This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.
Persistent or chronic pain is a common health problem among adolescents. Thus, it is important that they receive evidence-based strategies for symptom management.
The objectives of this study were to describe the translation and cultural adaptation of the app into the Norwegian context and evaluate the app’s usability using a phased approach.
Phase 1 included translation and cultural adaptation of the app into the Norwegian context. This process used an expert panel of researchers and target group representatives who were responsible for the linguistic quality assurance and assessment. In phases 2 and 3 the app’s usability was tested. For phase 2, the assessments of usability and user experiences included observation, the think aloud method, audiovisual recordings, questionnaires, and individual interviews in a laboratory setting. For phase 3, the assessment of usability and user experience over a 2-week home-based test included questionnaires and individual end-user interviews. Overall, app usability was determined based on ease of use, efficiency, and user satisfaction. Qualitative data were analyzed using deductive content analysis. Descriptive statistics were calculated for quantitative data.
End users did not report any misunderstandings or discrepancies with the words or phrasing of the translated and culturally adapted app. Participants in both the laboratory- and home-based usability tests found the app self-explanatory and reported that all 5 of its features were easy to use. All tasks were completed within the allocated time frame (ie, efficiency), with few errors. Overall System Usability Scale scores were high, with average scores of 82 and 89 out of 100 from laboratory- and field-based tests, respectively. Participants liked the idea of a social support function (feature IV), although qualitative and internet server data revealed that this feature was rarely used.
This study described the cultural and linguistic adaptation and usability testing of the Norwegian version of the
The prevalence of persistent or chronic pain in nonclinical adolescent populations is increasing and has become recognized as a growing health problem [
An increasing number of self-management interventions have been developed and are associated with reduced chronic pain among both children and adolescents [
Adolescents are comfortable using computerized technologies and have reported that internet-delivered self-management interventions are their preferred methods for gaining information about chronic pain and pain coping skills [
The
The
Component I is based on behavioral activation therapy, which was originally developed to treat mood disorders and is efficacious for reinforcing engagement with, and motivation for, meaningful activity [
Component II is based on social cognitive theory, originally called social learning theory developed by Albert Bandura, which has influenced our understanding of human behavior [
Conceptual framework showing the theories underlying the Norwegian iCanCope with Pain app for adolescents with persistent pain. Published as the original Canadian illustration. Source: Stinson et al. Used with permission by the original publishers [
Component III is based on CBT, with a focus on the interrelations among thoughts, feelings, and behaviors [
Component IV, social support, includes both quantitative (eg, number of friends) and subjective (eg, network appraisal) dimensions [
The primary objectives of this paper are to describe the translation and cultural adaptation of the app into the Norwegian context and to evaluate its usability using a phased approach. The phased approach assessed the translated and culturally adapted app’s usability and users’ experiences with its ease of use, efficiency, satisfaction, and sociability. An additional objective was to identify the users’ needs and technical issues, to refine the app for use in a planned prospective randomized controlled trial with a larger adolescent sample.
During phase 1, the
Norwegian iCanCope with Pain app translation and usability testing.
Participants were recruited from a high school in Southern Norway. During phase 1, 2 representatives from the target group (both aged 17 years) participated to ensure that the app translation and cultural adaptation were appropriate for their age group. During phase 2, 6 adolescents (aged 17 to 18 years) were recruited for a laboratory-based usability test. During phase 3, 5 adolescents (aged 16 to 18 years) were recruited for a 2-week home-based test to evaluate user experiences with the app over time and to identify additional user needs. Both usability tests were gender-balanced and included users of both Android and iOS operating systems to best represent the target group for an upcoming clinical trial. The inclusion and exclusion criteria for the phase 3 end-user group were also consistent with those planned for the upcoming clinical trial. We included 16- to 19-year-old adolescents with persistent pain (weekly pain lasting 3 or more months based on subjective reporting) who were able to read and understand Norwegian and owned a mobile phone. Adolescents with cognitive disability or diseases were excluded because of their inability to correctly understand the
A 2-stage approach was used for language and cultural adaptation of the original Canadian
The first stage was a 10-step process to ensure quality translation and adaptation of the age-appropriate pain education library to a Norwegian context, as illustrated in
The 10 steps of translation and cultural adaptation of the iCanCope with Pain app’s pain education library.
The second stage also followed the principles set forth by Wild et al to ensure credibility and understanding [
Screenshots of the Norwegian and Canadian user interface versions of the iCanCope with Pain app. Published with permission from the Centre for Global eHealth Innovation (Canada).
Before the laboratory usability test, 2 pretests were used to assess the protocol, logistics, and technology, and to determine the amount of time the tests would take, the number of participants needed, the number of tasks, and the level of app complexity. The 10 resulting predefined tasks had a stipulated time frame of approximately 1 min per task.
The task tests were carried out at the UiA laboratory facilities over 2 days with 6 adolescent participants. The laboratory facilities house control and test rooms are separated with a 1-way mirror (facility details have been previously reported by Gerdes et al) [
Each participant completed 10 predefined tasks corresponding to the 5 app components (
The SUS questionnaire was used to evaluate user satisfaction and comprised 10 open-ended polarity-balanced questions with a 5-point Likert scale for responses. The average scores were categorized based on the adjective ratings [
Adjective ratings, acceptability ranges, and school grading scales, in relation to the average System Usability Scale (SUS) score. Source: Bangor et al. Used with permission by the original publishers [
Finally, individual posttest semistructured interviews were conducted to assess user experiences with the app. The interview guide included 14 open-ended questions based on the 5 app components (
A total of 5 adolescents with persistent pain tested the Norwegian
The data collected (eg, internet server data, observation, audiovisual recordings, and interviews) corresponded to the 5 app components. Quantitative laboratory usability test (eg, task completion, time, errors) measures were evaluated based on users’ interactions with the app and to assess the app’s ease of use and efficiency. In both usability tests, quantitative data from the SUS questionnaire (10 questions, each scored from 0 to 4 points) were transformed by multiplying by 2.5 to convert scores to a 0 to 100 range and were categorized adjectivally [
The study was approved by the Norwegian Regional Committee for Medical Research Ethics South-East-B (REK reference 2017/350). Participants were informed verbally and in writing that their participation was voluntary, that they could withdraw at any time without a reason (in which case their data would be deleted and destroyed), and that confidentiality and anonymity of their data were ensured at all times. Participants signed informed consent forms before participating.
The participants did not report having any misunderstanding about or finding discrepancies with the words or phrasing (eg, meaning or activities) of the translated and culturally adapted pain education library, in either usability test. In addition, participant interviews and debriefings in the field usability test (phase 3) were conducted to ensure credibility and understanding of the software interface text. Overall, the participants found the software interface text, which comprised single words and short sentences, easy to understand and interpret, and found the phrasing suitable for their age group.
Participants successfully downloaded the Norwegian version of
Hmm, actually it seems like it [the app] has control. So, there is a lot of information. I did not understand at first how an app may help with pain when I first heard about it, but I get it now when I see what it is, yes.
Participants in the laboratory usability test did not make any suggestions regarding how the app could be improved; thus, no adjustments were made before the home-based usability test.
User satisfaction scores (0 to 100) in the laboratory usability test are shown in
System Usability Scale questionnaire scores from the laboratory usability test.
Questions | P1a | P2 | P3 | P4 | P5 | P6 | Mean (SD) |
I think that I would like to use this app frequently | 3b | 3b | 3b | 3b | 4c | 4c | 3.3 (0.5) |
I found this app unnecessarily complex | 2c | 2c | 2c | 1c | 2c | 1c | 1.6 (0.5) |
I thought this app was easy to use | 5c | 4c | 4c | 4c | 4c | 5c | 4.3 (0.5) |
I think I would need assistance to be able to use this app | 1c | 3b | 1c | 1c | 2c | 4d | 2 (1.3) |
I found the various functions in this app to be well integrated | 5c | 5c | 4c | 4c | 3b | 5c | 4.3 (0.8) |
I thought there was too much inconsistency in this app | 2c | 2c | 2c | 1c | 1c | 1c | 1.5 (0.5) |
I imagine that most people would learn to use this app very quickly | 4c | 5c | 3b | 5c | 5c | 4c | 4.3 (0.8) |
I found this app very cumbersome/awkward to use | 1c | 2c | 2c | 1c | 1c | 1c | 1.3 (0.5) |
I felt very confident using this app | 5c | 4c | 3b | 5c | 5c | 4c | 4.3 (0.8) |
I needed to learn a lot before I could get going with this app | 1c | 3b | 1c | 1c | 2c | 1c | 1.5 (0.8) |
Scores | 87.5 | 72.5 | 75 | 90 | 82.5 | 85 | —e |
Average | 82 | — | — | — | — | — | — |
aPx: participant x.
bNeutral response: neither agree nor disagree.
cPositive response: agree or strongly agree for positive questions; disagree or strongly disagree for negative questions.
dNegative response: agree or strongly agree for negative questions; disagree or strongly disagree for positive questions.
eNot applicable.
Each participant completed all 10 predefined tasks. As participants progressed through the tasks, some unwanted screen landings or touches were registered as errors. The predefined tasks were completed within the stipulated time frame. Task 3 was expected to be more time consuming as it required the participants to first find a specific article about coping, read the article quietly to themselves, and then read the preferred information bullet points aloud. Efficiency scores are presented in
Mean completion time in seconds (0 to 100) for each laboratory usability test task (N=6).
The daily check-in (ie, self-registration) feature is intended to give users insight into, and an overview of, how they are coping with pain. In total, 4 of the 5 participants used the daily check-in almost every day, primarily after school, with an average of 10.5 check-ins during the 14 testing days. One participant commented, “It [check-in functionality] was a reason for using the app every day” and that “I will miss doing it.” However, 1 participant only used the daily check-in twice and explained in the interview that this was because the app became a reminder of the pain; even positive feedback from the avatar figure
The average user satisfaction score (0 to 100) for the field usability test is shown in
System Usability Scale questionnaire scores from the field usability test.
Questions | P1a | P2 | P3 | P4 | P5 | Mean (SD) |
I think that I would like to use this app frequently | 4b | 2c | 5b | 3d | 4b | 3.6 (1.1) |
I found this app unnecessarily complex | 1b | 2b | 1b | 1b | 2b | 1.4 (0.5) |
I thought this app was easy to use | 5b | 5b | 5b | 5b | 5b | 5 (0) |
I think that I would need assistance to be able to use this app | 1b | 1b | 1b | 1b | 1b | 1 (0) |
I found the various functions in this app were well integrated | 5b | 4b | 5b | 5b | 5b | 4.8 (0.4) |
I thought there was too much inconsistency in this app | 2b | 3d | 1b | 1b | 2b | 1.8 (0.8) |
I would imagine that most people would learn to use this app very quickly | 5b | 5b | 5b | 5b | 5b | 5 (0) |
I found this app very cumbersome/awkward to use | 1b | 1b | 1b | 1b | 1b | 1 (0) |
I felt very confident using this app | 3d | 2c | 5b | 4b | 5b | 3.8 (1.3) |
I needed to learn a lot of things before I could get going with this app | 1b | 2b | 1b | 2b | 1b | 1.4 (0.5) |
Scores | 90 | 72.5 | 100 | 90 | 92.5 | —e |
Average | 89 | — | — | — | — | — |
aPx: participant x.
bPositive response: agree or strongly agree for positive questions; disagree or strongly disagree for negative questions.
cNegative response: agree or strongly agree for negative questions; disagree or strongly disagree for positive questions.
dNeutral response: neither agree nor disagree.
eNot applicable.
Here, we have described the process of translation and cultural adaptation of the
A 2-stage multistep approach was considered necessary to culturally adapt the app content. The thorough approach used herein may explain why participants found the Norwegian
The original Canadian
Despite the participants’ reports that they liked the idea of an app component that would allow them to seek social or peer support, this functionality was rarely used. Nevertheless, research has shown the advantages of peer support delivered via apps, which may provide effective interventions and alleviate stress within other health care systems [
The app was designed for a generic target group of adolescents with persistent pain originating from different etiologies. Our participants reported appreciating that they were able to access the app from home after school and learn from psychological strategies in the app, which were the most popular articles. Given the free time of adolescents may be limited, measures such as high efficiency (tasks completed within the allocated time frame) and ease of use might be of great importance, by not taking much of the adolescents’ free time. Accessibility of the internet, with options for what, when, and where to read, and creating their own goals could be beneficial for adolescents who might be in a stressful stage of life with school and everyday activities, and for those who may find traditional psychological therapies delivered by adults more difficult [
Several study limitations must be considered. TA was used during tasks to confirm when participants started and ended each of the predefined tasks, providing valuable insight into users’ thoughts and actions [
This study presented the process of language and cultural adaptation and 2 usability tests for the Norwegian version of the
cognitive behavioral therapy
International Organization for Standardization
System Usability Scale
think aloud
University of Agder
The authors thank the Centre for Global eHealth Innovation in Toronto, Canada, for their technical guidance, collaborators at SickKids Hospital, the linguistic center, and the information technology/eHealth center at UiA. The authors also thank all the adolescents who participated, for their valuable feedback. The iCanCope with Pain app was used in this study with permission from the Centre for Global eHealth Innovation (Canada) and The Hospital for Sick Children. Copyright for the app is owned by The Hospital for Sick Children and University Health Network.
KH, LF, SH, and JS developed the project protocol and contributed to the study design. SM and EG were responsible for usability tests. EG, CL, KH, LF, and SH were responsible for the translation and cultural adaptation and data analysis. All authors contributed to the manuscript preparation and approved its final version.
None declared.