The study was designed as a randomized controlled trial that examined the effectiveness of a 4-week online pain education program. The study was approved by the ethical committee of The Hong Kong Polytechnic University (ref. HSEARS20180519002). Data were collected from September 2018 to March 2019.

An online poster explaining the details with a quick response (QR) code for the app was designed and distributed in WeChat to attract participants. Individuals who were interested in participating could scan the QR code to register in the study. A total of 152 people applied to join in the program. The application process involved completing an online questionnaire to screen eligibility. Eligible participants were then randomly allocated to one of the two groups: (1) the group that received the pain education program (experimental group) or (2) the group that received only simple material (control group). To minimize the potential of study bias, randomization was performed using an online randomizer [28] with 1:1 ratio after the registration period by a person who was not involved in this study.

Participants were required to fulfill the following criteria: (1) presence of noncancer pain in the past 6 months, with a pain score of at least 2 when assessed using an 11-point scale; (2) age between 16 and 60 years; (3) full-time employment; (4) ability to understand Chinese; and (5) ownership of a smartphone to access the internet. Those who had mental disorders, drug addiction problem, or further treatments planned were excluded from this study. Of the 152 people registered, 95 fulfilled the criteria: 47 were allocated to the experimental group, and 48 were allocated to the control group. The Consolidated Standards of Reporting Trials map for this study is shown in Figure 1.

Before the eligibility assessment, individuals’ consent was obtained electronically, emphasizing that participation was voluntary and remunerative. It was clarified that withdrawal from the study was accepted at any stage. Participants were also informed that all their personal information would remain confidential.

Outcome measures were administered online at three time points: (1) baseline (T0): after randomization and before starting the education program, (2) posttreatment (T1): right after the experimental group finished the program, and (3) follow-up (T2): 1 month after finishing the program. A battery of well-designed questionnaires was used for outcome measures. The primary and secondary measures were administered at T0, T1, and T2. Participants’ learning performance, satisfaction, and acceptability assessment were administered after the intervention (ie, T1). The questionnaires were uploaded in WeChat at three outcome measurement points. To facilitate a high completion rate of the assessment, a reminder message was sent to the participants individually.

The Statistical Package for the Social Sciences (SPSS) version 23 (IBM corporation, Armonk, New York) was used for handling and analyzing the data. The outcome variables and demographic characteristics were presented using descriptive statistics. The differences in demographic characteristics and outcome variables between the two groups were compared using a Chi-square test. Independent sample t test was applied to compare the changes in mean scores of the outcome variables. One-way analysis of variance was conducted to test the within-group changes of the outcome at baseline, posttreatment, and 1-month follow-up. Bivariate correlation was used to assess the correlation between the dosage of intervention (ie, frequency of reading the online materials in WeChat) and the outcome variables. The significance level was set at .05 (two tailed); a P value <.05 was considered statistically significant. Responses to open-ended questions on satisfaction with and acceptability of this online program were analyzed using a conventional content analysis.

The baseline demographics, pain-related characteristics, and baseline outcome of all the participants are presented in Multimedia Appendix 2. The results suggested that more female participants experienced pain than male participants in both groups. More than half the participants were aged between 21 and 30 years. The study involved a predominantly college-educated population (91/95, 96%). In all, 34.7% of the participants were professionals, and 20% had a monthly salary over 10,000 CNY (US $1488), which accounts for the highest proportion in our study. Most of the participants were living in the Southern and Northwest China. There was no significant difference between any of the baseline characteristics of the two groups.

This study aimed to evaluate the effectiveness of an online pain education program and participants’ satisfaction and acceptability. After our education program, the pain intensity reduced significantly in the experimental group, and depression, anxiety, stress, and pain self-efficacy showed clinical improvement. A significant correlation was demonstrated between depression, anxiety, and dosage of the intervention. Our results also showed that this online program was acceptable, and participants were satisfied with the program and willing to recommend it to others.

In this study, participants were recruited online via WeChat. Open recruitment through local media or the internet is likely to attract individuals who are more motivated to participate [37]. Consistent with this finding, we found a high completion rate of 89% (42/27) in the experimental group. Results showed that the learning performance of participants was acceptable with the mean score of 9.67/10. This may be because of the socioeconomic status of the participants. Research has indicated that the proportion of people with reliable access to the internet is lower among those with lower socioeconomic status [18,38,39], and a higher risk of pain is correlated with a lower sociodemographic status [11,18,40]. Although the emerging evidence of the internet-delivered pain management program is encouraging, there are still many people who do not have reliable access to the internet and thus have difficulty in utilizing the online programs [18]. As reported by the National Bureau of Statistics of China in 2017, the average monthly income of general Chinese population was 2165 Yuan (US $318) and was lower in the rural areas [41]. The monthly income of approximately 73% of our participants was higher than the average among the general population. The income was high enough to cover the cost of the internet. In addition, participants with a high educational level accounted for the highest proportion. The good learning ability is indicated with the high level of education. Therefore, for most of the working adults in China, sufficient affordability and learning ability make the online pain education program applicable.

Major findings according to the primary outcome measures suggested that this pain education program has the potential to reduce the pain intensity. The result of the significant reduction of pain intensity is consistent with the previous studies conducted among different population in other countries [4,16,18,42]. Studies on internet-delivered pain management programs demonstrated that participants’ symptoms are relatively stable over time among those in the treatment-as-usual control group (without a target intervention) [18,19,36,43].

In our study, the significant reduction in pain interference indicated that participants had become more functional and could self-manage their pain more effectively in the daily life [44]. In the experimental group, compared with the control group, the reduction in pain interference was significant, indicating that our online pain education program has the potential to reduce disturbances caused by pain. Our results are consistent with those of previous online pain management studies that reported improved pain interference after the intervention [44-46].

However, the changes in pain intensity and pain interference were statistically nonsignificant in the control group, and the differences in the 1-month follow-up in this study were not significant between the two groups. This may relate to the loss to follow-up rate. As noted in this study, a rate higher than 50% (23/35) was demonstrated in the control group, which is considered one of the reasons for the nonsignificant differences within the control group over time. In addition, the one-page simple material provided at beginning to the control group perhaps was insufficient, and no interaction with participants may impact the outcome as well.

Only clinical improvements were observed in depression, anxiety, stress, and self-efficacy because of the length of the intervention and the follow-up period; a period of 1 month is possibly too short to achieve a significant effect. Contrary to the expectations, the stress level of the control group increased at the posttreatment assessment. This unexpected result may be because of the factors not related to the education program, such as participants’ heavy and busy work, as the participants were working adults. Other stress from their daily life rather than pain-related stress may also have impacted the outcome.

It is noteworthy that a significant correlation between the dosage of the intervention and the outcome variables was demonstrated in our study. In a pain self-management study, Nicholas et al [15] reported that a higher dose of the intervention could partially explain the better outcome achieved, which was consistent with our findings that a higher dosage of intervention resulted in less pain and better pain-related emotional well-being. However, the previous study provided the intervention using a face-to-face approach. Our results proved that dosage was an important factor that impacts the outcome in the internet-delivered program, which is similar to the face-to-face program.

The higher dosage of intervention in the education period compared with the follow-up is probably because of the reminders we sent. The reminders were sent regularly on a weekly basis, with the purpose of encouraging and supporting the participants to work through the education program and keep reading the materials. Although we expected the participants to read the materials and learn consciously, sometimes, participants may forget to do so when they are busy with work. A regular reminder is a good way to enhance participation. In the previous online pain management programs, emails or phone calls were used to prompt individuals to learn the information and apply the skills taught, and they also helped decrease the dropout rate and facilitate compliance [4,18,36,47]. An internet-based intervention study successfully used such email prompts to encourage use and return visits to online resources [48]. In addition, it was demonstrated that such prompts do not compromise the clinical outcomes and acceptability of the program [49]. WeChat massages were used as an alternative in our study and were effective in enhancing participation.

A previous online pain management program stated it did not involve any interactive component [19]; thus, the interactive module designed in our study was unique. Participants’ understanding of the knowledge provided can be improved during the interaction. The MCQs designed after each article can encourage participants to apply the knowledge learned immediately. Involving some interaction in an education program, particularly for the online program, is necessary. A previous study highlighted the importance of interaction in high-quality education [50]; the researchers stated concluded that the interaction is the most fundamental form of the education. In addition, increasing the amount of interaction can lead to more effective learning and improve satisfaction with the education program as well as the learning outcome [51]. Wright [52] illustrated that if the intervention includes a forum where participants can interact and support each other, they can gain some benefits from similar experiences of other participants. The interactive component including the MCQs and WeChat group designed in this study played a crucial role.

Our study has a number of strengths. First, this study was the first randomized controlled trial designed to explore an education program using an online approach for working adults to self-manage pain in China. Second, a high completion rate of the education program and questionnaires was achieved. Third, an interactive component was involved in this online program, and participants’ learning performance was evaluated. Fourth, we explored the correlation between the dosage of intervention and outcome. Finally, we supplemented satisfaction and acceptability ratings with qualitative analysis of participants’ feedback.

There are several limitations to this study. First, the sample size of the study was relatively small, which limited the statistical power to detect smaller effects. It is possible that significant differences would have been observed with a large sample size. In addition, the 1-month follow-up of participants in our study may not be sufficient. Indeed, a long-term follow-up (eg, ≥6 months) would assist in observing the long-term effect of the program [36]. The completion rate of 48.4% in the 1-month follow-up may indicate the need to have more frequent reminders, to retain the participants in the program in future studies.

Our findings highlight the significant potential of this online education program in the treatment of pain. Pain intensity reduced significantly after the education program, and pain-related emotional well-being was found to clinically improve. A significant correlation was demonstrated between depression, anxiety, and dosage of the intervention. We conclude that this online program is acceptable. Further promotion to the public can be made to help more people with pain.