Stakeholder engagement to identify implementation strategies to overcome barriers to delivering chronic pain treatments: A NIDILRR and VA TBI Model Systems Collaborative Project

Abstract

Objective:

The purpose of this paper is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with TBI.

Setting:

Community

Participants:

Healthcare providers (n=63) with two or more years’ experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain and qualitative research subject matter experts (SMEs) participated in the mapping approach.

Design:

Participatory-based research design, using descriptive and intervention mapping approaches.

Results:

Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: Cognitive Deficits of Patients (67%); Patient Comorbidities (63%); Mental Health and/or Substance Abuse Issues (59%); and Patient Participation (62%). SMEs used prioritized barriers to develop four primary objectives and implementation strategies designed to: (1) Engage consumers to validate and identify strategies; (2) Tailor pain treatment and delivery to overcome barriers; (3) Develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) Increase awareness, skills and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change.

Conclusion:

Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.

Among those with TBI in the US, 43% (or 3.2 million people) live with long-term, debilitating symptoms related to their injury, with the majority experiencing chronic pain.¹ Chronic pain, defined as pain that persists beyond 3-months and includes headache,^2–5 has been found in as many as 60% of individuals 1- to 30-years following hospitalization for TBI.⁶ This high rate of chronic pain, with resulting impact on outcomes,⁷ emphasizes the need to understand how those with TBI receive care for chronic pain.^8,9

Significant gaps exist between the evidence that supports approaches to addressing chronic pain and access to these treatments in clinical practice.^10,11 This healthcare quality chasm poses an even wider disparity for those following TBI, where navigation and engagement in healthcare services can be complicated by cognitive challenges.^8,9 Indeed, healthcare access barriers are associated with report of greater unmet rehabilitation needs specifically in those with TBI in the years that follow injury.¹²

Initiatives to address chronic pain are a national priority.^13–15 As clinical care teams have attempted to respond to chronic pain, the opioid crisis in the US has led to national legislative priorities in advancing evidence-based treatment and prevention measures to reduce the rate of opioids and addiction.^16,17 This is paramount among those with TBI, where increased severity of injury has been associated with increased likelihood of receiving an opioid prescription despite clinical practice guidelines cautioning use, and increased risk of opioid use disorder and unintentional overdose in this population.^18–20 While many existing clinical practice guideline treatments, both non-opioid and non-pharmacological, still need evaluation in individuals with TBI, getting these treatments to those in need also needs to be addressed. Research examining the barriers and facilitators to access to chronic pain treatment in the general population has identified a wide range of patient-and provider-related challenges across the healthcare access spectrum,²¹ including biases against treatments, patient-provider communication and trust, coordination and continuity of care, and availability and knowledge of resources.^22–30

As the field moves to generate knowledge about access to chronic pain management for individuals with TBI, what is currently known suggests patients’ perspectives on barriers to accessing care post TBI include, but are not limited to: health system-wide barriers, provider-specific factors, unidentified brain injury, external barriers and TBI related impairments.³¹ However little research has been published on perceived competencies and attitudes of healthcare professionals with respect to caring for individuals with TBI. There is some evidence that a lack of knowledge and misinformation about TBI exists among providers, specifically, Dams-O’Connor and colleagues,³¹ recommended efforts focusing on general practitioners and other health professionals to improve their knowledge about the needs of individuals with TBI. Our current work identified a myriad of barriers in treating chronic pain among persons with TBI including cognitive disability, limited patient engagement/participation in treatments, comorbidities, telehealth complexity, transportation challenges, and more.^8,9,32 More research is needed to understand barriers to access to chronic pain management from a multi-stakeholder perspective such that barriers can be addressed to ensure that appropriate treatments for those with TBI are available and accessible in the community.

Implementation science, the study of methods used to facilitate the adoption of evidence-based practices, interventions and policies into routine health care,³³ is needed to overcome barriers to accessing treatment for chronic pain among persons with TBI. Implementation science takes a systematic approach to using theory-based frameworks, such as RE-AIM^34,35 and the Consolidated Framework for Implementation Research (CFIR),³⁶ and evidence-based implementation strategies to support the effective adoption and sustainment of evidence-based practices.³⁷ Implementation strategies are ideally evidence-based methods used in isolation or in combination to support implementation of a program. Implementation science takes a key role in efforts to integrate evidence-based practices into routine general practice on an expeditious and progressive timeline.³⁸

Previous efforts have been conducted to improve the conceptual clarity, relevance, and comprehensiveness of evidence-base of implementation strategies,³⁹ as well as the development of conceptually distinct categories of strategies,⁴¹ and their unique importance and feasibility in practice. Powell and colleagues (2015) developed a refined compilation of 73 implementation strategies by systematically gathering input from stakeholders with expertise in implementation science and clinical practice.³⁹ Waltz and colleagues expanded these efforts by using concept mapping to characterize and categorize relationships among strategies and assess their feasibility and added value.⁴⁰ This work was further expanded when Powell and colleagues published four distinct methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that can be used to strategically select implementation strategies to address barriers in the implementation of an evidence-based practice.⁴¹ This collective work presents as a practical foundation for its functional use in addressing barriers to access to chronic pain care for persons with TBI.

The National Academies of Science, Engineering, and Medicine (NASEM) report on accelerating progress in TBI, specifically identifies the critical need to promote research translation using implementation science.⁴² The purpose of this paper is to leverage the previous advancements in the development of critical frameworks, implementation strategies, and mapping strategies to inform the systematic selection of strategies and to overcome barriers to access to pain care for persons with TBI. This paper describes the first three of five steps in a tailored evidence-based intervention mapping⁴¹ approach designed to foster implementation of evidence-based care. The three steps include preparatory activities prior to implementation strategies being used, and thus are considered a pre-implementation phase of work. Stakeholder engagement was used in this pre-implementation, systematic process to prioritize barriers to chronic pain interventions and map them to implementation strategies to improve healthcare access for chronic pain in persons with TBI. This pre-implementation portion of the process provides a “road map” to utilize for the final two steps of the five-step approach to move evidence-based care into practice. In the short-term, this approach is designed to strategically map implementation strategies to overcome barriers to pain management for TBI.

Methods

Design

A stakeholder engagement approach was leveraged in this study to review thematic data from a previously conducted study.^8,9 The current study then utilized an Intervention Mapping approach to align barriers identified in the previously collected qualitative interviews with relevant objectives and implementation strategies. Barriers were contextualized within the Levesque access to healthcare conceptual framework to identify dimensions that impact the delivery of health care as a function of supply (e.g., healthcare system) and demand (e.g., patient engagement) factors relative to a specified patient population.²¹ The primary core domains of this framework include recognition of a health care need, perception of it, desire for treatment, seeking and reaching health care, and then utilizing it to achieve an optimal outcome. The framework highlights dimensions from the supply and demand sides that interact to influence the core elements of health care access.

Participants and Setting

Sample for Identification of Barriers (separately reported).

Inclusion criteria for providers who participated in identifying barriers and facilitators to chronic pain treatments in qualitative interviews were: (1) a currently practicing clinician who treats TBI and/or chronic pain, (2) a US-based provider, (3) have more than 2 years’ experience treating individuals with TBI, and (4) see at least 10 individuals with TBI per year. Exclusion criteria for providers are: (1) do not speak or understand English, (2) an internationally based care provider, (3) not a currently practicing clinician, (4) do not treat TBI and/or chronic pain, (5) have less than 2 years’ experience treating individuals with TBI, and (6) treat less than 10 individuals with TBI per year. Interviews were conducted between October 2020 and November 2021, notably during the COVID-19 pandemic.

Sample for Intervention Matching (Engagement Cohort).

Clinician stakeholders representing various disciplines and specialties within psychology (chronic pain, rehabilitation, neuropsychologists) and medicine (physical medicine and rehabilitation, neurology, and internal medicine) from five [Tampa TBIMS (RR, GC, LW, CT, AM), RIM (RH), Mayo (TB), Washington (JH), Craig (SA)] TBI Model System Centers participated in the engagement activities. They were volunteers among co-investigators from the larger mixed methods study to characterize pain in persons with TBI.

Procedure and Analytic Approach

Abbreviated Procedure for Identification of Barriers (details separately reported).

A convenience sample of providers were approached via email to participate in semi-structured interviews. Purposeful and snowball sampling was conducted to ensure representation of different types of providers. Potential participants who responded to the email (N=80) were screened for eligibility and telephone consent obtained (N=64) with $50 payment for completed interviews. A 13-item open-ended semi-structured interview guide informed the identification of barriers faced when treating persons with TBI and chronic pain. Interviews were conducted via telephone or Microsoft Teams by two research team members with postgraduate-level qualifications and experience with qualitative methods. Interviews took 1-hour to conduct and were audio-recorded with permission. Interview recordings were professionally transcribed for conduct of analyses.

Content analysis of interview transcripts were conducted using a constant comparative method within ATLAS.ti v.7.5.18,⁴³ a qualitative data analysis software program, where text with similar meaning is labeled with the same code consistently by two coding team members. During coding, differences in interpretation were discussed and codes refined. The qualitative team established inter-rater reliability of at least 80%.^44,45 To maintain coding consistency, every fifth coded transcript was checked for drift, that is, inter-rater reliability checked to ensure both coders maintain over 80% agreement.⁴⁶ Study team and steering committee members reviewed the preliminary findings and provided input which led to decisions on final themes and organizing them along the access framework, by overall sample, type of organization, and provider type. Demographic questionnaire data were summarized to describe sample characteristics.

Procedure for Intervention Mapping.

Stakeholder engagement activities included a series of meetings with a senior implementation scientist (JH) that utilized pre-implementation activities informed by an Intervention Mapping^47–50 approach developed by Powell and colleagues. This approach consisted of five steps:(1) needs assessment to identify determinants (barriers) and guide the selection of intervention components; (2) development of program objectives to produce matrices that contain behavioral or environmental performance objectives, and determinants; (3) generate list of intervention methods (translate to implementation strategies) matched to program objectives; (4) design implementation strategy and program materials; and (5) monitor and evaluate progress. Intervention Mapping is a practical yet systematic approach to identifying interventions (or implementation strategies) that incorporates theory, evidence, and stakeholder perspectives. Informed by this approach, we conducted the first three pre-implementation steps: (1) conducted a needs assessment – to identify and prioritize barriers to develop strategic objectives (Table 1); (2) developed program objectives; and (3) listed intervention methods matched to program objectives (Table 2 & 3). Remaining steps, 4 and 5, will be conducted and reported in future translational efforts.

Table 1.

Sample characteristics for qualitative individual interviews.

Characteristic	Total Sample (n=63)
Gender (% female)	79.4%
Age	43 (10) [29,36,40,48,67]
Ethnicity (% Non-Hispanic)	59 (93.7%)
Race
White	46 (73%)
Black	4 (6.4%)
Asian	9 (14.3%)
Other	4 (6.4%)
Practice Setting
Civilian Healthcare Setting	37 (58.7%)
Military Treatment Facility	2 (3/2%)
Veteran Medical Center	25 (39.7%)
Provider Type
Psychologist	28 (44%)
Medical	15 (24%)
Rehabilitation Therapist	17 (27%)
Other	3 (5%)
Time in Setting
Academic Center	17.3 (37.1)
Community Center	3.2 (17.7)
Medical Center	45.6 (48.8)
Private Practice	1.6 (12.6)
Rehabilitation Center	39.7 (47.7)
Other	0.6 (4.0)
Work Inpatient, n (%)	35 (55.6%)
Work Outpatient, n (%)	49 (77.8%)
TBI Treatment Experience	63 (100%)
Chronic Pain Treatment Setting	15 (23.8%)

Table 2.

Supply and Demand Barriers to Pain Treatment for Persons with TBI.

Supply Side Barriers to Treatment
Access Dimensions	Subdimensions	Themes	n (%)
Availability and Accommodations	Geographic location	Remote Area (lack of services/ distance)	21 (33)
	Mechanisms	Policies and Procedures (professional licensing, COVID-19 policies, EHR, etc.)	29 (46)
	Appointments	Long Wait Times for Services	26 (41)
		Scheduling Issues	13 (21)
Appropriateness	Technical quality	Understaffed	22 (35)
	Adequacy	Cognitive Deficits of Patients	42 (67)
		Patient Comorbidities	40 (63)
		Mental Health and/or Substance Abuse Issues	37 (59)
	Coordination and continuity	Lack of or Pause in Services Due to COVID-19	30 (48)
		Referrals to Community (finding right match)	24 (38)
		Treatment Ends (PT, Psych) (but patients want more)	19 (30)
		Team Not Getting Patients into Rehab Quick Enough	14 (22)
Demand Side Barriers to Treatment
Access Abilities	Subdimensions	Themes	n (%)
Ability to Seek	Personal and social values	Patient Unsure of Telehealth	23 (37)
		Work Schedules/Issues	13 (21)
Ability to Engage	Adherence	Patient Participation (No Show, Don’t Follow Up, Non-Compliant)	39 (62)

Table 3.

Example of Mapping Matrix of Objectives, Theory/Research Basis and Implementation Strategies for a Prioritized Barrier.

Prioritized Barriers	Objectives	Theory/Research Basis	Implementation Strategy
• Cognitive deficits of patients (67%)  • Patient Comorbidities (63%)  • Patient Participation (62%)  • Mental Health and/or Substance Abuse Issues (59%)	Engage persons with TBI to validate, and/or identify, strategies to overcome barriers to accessing pain treatment, to promote uptake of tailored interventions and respond to their identified needs (e.g., cognitive deficits, comorbidities, etc.).	Principles of patient engagement & evidence-based practice to engage persons with TBI to identify their needs and inform tailored interventions.31,57	Continue engagement efforts to validate and inform strategies and implementation efforts:  • Intervene with patients/consumers to enhance uptake & adherence  • Involve patients/consumers and family members  • Obtain and use patients/consumers and family feedback  • Prepare patients/consumers to be active participants
	Tailor pain interventions, treatment and delivery to be appropriate for persons with TBI, and their identified needs (e.g., cognitive deficits, comorbidities, etc.).	Principle of Patient Centered Care to adapt interventions, treatment and delivery to meet the individualized needs of the patient.58,55	Tailor strategies: Employ evidence-based best practices and guidelines to inform tailored pain interventions, treatment and delivery to be appropriate for persons with TBI and their identified needs (e.g., cognitive deficits, comorbidities, etc.).
	Adapt evidence-based policies, guidelines, and best practices to facilitate access for persons with TBI, and their identified needs (e.g., cognitive deficits, comorbidities, etc.), and disseminate to target audiences.	Principle of Health Policy development to leverage evidence-based policies and guidelines to facilitate best practices in care.52–55,59	Mandate change: Work with leadership to declare the priority of appropriate tailored pain treatment and delivery to be for persons with TBI and their identified needs (e.g., cognitive deficits, comorbidities, etc.).
	Increase awareness, skills and readiness of workforce to deliver pain treatment to persons with TBI and their identified needs (e.g., cognitive deficits, comorbidities, etc.).	Evidence-Based Practice to increase workforce readiness through professional training and education.31,55	Develop workforce readiness to deliver pain treatment to persons with TBI and their identified needs (e.g., cognitive deficits, comorbidities, etc.):  • Conduct educational meetings  • Conduct educational outreach visits  • Conduct ongoing training  • Create a learning collaborative  • Develop educational materials  • Distribute educational materials

STEP 1: Needs Assessment - Identify and Prioritize Barriers

In Step 1, analysis of provider interviews identified saturated themes contextualized within the Levesque access to healthcare conceptual framework representing supply and demand-based barriers to care.²¹ Saturation was set at themes in which over 20% of the sample endorsed an identified barrier to pain treatment for persons with TBI. These saturated themes were prioritized based on those themes that had at least, or exceeded, 50% endorsement.

STEP 2: Develop Program Objectives

In Step 2, the team used the prioritized barriers from Step 1 to develop objectives that could be mapped to implementation strategies. This process was completed through a series of meetings, with the subject matter experts (SMEs) and the implementation scientist. Meetings were conducted using a participatory stakeholder engagement approach, designed to identify objectives that focused on overcoming the identified barriers, informed by evidence-based practices and literature.^51–54

STEP 3: Select Implementation Strategies Matched to Program Objectives

In Step 3, the team identified implementation strategies to map to the articulated programmatic objectives, based on research and literature base and practical SME knowledge. In this process, the SMEs consulted with the implementation scientist to review and select evidence-based implementation strategies that represented feasible strategies that will inform the objectives while accounting for the current state of the science and practice for responding to the identified data-driven barriers to pain treatment for persons with TBI.

To inform an evidence-based approach, the team leveraged the seminal paper by Powell and colleagues³⁹ to identify implementation strategies. The primary challenge for the SME team was contextualizing the breadth and depth of the identified 73 implementation strategies. As such, the team turned to the corresponding publication by Waltz and colleagues⁴⁰ in which the 73 strategies were sorted using multidimensional scaling and hierarchical cluster analysis to inform concept mapping of strategies into 9 categories, rating strategies by relative importance and feasibility. The work by Waltz and colleagues⁴⁰ provided the initial validation of the identified 73 implementation strategies being conceptually distinct, with ratings of importance and feasibility to inform the selection of strategies best suited for efforts in a particular setting. In this final step, all strategies were reviewed by stakeholder SMEs with input and clarifications by the implementation scientist (JH) who contextualized and mapped to the objectives identified for each of the prioritized barriers. An Intervention Mapping table was developed to show the alignment across prioritized determinants (i.e., barriers), SMEs identified objectives, theory/research-based justification(s), and aligned implementation strategies.

Data Sources

Data used to inform implementation intervention strategy mapping included themes from interviews about barriers to receipt of chronic pain treatment for persons with TBI from prior work.^8,9 Sixty-three participants were recruited for generating themes. Sample descriptives are briefly summarized in Table 1 and reported in greater detail elsewhere. Interview items aimed to identify supply and demand barriers to care within the context of the Levesque access to healthcare conceptual framework. Qualitative analyses were contextualized within the framework to identify relevant dimensions that impact the delivery of health care as a function of supply (e.g., healthcare system) and demand (e.g., patient engagement) factors relative to a specified patient population.²¹ The primary core domains of this framework include recognition of a health care need, perception of it, desire for treatment, seeking and reaching health care, and then utilizing it to achieve an optimal outcome. The framework highlights dimensions from the supply and demand sides that interact to influence the core elements of health care access.

Results

Intervention (Implementation Strategies) Mapping

STEP 1: Needs Assessment - Identify and Prioritize Barriers

Identified in prior work, supply and demand barriers (themes reaching saturation) for accessing chronic pain treatment for persons with TBI are listed Table 2. To prioritize implementation strategies, four barriers with the highest amount of saturation were selected (highlighted in Table 2). Prioritized barriers were: cognitive deficits of patients (67%); patient comorbidities (63%); and mental health and/or substance abuse issues (59%); and patient participation (62%).

These four barriers to accessing pain treatment by persons with TBI highlight how pain treatments may be inadequate or not accommodating to their patients’ needs. In the theme, cognitive deficits of patients, providers described how challenges related to cognition, such as memory, learning new information, and communication, can create barriers to implementing a treatment plan for pain management after a TBI. One respondent explained,

[For persons with TBI and pain who have] a lot of cognitive deficits, they just really don’t remember a whole lot. It gets so overwhelming for them. They get very frustrated, too many appointments, they can’t remember what [appointment] is for who.

Providers also described the difficulty of knowing what to treat first when a patient experiences TBI and has other comorbidities such as pain (theme, patient comorbidities). A respondent highlighted the challenges associated with treating a patient TBI and comorbid pain due to the multiple, complex symptoms and the potential for adverse treatment side effects:

It’s like educating the providers that, there’re other treatments out there for chronic pain and TBI besides “here’s a pill.” Granted there’s a lot of good medication for migraines headaches, for sure, but it’s when they jump to those meds that have the side effects of decreasing functioning and cognitive ability [that’s the problem].

Similarly, providers identified the challenge of treating patients with TBI and pain who were also experiencing mental health and/or substance abuse issues. Use of medications to treat pain in persons with TBI, had to be reevaluated due to concerns over the patient’s history with opioids and other medications. A respondent summed up, “The risk of substance abuse with some of the pain medications is certainly a challenge [for treating someone with TBI and pain]”.

Providers also highlighted patient participation as a main barrier, that is, non-adherence or lack of compliance to the treatment by not attending their appointment or following up. A respondent explained,

The main thing would be just compliance and remembering to do some of the homework assignments. So, if you tell them to do breathing exercises, for example, they’ll tell you the next session, “oh I forgot”. I think that could be a function of the TBI or trouble prioritizing things and so we often encourage them to put a reminder in their phones or calendars.

These SME prioritized provider-identified themes focus on barriers to healthcare utilization from the supply and consumer sides of the access to healthcare framework.

STEP 2: Develop Program Objectives

After review of the prioritized barriers, the SMEs developed objectives based on the theoretically driven core principles of participatory approaches and patient engagement to overcome barriers to participating in care (e.g., no show, don’t follow up, non-compliant), specific to supporting their needs relevant to cognitive deficits, comorbidities, and mental health and/or substance abuse issues. It was immediately determined that the cross-cutting nature of these barriers would lend themselves to a common set of objectives, including to: (1) Engage consumers to validate and identify strategies; (2) Tailor pain treatment and delivery; (3) Develop and disseminate guidelines and best practices when delivering care to persons with TBI; and (4) Increase awareness, skills and readiness of workforce to deliver pain treatment to persons with TBI. Table 3 illustrates the objectives in a proposed chronological order for these cross-cutting prioritized barriers.

STEP 3: Select Implementation Strategies Matched to Program Objectives

Once the barriers were identified and prioritized (Step 1) and objectives were developed (Step 2), the SMEs used the intervention mapping strategy to complete the mapping table. Table 3 is comprised of objectives, theory/research basis driving selection of strategy, and the selected implementation strategy identified as most appropriate to impact change. Each of the four objectives were tabled to respond to the prioritized barriers to access to care (e.g., cognitive deficits, comorbidities, participation, and mental health and/or substance abuse issues). Objectives and implementation strategies were selected and aligned by SMEs based on theories and research reflecting principles of patient engagement & evidence-based practice, patient centered care, health policy development, and evidence-based practices.

The SMEs first recommended, in alignment with the participatory stakeholder engagement approach, at the individual level - to continue engagement efforts to validate and inform strategies and implementation efforts to include several evidence-based implementation strategies, such as obtaining and using patients/consumers and family feedback. Due to the patient-specific nature of prioritized barriers, at the intervention level - tailoring strategies, was also identified as an appropriate strategy to be responsive to the needs of persons with TBI and cognitive deficits, comorbidities, participation barriers, and/or mental health/substance abuse issues. Due to the impact of system-level changes such as policy, the third strategy selected by SMEs was mandating change. Finally, at the provider level, the SMEs selected several strategies to develop workforce readiness. Collectively, the SME selected implementation strategies respond to patient-, intervention-, system- and provider/workforce-levels to support a comprehensive effort to overcome barriers to pain treatment for persons with TBI.

Discussion

As experts in the field identify and test evidence-based non-pharmacological treatments to reduce pain in the TBI population, identification of effective implementation strategies will be critical to ensure access to pain management for this at-risk population. To date, there has been minimal work related to implementation science in TBI, even less with regards to chronic pain. This paper illustrates a systematic approach to stakeholder-engaged implementation (intervention) strategy mapping to prioritize and respond to barriers to accessing chronic pain services for persons with TBI.

This pre-implementation work illustrates three of the ultimate five-step process to identify targeted implementation strategies for increasing access to chronic pain care for persons with TBI. While several barriers to pain treatment for individuals with TBI were identified, the 4 most frequently reported barriers were prioritized to begin the pre-implementation process of identifying objectives and mapping implementation strategies. The proposed mapping matrix of the prioritized barriers, with aligned objectives, theory/research-based justification, and the implementation strategies, can be leveraged, once validated by individuals with TBI and their families, to inform the final two steps: to design implementation strategy and program materials and to monitor and evaluate progress in future programmatic and research efforts. Given that all prioritized barriers were patient-specific and cross-cutting, it is notable that similar objectives and implementation strategies can be leveraged in plans developed in Steps 4 and 5 of the intervention mapping process.

Though timing was not formally assessed the objectives were organized to follow the natural chronological timeline, such that the first objective for each of the barriers would be to continue consumer engagement to validate and identify strategies to overcome barriers. As such, this work needs to circle back to a key stakeholder group for validation and/or identification of barriers, corresponding objectives and identified implementation strategies from the patient perspective.

Though this preliminary work provides an evidence-based approach to strategically mapping barriers, objectives and implementation strategies, subsequent work is needed to further assess and delineate a tailored approach. When responding to barriers to access due to patient cognitive deficits, comorbidities, and mental health and/or substance use disorders, current literature suggests research is needed to evaluate the potential positive impact – and implementation potential of adapting and tailoring, using a chronic disease management approach to TBI that includes surveillance, prevention and treatment of comorbidities on community re-integration and life satisfaction.

Based on the value added of tailored approaches to overcome barriers to access, and participation, the objective to develop and disseminate guidelines presents itself as an established best practice with maximal impact. Patients with TBI and comorbid mental health and/or substance issues, for example, may require alteration and further special consideration relevant to identification, symptom monitoring, and treatment practices.⁵⁵ As the field aims to mandate change through the development and dissemination of high-quality clinical practice guidelines to improve access to chronic pain management for persons with TBI, in alignment with recommendations from the field, prioritizing emphasis on dissemination and incorporation into practice^56–58 is warranted to optimize uptake and impact. Given the fact that persons with TBI receive care from a wide variety of providers, identifying implementation strategies – such as mandating change - that may be applicable across the healthcare system, as well as across civilian and Veterans Healthcare Administration systems will be beneficial to improving access to this patient population.

To support the uptake and sustained adoption of guidelines for improving access to care with this patient population, increasing awareness, skills and readiness of workforce to deliver pain treatment to persons with TBI is an evidence-based approach to impacting change. Tailored education and training are needed to improve practice,⁵⁹ and are more likely to improve professional practice than dissemination of guidelines alone. Due to the cross-cutting nature of the barriers and their corresponding objectives and implementation strategies, as implementation efforts progress, though there is a high level of overlap, the distinct approaches to responding to each identified barrier should remain discrete so outcomes and impact can be determined over time.

Strengths of this study include the identification of barriers from civilian and VA healthcare providers across a range of disciplines who have experience with individuals with TBI and chronic pain. This is an important perspective, given patient reports have indicated there is a lack of knowledge and misinformation about TBI among providers.³¹ This study used a systematic and rigorous participatory design that capitalized on established implementation science methods to better understand the ways in which pain treatment can be more accessible and better utilized by those with concomitant TBI. Notably, implementation science is a burgeoning field, respectfully the 73 ERIC implementation strategies can present as an overwhelming amount of information to assess for selection. However, this study provides a contextualized example of a strategic approach to analyzing barriers and facilitators to accessing treatment in an effort to identify implementation strategies that support data-driven objectives. The use of an implementation science approach in TBI is novel, but is also a limitation because a methodology in its infancy, especially in the TBI literature. This is one of the first studies to our knowledge to use such a process to understand the barriers and facilitators to accessing treatment in this patient group, and can inform future research.

A limitation to this work broadly, is that barriers identified were from providers with expertise in working with TBI patients and who work in rehabilitation facilities which may have more resources. As such, identified barriers are limited in scope, and notably don’t account for social determinants of health, which may reflect a bias of participating providers. Therefore, generalizability may be limited and there may be additional barriers, particularly from the perspective of patients that need to be examined and integrated into this ongoing effort. Particularly, patient facing access barriers should be prioritized throughout the implementation process.

Given that these barriers were identified from the provider perspective, future work needs to validate the findings and strategies with persons with TBI and chronic pain and/or their family members. In alignment with recommendations from the field, future work should optimize the use of stakeholder engagement in the intervention mapping process and evaluations of intervention strategy effectiveness.⁵¹ Future implementation science efforts to increase access to chronic pain treatments for persons with TBI through the use of strategic implementation strategies, should undergo comparative effectiveness trials to identify and disseminate best practices.

Conclusion

There is a gap between existing evidence-based treatments and implementation efforts to address access to chronic pain treatments for persons with TBI. Implementation science approaches are needed to translate knowledge into practice to improve access to chronic pain care for persons with TBI. An evidence-based participatory approach to intervention mapping was used to identify objectives and implementation strategies to address barriers to accessing chronic pain care by persons with TBI. These pre-implementation phase efforts will inform future implementation efforts within this crucial area of rehabilitation, to increase access to pain treatment for persons with TBI.