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Table 2 Factors related to uptake of non-pharmacological pain treatment modalities (NPMs)

From: Barriers and facilitators to use of non-pharmacological treatments in chronic pain

Category Barriers Facilitators
Access Transportation  •Distance to travel3F,3N  •Cost of travel  •Lack of transportation Scheduling  •Delays in NPM appointments  •Low availability of appointments  •Time of day services offered is not convenient Out-of-pocket cost  •High cost (of treatment, travel or equipment) or not covered by insurance1F  •Lack of insurance coverage Resources  •Some NPMs not available at VA1M  •Not having equipment to do at home  •Most programs are male-focused  •Not having ability to continue treatment because of limited number of sessions  •Lack of delivery of NPM in the format patient prefers (e.g., web based) Transportation  •NPM sessions closer to home2F,2N  •Covered mileage/pay for mileage  •Transportation assistance/voucher  •Fewer visits to the VA Scheduling  •Shorten wait time for NPMs  •Patients access treatments directly/self-referral  •Scheduling flexibility for NPM sessions, including evening/weekend appointments  •Consistent treatment schedule  •Quick/easy access to NPMs3P  •Patient leaves primary care visit with appointment for NPM  •Easy-to-use consult template in the electronic record Out-of-pocket cost  •No cost/low cost/covered by insurance Resources  •Wider variety of NPMs readily available1F  •Use non-VA treaters/contract services out  •Female only treatment sessions  •Ability to practice NPM while at appointment  •Ability to have appointments in more private settings to reduce stigma  •Treatments more individualized  •Sufficient staff in the specialty services to deliver NPMs  •Techniques patients can do own their own; self-management
Awareness or knowledge  •Both patients and providers not being sure what the NPM entails or rationale for it2N  •Both patients’ and providers’ lack of knowledge of which NPMs are available  •NPMs not advertised on television  •Patients’ poor understanding of pain  •Better explanation of what to expect and rationale for treatments3F, 1M  •Better advertising that these services are offered3N  •Increase patient knowledge about risks and benefits of NPMs1N  •Educating staff/providers about treatment availability  •Word of mouth from other Veterans  •Increase staff/provider knowledge about risks and benefits of NPMs  •Show providers the evidence/guidelines for choosing appropriate NPMs  •Educate the patient about nature of chronic pain
Patient-provider interaction  •Patient’s lack of motivation2M, 2F  •Difficult for patient to advocate for NPMs they would prefer  •Stigma of condition/having to explain it at NPM sessions  •Providers not believing pain; suggesting NPMs is evidence of that  •Disliking NPM provider  •Providers not believing pain  •Patients’ distrust that the referring provider is offering best plan  •Patient perception that NPM providers are “quacks”  •Patients with history of physical abuse don’t want to use NPMs  •Many women don’t like to be touched and many NPMs are hands on  •Empathy/compassion from provider  •Ready state of mind (patient)  •Respect for patients’ input on plan  •Patients’ good rapport with PCPs  •Open communication between PCP and patient  •Good personal qualities of the NPM providers  •Well thought out treatment plan specific to the patient  •Trusted provider promoting NPMs/multimodal care  •Shared decision-making regarding components of treatment plan
Treatment beliefs Perceived lack of efficacy of NPMs  •Patient skepticism about efficacy of NPMs1P  •Fear that treatment will fail  •Lack of commitment to treatment  •Elderly veterans don’t believe in “new age” treatments  •Provider and patient skepticism about efficacy of NPMs  •Patients’ perceptions of the VA as offering lower quality of care and NPMs are viewed in that same light Perceived burden of NPMs  •Pain, stress or other physical conditions prevent people from engaging with NPMs3M  •Lack of patient motivation/energy  •Time commitment  •Patients’ perception that they’re in too much pain to do some NPMs  •Long course of treatment requires a significant time commitment  •Patients’ preference to avoid self-care/self- management  •Expectation from patient of getting help (instead of having to do something active)  •Needing time off from work to attend treatment with multiple visits Perceived harm of NPMs  •Patients’ fear of adverse effects or injury  •Patients’ fear of pain getting worse with NPMs  •Expectation from patient of an opioid prescription; NPMs seen as substandard Medication-related  •Perception among patients that medications are more effective1N  •Previously formed opinions based on culture/ads: Need a magic pill2P  •Opioids have been used and worked3P  •Easier to take a pill Perceived efficacy of NPMs  •Perception among patients that medications are more effective1N  •Previously formed opinions based on culture/ads: Need a magic pill2P  •Opioids have been used and worked3P  •Reinforce positive NPM-related beliefs (e.g. NPMs may have less adverse effects than medications; NPMs promote an active lifestyle; NPMs may help you find other ways to do things you enjoy) Perceived safety of NPMs  •Comfort with the NPM provider/being touched Medication-related  •If patient wants to be on fewer pills/recognize NPMs are a healthier way than consuming chemicals3M  •If doctor won’t prescribe narcotics  •Not stopping pain medications all at once Other  •Mental health treatment involvement  •Elicit expectations of pain treatment and pain level patient can live with
Support Social  •Lack of patient support from family and doctor  •Clinicians not offering positive reinforcement  •Lack of positive family or friend influence  •Lack of community or club that does NPMs Healthcare system  •Encouragement from team that is trained, positive, and willing to work with you2M  •Have a coach  •Group support  •Support beyond the initial discussion; e.g. follow up to boost/maintain motivation  •Collaboration/trust between PCPs and specialists  •Specialty staff being friendly, engaging, rapport- building Social  •Supportive family  •Encourage family participation  •Encourage peer support
  1. 1 = highest scored factor, 2 = second highest scored factor, 3 = third highest scored factor
  2. M = male patient group, F = female patient group, N = nurse group, P = primary care provider group