for health workers and was based on a checklist for self-management support for chronic pain16. The main menu includes education on chronic pain and low back pain, self-monitoring of pain symptoms (diary for recording), pain storage and tracking, brief messages through reminders, goal planning, an exercise plan and strategies for pain crises, specific guidelines for patient positioning and mental health with breathing exercises, relaxation and meditation.
The screens in this first phase were designed by researchers using the Figma® software program, which enables creating even without knowledge of IT itself, with the sole purpose of evaluating the technical-scientific content. After creating the prototype screens, the content validation by judges began. This validation supported the final interface with new colors, images and media and increased the tool’s reliability for later implementation by professionals in the field.
Selection of judges, inclusion and exclusion criteria
The selection of judges took place between February and April 2023. Physiotherapists of both sexes with experience in the area of the construct were initially identified through the Lattes Platform of the National Council for Scientific and Technological Development (CNPq) through their resumes. Specific criteria were used, such as resumes updated in the last 12 months and professional experience in the area of physiotherapy and orthopedics. The terms used in the search were: “lombalgia” OR “fisioterapia ortopédica” and “dor lombar” OR “ortopedia”. Priority was given to PhDs, masters and specialists, considering that their experience adds credibility to the content analysis.
The selection followed inclusion criteria through a model adapted from Fehring17 that considered the degree, scientific production and professional experience with the following scores: master’s degree in Physiotherapy (2 points), master’s degree in Physiotherapy with a dissertation with relevant content within the clinical area (1 point), article published in the area of orthopedics in a reference journal (2 points), doctorate in the area of orthopedics (4 points), clinical practice of at least 1 year in the area of physiotherapy in orthopedics (2 points), and specialization in the area of orthopedics (2 points). Those with a score of 10 to 14 points out of a total of 14 points were considered judges. In addition, those who did not have scientific articles published in an indexed journal on musculoskeletal disorders of the spine and who only had a bachelor’s degree were excluded. Regarding the quantitative sample of judges, at least six specialists are recommended for validating technologies and instruments18.
Study protocol and data collection
After selection, the request for participation in the study occurred in two stages. First, an invitation letter was sent via email which was located from the professionals’ own CVs, articles they had authored or from the websites of institutions to which they were affiliated. The letter contained information about the study, objectives, context, population involved and an electronic link to access the Informed Consent Form (ICF).
Only after confirmation of participation by completing and returning the ICF was the validation form sent, together with the printed screens of the prototype and instructions, with a deadline of 10 days for completion. Another professional was invited in the event of refusal or lack of response after three contact attempts. Additionally, non-probabilistic snowball sampling was conducted at a local university to complement the sample. A professional with the necessary profile indicated another female professional from his/her network of contacts, who was invited to participate in the validation. Their qualifications were verified according to the criteria established in their respective Lattes CVs.
Data collection instrument
The content validation instrument was a semi-structured electronic form on the Google Forms Virtual Platform called: content validation instrument for low back pain. It included guidelines on the validation process, open and closed questions to characterize the professionals and items related to the relevance of the application content (objectives, structure/presentation and relevance), with validation scores and space for suggestions and/or recommendations (free comments). It was adapted from the Health Educational Content Validation Instrument (Instrumento de Validação de Conteúdo Educativo em Saúde - IVCES) based on the theoretical framework of instructional design, which presented satisfactory internal consistency and good reliability (interclass correlation index >0.8). It was built for the practice of researchers and professionals in the health area for creating educational content and is easily adaptable because it does not specify the theme, target audience and circumstances15.
Validation involved four points: 1 (not relevant), 2 (somewhat relevant), 3 (relevant) and 4 (very relevant)19. The four-point Likert scale is the most frequently chosen scale for analyzing results using the Content Validity Index (CVI) and is sufficient for a meaningful calculation20. A scale with fewer items could limit this method of data analysis. Symmetry was additionally sought, meaning the same number of positive and negative categories in relation to a question, for greater variability and reliability.
Data processing and analysis
The data were organized in a Microsoft Excel® spreadsheet and presented in tables. The statistical analysis was performed using the SPSS version 25 statistical software using a significance level of 5%. A descriptive analysis was conducted that included absolute and relative frequency, mean and standard deviation (SD). The agreement of the judges was analyzed by the CVI, which measures the proportion of judges who agree on the instrument components and uses the division between the sum of answers 3 and 4 and the total number of answers, totaling the total agreement of the judges. If scores 1 and 2 were marked, there was a space for justification. An agreement rate of 0.80 or 0.78 or above was considered when evaluated by 6 or more judges19.
Reliability was assessed by analyzing the internal consistency of the instrument items based on Cronbach’s alpha and Intraclass Correlation Coefficient (ICC) values, two-way mixed model with absolute agreement to measure the reliability between the scores assigned by the experts. Adequate values were defined as overall CVI ≥ 0.78; Cronbach’s alpha ≥0.70 and ICC ≥0.70 and relative agreement ≥0.7019. Items that received 1 or 2 points should be revised or removed19. The binomial test was used with a significance level of 5% to verify whether the proportion of agreement was statistically equal to or greater than 0.78, which was the value previously defined to consider the item valid.
Ethical aspects
The study was approved by the Research Ethics Committee, respecting the ethical aspects involving studies with human beings, in accordance with Resolution No. 466/2012 of the National Health Council.
RESULTS
The validation committee was formed by an intentional non-probabilistic sample composed of 11 participants, who presented an average score in the Fehring criteria of 11.72 points (SD 1.48). A total of 1,012 professionals were selected through the Lattes Platform. Of these, 103 achieved a score of 10 to 14 according to the Fehring criteria. Next, 95 e-mails were sent due to the possibility of refusals, and 10 professionals agreed to participate in the study, but only eight actually answered the questionnaire. Three attempts were made to contact them. Since the initial sample only consisted of men, three women were selected by snowball sampling. Thus, the final sample included 11 judges. The return of the form complied with the established deadline.
Participants’ profile
The physiotherapists were mostly men (72.7%) with ages ranging from 37 to 50 years old, with an average of 44.1 years (SD 5.3). The most used device in daily life was the computer (two, 18.2%) and smartphone (nine, 81.8%). The main purposes for using the smartphone were: all to make and receive calls; eight (72.7%) to access social networks; five (45.4%) to play games and have fun; and all to use instant messaging services. The majority of the judges, nine (81.8%), use applications for professional purposes and all would recommend health apps to patients as additional support for treatment. The characteristics of the judges are shown in Table 1.
Content validation results
The overall CVI obtained for the three domains evaluated by the judges was 0.84, indicating relevance and pertinence of the educational material. Cronbach’s alpha coefficient was 0.97, demonstrating that the various items exhibit correlation with each other and an almost perfect internal consistency. The binomial test to verify the proportion of agreement showed agreement among the judges. The CVI of each item individually varied between 0.73 and 1.00 for all domains. The items were relevant or very relevant in the three analysis blocks proposed for the judges: objectives (0.86), structure and presentation (0.84), and relevance (0.79). Only 10 of the 11 judges responded with the scores in the “Objectives” domain. Items seven, 14, 16, and 20 did not reach the established agreement index with 0.73, but adjustments were made. All other items reached CVI above 0.78, ranging from 0.80 to 1.00 (Table 2).
Regarding the three domains of the instrument (objectives, structure/presentation and relevance), 121 (56.28%) obtained a very relevant score in the percentage of responses, 59 (27.44%) a relevant score, 25 (11.63%) a somewhat relevant score and 10 (4.65%) a non-relevant score.
The reliability analysis using the Intraclass Correlation Coefficient indicated that there is excellent reliability between the scores attributed by the experts (Table 3).
The judges’ recommendations were taken into account, and adjustments were made mainly regarding the number of screens, increasing the clarity and objectivity of the information, adapting the exercises and emphasizing psychosocial issues. The items that obtained an CVI below 0.78 were submitted for analysis and the app was reformulated according to the judges’ suggestions, scientific literature and clinical evidence. Some judges did not justify their assessment regarding the irrelevant and somewhat relevant scores, and in this sense the assessment of the other evaluators with higher relevant and very relevant percentages was considered.
After the app was programmed, two more validations will be performed: usability with Information Science professionals; and appearance validity of the construct by users with low back pain to verify understanding of the content and subsequently favor better adaptation of the language to the level of the end users and also of figures, images, drawings and flow of the screens.
The judges’ main recommendations included: reducing the number of screens in the application presentation; prioritizing psychosocial issues instead of mechanical and structural ones; focus on maintaining daily activities rather than specific exercises; avoid reinforcing users’ negative beliefs; reassess the relevance of postural guidelines; delve deeper into topics related to the chronicity of low back pain, such as self-efficacy, kinesiophobia, fear and avoidance; use a uniform pattern for characters, whether photo or drawing, and improve the layout; simplify the language, avoiding technical terms; include guidelines on the use of simple therapeutic resources, such as heating pads and back support; highlight the importance of warming up and joint mobility exercises before regular physical activity; include exercises such as bridging, spinal stability on all fours and abdominal strengthening; and reorganize the flow of the screens in the “Understanding your pain” and “Self-care” sections.
Adjustments were then made to the prototype: fewer introductory notes were included in the app presentation and the concept of non-specific low back pain, red flags and safety issues were added; screens with biomechanical, structural, postural orientation and affirmations that reinforced negative beliefs (anatomy, ergonomics, intervertebral disc, spinal mobility) were excluded; the focus was directed to psychosocial issues, self-efficacy and stimulation of general and daily life activities (understanding your pain, good ideas, goal planning, breathing and relaxation techniques) in several sections of the app, contextualizing them objectively; some exercises were excluded, leaving some in the section during a pain crisis; exercise pictures were replaced by animated gifs and video demonstrations; guidelines on safe exercise were provided; the layout and navigation flow of the screens were changed.
DISCUSSION
The mobile app prototype aims to promote self-management in healthcare professionals with CLBP. The overall CVI was 0.84. Self-management is a challenge and few applications currently address this aspect. Self-management should be a key option, with the need to provide guidance and information tailored to individual needs to help manage low back pain21.
The “Lower Back Self-Care” application is interactive and provides healthcare professionals with resources to manage pain, promoting quality of life through empowerment, increased confidence and pain symptom control. This is achieved through education, personalization of resources, biomechanical and respiratory exercises and goal setting. The application aims to improve quality of life, even if pain is not completely eliminated, by using planning techniques, breathing exercises, meditation and relaxation to manage stress. In addition, the application can reduce dependence on medications, minimizing side effects and risks associated with medications. It can prevent complications, promote body self-awareness, identify pain triggers and develop strategies to cope with them, monitoring pain through a diary. It also offers tools to promote emotional resilience, including goal planning and psychological techniques to face challenges in a more adaptive way4,6,8,10-11,16.
Appropriate selection of judges promotes accuracy and reliability in validation studies. Their knowledge and professional practices were of utmost importance for content adequacy and validation. They had more than 10 years of professional experience, which characterizes good clinical experience. Although the CVI achieved was greater than 0.78, the judges’ recommendations were evaluated and accepted whenever possible, even for items that reached the determined agreement. Different CVI values were identified in other validation studies, with indices of 0.78, 0.82, 0.9722-24, but no specific studies on low back pain were found.
In the context of the first domain (objectives) of the assessment instrument, all items individually achieved scores of 0.80 or higher, indicating that the application successfully achieved an important objective and demonstrated its ability to promote self-care and behavior change, reflecting its potential to achieve its objectives and goals. This “objectives” domain is important for understanding the content to be studied. It is important to conduct an assessment of these aspects, as they can promote social empowerment of the individuals for whom they are intended. In addition, it is essential to provide correct and contextualized information in the materials to promote health and ensure the evolution of care for the target audience22.
Next, three items in the “structure and presentation” module achieved individual scores below 0.78, and these assessments resulted in adjustments and improvements to the content, making it clearer and more coherent, enhancing the flow and reducing the number of screens, and adapting the exercises. It is important that the content presents a logical sequence of ideas, organization, and comprehension22. Instructions for the exercises in text, audio, and video were included to increase clarity, engagement, and memorization. Reminders provide extra motivation3. Audio narration leads to more efficient learning capacity3.
Several adjustments and revisions were made from the judges’ evaluation for assessing the “relevance” module of the application until the final version to be programmed was achieved, taking into account the needs and particularities of the target audience and their social context. The assessment with end users taking into account their specific context will help to improve the content clarity. The usability of the software is a crucial aspect to be considered. A user-friendly interface ensures that patients from different sociocultural backgrounds can easily use the treatment program. Video software is particularly attractive, as it offers more enjoyable exercises, with visual and audio feedback. In addition, continuing the exercises can be more enjoyable when performed virtually3. In this sense, this subsequent stage will be essential.
When analyzing the judges’ recommendations and suggestions, the relevance of the observations and the contribution to increasing the quality of the technology through reformulating information, introducing new topics and support from the literature stand out. The focus was initially shifted away from biomechanical and structural aspects and greater emphasis was placed on education in the neuroscience of pain and psychosocial aspects such as self-efficacy, beliefs, kinesiophobia and catastrophizing, which are aspects involved in the chronicity of pain. Chronic pain causes changes in brain regions involved in cognitive and emotional processes. Factors such as depression, fear-avoidance beliefs and negative coping strategies are associated with worse pain outcomes, disability and response to treatment25.
Self-efficacy plays a crucial role in clinical outcomes in pain control and self-management programs for CLBP. It predicts disability and mood changes2. However, its importance has not yet been adequately explored and emphasized in these programs2,26. Studies indicate that low self-efficacy is associated with worse functional outcomes and the transition from acute to persistent pain, while increasing self-efficacy can improve functional status in persistent CLBP, regardless of the initial level of behavioral cognitions25-26. Strategies to increase self-efficacy would be relevant to the overall outcome of treatment, but how to perform these actions is not yet well defined in clinical practice or in the literature26. Self-efficacy was promoted within the software through several skills such as education about the psychological impact of pain, addressing dysfunctional beliefs, improving physical condition, relaxation techniques, goal setting, and exercise. Education was emphasized to convey clear information about pain, promote understanding of the condition, and encourage self-management. The clinical trial showed that education was effective in increasing self-efficacy beliefs2.
One participant expressed concern about perpetuating negative beliefs and suggested improving the information quality. Verbal communication plays a key role in the patient-therapist relationship and the non-specific effect of treatment, affecting patients’ beliefs and expectations about the disease and treatment. Beliefs about musculoskeletal pain also affect pain duration and participation in exercise. Therapists’ use of inappropriate language can increase anxiety and illness beliefs, triggering negative expectations in treatment27.
Beliefs such as viewing low back pain as a sign of serious injury, believing it will persist, or considering physical activity harmful can lead to greater disability, dependence on medication, and increased pain28. Negative beliefs and information with inaccurate diagnoses can add to pain catastrophizing, and have a potentiating effect on pain. Furthermore, these beliefs are related to mental disorders such as depression and anxiety. Patients with low self-efficacy and high fear of pain and movement avoidance are more likely to be disabled and require specific strategies to modify dysfunctional beliefs2.
Disagreement among health professionals regarding their own beliefs about musculoskeletal pain raises concerns about evidence-based practice. Beliefs about the body and musculoskeletal pain have a significant impact on people’s behavior and emotional response to pain29. Many professionals hold mistaken beliefs that are not aligned with low back pain guidelines and may not feel prepared to influence patients’ beliefs29-30.
Although non-specific CLBP is influenced by a combination of biological, psychological and social factors, many health professionals still tend to attribute it to a single (biomedical) factor and exclusively focus on this aspect in care30. Lack of familiarity with guidelines results in misconceptions about pain and disability, as well as a tendency to recommend less physical activity and more time off work. These beliefs can be modified and should be addressed in pain management28-29.
There was some ambiguity among the judges regarding exercise. However, the majority considered it appropriate. The exercise approach in chronic low back pain treatment is widely supported by guidelines, such as the National Institute for Health and Care Excellence, which consider it a first-line treatment option17. They recommend education or information to encourage self-care and/or inform and reassure patients about their condition or treatment based on their needs21.
Different studies have emphasized the effectiveness of exercises, including self-management strategies with added exercises that produced moderate positive effects in reducing pain and disability4. Home exercise programs are also recommended, increasing long-term adherence and being especially suitable for remote rehabilitation. They evaluated the effects of video-based exercise programs, showing improvements in clinical criteria and adherence to rehabilitation3.
Despite the variety of approaches, the guidelines emphasize the importance of encouraging people with chronic low back pain to choose their preferred exercises to promote adherence31. However, despite the positive evidence, there are still theories about which types of exercises or program features are more effective than others, highlighting the need for additional research to guide the best clinical practices31.
Low back pain is a common and debilitating condition, affecting many people worldwide. It has a significant impact on daily activities and work capacity. Although traditional treatments, such as physical exercises and therapies, are effective, they often fall short of expectations due to the high level of patient participation required and the need for self-management. These components may be undervalued in the traditional healthcare model. Therefore, it is important to explore innovative approaches to managing low back pain12. This app can assist in this process, however it is important to emphasize that it does not replace the care of a qualified professional, since users with non-specific CLBP need to be proactive with a reference professional to report to in times of crisis and also to maintain engagement and adherence to treatment.
Regarding the limitations of this study, it is important to highlight that the validation of the target audience’s interaction with the application interfaces has not yet been conducted and will be addressed in future research, so new adjustments will still be implemented. In addition, the validation was only based on printed screens of the app prototype, not allowing a complete analysis of features such as layout, screen flow and media elements, such as video and audio. The low response rate of those selected on the Lattes Platform also presented challenges, increasing time, stress for researchers and insecurity in the validation process. In addition, it consists of a non-random sample, despite being representative. Some low scores were not properly justified by the evaluators. There are also few mobile self-care apps for low back pain to support the study. In addition, the subject complexity of low back pain led to disagreements among evaluators despite the guidelines, and it is not known whether a group of evaluators can fully guarantee its content or reasoning process, also considering the specificities, experiences and preferences of the evaluators themselves. They may also be influenced by previous expectations or enthusiasm regarding the technology. Furthermore, low back pain is a multifaceted condition and measuring outcomes can be complex.
Further research is needed to test the capabilities and long-term follow-up of the effectiveness of the technology presented, including representative samples of end users, adequate control groups and reliable outcome measures. It is important that these technologies are developed and implemented based on sound scientific evidence and in accordance with clinical guidelines.
CONCLUSION
The overall CVI achieved was 0.84 and Cronbach’s alpha reliability was 0.973. The overall CVI among the judges demonstrates that the “Lower back self-care” app prototype, after being improved based on the suggestions of experts and the scientific literature, is reliable and valid, has the potential to lead to self-care for health professionals with non-specific CLBP and contribute to the clinical practice of other health professionals as another option and alternative for integration into existing clinical treatments. It can also have positive impacts on health systems, such as greater accessibility, cost reduction and improved communication. Thus, mobile therapies have the potential to play an important role in the sustainability of health systems.
ACKNOWLEDGEMENT
To the UFSC Nursing Postgraduate Program and especially to the professional judges for their relevant contributions to improve the mobile application prototype.
REFERENCES
-
1. Jradi H, Alanazi H, Mohammad Y. Psychosocial and occupational factors associated with low back pain among nurses in Saudi Arabia. J Occup Health [Internet]. 2020 [cited 2023 Aug 27];62:1. Available from: https://doi.org/10.1002/1348-9585.12126
» https://doi.org/10.1002/1348-9585.12126 -
2. Moraes ÉB, Martins Junior FF, Silva LB, Garcia JB, Mattos-Pimenta CA. Self-efficacy and fear of pain to movement in chronic low back pain: An intervention developed by nurses. Rev Gauch Enferm [Internet]. 2021 [cited 2023 Aug 27];42:e20200180. Available from: https://doi.org/10.1590/1983-1447.2021.20200180
» https://doi.org/10.1590/1983-1447.2021.20200180 -
3. Özden F, Sarı Z, Karaman ÖN, Aydoğmuş H. The effect of video exercise-based telerehabilitation on clinical outcomes, expectation, satisfaction, and motivation in patients with chronic low back pain. Ir J Med Sci [Internet]. 2021 [cited 2023 Aug 27];191:1229-39. Available from: https://doi.org/10.1007/s11845-021-02727-8
» https://doi.org/10.1007/s11845-021-02727-8 -
4. Rathnayake AP, Sparkes V, Sheeran L. What is the effect of low back pain self-management interventions with exercise components added? A systematic review with meta-analysis. Musculoskelet Sci Pract [Internet]. 2021 [cited 2023 Aug 27];56:102469. Available from: https://doi.org/10.1016/j.msksp.2021.102469
» https://doi.org/10.1016/j.msksp.2021.102469 -
5. Moura CD, Nogueira DA, Chaves ÉD, Iunes DH, Corrêa HP, Chianca TC. Physical and emotional factors associated with the severity of chronic back pain in adults: A cross-sectional study. Texto Contexto Enferm [Internet]. 2022 [cited 2023 Aug 29];31:e20200525. Available from: https://doi.org/10.1590/1980-265x-tce-2020-0525
» https://doi.org/10.1590/1980-265x-tce-2020-0525 -
6. Rowland SP, Fitzgerald JE, Holme T, Powell J, McGregor A. What is the clinical value of mHealth for patients? NPJ Digit Med [Internet]. 2020 [cited 2023 Oct 19];3:4. Available from: https://doi.org/10.1038/s41746-019-0206-x
» https://doi.org/10.1038/s41746-019-0206-x -
7. Sedhom R, McShea MJ, Cohen AB, Webster JA, Mathews SC. Mobile app validation: A digital health scorecard approach. NPJ Digit Med [Internet]. 2021 [cited 2023 Aug 28];4:111. Available from: https://doi.org/10.1038/s41746-021-00476-7
» https://doi.org/10.1038/s41746-021-00476-7 -
8. Kheirinejad S, Visuri A, Suryanarayana SA, Hosio S. Exploring mHealth Applications for Self-Management of Chronic Low Back Pain: A Survey of Features and Benefits. Heliyon [Internet]. 2023 [cited 2023 Aug 27];9:e16586. Available from: https://doi.org/10.1016/j.heliyon.2023.e16586
» https://doi.org/10.1016/j.heliyon.2023.e16586 -
9. Mitchaï PM, Mapinduzi J, Verbrugghe J, Michiels S, Janssens L, Kossi O, et al. Mobile technologies for rehabilitation in non-specific spinal disorders: A systematic review of the efficacy and potential for implementation in low- and middle-income countries. Eur Spine J [Internet]. 2023 [cited 2023 Oct 20];32:4077-100. Available from: https://doi.org/10.1007/s00586-023-07964-2
» https://doi.org/10.1007/s00586-023-07964-2 -
10. Du, S, Liu, W,Cai, S,Hu, Y, Dong, J. The efficacy of e-health in the self-management of chronic low back pain: A meta analysis. Int J Nurs Stud [Internet]. 2020 [cited 2023 Oct 20];106:103507. Available from: https://doi.org/10.1016/j.ijnurstu.2019.103507
» https://doi.org/10.1016/j.ijnurstu.2019.103507 -
11. Cargnin ZA, Schneider DG, Rosa- Junior JN. Digital self-care in the management of spine musculoskeletal disorders: A systematic review and meta-analysis. Rev Latino-Am Enfermagem [Internet]. 2023 [cited 2023 Oct 25];31:e3909. Available from: https://doi.org/10.1590/1518-8345.6423.3909
» https://doi.org/10.1590/1518-8345.6423.3909 -
12. Chen M, Wu T, Lv M, Chen C, Fang Z, Zeng Z, et al. Efficacy of Mobile Health in Patients With Low Back Pain: Systematic Review and Meta-analysis of Randomized Controlled Trials. JMIR mHealth and uHealth [Internet]. 2021 [cited 2023 Oct 25];9(6):e26095. Available from: https://mhealth.jmir.org/2021/6/e26095/authors
» https://mhealth.jmir.org/2021/6/e26095/authors -
13. Rintala A, Rantalainen R, Kaksonen A, Luomajoki H, Kauranen K. mHealth Apps for Low Back Pain Self-management: Scoping Review. JMIR mHealth and uHealth [Internet]. 2022 [cited 2023 Oct 25];10(8):e39682. Available from: https://doi.org/10.2196/39682
» https://doi.org/10.2196/39682 -
Didyk C, Lewis LK, Lange B. Effectiveness of smartphone apps for the self-management of low back pain in adults: A systematic review. Disabil Rehabil [Internet]. 2021 [cited 2023 Oct 25];7781-90. Available from: https://doi.org/10.1080/09638288.2021.2005161
» https://doi.org/10.1080/09638288.2021.2005161 -
15. Leite SD, Áfio AC, Carvalho LV, Silva JM, Almeida PC, Pagliuca LM. Construction and validation of an Educational Content Validation Instrument in Health. Rev Bras Enferm [Internet]. 2018 [cited 2023 Aug 25];71 Suppl 4:1635-41. Available from: https://doi.org/10.1590/0034-7167-2017-0648
» https://doi.org/10.1590/0034-7167-2017-0648 -
16. Devan H, Farmery D, Peebles L, Grainger R. Evaluation of Self-Management Support Functions in Apps for People With Persistent Pain: Systematic Review. JMIR mHealth uHealth [Internet]. 2019 [cited 2023 Aug 28];7(2):e13080. Available from: https://doi.org/10.2196/13080
» https://doi.org/10.2196/13080 -
17. Fehring R. Methods to validate nursing diagnoses. Heart Lung [Internet]. 1987 [cited 2021 Apr 05];16(6):625-9. Available from: https://pubmed.ncbi.nlm.nih.gov/3679856/
» https://pubmed.ncbi.nlm.nih.gov/3679856/ -
18. Pasquali L. Princípios de elaboração de escalas psicológicas. Rev Psiquiatr Clín [Internet]. 1998 [cited 2023 Aug 28];25(5):206-13. Available from: http://ppget.ifam.edu.br/wp-content/uploads/2017/12/Principios-de-elaboracao-de-escalas-psicologicas.pdf
» http://ppget.ifam.edu.br/wp-content/uploads/2017/12/Principios-de-elaboracao-de-escalas-psicologicas.pdf -
19. Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in instruments evaluation of reliability and validity. Epidemiol Serv Saúde [Internet]. 2017 [cited 2023 Aug 28];26(3):649-59. Available from: https://doi.org/10.5123/s1679-49742017000300022
» https://doi.org/10.5123/s1679-49742017000300022 -
20. Almanasreh E, Moles R, Chen TF. Evaluation of methods used for estimating content validity. Res Soc Adm Pharm [Internet]. 2019 [cited 2023 Aug 29];15(2):214-21. Available from: https://doi.org/10.1016/j.sapharm.2018.03.066
» https://doi.org/10.1016/j.sapharm.2018.03.066 -
21. Campos TF. Low back pain and sciatica in over 16s: Assessment and management NICE Guideline [NG59]. J Physiother [Internet]. 2017 [cited 2023 Aug 28];63(2):120. Available from: https://doi.org/10.1016/j.jphys.2017.02.012
» https://doi.org/10.1016/j.jphys.2017.02.012 -
22. Ferreira DS, Teixeira E, Brown DO, Koch R, Monteiro WF, Santos ER, et al. Content validation of an educational technology about men’s health. Rev Baiana Enferm [Internet]. 2020 [cited 2023 Aug 28];34:e36344. Available from: https://doi.org/10.18471/rbe.v34.36344
» https://doi.org/10.18471/rbe.v34.36344 -
23. Roy R, Sukumar GM, Philip M, Gopalakrishna G. Face, content, criterion and construct validity assessment of a newly developed tool to assess and classify work - related stress (TAWS - 16). PLoS One [Internet]. 2023 [cited 2023 Aug 29];18(1):e0280189. Available from: https://doi.org/10.1371/journal.pone.0280189
» https://doi.org/10.1371/journal.pone.0280189 -
24. Cardoso NLS, Costa CFP, Rodrigues JRS, Azevedo MIB, Guimarães ACL, Aviz LBN, et al. Development and validation of a web application for physiotherapy management in the trauma-orthopedics area. Res Soc Dev [Internet]. 2023 [cited 2023 Aug 29];12(1):e27012139773. Available from: https://rsdjournal.org/index.php/rsd/article/view/39773
» https://rsdjournal.org/index.php/rsd/article/view/39773 -
25. Hayward R, Stynes S. Self-efficacy as a prognostic factor and treatment moderator in chronic musculoskeletal pain patients attending pain management programmes: A systematic review. Physiotherapy [Internet]. 2021 [cited 2023 Aug 29];19(3):278-92. Available from: https://doi.org/10.1016/j.physio.2018.11.238
» https://doi.org/10.1016/j.physio.2018.11.238 -
26. van Hooff ML, Vriezekolk JE, Kroeze RJ, O’Dowd JK, van Limbeek J, Spruit M. Targeting self-efficacy more important than dysfunctional behavioral cognitions in patients with longstanding chronic low back pain: A longitudinal study. BMC Musculoskelet Disord [Internet]. 2021 [cited 2023 Aug 29];22:1. Available from: https://doi.org/10.1186/s12891-021-04637-3
» https://doi.org/10.1186/s12891-021-04637-3 -
27. Linskens FG, van der Scheer ES, Stortenbeker I, Das E, Staal JB, van Lankveld W. Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents. Patient Educ Couns [Internet]. 2023 [cited 2023 Aug 30];110:107649. Available from: https://doi.org/10.1016/j.pec.2023.107649
» https://doi.org/10.1016/j.pec.2023.107649 -
28. Rufa A, Dolphin M, Adams K, Brooks G. Factors associated with the low back pain-related attitudes and beliefs of physical therapists. Musculoskelet Sci Pract [Internet]. 2022 [cited 2023 Aug 30];58:102518. Available from: https://doi.org/10.1016/j.msksp.2022.102518
» https://doi.org/10.1016/j.msksp.2022.102518 -
29. Caneiro JP, Bunzli S, O'Sullivan P. Beliefs about the body and pain: The critical role in musculoskeletal pain management. Braz J Phys Ther [Internet]. 2020 [cited 2023 Aug 30]. Available from: https://doi.org/10.1016/j.bjpt.2020.06.003
» https://doi.org/10.1016/j.bjpt.2020.06.003 -
30. Fourré A, Vanderstraeten R, Ris L, Bastiaens H, Michielsen J, Demoulin C, et al. Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines? Int J Environ Res Public Health [Internet]. 2023 [cited 2023 Aug 30];20(9):5611. Available from: https://doi.org/10.3390/ijerph20095611
» https://doi.org/10.3390/ijerph20095611 -
31. Hayden JA, Ellis J, Ogilvie R, Stewart SA, Bagg MK, Stanojevic S, et al. Some types of exercise are more effective than others in people with chronic low back pain: A network meta-analysis. J Physiother [Internet]. 2021 [cited 2023 Aug 30]. Available from: https://doi.org/10.1016/j.jphys.2021.09.004
» https://doi.org/10.1016/j.jphys.2021.09.004
NOTES
-
ORIGIN OF THE ARTICLE
Extracted from the thesis “Aplicativo móvel de autocuidado para profissionais da saúde com dor lombar crônica inespecífica” development and validation, presented to the Postgraduate Nursing Program, of the Universidade Federal de Santa Catarina, in 2024.
-
FUNDING INFORMATION
This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001.
-
ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Santa Catarina, opinion n.º 5718456, Certificate of Presentation for Ethical Assessment 56237222.1.0000.0121.
-
TRANSLATED BY
Christopher J. Quinn.
Edited by
Publication Dates
-
Publication in this collection
06 Dec 2024 -
Date of issue
2024
History
-
Received
30 Aug 2023 -
Accepted
19 Dec 2023
