Group-based Integrative Pain Management: A multi-level approach to address intersectional stigma and social isolation in diverse primary care safety net patients with chronic pain

项目摘要 背景：这项拟议的研究旨在解决不同种族、 通过优化小学提供的多模式疼痛管理来优化社会经济弱势群体 护理安全网诊所。初级保健环境中存在多层障碍，在这些环境中，社会经济状况处于不利地位 患者最常接受治疗。在组织中缺乏获得多式联运和非药物护理的机会 在人际层面上，提供者偏见和其他形式的歧视导致了不平等 疼痛护理的评估、治疗和质量。污名化贯穿各个层面，并与 社会孤立在患有慢性疼痛的个人中很常见。基于群体的模型是一种很有前途的多层次模型 增加获得非药物治疗机会的方法，解决有助于 在疼痛护理方面存在差异，改善人际沟通，并在安全网中提供社会支持 患有慢性疼痛的患者。方法：本研究采用混合方法和务实的2×2随机设计 析因试验测试两个基于群体的模型：综合团体就诊(IGMV)和团体针灸。 这项研究测试了这样的假设：与通常的护理相比，每项研究干预都能改善疼痛 干预和社会隔离(主要结果)，这两者结合在一起具有协同效应 通过增加社会支持和减少安全网患者中跨部门污名的影响来进行中介 伴随着慢性疼痛。研究干预包括基于在小学测试的现有方案的每周12次 注意安全网设置。IGMV包括疼痛教育、社会和行为支持以及身心 方法(冥想、瑜伽)。群体针灸使用响应性手册，允许标准化 然而，个体化治疗。在R61阶段，一个由国家专家和患者利益攸关方组成的小组将 细化和优化IGMV的结构、流程和内容，旨在减少社会孤立和 作为疼痛管理的一部分的交叉污名。干预措施将以40种英语或西班牙语进行试点 在两家初级保健安全网诊所与慢性疼痛患者交谈。将测试研究程序并 适用于更大规模的试验。在R33阶段，将从两个安全网诊所招募360名参与者 并随机分为IGMV组、针刺组、两者或不针刺组。目标1是确定研究的效果 关于疼痛相关结果的干预措施(主要结果：疼痛干预和社会孤立)。AIM 2测试 社会支持和污名作为干预中介。Aim 3检查患者的疼痛体验 初级保健安全网环境中的管理、患者-临床医生关系和临床护理 定性研究方法。意义：需要多层次的方法来促进疼痛的健康公平 管理层。拟议的研究将有助于加深对基于群体的综合疼痛管理的认识 在初级保健中同处一处，以解决社会经济弱势群体在疼痛护理方面的差异。

PROJECT ABSTRACT Background: The proposed study seeks to address chronic pain disparities in racially diverse, socioeconomically disadvantaged individuals by optimizing multimodal pain management provided in primary care safety net clinics. Multilevel barriers exist in primary care settings where socioeconomically disadvantaged patients are most often treated. Lack of access to multimodal and nonpharmacologic care at the organizational level, and provider bias and other forms of discrimination at the interpersonal level contribute to unequal assessment, treatment, and quality of pain care. Stigmatization cross-cuts all levels and is closely linked with social isolation common among individuals with chronic pain. Group-based models are a promising multilevel approach to increase access to non-pharmacologic therapies, address time constraints that contribute to disparities in pain care, improve interpersonal communication, and provide social support among safety net patients with chronic pain. Methods: This study uses mixed methods and a pragmatic 2x2 randomized factorial trial to test two group-based models: integrative group medical visits (IGMV) and group acupuncture. The study tests the hypotheses that compared with usual care, each study intervention improves pain interference and social isolation (primary outcomes), and that the two combined have synergistic effects mediated by increased social support and decreased impact of intersectional stigma among safety net patients with chronic pain. Study interventions include 12 weekly sessions based on existing protocols tested in primary care safety net settings. IGMV includes pain education, social and behavioral support, and mind-body approaches (meditation, yoga). Group acupuncture uses responsive manualization, allowing for a standardized yet individualized treatment. During the R61 phase, a panel of national experts and patient stakeholders will refine and optimize the structure, process, and content of IGMV aimed at reducing social isolation and intersectional stigma as part of pain management. Interventions will be piloted in 40 English or Spanish speaking patients with chronic pain at two primary care safety net clinics. Study procedures will be tested and adapted for a larger scale trial. In the R33 phase, 360 participants will be recruited from two safety net clinics and randomized to IGMV, group acupuncture, both, or neither. Aim 1 is to determine the effects of study interventions on pain-related outcomes (primary outcomes: pain interference and social isolation). Aim 2 tests social support and stigma as intervention mediators. Aim 3 examines patient experiences with pain management, patient-clinician relationships, and clinical care in primary care safety net settings using qualitative methods. Significance: Multilevel approaches are need to advance health equity in pain management. The proposed study will contribute to knowledge of group-based integrative pain management co-located in primary care to address disparities in pain care for socioeconomically vulnerable populations.