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Research Paper

iPeer2Peer program

a pilot feasibility study in adolescents with chronic pain

Ahola Kohut, Sara; Stinson, Jennifer N.; Ruskin, Danielle; Forgeron, Paula; Harris, Lauren; van Wyk, Margaret; Luca, Stephanie; Campbell, Fiona

Author Information
doi: 10.1097/j.pain.0000000000000496
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1. Introduction

Chronic pain in children and adolescents is common5,31 with median prevalence rates ranging from 11% to 38%.26 Unrelieved or undertreated chronic pain can negatively impact all aspects of health-related quality of life.27 Chronic pain in children and adolescents results in numerous challenges including physical (fatigue, activity limitations, and poor sleep), emotional (increased stress, anxiety, and depression), and school and work attendance problems.12,14,30 Pain can also contribute to significant challenges in social interactions.14

Adolescence is a critical period for developing one's sense of self, which often occurs in the context of peer relationships.38 This developmental process may be disrupted in adolescents with chronic pain while they try to manage their symptoms. In addition to engaging in fewer peer activities, adolescents with chronic pain have fewer friends, often feel different from their friends, and are perceived as isolated and less likeable than their healthy peers.18,19 There is also a perceived decline in peer functioning over time in adolescents with chronic pain.17 This is concerning, because difficulties with social interactions and isolation have been reported as significant problems by adults with chronic pain.43,44 Increasing social supports for adolescents with chronic pain is a developmentally timely, and critical strategy to reduce long-term social isolation in adulthood as well as secondary problems (eg, depression and anxiety) caused by isolation.39

In addition to decreasing social isolation, social support such as peer mentoring, has the potential to positively influence health outcomes in adolescents with chronic pain by helping to encourage self-management skills and support the practice of these skills.10,11,35 Peer mentoring aims to provide individuals living with chronic illness with emotional, appraisal, and informational support from another person living with a similar condition.10 Peer mentoring may increase the likelihood of adolescent participation in self-management and help adolescents develop positive self-identity in the face of a chronic disease.10 Greater involvement in self-management could prevent worsening of chronic pain and facilitate successful transition to adult health care.25 Positive peer mentoring by one who has a shared experience may also prevent comorbid risk trajectories (eg, prevent depression stemming from isolation) in youth with chronic pain.39

Although peer support among individuals who share a common chronic illness has been found to be beneficial;1,3 the majority of these studies have focused on adult populations.11,35 Moreover, many studies focus on face-to-face interactions, which are challenging for youth with chronic disease to access because of (1) physical limitations, (2) lack of other local youth with similar conditions, or (3) lack of transportation outside of major cities. The efficacy and efficiency of peer support in adolescents with chronic illness requires more research;41 in particular, how to achieve greater reach and adoption using novel information and communication technologies.28 The aims of this study were to develop an online peer mentoring program, the iPeer2Peer program, and to determine its feasibility and acceptability in adolescents with chronic pain. The preliminary impact of the iPeer2Peer program was also assessed to inform appropriate outcome measures for future definitive trials.

2. Methods

2.1. Study design

A waitlist randomized controlled trial design was chosen to test the feasibility, acceptability, and explore outcome measures for the iPeer2Peer program in adolescents with chronic pain.

2.2. Participants

Twenty-eight consenting English-speaking adolescents aged 12 to 18 years from one large metropolitan pediatric tertiary hospital were randomized to either the experimental (iPeer2Peer program n = 14) or control (usual care n = 16) groups, with 3 participants completing the iPeer2Peer program after randomization and completion of the waitlist control (postintervention outcome data for these 3 participants were excluded from analysis). See Figure 1 for trial schema. Adolescents were eligible for participation if they were (1) 12 to 18 years old, (2) diagnosed with a chronic pain condition (eg, neuropathic pain, complex regional pain syndrome, chronic widespread pain, chronic daily headache), (3) able to speak and read English, (4) able to access the Internet on a computer capable of using free Skype software (96% of Canadian households have Internet access7), and (5) willing and able to complete online measures. Adolescents were excluded if they had (1) significant cognitive impairments or (2) major comorbid illnesses (ie, psychiatric conditions such as schizophrenia, bipolar disorder) likely to influence assessment of health-related quality of life, or if they were (3) participating in another peer support or self-management intervention.

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Figure 1:
Trial schema.

2.3. iPeer2Peer program development

The iPeer2Peer program was developed using a stepwise approach. First, based on the expressed desires of youth with chronic illness,47 the iPeer2Peer program was adapted from a successful peer support intervention developed and evaluated in adult chronic illness population.40 Second, we completed a systematic review of peer support interventions in children and adolescents with chronic illness to determine the program components associated with improvements in care.1 Third, our research team consulted with professionals experienced in training peer mentors as well as adults living with chronic illness and pain to inform the program components and process for training. Fourth, the content of the peer mentor training was informed by a conceptual framework for developing peer support in health care. This framework highlights the importance of providing informational (eg, providing advice, suggestions, and facts relevant to issues with which the peer is dealing), emotional (eg, expressions of caring, empathy, and reassurance), and appraisal (eg, affirmation of one's feelings and behaviours, encouraging persistence for resolving problems, and reassurance that frustrations can be handled) support during peer mentorship interactions.10 Finally, the method of delivery of the iPeer2Peer program, Skype-based video calls, was determined based on the expressed needs and desires of adolescents with chronic disease. Adolescents have reported that the Internet was a promising avenue to improve the accessibility and availability of psychosocial interventions and meaningful social supports.47

Participants enrolled in the iPeer2Peer program were randomized. Those in the intervention condition were matched with a trained peer mentor. Mentoring sessions consisted of 10 sessions of 20 to 30 minute Skype video calls conducted over 8 weeks. Participants had 2 sessions per week for the first 2 weeks, and 1 session per week for the remaining 6 weeks. Mentoring sessions occurred only during the scheduled times and participant-mentor contact outside of the mentoring sessions was discouraged. Call content was open-ended and tailored to each participant; however, mentors had access to all training materials to guide conversations if needed.

2.4. Peer mentors

2.4.1. Peer mentor selection

To be considered for the role of peer mentor, eligible young adults had to be nominated by a member of their health care team. Nominations were made based on the young adult's maturity, emotional stability, and verbal communication skills. Next, the research team determined whether they would be suitable based on the following criteria: 18 to 25 years old, diagnosed with chronic pain, self-reported adherence to current treatment plan (minimum 80% compliance), self-reported successful transition to an adult care facility, do not currently meet DSM-IV-TR2 criteria for a psychological or psychiatric illness as determined by health care team, self-reported self-efficacy in their ability to manage pain, and willingness and ability to complete peer mentor training.

2.4.2. Peer mentor training

Peer mentor training involved both self-directed in home training as well as attending 2 full day and 1 evening training session with research staff (total of 20 hours). In-class training comprised of lectures, active group discussion, case examples, small group activities, and role-play activities. When possible, members of the group were encouraged to pose and answer questions with one another and model good peer mentoring for each other. All peer mentors received a guidebook including all training materials as well as additional resources and reading lists. Individual iPeer2Peer calls were not structured, and mentors and participants were given the freedom to discuss whatever issues they chose. However, the training manual included suggested topics (eg, pain coping strategies, lifestyle management, communicating effectively with health care team), advice on structuring conversations, and guides to redirect conversation to self-management topics. Peer mentors had access to all training materials as well as research staff throughout the study. A member of the research team (S.A.K.) also contacted each mentor after their first iPeer2Peer program call with their first participant to ensure their confidence and comfort with their role as a mentor as well as provide feedback. If needed, mentors were given additional training by research staff throughout the study to help improve mentoring skills. Training was based on providing peer mentors with the skills necessary to provide informational, emotional, and appraisal support to adolescents. Concerns of the peer mentors and common concerns of adolescents with chronic pain were also reviewed throughout training, and potential solutions were developed as a group. Refer to Table 1 for major topics covered during the training session. Peer mentors' compensation included travel expenses to and from the training session and 20 dollars Canadian per mentoring call they completed with a participant. Peer mentors were not compensated for their time during the training process.

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Table 1:
Outline of topics reviewed during peer mentor training.

2.5. Procedure

Following institution Research Ethics Board approval, eligible patients who had a scheduled follow-up appointment at the chronic pain clinic at a tertiary health care centre were approached to participate. Eligible participants were invited to participate through an information letter signed by the principal investigator. The Clinical Research Project Coordinator (CRPC) then contacted participants through telephone or in person during their scheduled appointment. If interested in learning more, the CRPC further explained the study and obtained consent. Once informed consent was obtained, the CRPC obtained baseline data on participants (demographic and disease-related characteristics, from their medical charts) and e-mailed participants online pretreatment measures. Once baseline measures were complete, the participants were randomly allocated to the intervention or waitlist control group. A secure, web-based randomization service (www.randomize.net) was used to allocate participants to the trial groups. The CRPC then contacted participants to inform them of their group assignment and instruct them on the procedures to be followed (See Fig. 1 for trial schema).

2.5.1. Experimental group

In addition to standard medical care, adolescents in the experimental group received the iPeer2Peer program and were matched with a peer mentor based on gender and, when possible, diagnosis. The peer mentors encouraged participants to develop and engage in chronic pain self-management and transition skills and supported the practice of these skills. However, there was no specific intervention protocol that dictated the topics of conversation to be discussed during each call. Instead, peer mentors were encouraged to allow mentees to direct the conversation and thus focus on self-management concerns that were a priority for the mentee. During training, peer mentors were given a list of potential topics of conversation related to self-management if their mentee was shy or did not have any particular issues they wanted to address.

All calls were audio-recorded and uploaded to a secure research server. Mentors were trained to flag concerns that needed immediate follow-up by a member of the research team (eg, self-harm). To ensure safety, a member of the research team reviewed all calls within 48 hours. During this review, a log of all topics of conversation in each call was kept to determine the content of the iPeer2Peer program for each participant. Although the goal of the iPeer2Peer program was to train mentors who would be able to provide self-management and social support individualized to the circumstances of each participant, the log was used to determine the proportion of calls that discussed various pain-related topics (eg, self-management, coping, impact of pain on relationships, school, and work). This log was used as a measure of program adherence and mentor reliability during the mentoring calls.

2.5.2. Waitlist control group

The control group received usual care but without the iPeer2Peer program. Participants in the control group were offered the iPeer2Peer program after completion of postcontrol outcome measures.

2.5.3. Both groups

Both groups completed baseline (Time1 or T1) measures online before randomization. On program completion (Time2 or T2), participants were reminded by CRPC by phone or e-mail to complete the posttest measures online. Participants who completed the iPeer2Peer program were invited to complete a 15-minute semistructured interview describing the strengths and weaknesses of the program. A trained research assistant, who was not involved in the implementation of the iPeer2Peer program, conducted all semistructured interviews by telephone.

2.6. Measures

Primary outcomes and endpoints of this study focused on feasibility of the iPeer2Peer program as measured by (1) accrual and dropout rates, (2) adherence (or level of engagement) with the iPeer2Peer program (defined as 100% when the participant completed 10 calls over 8 weeks), (3) proportion of completed questionnaires (defined as 100% when all measures completed), and (4) satisfaction with the iPeer2Peer program as measured through semistructured phone interview with participants after involvement in the iPeer2Peer program.

Secondary outcomes of this study focused on the impact of the iPeer2Peer program. Given the focus of this study was feasibility, the exploratory secondary outcome measures were chosen based on the results of a systematic review of existing peer support interventions in youth with chronic disease. Previous evaluations of peer support interventions have found significant changes in domains such as health-related quality of life, self-efficacy, disease knowledge, depression, and measures of social engagement (eg, social support, social isolation).1 The results of this study will guide decisions surrounding appropriate outcome measures to use in future evaluations of the iPeer2Peer program. In addition to basic demographic and health information (Table 2), participants completed 6 measures at T1 and T2 to capture pain, emotional symptoms, function, perceived social support, self-management, self-efficacy, and pain coping.

  • (1) Pain and pain locations were assessed using the Recalled Pain Inventory,46 which measures current, least, average, and worst pain intensity and interference in the past 24 hours on an 11-point numerical rating scale (0 = no pain to 10 = pain as bad as you can imagine). Evidence of the construct validity of this instrument in an adolescent rheumatic population has been demonstrated.46
  • (2) Daily functioning and emotional symptoms were measured using the BATH Adolescent Pain Questionnaire,13 a 61-item questionnaire measuring the impact of chronic pain on an adolescent's life. There are 7 domain subscales: social functioning, physical functioning, depression, general anxiety, pain-specific anxiety, family functioning, and development. All domains are assessed on a 5-point Likert scale. The development subscale is measured from “very behind” to “very ahead,” whereas all other subscales are measured from “never” to “always.” Higher scores indicate increased negative impact of pain on life.13 In adolescent chronic pain and rheumatic populations, the BATH subscales have demonstrated internal consistency (Cronbach's α range = 0.79-0.89) and 17-day test-retest reliability (0.60-0.94, P < 0.01; except development in pain sample n.s.). Construct validity has been demonstrated through significant positive correlations between BATH subscales and measures of pain ratings, functional disability, social functioning, mood, anxiety, pain catastrophizing, and family functioning.13
  • (3) Perceived social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS),51 a 12-item questionnaire that captures perceived social support from various sources (ie, parents, siblings, friends, and peers). Items are scored on a 7-point Likert scale (0 = very strongly disagree to 6 = very strongly agree). Scores are summed for a total score with higher scores reflecting higher levels of social support. In a sample of university undergraduates, factor analysis demonstrated a 3 factor model measuring 3 domains of overall social support including support provided by significant others (loadings range = 0.74-0.92), family (factor loadings range = 0.81-0.84), and friends (factor loadings range = −0.79 to −0.86). The MSPSS total score demonstrated good internal consistency (Cronbach's α = 0.88) and 2 to 3 month test-retest reliability (r = 0.85, P < 0.01). The MSPSS is also significantly negatively correlated with depression and anxiety, demonstrating construct validity.50 Reliability and validity have also been demonstrated in an urban adolescent sample and in a sample of adolescents living with their families in Europe.8,51
  • (4) Self-management was measured using the Self-Management Skills Assessment Guide (SMSAG),48 a psychometrically sound and valid tool that measures self-management skills as a construct of transition-readiness.49 Items are scored on a 5-point Likert scale from “strongly disagree” to “strongly agree.” There are youth and parent report options of the SMSAG. Scores are summed to create a total score with higher scores indicating better self-management skills. In an adolescent sample with chronic disease, the SMSAG demonstrated internal consistency (Cronbach's α = 0.89). Interrater reliability was moderate between youth and parent report (r = 0.56, P < 0.01). Both youth and parent reports were significantly correlated with youth independence.48 Only the youth report of self-management was assessed in this study.
  • (5) Self-efficacy was measured using the Pain Self-Efficacy Questionnaire (PSEQ),33 a 10-item scale with demonstrated validity and reliability in adult pain populations that requires patients to take their pain into account when rating their self-efficacy beliefs.20,29 Items are scored on a scale from 0 = not at all confident to 6 = completely confident. Scores are summed to create a total score from 0 to 60 with higher scores reflecting higher self-efficacy. In adult pain populations, the PSEQ has demonstrated internal consistency (Cronbach's α = 0.92) and 3-month test-retest reliability (r = 0.73, P < 0.001). Factor analysis has shown that 58.6% of the total variance is accounted for by a single factor (factor loadings range 0.64-0.85) suggesting the PSEQ measures a single construct. Construct validity has been demonstrated through significant negative correlations between PSEQ and total number of medications used, impact of pain on daily life, mood, unhelpful coping strategies and beliefs, and significant positive correlations between PSEQ and active coping strategies.33
  • (6) Pain coping and coping efficacy was assessed using the Pain Coping Questionnaire,36 a 39-item valid and reliable measure widely used to measure pain coping in children and adolescents. Items are rated on a 5-point Likert scale from “never” to “very often.” The measure consists of 8 subscales that can then be categorized into 3 higher order factors, including approach (information seeking, problem solving, seeking social supports, and positive self-statement subscales), problem-focused avoidance (positive self-statements, behavioural distraction, and cognitive distraction subscales), and emotion-focused avoidance (externalizing and internalizing/catastrophizing subscales).22,36 Higher scores indicate more frequent use of that type of coping strategy. In a sample of children and adolescents with pain, a factor analysis has shown that the 3 higher order factors account for 54% of total variance. The Pain Coping Questionnaire demonstrated internal consistency for both the 8-subscale model (Cronbach's α range = −0.78-0.86) and the 3 higher order factor model (Cronbach's α range = 0.85-0.89). Construct validity was demonstrated through significant correlations with pain intensity, pain controllability, coping effectiveness, emotional distress, and functional disability.36
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Table 2:
Demographic and disease characteristics of participants and mentors.

2.7. Statistical analysis procedure

Data was analyzed using SAS version 9.1.3.42 Descriptive statistics were used to describe the sample characteristics at baseline, using means and SD for continuous variables, and frequencies and proportions for categorical variables. Rates of accrual, dropout, compliance, and missing data were calculated. T-test analyses were conducted to compare baseline characteristics between the experimental and control groups. Separate analyses were conducted for each outcome. Analyses were conducted using an intent-to-treat approach. Linear regression models were used to test intervention effects on outcome measures using an analysis of covariance with posttreatment measures compared between groups using baseline scores and age as covariates. Effect sizes were determined using Cohen's d with 0.2 indicative of a small effect, 0.5 indicative of a medium effect, and 0.8 indicative of a large effect. A level of 0.05 was used as the criterion for statistical significance. All semistructured interviews were recorded, transcribed, and then analyzed using qualitative content analysis to identify recurring themes.15

3. Results

3.1. Sample characteristics

Twenty-eight adolescents (93% female) aged 14.8 ± 1.6 years (range = 12-17 years) completed the study. Because of all male participants being randomized to the control group, male mentors were not matched to any adolescent participants. When asked about computer usage, participants rated 3.70 ± 0.61 out of 4 for comfort with computers and 3.85 ± 0.36 out of 4 for comfort with the Internet. Forty-one percent of the participants spend over an hour on the computer and the Internet every day with 85% of adolescents spending at least 30 minutes a day on the computer or Internet. There were no significant group differences on demographic variables at baseline. See Table 2 for a summary of the demographic and disease characteristics of the participants.

3.2. Primary outcome analysis

Our primary outcome for this study focused on the feasibility of the iPeer2Peer program. Of those adolescents who were approached and eligible to participate, 60.7% (n = 34) agreed and completed consent, and 53.6% (n = 30) completed baseline measures. Of those who agreed to participate, 11.8% (n = 4) withdrew before completing baseline measures and 5.6% (n = 2) withdrew after completing baseline measures but before beginning the intervention. Time commitment was the stated reason for withdrawing from the program. Once connected with a peer mentor, all participants completed the iPeer2Peer program. Participants were able to complete study questionnaires within 45 minutes and 96.8% completed baseline and 90.3% completed posttest measures. There was less than 1% missing data in the pilot study. Only 1 adolescent had to decline participation because of lack of sufficient and reliable Internet access to run Skype at home or at a nearby location (eg, library). With respect to male participation in particular, of those who were approached, eligible and able to participate, 42.9% (n = 3) agreed and consented. Of those 3 male participants, 2 males were randomized to control and completed the study and 1 male dropped out before completing baseline measures because of medical complications.

With regards to program adherence, 40% of participant-mentor pairings completed the program within 2 months. Mean program length was 116.40 ± 62.35 days (range = 52-237 days). If pairings missed a call, they were sent e-mail reminders from the CRPC to reschedule, if a subsequent call was missed the CRPC would follow-up through telephone to remind the mentor of the call schedule and offer problem solving support (eg, advice to schedule a consistent weekly call time). However, the most common reason for rescheduling mentor calls were tests, assignments, or sickness in either participant or mentor. With respect to call length (100% adherence defined as calls longer than 20 minutes), 91.3% of calls adhered to minimal call length. In fact, the average call length was twice the required amount with median call lengths of 42:37 minutes (SD = 15:37 minutes; range = 13:12-75:43 minutes). See Figure 1 for trial schema, including data on recruitment and dropout. A log of conversation topics discussed during the iPeer2Peer program suggests that pairings spoke most often about issues related to chronic pain. Over 50% of phone calls involved discussions of lifestyle management (eg, sleep hygiene, time management, staying motivated, and following clinician recommendations), psychological coping strategies (eg, distraction, relaxation, and positive coping thoughts), future concerns related to living with pain (eg, school, employment, and starting a family) and physical coping strategies (eg, hot or cold packs and stretches). Approximately 25% of calls involved a structured goal-setting and action-planning task (eg, use of the SMART goals). Please see Figure 2 for a summary of topics of conversation discussed during 25% or more of the iPeer2Peer program calls.

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Figure 2:
Outline of topics discussed during peer mentoring calls.

From the telephone interview data, participants reported satisfaction with the program and all would recommend the program to a friend. In response to how engaged they were with the program, participants reported mean engagement levels of 8.13 ± 1.09 on a scale of 0 to 10 (range = 6.5-10). During post iPeer2Peer program interviews, participants stated that they most enjoyed (1) meeting another person close in age with similar experiences with whom they could relate, (2) meeting someone older who is moving on with life despite pain, and (3) getting advice and tips on managing pain from someone who actually lives with pain.

3.3. Secondary outcome analysis

Baseline-adjusted analyses of covariances were computed to examine group differences on each secondary outcome including pain, emotional symptoms, function, perceived social support, self-management, self-efficacy, and pain coping. There were no significant group differences on secondary outcome measures at baseline. After controlling for baseline self-management score (T1), adolescents in the intervention group had higher self-management scores after the iPeer2Peer program compared with those in the control group (β = 8.5, P = 0.02). In addition, older participants reported higher self-management score posttreatment (β = 2.67, P = 0.03). There were no significant differences between groups in pain, function, self-efficacy, perceived social support, or emotional symptoms at T2. Although there were no significant differences in the use of pain coping strategies between groups, we found that adolescents who completed the iPeer2Peer program reported a higher degree of success and satisfaction with their ability to cope with pain than those in the control group (β = 0.54, P = 0.02). See Table 3 for a summary of the descriptive statistics on secondary outcome measures.

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Table 3:
Descriptive statistics on secondary outcomes for participants by treatment condition.

4. Discussion

This study demonstrated the feasibility, acceptability, and initial impact of a newly developed online peer mentoring program, the iPeer2Peer program, for adolescents with chronic pain. Adolescents enjoyed the iPeer2Peer program and found it to be acceptable and accessible. However, the length of the iPeer2Peer program needs to be amended to allow increased flexibility (ie, whether in program duration or number of calls) for scheduling difficulties, because only 40% of pairings were able to complete the program within the proposed 8 weeks. Program adherence may also be improved through increased mentor training on providing support to ensure protected time for calls. Preliminary efficacy findings indicate that the iPeer2Peer program significantly improved self-management skills and adolescents' beliefs that their coping efforts were successful.

The iPeer2Peer program is an intensive peer mentoring intervention that requires significant time commitment on behalf of the adolescents and the peer mentors. Of the adolescents who enrolled in the iPeer2Peer program, many were unable to complete the program in the proposed 8 weeks. Although the intensive nature may be valuable for many adolescents with chronic pain (eg, allows for a relationship to grow and provide a deeper connection), this type of peer mentoring may not be suitable for all adolescents with chronic pain. Given this is the first pilot study to determine the acceptability of this form of intervention, future research into the possibility of less intensive peer mentoring programs (eg, fewer sessions, drop-in format, 1:1 messaging or texting) is warranted.

Our systematic review of peer supports for children and adolescents with chronic illness found improvements in adolescents' behavioural, emotional, and social but not physical symptoms.1 This study supports these findings while adding that adolescents with chronic pain may benefit from peer mentoring support. However, in contrast to the systematic review, this pilot study did not demonstrate significant improvements in self-efficacy after completing the iPeer2Peer program. Perhaps improved self-management skills are a first step towards building self-efficacy, and as such, differences might emerge after a longer period of follow-up. In this chronic pain sample, adolescent males did not show interest in peer mentoring. This is in contrast to a study cited in our review that males with asthma had greater improvements in positive attitude towards illness than females.37 However, pediatric chronic pain populations are female dominated with upwards of 70% of the patient population being female.16,26 Additionally, it may be that males perceive this type of intervention as needing to participate in initiating personal sharing which would be in contrast to adolescent male peer relationships.4 More work is needed to identify how certain groups of adolescents benefit differentially to various types of peer support and how to design and present this type of support to adolescent males with chronic pain so that they feel comfortable in participating (eg, fewer or shorter sessions, options of instant messaging).

Peer mentoring in the health care context offers a unique complement to standard care.10 Our findings demonstrate that young adult peer mentors can be role models who not only normalize the adolescent's experiences of living with chronic pain but are also symbols of hope for managing pain and reaching their goals. Knowing another who has lived through the same experience may increase an adolescent's motivation to try and persist in using self-management strategies in the face of ongoing or recurrent pain. Peer mentors speak from lived experience and therefore offer self-management skills that may be more practical in nature.9 Young adult peer mentors provide information using nonmedical vocabulary, perhaps making it more readily acceptable and relatable to many adolescents. Connecting adolescents to young adult peer mentors also capitalizes on a developmental stage characterized by separating from parents and adults in favour of peers.38 Adolescents are therefore likely to be more receptive to information received from an individual closer in age.

There has been increased interest in the development of Internet-based programs geared at specific or generic disease self-management for adolescents.6,23,32,34,45 These programs offer education and skill-based teaching for youth with chronic disease, with some programs also providing telephone support from a trained health coach. Online self-management programs could be paired with peer mentors as a means to increase individualization of these programs and augment the role of health coaches. Using peer mentors as health coaches could help guide adolescents through online self-management programs, thus ensuring adolescents receive comprehensive informational support while adding comprehensive appraisal and emotional support components through 1:1 mentorship. Our results demonstrate that it is possible to train peer mentors to flag concerns necessary for follow-up by the health care team. This suggests that monitoring all calls by a health care provider may not be necessary, thereby making peer mentors a cost-effective method to support self-management that, in turn, may decrease burden on the health care system (ie, through the prevention of worsening of symptoms, improvement in self-advocacy and communication with health care team).

A strength of the iPeer2Peer program is its ability to provide peer mentoring remotely from home without losing the benefits of audio visual face-to-face interactions. The Internet has emerged as one of the top health information resources and modes of communication for adolescents making it ideally suited to provide interventions for this age group.21 In this study, peer mentors and mentored adolescents appreciated the flexibility that Skype-based calls afforded with respect to having calls on weekends or in the evening on weeknights. Accessing a peer mentor online at home was particularly helpful for adolescents on a “bad day” when they would have not have felt capable of leaving the home. Moreover, one participant was hospitalized during their involvement with the study but continued regular calls with their peer mentor from the bedside. The iPeer2Peer program focused on training the peer mentors to provide individualized support, such as required when an adolescent is hospitalized. This flexibility on behalf of peer mentors is essential because of the diverse support needs and wants of adolescent chronic pain populations.

Of the adolescents who participated in the study, several inquired about becoming a peer mentor themselves. This suggests the program may be able to create a pool of peer mentors thus promoting sustainability. After completion of the iPeer2Peer program, the majority of peer mentors reflected on the benefits they received from being a peer mentor and expressed interest in continuing should another study be funded. Average call lengths were consistently twice the required amount of time regardless of no increase in compensation. This suggests that mentors were dedicated to the program and enjoyed being a mentor and also that mentees found the conversations interesting and helpful. Moreover, in a recent study on the acceptability and impact of being a peer mentor in young adults after liver transplant, mentors demonstrated clinically significant improvements in their own treatment adherence. Interestingly, 35% of the mentors in that study stated that the most beneficial part of mentor training was peer support from others with shared illness and 72% of mentors enjoyed not only meeting and speaking with others with similar illness experiences but also attaining a “mentor identity.”24 Similar results have been found in the adult literature.40 Taken together, this suggests that the iPeer2Peer program may be beneficial to mentors, and future studies should include measures of mentor outcomes to determine the physical, emotional, social, or other health benefits of acting as a peer mentor.

4.1. Limitations

Despite the encouraging findings, there were limitations to this study that need to be considered. This is a pilot study that focused on the feasibility and acceptability of the iPeer2Peer program. Although the secondary outcomes included analysis of the impact of the iPeer2Peer program, we were underpowered in some of the analyses. Additionally, we recruited from only one pediatric chronic pain clinic, which despite the culturally and geographically diverse population, taken together with our small sample size limits generalizability of the findings. The study sample was also predominantly female, which may be representative of our clinic demographic, but might also represent a gender-based difference in interest in the iPeer2Peer program. Gender-based differences need exploring.

In conclusion, this study found that the iPeer2Peer program is a feasible and acceptable peer-mentoring program for adolescents with chronic pain. Using Internet-based video calling is an innovative method to deliver peer mentoring support to adolescents who may otherwise never meet other individuals with chronic pain. The iPeer2Peer program is demonstrating initial effectiveness in improving self-management and the successful use of pain coping strategies. Future qualitative research is required to adapt the iPeer2Peer program to increase male engagement and address issues of program adherence (eg, program duration or number of calls). Following qualitative research and refinement of the iPeer2Peer Program, a definitive randomized controlled trial with an adequate sample size will be needed to determine effectiveness of the iPeer2Peer program on outcomes. Further exploration into the benefits of peer mentoring on the mentors themselves and a cost benefit analysis of the iPeer2Peer program is also warranted. Nevertheless, the iPeer2Peer program is a systematically developed and promising new peer mentoring intervention for adolescents, which may complement standard care.

Conflict of interest statement

The authors have no conflicts of interest to declare.

This research was supported by funds from the Canadian Institutes of Health Research Catalyst Grant: eHealth Innovations (PIs: J.N.S. and F.C. [funding reference number 126528]), Pain in Child Health and Louise and Alan Edwards research stipends to S. Ahola Kohut, and an additional postdoctoral research stipend from J. N. Stinson's Early Research Award to S. Ahola Kohut.

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                          Keywords:

                          Peer support; eHealth; Chronic pain; Adolescents

                          © 2016 International Association for the Study of Pain