“It’s Better in a Group Anyway”:Patient Experiences of Group and Individual Acupuncture

Abstract

Objectives:

Chronic pain is prevalent, burdensome, and costly, and there are ethnic and racial disparities in treatment. Acupuncture is effective and safe, but access is limited. Group acupuncture can decrease cost and increase capacity by decreasing clinic space needs and increasing patient volume per acupuncturist; however, the effectiveness and patient acceptability of group and individual session acupuncture have never been directly compared.

Design:

The Acupuncture Approaches to Decrease Disparities in Pain Treatment (AADDOPT-2) study is a randomized comparative effectiveness trial of acupuncture for chronic pain. Semistructured in-depth interviews were conducted with a subset of patients enrolled in the trial.

Settings/Location:

Outpatient clinics in an urban, low income area serving a primarily black and Hispanic population.

Subjects:

Qualitative interviews were conducted with 46 patients; 23 in each arm of the AADDOPT-2 study.

Interventions:

Patients were randomized to receive either individual acupuncture or acupuncture delivered in a small group.

Outcome measures:

Transcripts of the interviews were analyzed using an inductive thematic framework to explore and compare the patient experience in group and individual settings.

Results:

Patients in both study arms valued the pain relief, improved quality of life, and relaxation experienced during acupuncture. Privacy and mixed-sex groups were cited as a concern by a minority of patients; however, most of those randomized to the group setting noted that these concerns abated after initiating treatment. Differences between arms included the depth of the relationship with the acupuncturist and misgivings related to the treatment space. Group dynamics varied; some groups fostered a supportive, therapeutic interaction, while others were more reserved.

Conclusions:

Patients in both arms valued their acupuncture experience. Participants described both positive and negative aspects of the group setting.

Introduction

Improved access to nonopioid treatments for chronic pain is urgently needed. Chronic pain affects an estimated 15%– 30% of the population^1,2 and accounts for a large volume of outpatient visits.^2–4 The use of prescription opioids to treat chronic noncancer pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality.^5–7 Access to pain treatment modalities in the primary care setting is limited.^4,8 Racial and ethnic minority patients experience a higher prevalence of chronic pain,² and less adequate treatment.^9,10

Acupuncture improves pain and functioning for patients with common chronic pain syndromes such as osteoarthritis and neck and lower back pain.^11–18 It is also acceptable in low-income, urban settings serving ethnic and racial minority patients.¹⁹ Community-based group acupuncture may increase access, reduce costs, and reduce disparities.^20,21 Nonrandomized studies suggest that group acupuncture is generally accepted by patients, but mixed-sex groups may deter some participants.^22,23 In individual acupuncture settings, relaxation, therapeutic alliance, and lifestyle advice were found to be important facilitators of acceptability,²⁴ and deep relaxation was an important the rapeutic component.²⁵ It is important to understand whether receiving acupuncture in the group setting affects these or other unexplore daspects of care. On the other hand,theremay be benefits of group acupuncture, including therapeutic relationships and information-sharing with other patients experiencing similar problems.

Our goal in this qualitative inquiry was to deepen our understanding of how the group acupuncture setting both resembles and differs from the individual setting in terms of the patient experience of care.

Materials and Methods

Between March 2015 and August 2017, 706 patients were recruited into the Acupuncture Approaches to Decrease Disparities in Pain Treatment (AADDOPT-2), a two-arm comparative effectiveness trial to assess whether acupuncture for chronic pain delivered in a group setting is as effective as individual acupuncture in an urban, low-income, primarily black, and Hispanic patient population at risk for health disparities. Patients were recruited from six primary care clinics. Patients who were at least 21 years old, had chronic joint pain due to osteoarthritis,orchronic neckorbackpainlastingthreeormore months,wereabletoprovideconsentinEnglishorSpanish,and were available for up to 24 weeks were eligible. Patients with pain due to cancer are excluded. This substudy is a qualitative inquiry into the experiences of a subset of patients in the trial. The Albert Einstein College of Medicine institutional review board approved this study protocol (IRB # 2014–4192).

The interview guide was created through an iterative process, including research team members and patient stakeholders (Appendix 1). Questions aimed to elicit (1) anticipation of acupuncture in group and individual sessions, (2) experience of acupuncture during sessions, including treatment experiences, social interactions with acupuncturists and other patients, and the experience of the physical environment, and (3) perceptions of the outcomes of acupuncture. The initial guide was used to interview four patients (two in each arm) and revised to interview the remaining patients. Revisions included starting the interview by eliciting patients’ pain narrative and adding several more specific questions about the presence of others for those randomized to group sessions. After this revision, interviews were conducted using the revised interview guide with 42 additional patients.

Patients assigned to Group (n=23 patients) and Individual (n=23 patients) acupuncture were interviewed by phone by author E.C., a qualitative research fellow at the time of the study. The 30–60min interviews occurred at least 24 weeks after initiation of acupuncture, or 12 weeks after completion, whichever was later. Purposeful sampling aimed to select patients from all sites and include representation of both sexes and patients with both good and poor functional status. A total of 76 patients were called; 28 could not be reached after 1–2 attempts and two declined to participate due to time constraints. Patients were not previously known to the interviewer.

Interviews were audio-recorded and transcribed. The data were examined and categorized using an inductive thematic analysis strategy.²⁶ The first 14 transcripts were read in depth by two of the researchers (E.C. and N.H.), who independently identified coding categories. A consensus set of codes was derived by group discussion (E.C., N.H., B.K., and M.D.M). These revised codes were then applied independently by at least two researchers (E.C., M.B., and J.G.) to the remaining transcripts, and the initial fourteen transcripts were recoded (M.B. and J.G.). The data were coded in the Dedoose™ software program (Hermosa Beach, CA). Differences in coding were rare and were resolved with discussion.

Once the coding was completed, the immersion/crystallization approach²⁷ was used to look for patterns in the data. This approach is used when there is no existing theoretical framework that fits the inquiry at hand. The researchers immerse themselves in a detailed reading of the texts followed by reflection on the analysis process to attempt to describe patterns or themes noticed, while immersed in the data. Immersion followed by crystallization was repeated (E.C., N.H., M.B., and J.G.), alternating with group reflective analysis with the research team (E.C., N.H., M.B., J.G., B.K., and M.D.M.), until all the data had been examined and the meaningful patterns and themes extracted and described. The interviews were then reread to identify any disconfirming data (E.C. and M.B.). Finally, the findings were presented to the patient stakeholders for member-checking of the themes and conclusions.

Preliminary data analysis showed that data saturation had beenreachedafterforty-sixinterviewswithnoadditionalthemes emerging from the final set of interviews. (See Supplementary Data; Supplementary Data are available online at www.liebertpub.com/acm).

Results

Patients who participated in qualitative interviews were generally representative of the study population (Table 1). The experiences relayed by patients clustered around three major themes: value of acupuncture, treatment experience, and group acupuncture.

Table 1.

Characteristics of Patients by Randomization

	Group	Individual
Characteristics	n=23	n=23
Age, mean±SD	54.7±12.6	58.3±12.0
Male (n, %)	5 (22)	5 (22)
Race/Ethnicity (n, %)
Non-Hispanic White	1 (4)	1 (4)
Non-Hispanic Black	11 (48)	6 (26)
Hispanic	8 (35)	14(61)
Other/multiracial	3 (13)	2 (9)
Primary language (n, %)
Spanish	3 (13)	3 (13)
English	20 (87)	20 (87)
Employment (n,%)
Full time	5 (22)	2 (9)
Part time	1 (4)	3 (13)
Homemaker	1 (4)	1 (4)
Retired	6 (26)	7 (30)
Unemployed	3 (13)	3 (13)
Unable to work due to disability	7 (30)	7 (30)
Insurance (n, %)
Medicaid	16 (70)	17 (74)
Private	5 (22)	4 (17)
Other	1 (4)	1 (4)
None	1 (4)	1 (4)
Annual income (n, %)
<$20,000	10 (43)	8 (35)
$20,000-$29,000	4 (17)	3 (13)
$30,000-$39,000	2 (9)	3 (13)
$40,000-$49,000	1 (4)	0 (0)
>$50,000	2 (9)	2 (9)
Missing/refused	4 (17)	7 (30)
Clinic site (n, %)
BE	3 (13)	6 (26)
CHCC	5 (22)	2 (9)
CFCC	4 (17)	7 (30)
FHC	7 (30)	2 (9)
WBFP	4 (17)	6 (26)
Global functioning scorea (n, %)
≤2	11 (48)	13 (57)
>2	12 (52)	10 (43)
Withdrew (<12 sessions)	2 (9)	6 (26)
Had prior acupuncture experience	3 (13)	11 (49)

^aBaseline score on question number 6 of the PROMIS Global Health Scale: “To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries or moving a chair?” 5=completely, 4=mostly, 3=moderately, 2=a little, 1=not at all.

BE, Bronx East; CFCC, Comprehensive Family Care Center; CHCC, Comprehensive Healthcare Center; FHC, Family Health Center; SD, standard deviation; WBFP, Williamsbridge Family Practice.

Value of acupuncture

Patients in both arms described valuing acupuncture as an additional option for pain relief. The most common experience for patients in both arms was incomplete pain relief and recurrence of pain after completing treatments. Afew patients reported complete and lasting relief from pain, and a small number reported no change in pain. Even those who did not experience pain relief valued the opportunity to try a new modality.

“I was just happy to hopefully try to get some relief from pain.” (Group Acupuncture/Female/English Speaking/57 years old)

“I’m very pleased with the results. Sincerely, they are very good. Good, good, good, like something that dropped from Heaven.” (G/F/Spanish Speaking/54Y)

“The acupuncture has been over for a while now, and my pain is coming back little by little, and it’s coming back like it was before.” (I/F/S/62Y)

Many described improvements in physical functioning and quality of life.

“You know, I was able to cope with my everyday living much better.” (I/F/E/50Y)

“Well, just let me say that, for me, since I have had treatment with acupuncture, I’ve felt. I think the word is “useful.” Before this, I didn’t feel useful for anything. I felt terrible.”(G/F/S/54Y)

Treatment experience

Most participants described some anxiety when anticipating the needling experience. The majority of patients in both arms experienced minimal discomfort with only a few reporting significant pain. None stopped treatment early due to pain.

“[I was] a little concerned about maybe it touching a nerve and maybe. The wrong nerve or something like that.” (G/ M/E/68Y)

“Most of them I didn’t feel at all and once, you know, if there was any it was like a slight pinch like a mosquito bite and that’s it.” (I/F/E/74Y)

Patients in both arms of the study reported receiving gua sha, massage, and health education as part of their treatment.

“Well, we were addressing weight which I know adds to the joint pain that I have and she gave me some things to try and like some things to just even eliminate from my diet to see if I could see any change in doing that.” (G/F/E/57Y)

Group acupuncture

When asked to recall their initial enrollment in the study, most participants reported no worry about potentially being treated in the group setting.

“I don’t care if the audience was there, you know? Their issue, I assume, is the pain, too.” (G/M/E/68Y)

A minority of patients in both arms recalled feeling uncomfortable before starting treatment with the idea of receiving acupuncture in the group setting.

“I’m very careful of anybody sharing my information out there, even with my body, you know, even though you’re not completely naked but just anybody just looking at me in a weird kind of way, I’m very uncomfortable with.” (I/F/E/32Y) “I just felt that it was something that should be more private, in case it was uncomfortable. I didn’t want to scream in front of a bunch of people or feel influenced by them.” (G/F/E/ 53Y)

“I think it would be distracting for me, personally.” (I/M/E/46Y)

For those who were actually assigned to group acupuncture, concerns about physical privacy and informational privacy were often put to rest after experiencing the group setting.

“They don’t go too personal what they are doing. Yeah, you don’t have to disrobe or something like that.” (G/M/E/66Y) “Well, because [the acupuncturist] would come to each of us and she had a nice soft voice. Other people would hear but it was nothing, it was really nothing major that I couldn’t say in front of other people.” (G/F/E/53Y)

Some patients in the group setting continued to experience mild discomfort in mixed-sex groups.

“I felt a little more uncomfortable when there-when it was a man, you know, because. I had to. unbutton my shirt or whatever. I mean, they didn’t see anything, but I just felt a little uncomfortable.” (G/F/E/71Y)

“It wasn’t difficult. sometimes you would have a woman sitting there and I thought, you know, it should be the women in a different room setting and men in a different room.” (G/ M/E/66Y)

Most patients, however, reported that mixed-sex groups did not affect their acupuncture experience.

“It was fine. There was one older man, that’s it and he would talk about his grandchildren.” (G/F/E/59Y)

Patients assigned to group acupuncture were more likely to voice concerns about the physical environment of treatment sessions.

“To tell you the truth, at first it felt again I’m saying hey, what is this, are you sure this is-the hospital is sponsoring this? I mean why’d they stick you in the basement in this big old [conference] room?” (G/M/E/76Y)

Most patients assigned to group acupuncture described being able to achieve a state of deep relaxation during treatments.

“I’m telling you, I fall asleep It was like something so peaceful.” (G/F/E/59Y)

“I just was like relaxed, released.” (G/F/E/50Y)

Very few patients assigned to group acupuncture, and none of those assigned to individual acupuncture, found it difficult to relax.

“I didn’t find it especially relaxing in the same way that some other people did, you know? . I didn’t find it as tranquil as some of the other people that would like sleep or kind of zone out.” (G/F/E/33Y)

Patients in both arms had generally positive things to say about their acupuncturists. Several patients assigned to individual acupuncture described meaningful bonds that developed with the acupuncturist.

“She didn’t just talk about acupuncture, she made me feel important.” (I/F/E/51Y)

“It was as if she were my psychologist, giving like emotional therapy, and I liked that.” (I/F/S/63Y) “It was hard to let her go, not to see her again.” (I/F/E/58Y)

This was in contrast to patients assigned to group acupuncture, who tended to describe the relationship with the acupuncturist in more general terms.

“I cannot remember her name at the moment, but she was very nice.” (G/F/E/33Y)

“Sort of friendly. I didn’t get too personal with her, but she was friendly.” (G/M/E/66Y)

Finally, groups varied in their social dynamics. Some groups interacted more and sometimes provided an extra layer of support for participants.

“It’s better in a group anyway, at least you got some company while you [are] sitting there and you can talk to somebody instead of being in a room by yourself with needles stuck in you staring at the walls, make you go crazy.” (G/F/E/50Y) “The group was good because I am with people who are worse than I am and who have more experience. That was like my source of support, and my encouragement to continue.” (G/F/S/54Y)

Other groups remained more reserved and interactions were described as inhibited.

“I was very mindful of that and didn’t want to intrude on other people’s experience.” (G/F/E/33Y)

One Spanish-speaking participant noted that language was a barrier to interactions with other group members.

“We never talked about our pain because in the earlier sessions they didn’t speak Spanish and I didn’t speak English. We just said hello and that was it.” (G/F/S/64Y)

Discussion

Based on our previous work, we know that individual acupuncture is acceptable to patients and effective in treating chronic pain in a low-income, ethnically diverse, and medically underserved patient population.^18,19,25 If group acupuncture proves to be as effective as individual acupuncture in treating chronic pain in this setting, this approach will provide a potentially important avenue to expand access through a more cost-effective delivery model. However, understanding the patient experience of treatment in the group setting to make this approach as widely acceptable as possible is also a critical component of developing this model.

Our findings are similar to previous studies, in that, patients valued acupuncture therapy.^23–25 It is reassuring that this was true for both individual and group treatment. Pain relief and improvements in function and quality of life were similar. This study also confirms that mixed-sex groups are a barrier for some.²³ The fact that they were not expected to disrobe and were allowed to wear street clothing alleviated some of this concern. Acupuncturists maintained privacy of information by interviewing the patient one time privately before initiating treatment, and speaking in a low voice during the group sessions.

We were concerned that the deep relaxation, which many patients describe as an important part of the acupuncture experience, would not be achieved during group acupuncture, both due to the presence of others and the fact that acupuncture was received in a seated, rather than supine, position. Most of the participants were able to achieve deep relaxation, even in the group setting. The group setting also did not appear to inhibit other aspects of treatment such as lifestyle advice.

Patients in individual sessions described richer therapeutic relationships with the acupuncturists compared with those treated in groups. However, some indicated that the group itself contributed to their experience by helping them relax and by forming social bonds with other participants. This finding was not consistent across groups.

Finally, this study highlights the importance of maintaining a professional physical environment in the group setting. We implemented group acupuncture in community health centers, in many cases in rooms that were not designed for treatment such as conference rooms. However, the lack of a professional appearance in some of these rooms caused unease among some participants. The results of this study suggest that modifications to the appearance of the conference rooms may improve acceptability.

There are several limitations to this study. To capture information on the duration of pain relief, we conducted interviews at least 12 weeks after completion of acupuncture. This likely limited recall, particularly for questions regarding anticipation of acupuncture. It was reassuring that participants were able to describe their experiences during sessions in detail. Another limitation is that there were too few patients from each clinic site to evaluate whether there were differences between sites. While it might have been informative to understand if feelings about group acupuncture changed with the particular clinic setting, the implications of this would be speculative and this was not the main research question. Finally, an important limitation of this study is that the group treatments were staggered. Patients arrived at 15-min intervals to allow a single acupuncturist time to place needles. This may have inhibited interactions between group members. The experience of community acupuncture may vary depending on the work flow, especially the presence of an acupuncture assistant.

Conclusions

We found that group acupuncture and individual acupuncture were similarly valued by patients, but that group acupuncture is a different experience from individual acupuncture. Referring clinicians can increase the acceptance of group acupuncture by reassuring patients that they will not be expected to disrobe, and acupuncturists can increase acceptance of group acupuncture with careful attention to clothing, informational privacy, and the physical environment. Future study should focus on the impact of interaction between group members on the outcomes and experience of care.

Appendix A

Interview Guide

Thank you for agreeing to discuss your experiences receiving acupuncture as a part of this study. This interview is expected to take about 30–45min of your time. There are no right or wrong answers to these questions; we are only interested in finding out your thoughts and feelings.

1. Can you tell me about your past experiences with pain?

   1. What impact has pain had on your life up to now?(b) What has helped you cope with pain in the past?
2. What made you decide to be part of the Acupuncture study?

   1. Can you tell me about what the conversation waslike with your doctor?

Prompt: What did the doctor say about it? What went through your mind when he/she said that?

Prompt: Why do you think that your doctor recommended this?

1. Do remember what your thoughts or ideas aboutacupuncture were going in to the study?

Prompt: What kinds of things did other people say/ did you read/hear about acupuncture?

1. Was there anything you were concerned about?

2. Had you ever had acupuncture before the study?What was that like?

3. Do you remember your thoughts and feelingswhen you heard you might receive acupuncture in a group setting?

   1. Let’s talk about your treatment experience during this study.

4. Try to remember a typical acupuncture sessionyou had during this study. Can you describe to me what that was like?

5. Tell me how the sessions began. What happenedbefore the acupuncturist began placing needles? What happened next?

6. How did the experience differ from what youwere expecting, if at all?

7. What, if anything, was different about the acupuncture experience from other healthcare experiences you have had?

8. How relaxed or tense did you feel after a session compared with when you first came in? Did this change from the earlier to the later sessions?

9. Over the course of your treatment, what changed in how you thought about or coped with your pain?

10. Did the acupuncturist treat any medical issuesother than your pain? What was that like?

11. Were there any other changes in your life relatedto the treatment experience other than a change in pain?

12. Can you tell me about any parts of the treatmentexperience that were especially useful to you?

13. Can you talk about what was difficult or uncomfortable about the treatment experience?

Prompt: How did you feel about discussing your health issues during your sessions?

Prompt: What was the physical environment like?

1. What would you tell a friend if they asked aboutgetting acupuncture?

Prompt: What would you tell them about getting acupuncture in a group setting?

1. Now I would like to know more about your social experiences during treatment.

   1. What was your relationship with the acupuncturist like?

IF PATIENT WAS ASSIGNED TO INDIVIDUAL ACUPUNCTURE, SKIP TO QUESTION #5

1. What was it like to be treated with other peoplenear you in the group?

Prompt: How did the presence of other people affect your experience?

1. Think about a typical week. How many peoplewere usually in the group? Were you seeing the same faces every week?

2. Can you tell me more about the interactions between members in your group?

3. What were your relationships with your fellowgroup members like?

4. How did you feel about being in a group withboth men and women?

5. Did you learn anything from being in the groupthat you might not have learned from an individual session?

6. What else would you like to tell us about theexperience of having acupuncture in the group setting?

   1. (5) Think about your whole experience during this study from the referral process to today. Is there anything else you would like to tell us about how it went?

Prompt: Do you have any feedback you would have given to the person who took care of you?