Maria Teresa Chao

Social support is associated with improved outcomes for people with chronic pain and is an important but understudied component of biopsychosocial pain care. We sought to explore how group medical visits facilitate 4 distinct types of social support-emotional, appraisal, informational, and instrumental-among primary care patients with chronic pain. We collected qualitative data within a randomized trial of integrative group medical visits for chronic pain, focusing on 2 cohorts of English-speaking patients randomized to group medical visits. Data came from 16 observed group medical visits, 2 focus groups, and 12 semistructured interviews. The group medical visit intervention entailed 12 weekly sessions combining clinical care, pain education, mindfulness meditation, therapeutic movement, and facilitated discussion. We analyzed data using team-based flexible coding and codebook thematic analysis. The 26 participating patients were predominantly low-income (80.8% had an annual household income of less than $50,000); 50.0% identified as Black or African American, 15.4% as Hispanic or Latine, and 23.1% as White. On average, they had severe pain with a mean intensity rating of 7.7 out of 10. All 4 social support types emerged through structured program components (curriculum, facilitation strategies, program structure) and interactions among peers and facilitators. Emotional support fostered belonging and countered isolation and stigma. Appraisal support normalized struggles and fostered self-compassion. Informational support combined interactive education with peer-to-peer knowledge exchange. Instrumental support provided concrete assistance. Our findings illustrate how group medical visits for chronic pain mobilize 4 interwoven and reinforcing forms of social support as core therapeutic processes. They also highlight group medical visits as a potential model for biopsychosocial chronic pain management among primary care patients.

Background: Integrative health efforts typically offer clinical services of Western and non-Western origin in a biomedical context. Indigenous communities and other minoritized populations would benefit from improved equity efforts in integrative healthcare. Objective: As an approach to improve healthcare for Kānaka ‘Ōiwi (Native Hawaiians), we explore multi-eyed seeing, an elaboration on two-eyed seeing, emphasizing decolonialism and adaptive use of healing traditions from multiple cultural backgrounds. We also discuss the ways multi-eyed seeing may be used to address challenges to integrative health inequities. Methods: Using the transformative paradigm and community-based participatory action research, we conducted 1 focus group and 38 in-depth interviews. Data were analyzed using grounded theory, a decolonial intersectionality method, ho‘omana i nā leo (empowering the voices), and thematic analysis. To triangulate data, recruitment targeted 3 categories: mental and behavioral health providers who primarily serve Kānaka ‘Ōiwi (n = 12), Kanaka ‘Ōiwi clients who experienced depressive symptoms (n = 19), and Kanaka ‘Ōiwi cultural leaders (n = 10). Results: Three primary themes emerged, suggesting that multi-eyed seeing: 1) supports Indigenous wellbeing at multiple levels; 2) necessitates unique spaces for healthcare and healing; 3) may illuminate similarities across cultures and underlying mechanisms for healing and health. Findings also include 2 secondary themes, 1 describing the potential role of multi-eyed seeing in idiographic and transdiagnostic approaches to behavioral and integrative healthcare and another describing potential barriers to multi-eyed seeing. Conclusions: By drawing upon strengths of Indigenous, Western, Eastern, and other pathways to wellbeing, a synergistic weaving may be stronger than the sum of its parts. At the levels of ontology, epistemology, axiology, and praxis, multi-eyed seeing provides approaches to equity in integrative healthcare. We offer critical reflections and analyses of the processes that may uplift the work of multi-eyed seeing as a decolonial approach and invite dialogue around this concept for future exploration.

Purpose: This pilot study tested the feasibility and acceptability of a pragmatic randomized trial evaluating group-based non-pharmacologic approaches to increase access in primary care and improve pain-related outcomes. Methods: This 2 × 2 factorial trial assessed two 12-week interventions: group acupuncture and integrative group medical visits (IGMVs). Adults with chronic pain lasting ≥3 months were enrolled from safety-net primary care clinics. Participants were randomized to group acupuncture, IGMVs, both, or neither (usual care). We analyzed data using linear mixed models, ANCOVA, and abductive qualitative analysis. Results: Overall, 44 participants were randomized (25 English-speaking and 19 Spanish-speaking); 59% were female (mean age = 55 years), 21% African American or Black, 52% Latine, 21% non-Latine White, and 5% more than 1 race; and 78% had annual income <$25 000. At baseline, the average duration of chronic pain was 13.0 years, and the mean pain impact score was 36.0 (SD = 6.4). Participants randomized to interventions attended 6 of 12 sessions on average; 89% would participate again; and 86% reported clinically relevant pain improvements versus 20% in usual care ( P < .001). Qualitative data revealed substantial barriers to accessing multimodal care and social benefits of group-based models. Conclusion: Group-based integrative pain management is feasible and acceptable when co-located within safety-net primary care. Clinicaltrials.gov Registration Number : NCT05906784 ( http://clinicaltrials.gov/study/NCT05906784 ).

Background: Mental health of emerging, young adults remains a concern, particularly in lower income groups who receive less mental healthcare. Mindfulness-based interventions yield mental health benefits and have been widely applied, though reach and accessibility remain limited. Poor mental health can negatively impact job performance, physical health, and life trajectories. Objective: A mindfulness elective was offered through a year-long job training program serving diverse, low-income emerging adults. We investigated relevant outcomes in a mixed methods quasi-experimental study. Methods: Pre-/post-elective surveys assessed mindfulness, mental health, and well-being using established measures. We analyzed within- and between-group differences comparing mindfulness vs control (Year 1) and 12-week vs 6-week (Year 2) participants using t-tests and mixed effects models. Focus groups were conducted and analyzed using codebook thematic analysis. Results: Participants (n = 212) provided evaluation data. Over two years, 195 participated in a mindfulness elective (mean age = 22.3 [SD = 2.7] years; 47.2% female, 94.4% from racially and ethnically minoritized groups). In Year 1, mindfulness participants exhibited many pre-to-post improvements, including greater mindfulness (+8.4, 95% CI: 5.8, 11.0) and life satisfaction (+10.3, 95% CI: 7.0, 13.6) and lower stress (−8.2, 95% CI: −10.4, −5.9); no changes in controls were observed. In Year 2, mindfulness participants improved in mindfulness and life satisfaction plus self-compassion (12-week: +0.6, 95% CI: 0.4, 0.8; 6-week: +0.4, 95% CI: 0.1, 0.6), connectedness (12-week: +0.7, 95% CI: 0.5, 0.9; 6-week: +0.4, 95% CI: 0.2, 0.6), and mind-body connection (12-week: +1.8, 95% CI: 1.2, 2.4; 6-week: +0.6, 95% CI: 0.0, 1.3). Additional benefits were observed (eg, in stress, focus, emotional reactivity) but significance varied by elective length. Focus groups were generally concordant with quantitative results. Respondents described how the elective enabled self-care, supporting health and professional development. Conclusions: Integrating mindfulness into job training for underserved emerging adults was well-received, effective, and supports mental health equity.

Background: The COVID-19 pandemic exacerbated pain care inequities for low-income people. The Telehealth Integrative Pain Management Program (t-IPMP) was developed to provide pain management services for patients in public health clinics of the San Francisco Health Network (SFHN). Adapted from an existing program, t-IPMP delivered multimodal pain treatment via telehealth groups when in-person healthcare was restricted. Objective: This mixed-methods study evaluates the feasibility and acceptability of t-IPMP. Methods: We conducted a single-arm evaluation of three cohorts of t-IPMP, comprising 12 two-hour weekly online sessions on pain education, mindfulness, therapeutic movement, and self-acupressure. Participants were adults with chronic pain referred by SFHN primary care providers. We conducted baseline surveys, three-month surveys, and qualitative interviews (n = 15); participant observation of three sessions per cohort; and 3 focus groups (n = 20). Mixed-methods analysis included descriptive statistics, pre/post comparisons using t-tests, and codebook thematic analysis. Results: The t-IPMP received 107 referrals from 52 providers at 11 clinics, and 35% of referrals enrolled. Participants (n = 37) attended an average of 6 sessions. Participants who completed surveys (n = 15) were majority cisgender women (67%) with below-average wealth (87%) from diverse racial and ethnic identities. Qualitative data highlighted that t-IPMP created a supportive environment which fostered social connection and reduced social isolation. Social support encouraged use of new mind-body practices for pain. Telehealth was well received, though some participants preferred in-person interaction. From baseline to three-month follow up, average scores increased on measures of physical function (mean = 1.9, 95% CI 0.2-3.6); global quality of life (mean = 3.8, 95% CI 1.6-6.0); and pain self-efficacy (mean = 5.3, 95% CI 0.9-9.7). Conclusion: Integrative, multimodal pain management delivered through telehealth groups is feasible among primary care safety net patients, however, may not be optimal for all. Findings indicate that offering options for participating either online or in-person may best address patient needs and preferences.

Background: Socioeconomically disadvantaged populations have a high prevalence of chronic pain, exacerbated by social isolation, intersectional stigma, and disparities in pain assessment and treatment. Effective interventions using a multilevel, biopsychosocial approach are needed to decrease the unequal burden of pain. Group-based integrative pain management in primary care safety net clinics is a promising model to improve pain care for racially and ethnically diverse low-income people. Objective: To describe a study protocol to test the impacts of 2 group-based models – group acupuncture and integrative group medical visits – on multilevel pain-related outcomes. Methods: The study uses a 2x2 factorial randomized clinical trial to test two 12 week group-based models: group acupuncture and integrative group medical visits (IGMV, with psychoeducation, mind-body approaches, and social support). English or Spanish-speaking adults with chronic pain for ≥3 months receiving care in San Francisco Department of Public Health primary care clinics are eligible for the trial. All participants will receive usual care and be randomized to group acupuncture, IGMV, both, or waitlist control. The primary outcomes are changes from baseline to 3 month follow-up in pain impact and in social support for chronic pain. Secondary outcomes include pain interference, pain intensity, depression, anxiety, quality of life, and social isolation. Data will include patient-reported outcomes, electronic health record data, and qualitative interviews, focus groups and observations to assess multilevel individual, interpersonal and organizational outcomes. Discussion: Multilevel approaches are needed to advance health equity in pain management. Our study contributes to knowledge of group-based integrative pain management in primary care safety net clinics to address multilevel barriers and disparities in pain care.

Background: Mindfulness-based interventions (MBIs) are supported by clinical practice guidelines as effective non-pharmacologic interventions for common symptoms experienced by cancer patients, including anxiety, depression, and fatigue. However, the evidence predominately derives from White breast cancer survivors. Racial and ethnic minority patients have less access to integrative oncology care and worse cancer outcomes. To address these gaps, we designed and piloted a series of mindfulness-based group medical visits (MB-GMVs), embedded into comprehensive cancer care, for racially and ethnically diverse patients in cancer treatment. Methods: As a quality improvement project, we launched a telehealth MB-GMV series for patients undergoing cancer treatment, delivered as four weekly 2-hour visits billable to insurance. Content was concordant with evidence-based guidelines and established MBIs and adapted to improve cultural relevance and fit (eg, access-centered, trauma-informed, with inclusive communication practices). Program structure was adapted to address barriers to participation, with ≥50% slots per series reserved for racial and ethnic minority patients. Intake surveys incorporated a demographic questionnaire and symptom assessments. Evaluations were sent following the visits. Results: In our first ten cohorts (n = 78), 80% of referred patients enrolled. Participants were: 22% Asian, 14% Black, 17% Latino, 45% non-Latino White; 65% female; with a median age of 54 years (range 27-79); and 80% had metastatic cancer. Common baseline symptoms included lack of energy, difficulty sleeping, and worrying. Most patients (90%) attended ≥3 visits. On final evaluations, 87% patients rated the series as “excellent”; 81% “strongly agreed” that they liked the GMV format; and 92% would “definitely” recommend the series to others. Qualitative themes included empowerment and connectedness. Conclusion: Telehealth GMVs are a feasible, acceptable, and financially sustainable model for increasing access to MBIs. Diverse patients in active cancer treatment were able to participate and reported high levels of satisfaction with this series that was tailored to center health equity and inclusion.

In this viewpoint, we define integrative health equity as optimal health for all through a whole-person approach that explicitly recognizes cultural, social, and structural determinants of health. We describe seven guiding principles, along with organizational goals, strategies, and reflections to advance integrative health equity.