Continuum Model of Determinants Across Socioecologically Nested Health Care Partners: Patient,Clinician,and Administrator Perspectives on Complementary and Integrative Health Care for Nonpharmacological Pain Management

Abstract

Purpose:

This work explores perceptions across a state with both rural and urban populations in an ecologically informed mapping of health care partners to gain a panoramic view of potential barriers and facilitators to using complementary and integrative healthcare (CIH) for nonpharmacological pain management (NPM).

Materials and methods:

Semi-structured interviews (N = 48) were conducted with a regionally representative recruitment in six stakeholder groups: chronic pain patients (n = 15), CIH providers (n = 12), clinicians (primary/specialty care providers, nurse practitioners, n = 8), health care administrators (n = 6), and health insurance representatives (n = 7). A six-phase approach using collaborative and iterative thematic analysis was employed.

Results:

Findings suggest that themes of determinants exist on a continuum from barrier to facilitator, rather than in isolation. Continuums emerged in four categories of themes: Financial, Logistic, Relational, and Experiential. Major barriers were access, insurance, biases, and education, and major facilitators were partnership, education, and awareness. Ecological nesting of stakeholder major themes showed that perceptions by patients emphasized Financial and Experiential categories; providers emphasized Financial, Logistical, and Relational; administrators emphasized Relational and Experiential; and insurance representatives emphasized Relational.

Conclusion:

The continuum model enables use of person-centered scaling of barriers to facilitators in four categories to communicate their own personal context. Socioecological mapping reveals potential differences in perceptions of health care partners. Future work includes systematic review of the literature within the categories and development of a tool to identify person-centered barriers, needs, and facilitators to utilization of CIH for NPM.

Keywords

nonpharmacological pain management complementary and integrative health care barriers facilitators determinants

Introduction

With millions suffering from pain each year, pain management is an inarguably important area of focus across medical communities. Twenty-one percent of U.S. adults experience chronic pain,¹ and reports of painful health conditions are increasing.² While often categorized as a symptom, experts suggest that treatment and psychological implications should be considered.³ Pharmacological intervention hasn’t worked. Evidence is inconsistent for long-term effectiveness of opioids⁴ for chronic pain.⁵ Coined the opioid epidemic, the crisis disproportionately impacts marginalized populations⁶ and adults in rural areas are more likely to be prescribed opioids for pain.⁷ Because opioids can be harmful, they should be judiciously and scarcely prescribed.⁸ Nonpharmacological pain management (NPM) should be a first line of treatment.⁹

While there is evidence for NPM in comprehensive pain care, barriers to NPM implementation are widely reported. Research on barriers is limited to specific patient populations, such as older adults¹⁰ and low back pain patients,¹¹ or specific patient groups, such as veterans¹² and rural residents.¹³ Furthermore, the study of barriers often overlooks how the occur or change over time.¹⁴ Determinants of implementation of evidence-based practices should map barriers in a way that aids in prioritizing interventions,¹⁵ as experiences may differ across rural and metropolitan populations. Furthermore, inclusion of health care partners, such as providers,¹⁶ administration, and insurance representatives, is necessary.

Multiple perspectives of health care partners can be studied with a socioecological lens.¹⁷ To do so, perceptions can be mapped in a framework of nested circles using environmental context,¹⁸ with the patient at the center.¹⁹ Integrative medicine, also known as complementary and integrative healthcare (CIH), provides care for pain with a patient-centered approach.²⁰ Exploring perceptions of NPMs within a nested model of interaction or influence allows for patient-centered approach to multidisciplinary care, which aligns with a key initiative of pain management best practices.²¹

CIH serves as a promising nonpharmacological field. Use of CIH modalities to manage pain is on the rise²¹ with positive effects on various pain outcomes²² and mediators of pain.²³ Participation in CIH may enable decreasing opioid doses more than with conventional care.²⁴ There are efforts to integrate approaches from CIH and conventional health care.²⁵ Multidisciplinary efforts are also starting to be fruitful; for example, primary care providers in the Pacific Northwest, USA, are willing to comanage care,²⁶ yet there are issues with licensure and scope of practice. Indeed, CIH modalities are often considered outside the mainstream.²⁷ CIH practitioners find themselves both within and outside the concentric circles of patient-centered care, shifting the socioecological frame to include a circle within and outside the model (see Fig. 1).

FIG. 1.

Ecological orientation of health care partners.

Key elements of an ideal population for a qualitative study to explore NPM include (1) rural and urban areas with the same legislative structure (i.e., one state); (2) perspectives of health care partners and patients; and (3) longstanding history of CIH. One such state is Minnesota, which includes rural regions as well as the metropolitan city of Minneapolis. Furthermore, the state has had legislative committees about CIH since the 1990s. Hennepin Healthcare System invested in the Non-Opioid Pain Alleviation Information Network (NO PAIN)²⁸ across Minnesota to battle the opioid epidemic and better understand determinants of NPM for CIH. The NO PAIN project offers a unique opportunity to understand perspectives across stakeholder of an unspecified treatment population of both rural and urban individuals experiencing chronic pain.

The purpose of the current work is to develop model of understanding choices around NPMs, specifically CIH modalities, that can be used in the exploration of determinants across Minnesota. The current qualitative study is in conjunction with a larger study exploring mapping resources for NPM in Minnesota.²⁸ Specifically, our study aims were:

Aim 1: Explore determinants of CIH for NPM across Minnesota.

Aim 2: Identify major barriers and facilitators of NPM between and across socioecologically nested health care partners (depicted in Fig. 1).

Materials and Methods

To allow for rich data, a separate qualitative approach²⁹ was employed within a larger mixed-methods study.²⁸ The work was approved by the authors’ institutional review board.

Participants

To ensure different levels of interaction or influence, purposive sampling³⁰ was employed. The aim of recruitment was to reach a total number of 50 participants for sufficient³¹ conceptual depth³² of themes. As the primary aim of exploring perceptions across health care partners representation, rather than saturation, within stakeholder groups influenced recruitment efforts. Therefore, recruitment was pursued to ensure participants across Minnesota regions and roles. Roles were defined using a socioecological nesting of health care partners (see Fig. 1). To depict the transdisciplinary nature of CIH providers,³³ they are depicted as nested both within and outside the system. Recruitment was through word-of-mouth, electronic, and in-person outreach.

Interviews

Semi-structured interview guides³⁴ for each stakeholder group were developed with experienced external collaborators (T.J.R.), and were reviewed and piloted. Interviewers with experience in CIH were trained in qualitative interviewing (R.P., M.V.). Interviews were 30–60 min, using a Health Insurance Portability and Accountability Act (HIPAA) compliant virtual platform or in-person. Recordings were transcribed (Same Day Transcriptions).

Analysis

Using an analysis process that allows for trustworthy yet reflexive pattern recognition, a six-phase thematic analysis was employed.³⁵ Researchers (R.P., M.V., S.K., T.J.R.) (1) reviewed content, (2) generated initial codes (in Dedoose³⁶), (3) identified themes, (4) reviewed themes and codes, (5) defined major and minor themes, and (6) mapped results.³⁷ A collaborative approach was used to find agreement, which allows for reflexivity and depth.³⁸ Conceptual depth was considered to be met when themes across all participants offered range, subtlety, complexity, and resonance.³² Identified themes derived from subthemes (i.e., codes). Themes and associated statements were explored collaboratively with visual and narrative stories, for example, thematic mapping (i.e., visual representation³⁷), such as collaborative whiteboarding (see Supplementary Data for example).

To prioritize anonymity, mapped thematic statements also had any identifiers redacted and replaced with bracketed meanings. For example, clinic names and specific modalities were replaced with CIH. To keep reporting concise, the final map of themes is presented as a model with subthemes (i.e., codes) listed. Codes with definitions and examples can be found in the Supplementary Data. Additionally, the socioecological nesting of stakeholder major themes is presented.

Results

The 48 interviews included chronic pain patients (n = 15), primary and specialty care (PCP) providers (n = 8), CIH providers (n = 12), hospital administrators (n = 6), and health insurance representatives (n = 7). Forty participants completed an optional demographic survey. Data were stratified into stakeholder groups and regions (Table 1). Participant median age was 47.45 (standard deviation: 12.99), with slightly more women (60%) than men (40%), and employed (60%), resembling the population of Minnesota. To protect the anonymity of patients, there is no further demographic segmentation reporting. Similarly, to protect the anonymity, no suggestion of identity (including synonyms) is reported. Participant quotes were selected based on their representation of themes; however, no more than two sentiments per participant are used. Patients were represented across regions except southwest. CIH providers were distributed across regions. PCPs were predominantly from southeast and metropolitan, while hospital administrators and insurance representatives were exclusively from the metropolitan region.

Table 1.

Chronic Pain Health Care-Partner Groups Participation by Region

	Minnesota region
Stakeholder, N (%)	Northeast	Northwest	Central	Southwest	South Central	Southeast	Metro	Total
Chronic pain patient	4 (26.7)	1 (6.7)	2 (13.3)	0 (0.0)	1 (6.7)	1 (6.7)	6 (40.0)	15 (100.0)
Complementary and integrative health provider	2 (16.7)	1 (8.3)	1 (8.3)	1 (8.3)	2 (16.7)	2 (16.7)	3 (25.0)	12 (100.0)
Primary care provider	1 (12.5)	1 (12.5)	1 (12.5)	0 (0.0)	0 (0.0)	2 (25.0)	3 (37.5)	8 (100.0)
Hospital administrator	1 (16.7)	1 (16.7)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	4 (66.7)	6 (100.0)
Insurance representative	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	7 (100.0)	7 (100.0)
Total	8 (16.3)	4 (8.2)	4 (8.2)	1 (2.0)	3 (6.1)	5 (10.2)	24 (49.0)	48 (100.0)

Findings suggest an interconnected model of four themes, suggesting that determinants exist on a spectrum. Themes emerged as continuums from barrier to facilitator: (1) Financial, (2) Logistical, (3) Relational, and (4) Experiential. The continuum model emerged in phases 4 and 5, reviewing and defining, of analysis because codes were emerging as both barriers and facilitators. For example, “Br_access” had both positive (i.e., a facilitator) and negative (i.e., a barrier) sentiments, which were best depicted as a continuum. An illustration of the continuum concept, deriving from the thematic mapping analysis,²⁸ is depicted in Figure 2.

FIG. 2.

Data-derived model of NPM barriers and facilitators. NPM, nonpharmacologic pain management.

Financial continuum subthemes were Cost, Insurance, Time, and Aid. Logistical continuum subthemes were Access, Web Information, and Transportation. Relational continuum subthemes were Trust, Culture, Referral, and Partnership. Experiential continuum subthemes were Knowledge, Education, and Events. See Table 2 for examples of each subtheme.

Table 2.

Verbatim Examples of Subthemes

Theme	Subtheme	Example
Financial	Cost	“[CIH] all work. It just, with finances and things like that I couldn’t afford it really … finance is the biggest [barrier].” Chronic Pain Patient “We do have this fee for service model where we have to do like, you know, we have to do a certain number of encounters every day. You have a goal that you have to meet. If you don’t meet that goal, then our revenue starts to dive. So it’s really challenging. You’ve got to find a way to sort of like pay for this stuff, right. We’ve got to keep the doors open and the lights on.” Hospital Administrator “We receive a capitated amount per member per month to cover the services that are part of the plan. So if cost is just a a very practical barrier to what services require.” Insurance Representative
	Time	“I think hours of availability or wait times, how long, typical average if it’s a four-week scheduling out or if you can see I don’t know if that’s possible but that would be nice to be able to see if you can compare providers that maybe one has got two weeks before they can see somebody but another one might have three months or something like that.” Chronic Pain Patient “I really had to be cognizant of scheduling my appointments far in advance and making sure that I committed to them because it’s hard to get in.” Hospital Administrator
	Aid	“I was able to use [aid program] … where I could go to fitness places and utilize what they had there, based on what I learned.” Chronic Pain Patient “Many of our employer groups also have access to, like, an employee wellness program where they might get gym memberships or discounts on gym memberships that would offer yoga-type classes. And so very commonly, that’s covered under a different program.” Insurance Representative
	Insurance	“Definitely a lack of insurance coverage for some of these treatments. Then the cost, paying out of pocket.… I drive 35-40 minutes one way. I pay a co-pay because they won’t take my medical assistance because it’s through [Insurance].” Chronic Pain Patient “We tend to have some coverage for things, yeah. But those plans typically tend to be, they’re smaller employers. And so those plans tend to be, oftentimes, a little bit more, kind of, bare bones just because, again, those smaller employers really are looking for a low-cost product.” Insurance Representative
Logistical	Access	“I really feel for people that don’t have access. I’m aware of what a privilege it is for me to have access to all of these different types of treatment … I really feel for people that don’t have any [CIH].” Chronic Pain Patient “I was looking … they were not there, they were not always easy to find.” Chronic Pain Patient “It’s real limited as far as providers, like how many are up here.” Chronic Pain Patient “The issue in Northern Minnesota is access.” Admin
	Transportation	“It was really hard to move about, honestly. I wouldn’t lie about that. It was really hard to—and because of transportation … it was really hard.” Chronic Pain Patient “I don’t have a car.” Chronic Pain Patient “Right and I had to drive 65 miles each time to go see her because we lived a little bit farther away at that time, but she was the only one around.” Chronic Pain Patient “So, my multi-comorbid Medicaid patient who has pain, I’ve got 85 challenges related to transportation and getting to appointments and completing the burden of that type of care.” PCP
	Web information (website)	“It would really help if I could lay my eyes on more and more information concerning the acupuncture and places or people I can visit who would help me out. So this would be very helpful to me.” Chronic Pain Patient “When you get online, what you find is you find so many divergent opinions ranging from people who are, who are fairly benign, who are trying their best to to explain something that’s either hard, or that they only understand a little bit, all the way up to, frankly, malignant, where people are profiteering off people’s fears.” PCP
Relational	Trust	“My only concern was actually the fact that she wasn’t licensed as a therapist so that was my hesitancy.” Chronic Pain Patient “[Barrier is] Not knowing who is good and reputable.” PCP “The other barrier that I see is lack of confidence in the individual practitioners.” Insurance Representative
	Culture	“I just think of this in mind but it’s like the middle-aged male is, when I talk to them about changing activity modification or adaptations, it’s completely shot out the window… And it’s completely dismissed because.” Chronic Pain Patient “And so there’s not racial concordance a provider to patient.” Insurance Representative “There is no availability of non-White providers, or it is very sparse.” Hospital Administrator
	Referral	“Think I think people who have established primary care relationships largely do rely on their primary care providers, kind of, a trusted individual for a referral.” Insurance Representative “[Barrier is] Not knowing who is good and reputable. So, building a network.” PCP “I would say providers still could use help with referrals. I feel like I get referrals from certain providers, but there’s so many patients that come through this clinic. And some providers don’t make very many referrals, and other providers make a lot of referrals to me. So, I feel like there needs to be more of that comfort level of like remembering that I’m here and remembering to suggest it to patients versus just waiting for the patient to ask for it.” CIH
	Partnership	“Our collaboration with the [CIH] team is wonderful down there, working with the spine team, and our patients love him.” PCP “I think what I’ll say is I think our leadership, which is what I really have oversight of, and then we cascade it down, very open. In fact, [patients would] be hungry for something like this because it’s not—maybe it is, but it requires a lot of research and individual sort of silos to get there.” Hospital Administration “We’re going to work on what we can from every single different perspective. So we’re going to get everybody involved and I think that that’s what missing.” PCP
Experiential	Knowledge	“You know, simply not knowing is probably a really big thing.” Chronic Pain Patient “I think having a publication that talks about … then what are they, what is it and how is it different from this other type of modality. It may be similar but how is it different.” Chronic Pain Patient “And now we’re trying to arc it back where we see so much of the destructive social and medical. So I think being able to articulate that in that there’s alternatives that really can work and improve people’s quality of life. That’s a huge. That’s a huge.” Hospital Administrator
	Events	“Then it is kind of a trial and error because not everything is going to work the same for everybody.” Chronic Pain Patient “The way that we, as a society, think about chronic pain and the way that patients receive the information we give them and as you alluded to a15 minute visit is not the place to do this because your patient can’t feel heard. They can’t understand your rationale … we’ve got to fix every single aspect of it, not telling them they’re crazy.” PCP
	Education	“Education is really important. I think people understanding the problem and the injury that they’re having so to me, education is really an important.” Chronic Pain Patient “I think those are the resources. So education. And how we do it, and then being able to share the evidence-based or the trend of it of how we can improve community health.” Hospital Administrator

Financial continuum

Cost barriers reported by chronic pain patients included statements around finances like “I haven’t been able to afford [CIH] for years” and “it’s whether I’m going to pay my rent and eat.” Hospital administrators added nuance to the cost barrier, for example, “there’s no current roadmap at all for [CIH] services to be supported financially. You know, they cost money that I have to pay staff who have been, you know, who have that knowledge.” Cost and Insurance sometimes overlapped around barriers; for example, a chronic pain patient said simply, “one of the biggest barriers is the high deductible.” PCPs also expressed concern that patients were not covered, for example, “We want a patient to have [CIH] whenever they can. But I think because many of them are non-covered, it really is a, it really is a financial situation.”

Patients expressed concern around changes in insurance status, like “after I didn’t have insurance anymore, I had to pay out of pocket.” Insurance was referenced as important, for example, one CIH provider said, “First question often times: ‘do you accept insurance?’ when you’re out chatting with people in the community.”

Time barriers reported by pain patients included wait time, like “it took six weeks at least before I could even get an eval. So that was a big barrier.” Providers speculated that schedules might influence CIH use, such as “I would say moms with young kids or parents with younger kids, I don’t see as many of those parents, unless their work is really flexible or seasonal” and saw their own schedule barriers, for example, “my schedule can be a limitation. I see about thirty patients a week, but my clinic hours are about twenty-two clinic hours a week.”

Aid, such as “a sliding scale, I know that in the beginning it can be really helpful” from a pain patient and “[CIH] has a van so we can support some patients with travel” from a hospital administrative, included “programs to assist patients.”

Logistical continuum

Access described whether desired CIH modalities were within reach, for example, one provider exclaimed, “My patients actually are wildly enthusiastic about [CIH]. I don’t have to twist their arms to get them to try this. My biggest challenge is getting them connected to someone.” Other Access statements included location restrictions or lack of providers or specialties, such as “there was nobody in my area in our little towns that provided that kind of service or that care.”

Web Information emerged with finding CIH as a facilitator but sifting through information as a barrier. As one patient explained, “I’ve been searching the internet a whole lot.” A PCP added the desire for a go-to website: “So I would love to have a trusted site that I can send people to for information like that. The internet, when I’m thinking about how to, how, how to describe it, I guess, it’s kind of, like, herding cats.”

Transportation included location and available transportation. One hospital administrator said that even if they have a car, parking is a barrier: “logistics right now … parking is almost next to impossible. And when you’re a person living with immunocompromised issues, and now you have to walk three or four blocks to get to our building and not a half a block, your desire to come here might be a little bit diminished.” A patient talked about “healthcare workers coming to the house” as a facilitator, yet one CIH provider explained how difficult that might be to maintain, saying, “that would be treacherous in the winter. There is somebody who’s a half hour away, but it’s kind of on backcountry roads.”

Relational continuum

Trust barriers related to CIH standards. An insurance representative said, “standardization and training, who is the licensing board? how uniform is that across the country? what is the malpractice? There is work to be done in [CIH] professions.”

Culture barriers included stigma of CIH, for instance, one pain patient said, “The whole alternative and body work field was really mixed up with a lot of the esoteric spiritual kind of stuff,” as well as the potential for differences across race and gender. One insurance representative said, “Black females make very different decisions than White males who make very different decisions than White Hispanics that make very different decisions than female Asians.”

Referral described both “word of mouth” by “a friend or someone close.” For example, one pain patient said she “asked a family member if they know of a place she can get help, and they recommended [CIH clinic],” and primary care referral. One patient described it as a barrier, saying, “I get the sense that [my PCP] are not really interested [in integrative services],” while another underlined how important it was, saying, “There is nothing better than a referral from like my [PCP] … You know? It is if he thinks this is what is best.”

Finally, participants expressed Partnerships as a crucial, saying, “There is bottomless demand. We can’t possibly meet it ourselves as a healthcare system in that sense, or at least we are struggling to make that a financially viable long-term situation. We need the community to be integrated, but we don’t have a stable list of how to reach out.” A patient emphasized this, explaining, “[a barrier is] coordination of care, I guess, and everybody having access to what each other is doing, just having more of that instead of going to a [CIH] over here and she doesn’t know what the hell my physical therapist is doing.”

Experiential continuum

Knowledge barriers focused on research, or the evidence-base, for instance, one hospital administrative said, “we are a little behind the curve on studies.” An insurance representative explained, “But as we look at our criteria in terms of what we feel is medically necessary, it’s usually an evaluation of the literature. The difficulty in the alternative medicine space is that the literature can—the quality of studies is generally lower as we rank quality of studies … and it’s hard to make a determination as to what we believe the outcome will be based on the literature that is available.”

Events included experiences, for example, a chronic pain patient described, “Prior to finding [CIH] I had only ever experienced regular [PCP]. When I find something, I go try it. I go see what it is, I read up on it, I learn what I can about what is-it that they are doing, does it make sense then I go try it. If it seems like it is actually doing something, then I will stay with it.” Others described the wide variety of experiences, saying, things such as, “You could go to ten of them and get ten different experiences. I think that is kind of the biggest barrier. It is having the continuity of care.”

Education sentiment barriers were about gaps in information being shared that eluded to a need for further education. Simple statements such as “I’m no expert” and “handout for those that aren’t quite as knowledgeable” from two separate pain patients. As well as examples of educating, such as the primary care provider who said “I talk with patients about diet, anti-inflammatory diets, and just talk through that. Every time patients come in we talk about, I ask them what kind of exercise program they do. I really encourage walking for the back pain. Just had a conversation with a patient just this morning about that. Talking about how important it is.”

Socioecologically nested themes

The socioecological model of major themes revealed potential differences in focus across health care partners, illustrated in Figure 3. Patients’ major themes were logistical barriers but experiential facilitators. Providers’ major themes were financial and logistical barriers but relational facilitators. Hospital administrators’ major themes were financial and relational barriers but experiential and logistical facilitators. Insurance representatives’ major themes were relational for barriers and facilitators. The socioecological mapping of health care partners may hint that the patients focused on Financial and Logistical determinants while outer nested groups focused on Experiential and Relational determinants.

FIG. 3.

Barriers and facilitators by stakeholder group.

Limitations

The current study used qualitative methodology, a six-phase thematic analysis, and socioecological stratification of health care partners. The rigor of qualitative exploration allowed for sufficient depth and trustworthiness; however, themes gleaned were not tested. Furthermore, perceptions of a continuums of barrier to facilitator may different than may look very different in action. Future research should test continuum models to confirm perception and see how it acts in implementation, using the Reporting Process mapping and Analysis for Implementation Research¹⁵.

Continuums might offer valuable insights for use of CIH modalities for NPM. The current work may provide some likeness with states that have both rural and metropolitan populations; however, the current work intentionally focused on participants from one state across both health care partners and patients. Additionally, despite repeated recruitment efforts, there was no participation from the southwest region of Minnesota. Therefore, findings should not be generalized, but rather used to better explore barriers and facilitators. Specifically, continuum, or determinant, differences in rural and metropolitan areas were not explored in the current study. Rather, with a model derived from a state with both, it can now be used to better understand how differences exist.

The current work’s focus on the state of Minnesota might influence findings because state the overarching ecosystem is influenced by legislature and policy. Future work might expand to include policy and decision-makers as health care partners. The purpose of the current study did not include the study of policy; however, it is important to note that the political landscape can and does influence perceptions, determinants, and opioid use. That said, future work should include methodology that incorporates local and regional policies that might influence determinants.

The socioecologically informed model might offer valuable insight into perceptions across health care partners. However, this approach was not a comprehensive exploration of individual experiences, either as patients or health care providers. Future research using the continuums with in-depth inquiries into the experiences of these groups would deepen understanding and inform tailored interventions.

To pursue representation, recruitment strategies were carefully considered. While health care providers declined remuneration, the $20 gift card offered to patient participants may not have been a sufficient incentive. Given the intensive nature of qualitative interviews, future studies should aim to provide meaningful incentives to ensure representation.

Finally, it is important to note that interviews were conducted during COVID-19, a period marked by widespread restrictions and health care facility closures. Although the research process itself was not directly disrupted, the context may have indirectly influenced participants’ perceptions. For example, the Access subtheme may have been top-of-mind for participants as health care access in general was limited during that time.

Discussion

This work offers potential for both a method of understanding and a method of inquiry toward determinants of CIH for NPM. Findings suggest that themes exist on a continuum from barrier to facilitator: Financial, Logistic, Relational, and Experiential. There is a wealth of research supporting these findings; however, this is the first study to present four distinct categories on a continuum in a geographically distinct area and across diverse health care partners. The continuum of barriers to facilitators may be used in implementation mapping of determinants.¹⁵ Furthermore, the socioecological analysis provided insight into how interaction with CIH and/or pain may influence perception of major barriers to facilitators. Findings revealed that across health care partners, from patients and providers to administration and insurance representatives, there is a desire for a shift in how CIH is supported and/or represented. The continuum model provides a way to take action toward moving the proverbial needle.

The focus on Minnesota was intentional because the infrastructure of the state itself influences the experience of barriers or facilitators to CIH use. Specifically, the rural and urban populations and longstanding history of CIH offered an opportunity for insight into how barriers might be positioned differently. The current findings offer themes and subthemes that are noted by individuals across the state but experienced in different ways. For example, transportation barriers were reflected in parking for metropolitan pain patients but in travel limitations for rural pain patients. This offers a model of determinants that can be tested in other regions and states.

Shifting into using continuums of determinants, from barriers to facilitators, must start at the individual level. In doing so, a dynamic use of person-centered care to improve implementation of CIH for NPM emerges. The shift to a whole-person³⁹ approach in medicine acknowledges contextual, relational, and individual interplays that may hinder or support use of CIH. Using the continuum, an individual can map their barriers and facilitators to communicate their own personal context. This person-centered sliding scale could facilitate personalized intervention (Fig. 2). For example, a pain patient with relational and experiential barriers, but more financial and logistical facilitators, suggests that building trust may be far more impactful than offering child care. Indeed, implementation science offers a strong argument for a comprehensive model of inner and outer contextual factors that influence change, starting with exploration, then moving through adoption, implementation, and sustainment.¹⁵ A person-centered sliding scale of determinants could be used in the exploration phase, and perhaps throughout all phases, to better inform adoption, implementation, and sustainment.

Each of the four themes has a wealth of research. The Financial theme of barriers to facilitators includes cost and time continuums. Research suggests that cost is one of the highest barriers to utilization.⁴⁰ Our findings are in line with such work that ability to pay⁴¹ and insurance⁴² are barriers. Our participants also suggested insurance can also be a facilitator. Time was also a reported financial constraint. The Logistical theme includes access and transportation continuums. Transportation is often reported as one of the highest barriers to utilization.⁴³ Geography is a complex indicator of various health disparities.^42,44 In the current work, participants persistently reported that the closest facility was too far away. Indeed, transportation is a barrier for nonpharmacological care and health care utilization. A potential solution to individuals with high barriers in this continuum is co-opting care in integrated ways with CIH held alongside clinical care. For example, veterans are more likely to use CIH modalities at one of the “flagship” sites within the VA (i.e. Veterans Affairs),⁴⁵ suggesting that, in part, the experience at the site itself could have been an influencing factor. The Relational theme includes trust and culture continuums. Cultural and social factors either hinder or promote engagement with NPM and CIH services. The influence of cultural and relational factors on health behaviors has been well documented.⁴⁶ Trust may be enhanced through referrals and partnerships. There is potential for improved trust and access when care delivery systems incorporate referrals, shared locations, and cohesive care models. The current work highlights the relationship between epistemological frameworks and access to information. Notably, in the ecological analysis, the critical role of communication and partnership between CIH providers and primary care providers emerged. Indeed, the Consolidated Framework for Implementation Research suggests that communication, knowledge, and self-efficacy of primary care physicians are crucial barriers to CIH referrals.^47,48 Developing stakeholder interrelationships is a key component of the Expert Recommendations for Implementing Change Taxonomy²⁹ used to guide implementation strategies in CIH NPM.⁴⁹ Strengthening partnerships may address barriers identified in recent qualitative studies. For example, critical care clinicians have reported challenges related to professional credibility, time constraints, costs, and a perceived lack of evidence for interventions in the CIH field.⁵⁰ The Experiential theme includes knowledge and experience continuums. Knowledge and beliefs have an influence on nonpharmacological decision-making.⁵¹ Additionally, information about individual experiences has been shown to impact health care decisions.⁵² In the context of CIH, the current work confirms and extends these insights by acknowledging experiences as foundational component, further underscoring the critical need for all clinicians to receive adequate resources to deliver holistic, evidence-based, and compassionate care to pain patients.⁵³

Socioecological mapping of health care partners provides a lens to explore perceptions within the whole system of patient experience. At the forefront of understanding determinants of CIH modalities for pain management, a multi-stakeholder and multi-level implementation strategy is currently being tested.⁴⁹ Major themes across ecologically organized health care partners suggest a systems approach to move the needle(s) from barriers and health care needs to facilitating health care utilization. Our findings hint at differences, such as administrators seeing relational barriers while providers and insurance representatives see relational facilitators (see Fig. 3). Booker⁵⁴ proposes a multi-sectoral systems approach, incorporating spheres of influence, such as education, research, and policy, to address health disparities in pain management. The current work bridges traditionally conceptualized as the intersection of individual characteristics, environmental factors, and health care systems⁵⁵ to systems approaches.

Future work

The continuum model, with four distinct categories, offers a way to organize and understand determinants of CIH for NPM. While the current work offers preliminary insight into current literature, a systematic review using this model as a framework is an important next step in verifying the model.

Additionally, this continuum model can be more widely quantified in subjective psychometrics. Using the current work, an instrument can be designed and tested to elicit a person-centered sliding scale of financial, logistical, relational, and experiential barriers to facilitators. Once developed a psychometric tool could be used across and between populations to inform population-directed intervention.

Each category in this continuum model offers specific area of focus for development and assessment. Using a person-centered sliding scale, individual responses can provide individual-directed intervention. On the financial spectrum, aid, insurance, and/or assistance in monetary costs like child care may be identified. On the logistical spectrum, user interfaces and offering transportation may be identified. On the relational spectrum, offering groups and/or family involvement may shift perspectives and invite more participation. Finally, on the experiential spectrum, acknowledging past interactions and meeting patients where they are may be identified. In short, the continuum model can be used to identify individual needs, which supports a whole-person approach to care.

Conclusion

From rich qualitative data, themes emerged not as distinct categories of barriers or facilitators but as continuums of barriers to facilitators. Findings present four categories of financial, logistical, relational, and experiential barriers to facilitators that are in line with previous research. The current work provides an opportunity to support a person-centered sliding scale for personalized interventions. Ecologically nested major themes across health care partners provide initial insight into differences in perceptions based on interaction with CIH and NPM. Future work can refine and test the categories and implementation of the person-centered sliding scale. While much more needs to be done, the current work has started a roadmap for the development, assessment, and iterative improvement of programs aimed at decreasing the impact of the current opioid epidemic.

Authors’ Contributions

Author contributions are noted in the article and below with initials. Contributions were as follows: R.P.: Conceptualization, data collection, data analysis, project administration, reviewing, and editing. A.P.: Conceptualization, reviewing, and editing. M.V.: Project administration and data analysis. S.K.: Project administration and data collection. J.A.D.: Conceptualization, review, and editing. T.J.R.: Conceptualization, methodology, data analysis, and writing.

Footnotes

Author Disclosure Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

This scholarly work was supported by the Minnesota Department of Health awarded to Hennepin Healthcare System (178835).

Data Availability Statement

Due to the in-depth and personal nature of the data, raw data have the potential for gaps in confidentiality. To protect the anonymity of the participants, data are not made publicly available.

Supplemental Material

References

Rikard

, Strahan

, Schmit

, Guy

. Prevalence of pharmacologic and nonpharmacologic pain management therapies among adults with chronic pain—United States, 2020. Ann Intern Med, 2023; 176(11):1571–1575.

Nahin

, Sayer

, Stussman

, Feinberg

. Eighteen-year trends in the prevalence of, and health care use for, noncancer pain in the United States: Data from the medical expenditure panel survey. J Pain, 2019; 20(7):796–809; doi: 10.1016/j.jpain.2019.01.003

Cohen

, Vase

, Hooten

. Chronic pain: An update on burden, best practices, and new advances. Lancet, 2021; 397(10289):2082–2097.

Dowell

, Ragan

, Jones

, et al. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep, 2022; 71(3):1–95; doi: 10.15585/mmwr.rr6501e1

Volkow

, Benveniste

, McLellan

. Use and misuse of opioids in chronic pain. Annu Rev Med, 2018; 69:451–465; doi: 10.1146/annurev-med-011817-044739

Gondré-Lewis

, Abijo

, Gondré-Lewis

. The opioid epidemic: A crisis disproportionately impacting Black Americans and urban communities. J Racial Ethn Health Disparities, 2023; 10(4):2039–2053.

Prunuske

, St Hill

, Hager

, et al. Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: A population-based study using 2010 NAMCS data. BMC Health Serv Res, 2014; 14:563; doi: 10.1186/s12913-014-0563-8

Dowell

, Ragan

, Jones

, et al. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep, 2022; 71(3):1–95; doi: 10.15585/mmwr.rr7103a1

Tick

, Nielsen

, Pelletier

, et al.; Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-based nonpharmacologic strategies for comprehensive pain care: The consortium pain task force white paper. Explore (NY), 2018; 14(3):177–211; doi: 10.1016/j.explore.2018.02.001

10.

Garrett

, Nicosia

, Thompson

, et al. Barriers and facilitators to older adults’ use of nonpharmacologic approaches for chronic pain: A person-focused model. Pain, 2021; 162(11):2769–2779.

11.

Roseen

, Joyce

, Winbush

, et al. Primary care barriers and facilitators to nonpharmacologic treatments for low back pain: A qualitative pilot study. Pm R, 2024:10.1002/pmrj.13183.

12.

Cotner

, O’Connor

, Nakase-Richardson

, et al. Facilitators and barriers to non-pharmacologic chronic pain treatment for service members and veterans with traumatic brain injury. Arch Phys Med Rehabil, 2021; 102(10):e68–e69.

13.

Baker

, Liu

, Bully

, et al. Overcoming barriers: A comprehensive review of chronic pain management and accessibility challenges in rural America. Healthcare (Basel), 2024; 12(17):1765.

14.

Aarons

, Hurlburt

, Horwitz

. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health, 2011; 38(1):4–23; doi: 10.1007/s10488-010-0327-7

15.

Roseen

, Natrakul

, Kim

, Broder-Fingert

. Process mapping with failure mode and effects analysis to identify determinants of implementation in healthcare settings: A guide. Implement Sci Commun, 2024; 5(1):110; doi: 10.1186/s43058-024-00642-4

16.

Sabeti

, Mohammadpour

, Pouraboli

, et al. Health care providers’ experiences of the non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care units. J Pediatr Nurs, 2021; 60:e110–e116.

17.

Nolan

, Owen

. Medical student experiences of equality, diversity, and inclusion: Content analysis of student feedback using Bronfenbrenner’s ecological systems theory. BMC Med Educ, 2024; 24(1):5.

18.

Warren

, Young

, Carlisle

, et al. A systems approach to the perceptions of the integration of public health into pharmacy practice: A qualitative study. Explor Res Clin Soc Pharm, 2023; 10:100279.

19.

Bronfenbrenner

. Ecological models of human development. Int Encycl Educ, 1994; 3(2):37–43.

20.

Nahin

, Rhee

, Stussman

. Use of complementary health approaches overall and for pain management by US adults. JAMA, 2024; 331(7):613–615.

21.

Singh

. Final recommendations from the pain management best practices inter-agency task force. ASA Monit, 2019; 83(8):22–23.

22.

Dyer

, Surdam

, Dusek

. A systematic review of practice-based research of complementary and integrative health therapies as provided for pain management in clinical settings: Recommendations for the future and a call to action. Pain Med, 2022; 23(1):189–210.

23.

Dusek

, Gao

, Kim

, et al.; PRIMIER Writing Group*. Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER) of the BraveNet practice-based research network: Results of the chronic pain cohort. Integr Med Res, 2025; 14(2):101141; doi: 10.1016/j.imr.2025.101141

24.

Zeliadt

, Douglas

, Gelman

, et al. Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain. BMC Health Serv Res, 2022; 22(1):1053.

25.

National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: What’s in a name? 2018. Available from: https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name [Last accessed: May 24, 2021].

26.

Schwartz

, Cole

, Keppel

, et al. Complementary and integrative health knowledge and practice in primary care settings: A survey of primary care providers in the Northwestern United States. Glob Adv Health Med, 2021; 10:21649561211023377; doi: 10.1177/21649561211023377

27.

Miller

. Complementary and integrative medicine. Complementary and Integrative medicine and nutrition in otolaryngology, an issue of otolaryngologic clinics of North America, E-book: Complementary and integrative medicine and nutrition in otolaryngology, an issue of otolaryngologic clinics of North America, E-Book. Otolaryngol Clin North Am, 2022; 55(5):891.

28.

Prasad

, Printon

, Vang

, et al. Mapping evidence-based non-opioid and non-pharmacological pain management modalities across Minnesota: The non-opioid pain alleviation information network project. J Integr Complement Med, 2024; 30(7):645–653; doi: 10.1089/jicm.2023.0031

29.

Creswell

, Poth

. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage Publications; 2016.

30.

Patton

. Qualitative Evaluation and Research Methods. Sage Publications; 1990.

31.

Dey

. Grounding Grounded Theory: Guidelines for Qualitative Inquiry. Emerald; 1999.

32.

Nelson

. Using conceptual depth criteria: Addressing the challenge of reaching saturation in qualitative research. Qualitative Research, 2017; 17(5):554–570.

33.

Menard

, Weeks

, Anderson

, et al. Consensus recommendations to NCCIH from research faculty in a transdisciplinary academic consortium for complementary and integrative health and medicine. J Altern Complement Med, 2015; 21(7):386–394.

34.

Charmaz

. Grounded theory: Objectivist and constructivist methods. In: ( Denzin

, Lincoln

., eds). Strategies of Qualitative Research. Sage Publications; 2003:249–291.

35.

Braun

, Clarke

. Conceptual and design thinking for thematic analysis. Qual Psychol, 2022; 9(1):3–26; doi: 10.1037/qup0000196

36.

Salmona

, Lieber

, Kaczynski

. Qualitative and Mixed Methods Data Analysis Using Dedoose: A Practical Approach for Research across the Social Sciences. Sage Publications; 2019.

37.

Braun

, Clarke

. Using thematic analysis in psychology. Qual Res Psychol, 2006; 3(2):77–101; doi: 10.1191/1478088706qp063oa

38.

Nowell

, Norris

, White

, Moules

. Thematic analysis: Striving to meet the trustworthiness criteria. Int J Qual Methods, 2017; 16(1):1609406917733847.

39.

Hansen

, McKernan

, Carter

, et al. A replicable and sustainable whole-person care model for chronic pain. J Altern Complement Med, 2019; 25(S1):S86–S94; doi: 10.1089/acm.2018.0420

40.

Yoder

. Are people willing and able to pay for health services? Soc Sci Med, 1989; 29(1):35–42; doi: 10.1016/0277-9536(89)90125-1

41.

Chatterjee

. Evaluating the barriers to the utilization of Complementary and Alternative medicine (CAM) in the United States: An exploratory study. Adv Integr Med, 2023; 10(4):167–171.

42.

Becker

, Dorflinger

, Edmond

, et al. Barriers and facilitators to use of non-pharmacological treatments in chronic pain. BMC Fam Pract, 2017; 18(1):41; doi: 10.1186/s12875-017-0608-2

43.

Swift

. Geography and disparities in health care. In: Guidance for the National Healthcare Disparities Report. National Academies Press (US); 2002.

44.

Arcury

, Preisser

, Gesler

, Powers

. Access to transportation and health care utilization in a rural region. J Rural Health, 2005; 21(1):31–38.

45.

Resnick

, Zeliadt

, Ganz

, et al. Changes in use of complementary and integrative health therapies at the veterans affairs: Findings from a whole health system pilot program. J Integr Complement Med, 2023; 29(12):805–812.

46.

Dressler

, Oths

. Cultural determinants of health behavior. In: Handbook of Health Behavior Research I: Personal and Social Determinants. 1997; 1:359–378.

47.

Damschroder

, Reardon

, Widerquist

MAO

, Lowery

. The updated consolidated framework for implementation research based on user feedback. Implement Sci, 2022; 17(1):75.

48.

Kirchner

JEWT

, Powell

, Smith

, Proctor

. Implementation strategies. In: ( Brownson

RPE

, Colditz

., eds). Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford University Press: New York; 2018. pp. 245–66.

49.

Roseen

, Bussières

, Reichman

, et al. A multi-level implementation strategy to increase adoption of chiropractic care for low back pain in primary care clinics: A randomized stepped-wedge pilot study protocol. Chiropr Man Therap, 2025; 33(1):9; doi: 10.1186/s12998-024-00565-w

50.

Papathanassoglou

, Park

, Punjani

, et al. Implementing integrative therapies in adult critical care: Barriers and strategies. Aust Crit Care, 2024; 37(4):563–570; doi: 10.1016/j.aucc.2023.11.002

51.

Ware

, Wilson

. Influences on non-pharmacological pain management decision-making. Pain Manag Nurs, 2022; 23(2):239.

52.

Entwistle

, France

, Wyke

, et al. How information about other people’s personal experiences can help with healthcare decision-making: A qualitative study. Patient Educ Couns, 2011; 85(3):e291–e298.

53.

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press; 2011.

54.

Booker

, Merriwether

, Powell-Roach

, Jackson

. From stepping stones to scaling mountains: Overcoming racialized disparities in pain management. Pain Manag, 2024; 14(1):5–12; doi: 10.2217/pmt-2023-0098

55.

Penchansky

, Thomas

. The concept of access: Definition and relationship to consumer satisfaction. Med Care, 1981; 19(2):127–140.

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