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Global Implementation Research and Applications
https://doi.org/10.1007/s43477-025-00157-7
Implementation Strategies toAddress Barriers toFamily Caregiver Use
of PainChek®: AMulti‑stakeholder Evaluation
AreejHussein1 · AndrewStaord1,2 · JeeryHughes1 · JoannaC.Moullin1,2
Received: 17 June 2024 / Accepted: 13 February 2025
© The Author(s) 2025
Abstract
Despite its established use in aged care facilities, PainChek®, an approved medical application for assessing pain in individu-
als with advanced dementia, has not been utilised in community settings by family caregivers. This study aimed to determine
effective modes of delivery for the key intervention functions—of education, training, enablement, persuasion, and modelling,
for the implementation of PainChek® in community-dwelling individuals with dementia. Step 8 of the Behaviour Change
Wheel process was followed. To identify appropriate modes of delivery, family caregivers of people living with dementia and
healthcare professionals participated in idea generation surveys and two rounds of a modified RAND/UCLA Appropriate-
ness Method. PainChek® Ltd staff then rated the final list of modes of delivery for feasibility. Nine family caregivers, eight
healthcare professionals, and thirteen PainChek® Ltd staff participated. In total, 44 delivery modes were assessed as both
appropriate and feasible, with digital methods emerging as highly viable. The findings offer valuable insights for implement-
ing PainChek® in community settings, improving pain management for people living with dementia.
Keywords mHealth· Pain· Dementia· Family caregivers· Modes of delivery· Implementation strategies
Dementia is a syndrome usually of a chronic or progressive
nature that leads to disability and dependency. People with
dementia often unnecessarily suffer from manageable but
unrecognised pain (Collins etal., 2023; Hadjistavropoulos
etal., 2014; Prince etal., 2015). Because the majority of
people with dementia live at home (AIHW, 2024), fam-
ily care is an important component in providing help and
support (Brodaty & Donkin, 2009; Lindeza etal., 2024),
including in the management of comorbidities (Lindeza
etal., 2024).
Many family caregivers rely on digital health tools or
telehealth to support their caregiving, particularly since the
COVID pandemic (AIHW, 2024). Digital technology in
the form of mobile health applications (mHealth app) has
the potential to support well-being, and address some of
the health and social care needs of an ageing population,
particularly those living with long-term conditions such as
dementia (Ahmad etal., 2020). Some apps have been used to
assist and monitor patients with acute or chronic pain, and to
improve family caregivers’ knowledge about pain manage-
ment (Yousaf etal., 2019).
Among mHealth apps developed for management of
various chronic medical conditions in people with demen-
tia (Ahmad etal., 2020; Yousaf etal., 2019), PainChek®
(formerly known as ePAT) was developed as an obser-
vational pain assessment tool in the form of an mHealth
app. PainChek® combines artificial intelligence and smart
automation to identify and quantify pain in real-time
(Atee etal., 2017, 2018a, 2018b). PainChek® uses auto-
mated facial detection and analysis to detect facial muscle
movements (facial action units) which are indicative of
the presence of pain. The user then inputs other observed
non-facial features through a series of digital checklist
across a further five domains (Voice, Movement, Behav-
iour, Activity and Body). The app then automatically cal-
culates a pain score and assigns a pain intensity (Atee
etal., 2017, 2018a, 2018b). Several clinical studies have
reported that PainChek® is valid, reliable and accurate in
identifying pain in people with moderate to severe demen-
tia living in aged care facilities (Atee etal., 2017, 2018a,
2018b; Babicova etal., 2021). PainChek® has regulatory
* Areej Hussein
a.hussein1@postgrad.curtin.edu.au
1 Faculty ofHealth Sciences, Curtin University, Perth,
Australia
2 enAble Institute, Curtin University, Perth, Australia
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Global Implementation Research and Applications
clearance as a Class 1 medical device in Australia, New
Zealand, Canada, Singapore, Malaysia, the United King-
dom and the European Union.
In 2019, the Commonwealth Department of Health
funded a national rollout of PainChek® across Australian
residential aged care facilities. The aim of the rollout was
to improve the diagnosis and management of pain in peo-
ple with dementia or cognitive impairment. More than
half of these facilities participated, with approximately
1,403,290 PainChek® assessments completed (PainChek,
2020).
PainChek® is currently used by healthcare profession-
als and trained professional caregivers (e.g. personal care
assistants) in aged care practice (Cotton, 2024). However,
its implementation in the assessment and monitoring of
pain by family caregivers of community-dwelling individ-
uals with dementia has not yet been tested or researched.
PainChek® Ltd, in attempting to introduce its innovative
technology into community use, requires an understanding
of the challenges which it might face in getting family car-
egivers to use it. As a result, using implementation science
as guidance, in a previous study, we identified the barriers
and facilitators to PainChek® use by family caregivers of
a person with dementia living in the community (Hussein
etal., 2024). These were grouped as user-related factors
(i.e., family caregivers), intervention-related factors (i.e.,
PainChek®) and context-related factors (Hussein etal.,
2024). These findings were based on the perceptions of
family caregivers of people with dementia living in the
community setting and healthcare professionals experi-
enced in delivering community-based dementia services
(Hussein etal., 2024). In a subsequent study and also
guided by principles of implementation science (Bauer
& Kirchner, 2020; Hussein etal., 2025), the Behaviour
Change Wheel which incorporates with the COM-B model
(capability, opportunity, and motivation) of behavioural
change (Michie etal., 2014), was utilised to draft broad
implementation strategies or intervention functions aimed
at increasing (i) family caregivers’ use of PainChek®, (ii)
and the communication of the results of family caregiver
pain assessments with healthcare professionals. Five
potential intervention functions were identified: educa-
tion, training, enablement, persuasion, and modelling.
These potential intervention functions were linked to 19
behaviour change techniques identified during two consen-
sus meetings (Hussein etal., 2025). The final step of the
Behaviour Change Wheel process is to select the mode(s)
of delivery, i.e., ways of delivery (e.g., face‐to‐face group
training sessions, digital media) for the identified inter-
vention functions. The abundance of available modes
of delivery emphasises the need for a careful and effec-
tive selection process, perhaps especially in community
settings where the end-users are family caregivers with
diverse needs and requirements.
Aim
The aim of this study was, from the perspective of key stake-
holders, to identify the most appropriate and feasible modes
of delivery for the intervention functions—education, train-
ing, enablement, persuasion, and modelling—to implement
PainChek® in the community.
Methods
Study Design
A mixed-method design was employed. The study consisted
of: (a) Idea Generation to identify the potential modes of
delivery; (b) Appropriateness Evaluation using a modified
RAND/UCLA Appropriateness Method (RAM) to engage
stakeholders in the selection of the most appropriate modes
of delivery for family caregivers (Fitch etal., 2001); (c)
Feasibility Evaluation involving a final review by a cohort
of staff at PainChek® Ltd to assess the feasibility of these
modes of delivery (Fitch etal., 2001). The study was con-
ducted between February and August 2023.
Participant Inclusion Criteria
To ensure diverse perspectives on the modes of delivery,
three groups of key stakeholders were engaged for this study:
(i) family caregivers, (ii) healthcare professionals, and (iii)
PainChek® Ltd staff. Each group aimed to have between 7
to 15 members as recommended by the RAM (Fitch etal.,
2001). The inclusion criteria of family caregivers included:
(1) > 18years of age, (2) English speaking, (3) self-identi-
fied as a family/friend caring for a person in any stage of
dementia living in the community. Participants in the group
of healthcare professionals were required to have knowledge
of pain and dementia care. PainChek® Ltd staff had to have
roles that were directly involved in product development,
customer service or clinical support of PainChek®.
Participant Recruitment
The study employed a combination of convenience and pur-
posive sampling techniques through multiple recruitment
methods. Family caregivers and healthcare professionals
were recruited through the StepUp for dementia research
(https:// www. stepu pford ement iares earch. org. au). This
website connects researchers with individuals have experi-
ence with dementia, including people living with dementia,
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Global Implementation Research and Applications
family caregivers and healthcare professionals. In addition,
healthcare professionals were recruited through personal
networks, having been invited by a friend who participated
in the recruitment process. Further, the recruitment process
included the distribution of flyers across Curtin University’s
Bentley campus in Western Australia and advertisements
on Facebook groups that involved family caregivers of peo-
ple with dementia. Family caregivers who had participated
in the previous qualitative study were emailed directly. All
participants received a gift voucher ($100) at the completion
of the study as compensation for their time.
For recruiting participants from PainChek® Ltd, an online
presentation was prepared outlining the research objectives,
progress made, and the role of PainChek® Ltd in the study.
The presentation was shared with PainChek® Ltd staff dur-
ing a fortnightly meeting with the support of an author (JH)
who is one of the co-inventors of PainChek®, to seek their
collaboration and access to potential participants. All par-
ticipants provided electronic consent within the question-
naires and through email correspondence.
Ethics
Curtin University Human Research Ethics Committee
approved the study (Project Number: HRE2019-0384).
Idea Generation
Participants Participants in this stage included family car-
egivers and healthcare professionals, with a recommended
sample size of 7 to 15 participants (Fitch et al., 2001).
Recruitment procedures and inclusion criteria for these
groups were outlined earlier.
Data Collection Online questionnaires were developed for
family caregivers and healthcare professionals to gather
their perspectives on potentially appropriate modes of deliv-
ery for each intervention function (education, training, ena-
blement, persuasion and modelling) to address previously
identified barriers (Hussein et al., 2024). Whilst the intent
of each question was the same for both groups of respond-
ents, the wording of the questions differed based on whether
they were a family caregiver or healthcare professional.
Questions for family caregivers were framed according to
intervention functions appropriate to them, whereas ques-
tions for healthcare professionals asked about intervention
functions appropriate for family caregivers.
Twelve questions were presented across the five inter-
vention functions to both cohorts. Participants were able to
provide up to nine responses for each question (Supplemen-
tary Materials 1 and 2). Both online questionnaires began
with a consent form and basic demographic information,
followed by an introductory 30-s video about PainChek®.
This video provided participants with a brief overview about
what PainChek® is and how it works. In addition, the ques-
tionnaires were reviewed for face validity (Patel and Desai
2020) by four healthcare professionals and three local com-
munity members. Their feedback was incorporated prior to
distribution to the study participants.
Both family caregivers and healthcare professionals
were provided with the participant information statements
via email followed by personalised invitations containing a
secure link provided by Curtin University's Qualtrics (Qual-
trics, Provo, UT),1 an online survey system, to the appropri-
ate questionnaire based on participant type. This link was
sent exclusively to participants who were included in the
study. Access to the questionnaire was controlled through
unique, one-time use links that ensured only invited par-
ticipants could access it. Data were collected between mid-
February and mid-April 2023.
However, participants were followed up with reminder
emails after one and two weeks to encourage their timely
response. At the end of the questionnaire, participants were
asked to provide their email address if they wanted to con-
tinue to be involved in the next stage of the research.
Data Analysis The data analysis was conducted by the first
author, who initially listed all modes of delivery suggested
by participants under each questions asked. The first author
used the classification of modes of delivery for intervention
functions suggested by Michie etal. (2014) to organise the
proposed modes from the idea generation according to rel-
evant categories and themes, helping to remove any duplica-
tions or redundancies (Michie etal., 2014). These modes of
delivery were compiled into an Excel file, which was shared
with the co-authors for review and discussion. During this
collaborative process, any discrepancies in the interpreta-
tion of the data were resolved through consensus among the
authors, ensuring data clarity and aclcuracy.
Appropriateness Evaluation
Having identified potential modes of delivery, their appro-
priateness was evaluated using two rounds of RAM (Fitch
etal., 2001).
Round 1 Appropriateness Evaluation Data Collection Par-
ticipants were provided with the list of potential modes of
delivery identified in the idea generation stage and asked to
rate their appropriateness to support family caregivers’ use
of PainChek® and communicating its results to healthcare
professionals. Ratings were on a scale of 1 to 9, where 1 was
‘not appropriate at all’ and 9 was ‘completely appropriate’.
1 https:// resea rch. curtin. edu. au/ erese arch/ qualt rics/
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Global Implementation Research and Applications
Adapted from the RAM (Fitch etal., 2001), appropriate-
ness was defined as ‘how suitable a method of delivery of
a particular strategy to support the use of PainChek® is for
family caregivers’. Participants were instructed to consider
relevance and usefulness for family caregivers, suitability
to their needs and abilities, and ethical standards and prin-
ciples, regardless of cost considerations (Bunn etal., 2018;
Campbell etal., 2019; Fazio etal., 2018).
Similar to idea generation questionnaires, secure links
to the questionnaires in Qualtrics (Supplementary Mate-
rials 3 and 4) were sent out to participants via e-mail. A
reminder was sent after two weeks to participants who had
not responded. The data collection period took around one
month, starting from end of April to June 2023.
Round 1 Data Analysis Following the completion of Round
1, rating data were analysed by calculating the median
value for each mode of delivery. The inter-percentile range
adjusted for symmetry (IPRAS) technique was used to assess
the level of agreement between the responses for each mode
of delivery and to construct a disagreement index (DI). DI
was calculated by dividing the inter percentile range (IPR)
by the inter percentile range adjusted for symmetry (IPRAS)
(Fitch etal., 2001). Any mode of delivery that had a DI > 1
showed disagreement within the group. A DI ≤ 1 demon-
strated sufficient agreement between the participants. The
calculation of DI, values for the median, IPR and IPRAS
were supported by inputting the data using Stata version 15
(StataCorp, College Station, TX, USA). The results were
then shared with other co-authors to provide their feedback.
Consistent with Fitch etal. (Fitch etal., 2001), the modes
of delivery were then classified into three categories: (a)
appropriate mode of delivery: when the median appropriate-
ness rating was between 6.5 and 9, with DI ≤ 1 (b) uncertain:
with a median between 4 and 6 with DI ≤ 1 or any median
values with DI > 1, and (c) inappropriate: when the median
between 1 and 3 and DI ≤ 1.
Round 2 Appropriateness Evaluation Data Collection The
second round of the study aimed to establish a consensus
among participants for the modes of delivery whose appro-
priateness was classified as “uncertain” and “inappropriate”
during round 1. These modes were discussed in two focus
groups, one for family caregivers and one for healthcare
professionals. Materials used for round 2 included facilita-
tor guides (Supplementary Material 5) and evaluation forms
(see Supplementary Material 5), which included partici-
pants’ personalised ratings alongside deidentified ratings of
the other participants, to facilitate comparison. These forms
served as the basis for discussion during the focus group
sessions. Participants collectively reviewed and deliber-
ated on each mode of delivery, referencing their personal
ratings and the responses of their peers. The focus group
discussions were conducted via the Microsoft Teams plat-
form (Microsoft Corporation, 2023) and audio recorded.
Following the discussions, participants completed an online
questionnaire using Qualtrics whereby they re-rated the dis-
cussed modes of delivery.
Participants unable to attend the focus groups, despite
their willingness to participate, were provided with online
questionnaires that included summarised focus group feed-
back on the discussed modes of delivery. These participants
re-rated the discussed modes of delivery using the ques-
tionnaires and provided reasons for changing or maintaining
their initial assessments. The data for this round were col-
lected during June 2023.
Round 2 Data Analysis Data from round 2 underwent qual-
itative and quantitative analyses. First, the data was tran-
scribed, and initial themes based on agreement, disagree-
ment, and neutrality were identified by the first author and
confirmed by co-authors. The finalised results were incor-
porated into an online questionnaire, which was shared with
individuals who were unable to attend the focus groups,
enabling them to provide feedback and re-evaluate the dis-
cussed modes of delivery.
Quantitative data was analysed as per Round 1. The
modes of delivery that were rated appropriate (Median ≥ 6.5
with DI ≤ 1) were then included in the subsequent feasibility
evaluation by PainChek® Ltd staff.
Feasibility Evaluation
Data Collection Participants rated the feasibility of each
mode of delivery on a scale of 1 to 9, where 1 indicated
‘not feasible at all’ and 9 indicated ‘completely feasible’.
Participants were asked to rate feasibility by considering
financial viability (ensuring a reasonable cost), equitable
access and benefits (promoting fairness and equal oppor-
tunities), and minimising burdens for end users (i.e., fam-
ily caregivers). Participants were also given the options to
answer ‘not able to determine’ and to provide a comment
to offer deeper insights into their ratings. A link to the fea-
sibility questionnaire, hosted on Qualtrics, as well as the
Participant Information Statement were sent to 26 partici-
pants from PainChek® Ltd. The data were collected during
August 2023.
Data Analysis Median scores and DI values were calculated.
Consistent with Fitch etal. (Fitch etal., 2001), the modes
of delivery were classified into three categories as per the
definitions used in the previous stage: (a) feasible mode
of delivery: when the median was between 6.5 and 9 and
DI ≤ 1, (b) uncertain mode: with a median between 4 and 6
among participants DI ≤ 1or any median values with DI > 1,
and (c) infeasible mode: median between 1 and 3 and DI ≤ 1.
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Global Implementation Research and Applications
From the comment boxes, feedback provided by PainChek®
Ltd staff were collected and organised into themes. At the
conclusion of the feasibility assessment, a final list of modes
of delivery that were appropriate and feasible to operation-
alise predefined intervention functions was prepared.
Results
Participants
A total of 10 family caregivers and 10 healthcare profession-
als were recruited, voluntarily consented to participate, and
completed the idea generation stage. For the RAM rounds,
the majority of the participants continued with two health-
care professionals withdrawing before completing round 2
and one family caregiver during round 2. Consequently, the
completion rate for family caregivers was 9 (90%), and 8
(80%) for healthcare professionals. Participant demographics
are described in Table1.
Out of 26 PainChek® Ltd employees who attended the
presentation and were invited to participate in the study,
13 (50%) completed the feasibility rating. The sample of
PainChek® Ltd employees encompassed a heterogeneous
mix of experience levels and positions within the organisa-
tion (See Table1).
Idea Generation
A total of 326 ideas were generated and gathered from fam-
ily caregivers, and 353 from healthcare professionals. These
numbers were reduced to 112 after removing duplications
and redundancies (see Fig.1). Idea generation resulted in
a range of modes of delivery options for each intervention
function and barrier.
Appropriateness Evaluation ofProposed Modes
ofDelivery
A total of 112 modes of delivery were rated for appropriate-
ness. These 112 modes of delivery were reduced to 95 after
removing additional duplicates and redundancies between
the ideas generated by family caregivers and healthcare pro-
fessionals (Supplementary Material 6 Table1 and Table2).
Of these 95 modes of delivery, participants deemed 77 as
appropriate.
Some modes of delivery (n = 17), such as social media,
educational emails, and advertising, were categorised as
uncertain or deemed inappropriate, and were set aside for
further evaluation in the round 2. The result of ratings of the
modes of delivery included in round 2 compared to round 1
are shown in Table2. The modes of delivery rated appropri-
ate from round 2 were combined with the 77 modes from
round 1 resulting in a total of 82 modes of delivery taken to
PainChek® Ltd staff for feasibility rating.
Feasibility Evaluation ofSelected Modes ofDelivery
Prior to feasibility rating the modes of delivery were refined
whereby certain modes were split. For instance, under the
education intervention function, there was ‘Online educa-
tion’ which included YouTube videos, workshops, webinars
and interactive sessions, online lectures, and resources. This
was broken down into five modes instead of one overarch-
ing category of online education. These modes of delivery
are identified by an asterisk in Supplementary Material 6
Table3. This approach resulted in a total of 100 modes
of delivery being included in the feasibility evaluation, as
shows in Supplementary Material 6 Table4.
Among the modes of delivery rated as appropriate from
RAM rounds (n = 100), PainChek® Ltd staff perceived 44
to be feasible with a predominant focus on digital content
(n = 23). Notably, there were also 18 non-digital modes
endorsed as feasible by PainChek® Ltd staff, including
printed materials, peer education by other family members,
and guidance and support from healthcare professionals.
Some modes of delivery (n = 3) such as testimonials in posi-
tive benefits of documenting and reporting a care recipi-
ents’ pain and testimonials from general practitioners were
not specified as digital or non-digital but rated as feasible.
Table3 shows details on the modes of delivery rated fea-
sible among PainChek® Ltd staff under each intervention
function.
Among the modes of delivery with a median rating below
6.5, 19 digital, 35 non-digital and 2 unspecified modes were
deemed uncertain or infeasible (Supplementary Material 5
Table4). The comments from PainChek® Ltd staff com-
monly centred around cost as the primary reason for rating
them lower. Most comments were grouped under the theme
of ‘Economic concerns’. Various other reasons included
‘Case-specific considerations’, ‘Accessibility’, and ‘Contex-
tual factors’. Participants also provided recommendations or
conditions for modes of delivery to be considered feasible.
For instance, one staff member commented that video-based
persuasion would be feasible if it was non-interactive and
available as a pre-recorded video. Another suggestion was
related to the availability of testimonials or reassurances
from general practitioners, specifically if they were acces-
sible online.
Discussion
To the best of our knowledge, this evaluation represents the
first investigation into the appropriateness and feasibility
of various modes of delivery of interventions to support the
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Global Implementation Research and Applications
implementation of an mHealth app, such as PainChek®, within
community settings by family caregivers. Through a rigorous,
evidence-based process, 44 modes of delivery across five inter-
vention functions were identified as appropriate and feasible by
key stakeholders. In our opinion, incorporating the views of key
stakeholders increases the overall value of the study, making
the study findings align better with practical implementation,
as recommended by Greenhalgh and their colleagues (Green
etal., 2017; Greenhalgh etal., 2004). Stakeholder incorporation
ensures that study outcomes, particularly in identifying appro-
priate and feasible modes of delivery, are tailored, empowering,
and effectively address the specific concerns and priorities of
Table 1 Participant demographics
FC family caregiver, HCP Healthcare professional
a. Family caregiver and healthcare professions
FCs (N, %) HCPs (N, %)
Gender
Male 1 (11.1%) 2 (25%)
Female 8 (88.9%) 6 (75%)
Age (years)
21–30 1 (12.5%)
31–40 2 (25%)
41–50 2 (25%)
51–60 4 (44.4%) 1 (12.5%)
61–70 5 (55.6%) 2 (25%)
Education status
PhD degree 1 (12.5%)
Bachelor’s degree 5 (55.6%) 5 (62.5%)
Master’s degree 4 (44.4%)
Graduate Certificate 1 (12.5%)
Advanced Diploma 1 (12.5%)
Employment status
Retired 4 (44.4%)
Employed 5 (55.6)
Occupation
Nurse 5 (62.5%)
Occupational therapist 1 (12.5)
Community care workers 2 (25%)
Person under care
Mother 6 (66.7%)
Sister 1 (11.1%)
Wife 1 (11.1%)
Husband 1 (11.1%)
PainChek® awareness
Yes 3 (33.3%) 4 (50%)
No 6 (66.7%) 4 (50%)
b. PainChek®Ltd Staff
Role within PainChek®Years of experience Mean
1–3years 4 + years less than 1year
Technical work 2 2 2 2.17
Management 1 2 3.33
Clinical training 2 2.00
Customer Success 1 2.00
Operations 1 2.00
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Global Implementation Research and Applications
those who will be most affected by or involved in their imple-
mentation (Green etal., 2017; Greenhalgh etal., 2004). This
approach allows for the development of strategies grounded
in real-world challenges, enhancing the relevance of practical
study and the potential to influence policy and practice (Lewis
etal., 2020).
For Education and Training, the findings suggested a need
for a combination of digital and non-digital approaches to
tackle barriers associated with family caregivers’ understand-
ing of pain in dementia and mHealth apps like PainChek®,
as well as potential concerns regarding data privacy and
accuracy, and the effective utilisation of PainChek®. Modes
of delivery rated as appropriate included online, traditional
face to face, and printed materials. However, literature con-
sistently emphasises the benefits of electronic education for
family caregivers on dementia care and related health issues
combined with interpersonal educational programmes and
training (Klimova etal., 2019; Leng etal., 2020). Previous
studies identified that e-learning programs enhance caregiver
confidence, reduce stress, and improve empathy in dementia
care; however, successful implementation as a support tool
for informal caregivers requires professional training in the
use of technology (Klimova etal., 2019). This highlights the
need for digital education designed for informal caregivers
(such as family caregivers) to be skills-based, ensuring that
they are able to effectively use digital tools or interventions,
such as online apps or programmes. A study on health com-
munication preferences among older primary care patients
found a variance in opinion of electronic modes based on
socioeconomic factors (Fridman etal., 2023). Fridman etal.
(2023) reported that lower income and lower education were
associated with a preference for telephone communications
over patient portals, emails, and texts highlighting the digi-
tal divide (Fridman etal., 2023). In contrast, our findings
Fig. 1 Comprehensive Analysis of Modes of Delivery throughout
the Three Study Phases. MODs Modes of delivery, Q1, Q2, etc.:
Questions asked in the Idea generation stage, FCsFamily Caregiv-
ers, HCPs Healthcare professionals, nNumber of participants, *the
number of modes of delivery after removing duplications and after
splitting some modes of delivery into sub-modes before undergoing a
feasibility assessment
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Global Implementation Research and Applications
highlight the emails were not desirable, emphasising the
need to consider contextual factors and diverse preference
among users.
PainChek® Ltd staff perceived digital modes of delivery
as being more feasible for providing education and training.
Literature highlights the ease of implementation, the cost-
effectiveness and scalability for digital modes of delivery
(LaMonica etal., 2021; Marcu etal., 2022; Verma etal.,
2022). It is important to emphasise that the modes of deliv-
ery evaluated for feasibility by PainChek® Ltd staff were
also already identified and considered appropriate by family
caregivers and healthcare professionals, although they also
rated non-digital modes as appropriate. Indeed, non-digital
modes of delivery may need to particularly be considered
for those with less digital literacy or living in low-resource
settings. These people may face greater disadvantage in
accessing services provided through digital platforms only
(Knapp etal., 2022). Consequently, it is recommended to
offer diverse modes of delivery to accommodate different
levels of digital literacy (Rasheva-Yordanova etal., 2017).
Participants identified that involving a variety of forms of
support to deliver Education and Training as appropriate and
feasible. For example, partnerships with Alzheimer's Asso-
ciation or dementia groups have improved family caregivers’
interactions with services in other studies (Alzheimer's Soci-
ety, 2024). In addition, all participant groups in our study
agreed on the importance of involving additional family
members, especially those with lower digital literacy. Pre-
vious studies emphasised that family involvement is needed
to achieve high quality and sustainable care (Häikiö etal.,
2020). Finally, all participants included utilising peers for
Education, Training, and Enablement intervention functions,
to empower family caregivers in pain assessment and com-
munication. These findings align with literature emphasising
the crucial role peers play as facilitators in education and
Table 2 Comparison of
appropriateness ratings
1 Medians less than 6.5 for modes from round 1
2 Medians of these modes after focus group discussion in round 2
3 DI represents Disagreement Index of round 2
Methods of delivery Median1
Round 1
Median2
Round 2
DI3
Round 2
Family caregivers
Education
Social media 5 4 0.52
Advertising 6 7 1.04
Prints 6 7 0.001
Electronic resources 6 7 0.37
Training
Remote instruction 6 8 0.00
Automated instruction/Training 4 3 0.49
Enablement
Video-based support 5 3 0.65
App-based guidance 6 3 1.04
Persuasion
Social media persuasion 5 3 0.52
Creative persuasion 5 5 0.85
Modeling
Social media and other online platforms 4 3 0.65
Advertising in medical centres 6 7 0.52
Mass media 5 7 1.61
Healthcare professionals
Education
Emails 4 4.5 1.01
Training
Educational emails 4 4.5 1.28
Persuasion
Testimonials or reassurances 6 7 0.44
Presentations at conferences or webinars 5.5 5 0.87
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Table 3 The Modes of Delivery Rated Feasible
Questions1Mode of delivery N2Median3DI4
Education
Q1: ‘increasing family caregivers’ understanding of pain in dementia and the
importance of documenting and sharing this information with healthcare profes-
sionals’
Video-based education such as YouTube videos 13 9 0.001
Webinars 13 9 0.13
Online workshops 13 7 0.22
Website resources 13 9 0.29
Audio content information 12 7 0.50
Q2: ‘helping family caregivers better understand mobile health apps, such as
PainChek®, and addressing concerns about data privacy and accuracy’
Group education: Peer education 12 6.5 0.52
Video-based education such as YouTube 13 9 0.13
Websites 13 9 0.29
Webinars and interactive sessions 12 7 0.50
Mobile apps with educational content 12 7 0.19
Visual aids such as posters in GP clinics, hospitals, and health facilities 13 7 0.65
Prints such as brochures, information packs, and step-by-step written guide 13 7 0.22
Advertising such as Real user endorsement 12 7 0.49
Training
Q3: ‘increasing family caregivers' confidence in using mobile health apps like
PainChek®, as well as for using PainChek® smoothly and accurately for pain
assessment’
Online training courses 13 7 0.37
Workshop videos 13 8 0.29
Frequently Asked Questions (FAQs) presented in video format 13 8 0.29
App-based training: Instruction video or links embedded in the app 13 7 0.29
Prints such as step-by-step written guides 13 7 0.75
Involvement of family members 12 7 0.83
Partnership with Alzheimer's Association or dementia groups 12 7 0.75
Q4: ‘helping family caregivers effectively use PainChek® situations such as a per-
son with dementia may not cooperate or may feel uncomfortable’
Online: Online training courses, demonstrations and case studies 13 8 0.29
Involvement of family members 12 7 0.43
Enablement
Q5: ‘helping family caregivers talk more openly to healthcare professionals about
the pain their loved ones are feeling’
Professional guidance and support from community-based healthcare organisations:
such as visiting a local nurse/health carer during home visits can offer guidance
on using PainChek® and share the results with the healthcare professionals
12 6.5 0.43
Peer support: groups of people with similar experiences who can provide emotional
and practical support to each other, including discussions about using PainChek®
11 7 0.22
Electronic resources: A diary provided with the app (electronic or paper) for
appointments
11 7 0.65
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Global Implementation Research and Applications
1 Refer to Supplementary file 1 (see Table3) for details about these questions
2 N refers to the number of participants
3 Likert scale where 1 = Not at all feasible and 9 = Extremely feasible
4 DI represents Disagreement Index
Table 3 (continued)
Questions1Mode of delivery N2Median3DI4
Q6: ‘support family caregivers to overcome any physical limitations’ Professional guidance and support from community-based healthcare organisations:
such as visiting a local nurse/health carer from Silver Chain, Attending or phone
calling healthcare services
12 7 0.65
Professional guidance and support from disability services: such as consider reach-
ing out to Senses Australia for assistance
10 7.5 0.65
Electronic resources: Step-by-step instructions recorded for caregivers with eye-
sight issues
11 8 0.29
Physical guidance: Use of stylus for dexterity issues 11 7 0.49
Persuasion
Q7: ‘diminishing family caregivers’ fear of pain medication’ Healthcare providers/experts from healthcare services (Health Direct, Clinical Liai-
son, Palliative Care) to talk to family caregivers about pain medication
13 7 0.65
Testimonials or reassurances from the general practitioners 12 7 0.50
Government publications can inform about non-addictive pain medication 12 7 0.49
Q8: ‘for convincing family caregivers to document their care recipient’s pain and
share the results with healthcare professionals’
Healthcare Provider/Expert: Interview with a healthcare professional about benefits 12 7 0.87
YouTube role models/actors demonstrating pain conversations and simple docu-
mentation technique,
12 8 0.21
Testimonials in positive benefits of documenting and reporting a care recipients’
pain
12 7.5 0.50
List of benefits 12 7 0.61
Modelling
Q9: ‘showing the benefits of using mobile health apps like PainChek®’ Video-based: App demonstrations 13 7 0.49
Video-based: Real-time pain management 13 8 0.49
Video-based: Success Stories 13 9 0.29
Video-based: Benefits Showcase 12 9 0.29
Partnership with Alzheimer's Association or dementia groups 12 7.5 0.61
Q10: ‘showing how PainChek® can help you better understand and manage the
family member living with dementia’s pain’
Healthcare professional endorsements 12 8.5 0.39
Carer video testimonials 13 8 0.49
Print materials 13 7 0.52
Partnership with Alzheimer's Association or dementia groups 12 8 0.49
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Global Implementation Research and Applications
training programs for dementia care and related healthcare
services (Murphy etal., 2023).
The involvement of healthcare professionals was deemed
appropriate and feasible for both Enablement and Persua-
sion. Previous studies underscored the vital role of health-
care professionals in guiding patients and their caregivers to
access reliable information (Grieve etal., 2019; Soong etal.,
2020). It is noteworthy that half of the participants lacked
awareness about PainChek®, which underscores the impor-
tance of incorporating awareness-building initiatives into
PainChek® strategies to enhance its visibility and adoption.
For the intervention function of Enablement, we found
that healthcare professional participants saw digital modes
as particularly relevant for family caregivers to helping them
talk more openly with healthcare professionals about the
pain experienced by their family member with dementia and
also as a means of supporting family caregivers to overcome
any physical limitations that may limit their ability to use
PainChek®. The preference for digital delivery may stem
from an appreciation of the accessibility and flexibility of
digital platforms, which can provide consistent and reliable
information, and interactive learning experiences (Luo etal.,
2020). Healthcare providers may also view digital platforms
as a way of delivering personalised learning and meeting the
diverse needs of caregivers with different levels of experi-
ence and knowledge in dementia care (Allida etal., 2020;
Zhai etal., 2023). Thus, there appears to be an openness
among healthcare professionals for family caregivers to use
digital modes to discuss pain outcomes with them.
On the other hand, for Enablement, despite a rise in the
use of digital delivery methods for dementia care during the
COVID-19 (Singh etal., 2021), family caregivers showed
a preference for non-digital modes of delivery as a way to
enable them to talk more openly with healthcare profession-
als. This may be driven by a desire for more personal and
practical experiences, where empathic understanding and
skills play a pivotal role (Granström etal., 2020). While
family caregivers may recognise the advantages of deliv-
ering health-related services through digital modes (Xiong
etal., 2022), varying levels of comfort and familiarity with
technology exist, particularly given the diverse age groups
and backgrounds of participants.
Participants indicated a range of modes of delivery for
the intervention function of persuasion. Using persuasion
techniques can enhance the impact of educational content,
making it more relevant and motivating for community
participants (Qasim etal., 2018). PainChek® Ltd evalu-
ated testimonials, reassurances from healthcare profes-
sionals, and government publications as feasible methods
to persuade family caregivers regarding the advantages
of documenting and reporting pain in individuals with
dementia. This underscores the importance of the trust-
worthy sources of information employed in persuasive
efforts. Joo etal. (2021) found that non-commercial
apps are usually viewed as more credible compared to
commercial apps, emphasising the crucial role of con-
tent in shaping user perceptions of credibility (Joo etal.,
2021). Moreover, family caregivers deemed certain digital
modes, like social media and app-based guidance, inap-
propriate due to concerns about information credibility.
Consequently, PainChek® Ltd staff may need to raise
awareness about credibility, validity, and reliability of
the PainChek® app. For example, as documented in the
Australian Aging Agenda (Egan, 2019), the $5 million
federal government grant awarded to PainChek® Ltd to
start a national roll-out in aged care facilities, makes a
compelling offer of institutional and government support
and validation. This reinforces to family caregivers that
PainChek® is reputable and well supported.
In the context of the Modelling intervention function,
the partnership with Alzheimer's Association or dementia
groups and video scenarios for demonstrating the advantages
of using mHealth apps like PainChek® were deemed both
appropriate and feasible. Healthcare professional endorse-
ments further affirmed the appropriateness and feasibility of
showcasing how PainChek® can aid in the improved under-
standing and management of pain in family members with
dementia. This aligns with literature suggesting the impact-
ful role of multimedia and professional endorsements in
health interventions (Elrod & Fortenberry Jr, 2020; Grieve
etal., 2019; Shu & Woo, 2021). However, traditional modes
of delivery such as mass media (television and radio), adver-
tising in medical centres, and posters in hospitals and clinics,
were identified as not feasible, despite their impact in health-
care promotion (Elrod & Fortenberry Jr, 2020), and both
family caregivers and healthcare professionals considering
them appropriate. This discrepancy prompts further inves-
tigation, as it suggests a potential shift in the perception of
the effectiveness of these modes of delivery. Therefore, it is
recommended that PainChek® reevaluates the feasibility of
these traditional modes, considering integrating these modes
within digital approaches that reflect current best practices
in health promotion.
Strengths andLimitations
This study provides a comprehensive example of stakeholder
engagement. The inclusion of diverse stakeholders’ insights
enriched the depth and breadth of our findings. Incorporat-
ing stakeholders from community settings, including fam-
ily caregivers and healthcare professionals with firsthand
experience in dementia care, is fundamental in developing
behaviour change interventions to ensure they are equitable,
efficient, effective, user-centred, and appropriate (Roberts &
Shehadeh, 2021; Smith etal., 2021). Additionally, the active
participation of PainChek® Ltd staff lends a significant
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Global Implementation Research and Applications
degree of credibility to the study by providing first-hand
knowledge during the feasibility evaluation stage, ensuring
that the identified delivery modes for the implementation
strategies were feasible from an operational standpoint. The
mixed methods approach employed enhanced this engage-
ment. Quantitative data, derived from stakeholders’ ratings,
provided a systematic assessment of the appropriateness
and feasibility of different modes of delivery specifically for
family caregivers. This allowed to objectively prioritise and
identify the most appropriate and feasible modes of delivery
from the perspective of those who would directly benefit. In
parallel, qualitative data delved deeper into understanding
the reasons and motivations behind stakeholder ratings of
these modes. By integrating quantitative and qualitative find-
ings, there were a number of recommendations generated
for the implementation of PainChek® that are supported by
stakeholder perspectives.
While the study offers valuable insights, it is essential
also to acknowledge its limitations. Participants varied in
their initial familiarity with PainChek®. Among family
caregivers and healthcare professionals, only 10 out of 17
participants had any knowledge of PainChek® at the study’s
inception. This may potentially affect the generalisability
of the findings as their responses may not fully represent
perspectives informed by prior awareness of the technology.
However, all participants were provided with standardised
background information about PainChek® in the Participant
Information Statement. There was also an educational video
included in the questionnaires at the start of the study. On
other hand, this may also represent a strength of the study,
reflecting real-world conditions. Lack of prior experience
provides valuable insights into the actual challenges and
learning curves that users might face when first encounter-
ing the PainChek® app. A second potential limitation arises
from the failure of some participants during appropriate-
ness and feasibility ratings to complete assessments for all
modes of delivery. Consequently, during the analysis, these
instances were treated as missing data and analysis focused
solely on the completed responses. Lastly, we were unsuc-
cessful in our attempts to recruit people with dementia to
seek their perspectives, highlighting an opportunity for
future research.
Conclusion
This study gathered insights from key stakeholders to iden-
tify 44 modes of delivery to operationalise implementation
strategies for PainChek® in community settings. While
digital approaches for education, training, enablement, per-
suasion, and modelling were prioritised, the importance of
non-digital modes of delivery was made clear by family car-
egivers. These findings provide valuable recommendations
for the implementation of PainChek® in community set-
tings. Future research will focus on testing these findings to
validate their effectiveness and applicability in real-world
settings.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s43477- 025- 00157-7.
Acknowledgements The authors would like to thank all the par-
ticipants involved in the study for their time and valuable input. The
authors also thank the people participating in the pilot face validation
process.
Funding Open Access funding enabled and organized by CAUL and
its Member Institutions. The author(s) received no financial support for
the research, authorship, and/or publication of this article.
Data Availability All data generated and analysed during this study
are included in this published article and its supplementary informa-
tion files.
Declarations
Conflict of interest Two authors have conflicts of interest to declare.
Professor Jeffery Hughes is one of the co-inventors of PainChek, the
Chief Scientific Officer of PainChek® Ltd (formerly known as EPAT
Technologies Ltd) and a shareholder in the company. Dr Andrew Staf-
ford is also a shareholder in the company. Positive results from the
study will further support the use of PainChek® and hence could po-
tentially benefit Professor Hughes and Dr Stafford through their share-
holdings. The other authors have no conflicts of interest to declare.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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