A postal survey was distributed to 200 people aged 50 years and older with chronic (>6 months' duration) knee, hip and/or back pain who had participated in a trial based on the ESCAPE-pain program in the West of England in the United Kingdom [38]. Of these trial participants, 100 were “experienced” (ie, had undertaken the ESCAPE-pain program, in order to understand what they found useful and necessary to be included in a Web-based program) and 100 people were “naïve” (ie, they had not participated in the program but had received a verbal description of the program’s content and format) in order to understand the needs of a typical person taking part in the Web-based program. Demographic data and Internet use and experience of the participants were collected. The survey posed questions and invited comments about the format and content of the proposed Web-based resource and people’s preferences [39] for features that may improve the effectiveness of Web-based interventions (text messaging, prompts, diaries, support forums, and so on) [37,40-42]. Descriptive analyses were used to describe the survey data.

To gain a better understanding of people’s (dis)likes, opinions, and preferences about the ESCAPE-pain program, how to engage people, and what the Web-based program needed to convey, four focus groups were conducted (n=24 participants in total). Table 1 provides further details of the participant characteristics. Two focus groups involved “experienced” people who had participated in the program (n=11), and two focus groups involved people “naïve” to the program (n=13). Participants were purposively selected from the survey based on characteristics of age, sex, duration and site of pain, and their use of and confidence in using the Internet. Focus groups comprised five to seven participants. The focus groups took place in university or hospital settings, facilitated by one of the authors (JP) using a topic guide (Multimedia Appendix 1), and lasted on average 94 minutes (range 84-105 minutes). Field notes were also taken.

The focus groups and interviews were recorded, transcribed, checked for accuracy, and anonymized, and emerging themes were identified using thematic analysis [43]. Transcripts from all focus groups were coded by JP. The first two focus group transcripts were independently coded by all the authors, who discussed the coding and initial emerging themes. The topic guide was amended to reflect the emerging themes, which was used in the following focus groups. The additional focus group transcripts were independently coded by DC.

The results of the survey and emergent themes from the focus groups were used to design a prototype website (see Figure 1). This had limited online function and offline material and resources, consisting of four external pages and four internal pages. The external pages included the following:

The internal pages consisted of the following:

The prototype website was then tested by eight participants using semistructured interviews and a modified “think-aloud” technique [44]. The participants were purposively selected based on the key characteristics of age, sex, duration, site of pain, and their confidence in using the Internet. JP conducted the interviews at participants' homes, which lasted on average 107 minutes (ranging between 78 minutes and 142 minutes). Participants were shown the prototype Web-based version of ESCAPE-pain and asked questions using a topic guide developed from themes emerging from the survey and focus groups and features of the prototype website (Multimedia Appendix 2). Table 1 indicates those participants who were involved in the “think aloud” interviews.

The interviews were analyzed using a thematic analysis [43]. JP coded all the interviews, the first two interview transcripts were independently coded a second time by MH, DC, and NW, then each member coded two additional transcripts so that each interview was coded independently by three authors. The final themes were then mapped to the behavioral change taxonomy [19]. The findings from the focus groups and interviews are presented together.

Ethics

Ethics approval was obtained from the National Research Ethics Service Committee South West-Central Bristol (Research Ethics Committee reference 11/SW/0053). All participants received information about the project and gave signed informed consent.

The survey response rate was 42% (83/200). The demographics of the respondents reflect the demographics of people with OA, predominantly female (56/83, 67%), mean age was 67 years (range 53-84 years), over two thirds were retired and had pain in several joints for a prolonged time (Table 2).

Most respondents (71/83, 86%) had used the Internet, of whom 83% (59/71) used it daily and almost exclusively at home (99%). Most people felt confident or very confident using the Internet (49/71, 69%) with personal computers, tablets, laptops and/or mobile phones. Although more than three-fourths of the people used the Internet to search for information about health problems, few (14/71, 20%) had used this information to manage their condition (Table 3).

From the focus groups and “think aloud” interviews, three key themes emerged that influenced people's use of the proposed website (Table 4): (1) initial and sustained engagement with the website, (2) acceptability of a Web-based exercise-based self-management program, and (3) content/structure of the program.

Finding a health-related website usually results from a purposeful search for information about a specific health issue, for example, joint pain. However, people are often skeptical and mistrustful of information they find online. In our study, people wanted to be directed to Web-based resources by a trusted “source” such as a health care professional [45] or credible organization (ie, a statutory health body) [46-48]. They were mistrustful of commercial websites with advertisements, which they saw as promoting goods for financial gain with little regard to whether it will help the patient [46,47]. The website needed to capture people's attention visually, with content that was obviously relevant and created a positive association between the website and the health benefits it could bring [46,47]. Important determinants for engagement with the website were video testimonials of people discussing their experiences of participating in the program, with personal and social traits that potential users could identify with [46,47].

In general, people thought a Web-based ESCAPE-pain program could be an effective way to help them self-manage their condition. However, they thought there were limitations to how well they could do this and wanted to know when to seek advice from a health care professional, especially in regard to the exercise regimen. Some people were willing to accept the Web-based program as a replacement for face-to-face contact, while others saw it as an adjunct to the supervised face-to-face program that would help them sustain benefit and motivation after completing the program.

Acceptability partly depended on people's technical ability in using Web-based resources. Regular Internet users, familiar with technology and using Web-based resources to manage a health condition, were most accepting of the proposed website. Infrequent users, unconfident in their ability to use the Web-based resource correctly, thought they were less likely to use the website.

The website had to be aesthetically pleasing, which was defined as simple, bright, attractive, and interesting. However, people's aesthetic preferences (ie, color schemes, layout, icons, dropdown menus, scroll bars, and so on) varied greatly and were frequently mutually exclusive.

Navigation around the website had to be easy and intuitive so people could find what they wanted quickly, and information had to be easy to understand and free from jargon and acronyms. Internal and external links needed to be working, obvious, self-explanatory, and up to date. The website also needed to be optimized to work on different devices (ie, laptop, mobile phone, tablet), platforms (ie, Android, iOS), and Web browsers.

People wanted information and advice tailored to their personal needs, which was easy to understand, was practicable, and brought tangible benefits [48]. To surmount the difficulties of individuals having different needs and preferences, they suggested each person could have “their own website” that stored personalized information and advice, allowed for creation and adjustment of personal goals, as well as monitoring and recording of progress and achievements. When it was suggested that people might need to register to use the website to its full potential (ie, monitor, record, and chart progress and enable provision of targeted personalized support) many people were uncomfortable [48]. Even if registration was free they thought it might be a barrier to some people using the website because they would be suspicious about the reasons for registration. People also expressed concerns about the difficulty of remembering usernames and passwords.

In general, people who had “experienced” ESCAPE-pain thought a Web-based version should replicate the program. People “naïve” to ESCAPE-pain asked for broader information to explain their joint pain and how to cope with its effects. For example, they wanted to know about the following: why they get pain at night; home adaptations or assistive devices that might help them cope; what the “placebo effect” was; and the association between alcohol and joint pain. People also wanted information about the effectiveness of diet and complimentary medicines (ie, fish oils, food supplements, acupuncture) in preventing or relieving joint pain. They thought this might be best presented as a brief summary of essential information, educational videos, supplemented with printable leaflets for reference and linked to reputable external sources for more in-depth information [39].

When delivered face-to-face in a clinical setting, the educational sessions of ESCAPE-pain are presented in a specific sequence. However, people thought that online this would be very restrictive and cumbersome; they wanted easy access to relevant information when it was most appropriate rather than having to navigate through “irrelevant” information. For example, people wanted to find information about dealing with an exacerbation of pain when they were in pain without going through sessions discussing weight control and diet.

The survey response rate (83/200, 42%) was reasonable and allowed us to recruit focus groups and interviewees representative of people with chronic joint pain. Using participants who were “experienced” to an ESCAPE-pain based program enabled us to understand what they considered important to convey and how to convey it, while using people “naïve” to the program enabled us to understand what more “typical” people with no prior experience of the program would need in order to apply it.

Although participants were purposely sampled to reflect the wide opinions of people, only one person in the focus groups and none of the participants selected to test the website were unconfident about using the Internet. This means that Internet users lacking confidence were underrepresented. However, this did not have a significant impact on our findings because the prototype tested had limited functionality and was problematic even for experienced, confident Web users. Another limitation of the study was that the prototype website could only be displayed on a laptop or desktop computer, meaning it was difficult for users who are familiar with other devices, such as tablets, to feel as confident when testing the website and giving their opinions.

As more people live longer, and obesity and sedentary lifestyles increase, the prevalence of chronic joint pain will increase [1,2]. Web-based programs have the potential to reach the large number of people requiring help, but historically the uptake of, effectiveness of, and adherence to Web-based interventions are notoriously poor [64-66]. Persuasive technology and human-centered design and business modeling can inform the design and content of engaging, effective Web-based behavioral change programs.