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
Restricted accessResearch articleFirst published online January, 2026
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
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.
RikardSM, StrahanAE, SchmitKM, GuyGP. Prevalence of pharmacologic and nonpharmacologic pain management therapies among adults with chronic pain—United States, 2020. Ann Intern Med, 2023; 176(11):1571–1575.
2.
NahinRL, SayerB, StussmanBJ, FeinbergTM. 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
3.
CohenSP, VaseL, HootenWM. Chronic pain: An update on burden, best practices, and new advances. Lancet, 2021; 397(10289):2082–2097.
4.
DowellD, RaganKR, JonesCM, 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
5.
VolkowN, BenvenisteH, McLellanAT. Use and misuse of opioids in chronic pain. Annu Rev Med, 2018; 69:451–465; doi: 10.1146/annurev-med-011817-044739
6.
Gondré-LewisMC, AbijoT, Gondré-LewisTA. The opioid epidemic: A crisis disproportionately impacting Black Americans and urban communities. J Racial Ethn Health Disparities, 2023; 10(4):2039–2053.
7.
PrunuskeJP, St HillCA, HagerKD, 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
8.
DowellD, RaganKR, JonesCM, 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
9.
TickH, NielsenA, PelletierK, 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.
GarrettSB, NicosiaF, ThompsonN, 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.
RoseenEJ, JoyceC, WinbushS, 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.
CotnerB, O’ConnorD, Nakase-RichardsonR, 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.
BakerMB, LiuEC, BullyMA, et al.Overcoming barriers: A comprehensive review of chronic pain management and accessibility challenges in rural America. Healthcare (Basel), 2024; 12(17):1765.
14.
AaronsGA, HurlburtM, HorwitzSM. 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.
RoseenEJ, NatrakulA, KimB, Broder-FingertS. 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.
SabetiF, MohammadpourM, PouraboliB, 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.
NolanHA, OwenK. 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.
WarrenR, YoungL, CarlisleK, 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.
BronfenbrennerU. Ecological models of human development. Int Encycl Educ, 1994; 3(2):37–43.
20.
NahinRL, RheeA, StussmanB. Use of complementary health approaches overall and for pain management by US adults. JAMA, 2024; 331(7):613–615.
21.
SinghVM. Final recommendations from the pain management best practices inter-agency task force. ASA Monit, 2019; 83(8):22–23.
22.
DyerNL, SurdamJ, DusekJA. 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.
DusekJA, GaoQ, KimRS, 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.
ZeliadtSB, DouglasJH, GelmanH, 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.
SchwartzMR, ColeAM, KeppelGA, 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.
MillerMC. 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.
PrasadA, PrintonR, VangM, 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.
CreswellJW, PothCN. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage Publications; 2016.
30.
PattonM. Qualitative Evaluation and Research Methods. Sage Publications; 1990.
31.
DeyI. Grounding Grounded Theory: Guidelines for Qualitative Inquiry. Emerald; 1999.
32.
NelsonJ. Using conceptual depth criteria: Addressing the challenge of reaching saturation in qualitative research. Qualitative Research, 2017; 17(5):554–570.
33.
MenardMB, WeeksJ, AndersonB, 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.
CharmazK. Grounded theory: Objectivist and constructivist methods. In: (DenzinNK, LincolnYS., eds). Strategies of Qualitative Research. Sage Publications; 2003:249–291.
35.
BraunV, ClarkeV. Conceptual and design thinking for thematic analysis. Qual Psychol, 2022; 9(1):3–26; doi: 10.1037/qup0000196
36.
SalmonaM, LieberE, KaczynskiD. Qualitative and Mixed Methods Data Analysis Using Dedoose: A Practical Approach for Research across the Social Sciences. Sage Publications; 2019.
37.
BraunV, ClarkeV. Using thematic analysis in psychology. Qual Res Psychol, 2006; 3(2):77–101; doi: 10.1191/1478088706qp063oa
38.
NowellLS, NorrisJM, WhiteDE, MoulesNJ. Thematic analysis: Striving to meet the trustworthiness criteria. Int J Qual Methods, 2017; 16(1):1609406917733847.
39.
HansenKA, McKernanLC, CarterSD, 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.
YoderRA. 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.
ChatterjeeA. 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.
BeckerWC, DorflingerL, EdmondSN, 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.
SwiftEK. Geography and disparities in health care. In: Guidance for the National Healthcare Disparities Report. National Academies Press (US); 2002.
44.
ArcuryTA, PreisserJS, GeslerWM, PowersJM. Access to transportation and health care utilization in a rural region. J Rural Health, 2005; 21(1):31–38.
45.
ResnickA, ZeliadtSB, GanzDA, 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.
DresslerWW, OthsKS. Cultural determinants of health behavior. In: Handbook of Health Behavior Research I: Personal and Social Determinants. 1997; 1:359–378.
47.
DamschroderLJ, ReardonCM, WiderquistMAO, LoweryJ. The updated consolidated framework for implementation research based on user feedback. Implement Sci, 2022; 17(1):75.
48.
KirchnerJEWT, PowellBJ, SmithJL, ProctorEK. Implementation strategies. In: (BrownsonRPE, ColditzG., eds). Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford University Press: New York; 2018. pp. 245–66.
49.
RoseenEJ, BussièresA, ReichmanR, 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.
PapathanassoglouE, ParkT, PunjaniN, 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
EntwistleVA, FranceEF, WykeS, 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.
BookerSQ, MerriwetherEN, Powell-RoachK, JacksonS. 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.
PenchanskyR, ThomasJW. The concept of access: Definition and relationship to consumer satisfaction. Med Care, 1981; 19(2):127–140.
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