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Advancing the Science of Integrative Health Equity - Original Article
Global Advances in Integrative Medicine and Health
Volume 14: 1–15
© The Author(s) 2025
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DOI: 10.1177/27536130251326938
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The Hidden Complexity of Virtual
Mindfulness-Based Group Medical Visits:
Comfort, Challenge, and the Influence of
Social Determinants of Health
Jessica L. Barnhill, MD, MPH
1
, Gabriela Castro, MD
1
, Christine Lathren, MD, MSPH
1
,
Elondra Harr, MPH
1
, Isabel Roth, DrPH
1
, Jose E. Baez, MD
2
, Ruth Rodriguez, MD
2
,
Suzanne Lawrence, MA
3
, Paula Gardiner, MD, MPH
4
, Carol M. Greco, PhD
5
,
Holly N. Thomas, MD, MS
3
, Susan A. Gaylord, PhD
1
, Graham Dore, MA
3
,
Anita Bengert, BS
3
, and Natalia E. Morone, MD, MS
2
Abstract
Background: Chronic low back pain is globally prevalent and associated with significant impairment in quality of life. Fur-
thermore, people from historically marginalized communities are less likely to receive treatment, contributing to health
inequities. Group mindfulness-based interventions improve pain and function, and virtual delivery has been demonstrated to be
feasible. Little is known about how participants experience the virtual delivery of mindfulness-based interventions, especially
participants from historically marginalized communities.
Objective: This study explored participant perspectives of a virtual mindfulness-based group medical visit for people with
chronic low back pain.
Methods: Participants were recruited from the intervention arm of OPTIMUM, a study of virtual medical group visits using an
adapted Mindfulness-Based Stress Reduction program for chronic low back pain. Semi-structured exit interviews were ex-
amined, and reflexive thematic analysis was used to compose key themes.
Results: Interviews from 59 participants (mean 56 years, 69.5% women; 45.8% Black or African American) were examined.
Two major themes were derived from analysis. The first theme was ‘effects of the external environment,’ie, the physical
location from which the participant engaged with the session. The subthemes were comfort, social demands in the home setting,
and sharing personal spaces. The second theme was ‘navigating the virtual platform.’Subthemes were ease, struggle, and levels of
support.
Conclusion: Patient experiences varied substantially during the virtual mindfulness-based group medical visit intervention and
this variation was influenced by social determinants of health. The key themes bring attention to the effects of the external
environment and the technology itself on participation for people from historically marginalized communities. Basic tenets of
mindfulness, such as present state awareness and equanimity, can provide a structure within which to navigate virtual participation
amid home environments. Future studies are needed to explore differences in virtual and in-person mindfulness programs and
to adapt virtual mindfulness programs.
1
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
2
Boston University Boston Medical Center, Boston, MA, USA
3
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
4
Director of Primary Care Implementation Research, Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA, USA
5
University of Pittsburgh School of Medicine and School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
Corresponding Author:
Jessica L. Barnhill, University of North Carolina at Chapel Hill, 1807 Fordham Blvd, Chapel Hill, NC 27514, USA.
Email: jbarnhil@email.unc.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the originalwork is attributed as specified on the SAGE and
Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Clinicaltrials.gov ID number: NCT04129450.
Keywords
mindfulness-baseed stress reduction, mindfulness, pain, telemedicine, whole health, virtual
Received August 19, 2024; Revised February 13, 2025. Accepted for publication February 24, 2025
Introduction
Chronic low back pain (cLBP) is one of the most common
pain conditions globally, affecting 619 million individuals,
and it is associated with significant impairment in quality of
life.
1
Furthermore, mechanisms underlying chronic pain are
poorly understood and strictly biomedical therapies have
demonstrated limited efficacy.
2
Integrative therapies, in-
cluding mindfulness-based interventions (MBIs), can im-
prove pain and function for patients with chronic pain,
including chronic low back pain.
3-5
Despite this demonstrated
efficacy, many people with cLBP have limited or no access to
MBIs.
6
Structural and societal factors like income inequality,
and disparities in healthcare access and infrastructure may
limit the reach of this effective therapy in target populations.
7
Patients in rural communities, Black people and people with
lower incomes suffer a disproportionate burden of chronic
pain and undertreatment of chronic pain.
8
Low socioeco-
nomic status is also associated with a higher burden of
chronic pain.
9,10
Introducing MBIs into primary care settings
could improve treatment of chronic pain, particularly among
historically marginalized communities. Integrative group
medical visits are an important model for treatment of chronic
pain. In this setting, patients benefit from peer learning, social
support, and clinician access.
11-13
Moreover, this type of
clinical encounter is covered by most insurers. Many benefits
have been linked to the group medical visit model, including
improved patient and provider satisfaction.
14,15
Videoconferencing is an integral part of clinical care and
health education in the post-COVID-19 pandemic era, and
MBIs are feasible in virtual settings.
16,17
As telehealth is now
fully integrated into most healthcare settings, it is important to
understand how this model affects participant experience.
Evidence to date suggests participation in synchronous vir-
tual group MBIs can improve mental health symptoms in
adult populations
18-20
and improve pain outcomes 30 days
postoperatively.
21
People with chronic pain conditions may
perceive virtual interventions as more accessible due to the
challenges of seeking care when chronically ill.
22,23
How-
ever, factors such as variable digital access and literacy,
differences in acceptability, and concerns about privacy may
affect experiences and outcomes.
24
Research is needed to inform the design, implementation
and evaluation of virtual mindfulness-based group medical
visits. From a health equity lens, group visits provide im-
proved access to medical care, education, and peer support for
low income and historically marginalized communities, who
are more likely to experience worse outcomes from chronic
pain.
25
To equitably increase access to MBIs, it is necessary
to learn more about how people, especially those from his-
torically marginalized communities, experienced this inter-
vention in the virtual setting.
Using reflexive thematic analysis of post participation
interviews, the study explored the experiences of participants
with cLBP who were learning adapted Mindfulness-Based
Stress Reduction (MBSR)
26
in a videoconference-based (ie,
virtual) group medical visit format. A framework was de-
veloped to evaluate how differences in experience correlate
with social determinants of health at multiple levels of the
intervention (See Table 2).
Methods
Study Design
This qualitative study was part of Optimizing Pain Treat-
ments In Medical settings Using Mindfulness (OPTIMUM)
and was approved by a single Institutional Review Board, the
University of Pittsburgh Institutional Review Board
STUDY20110378. OPTIMUM is an ongoing pragmatic
randomized controlled trial investigating the effect of an
adapted MBSR intervention, vs usual primary care, on pain
and function among primary care patients with cLBP.
27
The
intervention entails an 8-week virtual group medical visit led
by an experienced, trained MBSR instructor alongside a
primary care clinician. The intervention was delivered over
the Zoom platform (Zoom version 1.8.0.2305) from No-
vember 2021 to April 2024. The standard MBSR program
was adapted to include brief visits with a healthcare provider
via a private breakout room within each 2-h session, chair-
based mindful movement, and, unlike traditional MBSR
programs, did not include a retreat day. Guided mindfulness
meditation audio-recordings were made available to partic-
ipants for home practice. In addition, the 8 weekly sessions
were each 2 h long and included time to accommodate in-
dividual breakout-room meetings with the primary care
provider. This is distinct from the standard MBSR curricu-
lum, which is 2.5 to 3 h long.
Participants were encouraged to identify a quiet, private,
and regular space from which to establish their virtual
connection. Earphones, tablets, and support for connectivity
were available to facilitate participation. In addition to a brief
2Global Advances in Integrative Medicine and Health
introductory and technical troubleshooting session, staff were
available to call and walk participants through the log-on in
real time at the start of the session or in case of lost con-
nections. Video participation was encouraged but not re-
quired for participants. Mindfulness instructors and clinicians
remained on camera throughout the sessions and participants
were reminded to turn their cameras on if they were able.
However, they were not required to do so. Due to technical
limitations, some people attended via audio connection or
phoneline only. These within group intervention variations
were consistent with the pragmatic clinical trial design that
asks whether the intervention can work under usual condi-
tions vs an explanatory trial that asks whether the intervention
works under ideal conditions.
28
Participants in the OPTIMUM intervention were invited to
complete an optional post-intervention one-on-one interview.
As part of these semi-structured exit interviews, participants
were asked about their experience of the virtual aspect of the
mindfulness intervention (see Appendix A).
Study Population
English-speaking, non-pregnant adults with chronic low back
pain were recruited from primary care practices including one
Federally Qualified Health Center in central North Carolina
and three academic health systems from Pittsburgh, Penn-
sylvania, Boston, Massachusetts and Chapel Hill, North
Carolina.
27
People with worsening pain, or unexplained fever
or weight loss during the past month, and people with
metastatic cancer were excluded from the OPTIMUM trial.
Data Collection
Groups ranged in size from 4 to 13. Upon completion of the
group, OPTIMUM intervention participants were contacted
by phone, text or email by the research teams and invited to
participate in audio-recorded virtual semi-structured exit
interviews via teleconference platform. Given the size and
multi-site design of the trial, it was more pragmatic for each
site to identify their own interviewers. Interviewers utilized a
common interview guide to help minimize bias. Interviews
were conducted by 4 female MDs, one male MD, and one
DrPH all of whom were trained in semi-structured interview
techniques. Interviewers’self-identified racial identities in-
cluded: Mixed Race, Black or African American and White,
and White. Their self-identified ethnic identities included:
Latina, Hispanic, and Non-Hispanic. Some interviews in-
cluded a second researcher who was training to conduct
interviews. Some participants had a working relationship
with these interviewers throughout the enrollment and in-
tervention process. Interviews at one site were conducted by
an independently contracted qualitative research center. In-
terviewers followed a pilot-tested guide that included
prompts to describe participants’experience in the program,
their expectations about the program, their use of mindfulness
skills in daily life, their motivations to continue to participate
in the sessions, and their feelings about the virtual group
format. For example, the guide included questions regarding
the use of technology, facilitators and challenges, privacy
concerns, and about having the clinician present (See
Appendix A). Interviewers encouraged participants to speak
openly about their experiences and informed them that de-
identified feedback would be used to improve the program for
future participants. Participants were compensated $50 for
completion of the approximately 20-min interview. Most
participants joined the virtual interview from a private space
in their home. However, some participants joined from their
work setting, car, or yard. In total, 59 participants provided
exit interviews. The 59 interviews were transcribed verbatim,
de-identified and uploaded to ATLASti (ATLASti version 7).
Exit interviews were collected from 59 out of 122 partici-
pants. Transcripts were not returned to participants, and
participants did not provide feedback on the findings, because
there was concern about the frequency with which partici-
pants were already asked to provide data (monthly for
12 months).
Data Analysis
For this manuscript, the interview data were analyzed using a
reflexive thematic analysis approach.
29
This approach was
chosen as it is a flexible methodology that aims to identify
patterns of shared meaning across participants’experience,
while also recognizing and valuing the influence of the re-
searchers’subjectivity in this process. We approached the
data from a constructivist/interpretive standpoint. From this
view, there is no one ‘reality’to uncover, but rather, reality is
dependent on interpretation. Thus, we acknowledge that the
patterns of meaning identified here represent one of many
ways to understand participant experience. Furthermore, due
to this standpoint, we refrained from methods that aim to
eliminate bias (eg, inter-rater reliability, data saturation) as
these are not appropriate in a reflexive approach. For ex-
ample, Braun has discussed the pitfalls of reporting inter-rater
reliability and data saturation when utilizing reflexive the-
matic analysis.
30
Instead, we acknowledge the subjectivity
and perspectives of the participants and the researchers and
the role that this subjectivity plays in co-creating this analysis.
Initial rounds of coding were conducted by authors RR,
JB, JLB, EH, CL, and IR, who developed a codebook
containing 22 codes. This initial phase of analysis was de-
scribed in detail in the manuscript, “Pragmatic approaches to
team-based qualitative analysis of exit interview data in a
pragmatic clinical trial.”
31
Then, analysts MGC, CL and JLB
built their analysis upon this initial work.
JLB is a Family Medicine physician and researcher at a
large academic research center who studies group-based
interventions for chronic pain and post-COVID conditions.
MGC is an academic Family Medicine physician embedded
in a Federally Qualified Health Center with a specific interest
Barnhill et al. 3
in mind-body medicine, addiction care and chronic pain. CL
is a former physician and current researcher who examines
interpersonal relationships, mindfulness and self-
compassion. Given that all 3 researchers had experience in
clinical medicine, their perspectives regarding the clinician-
patient relationship and healthcare communication influenced
the analysis process. This included determining what data
were meaningful to the research topic and what thematic
groupings were most important.
Their coding process was iterative and included inductive
coding (derived from the data) and deductive coding (derived
from the interview questions). They began by analyzing
segments of interviews coded as “virtual experience”and
ultimately re-read the interviews and re-coded the segments
relevant to research questions. Coders chose meaningful
portions of text that appeared relevant to the research aims.
Some codes were descriptive (eg, “convenience”), while
other codes were latent (eg, “role strain”). We followed
6 steps as suggested by Braun and Clark.
29
(1) First, all
3 coders familiarized themselves with the transcripts by
reading through them several times and creating reflective
memos with observations for each transcript. (2) Next,
coders applied codes to segments of text in a subset of
6 transcripts. The coders met to discuss coding and include
diverse perspectives on code development. Coding con-
tinued for the remaining transcripts. (3) An initial set of
themes were generated by going back and forth between
the codes, selecting key quotes, and re-coding segments as
needed as part of theme development. Discussions between
the 3 coders and reference to their memos continued to play
an important role in this process. (4) Themes were de-
veloped with attention to key quotes, and then (5) refined
and defined through discussion. (6) The last step was
manuscript development, with re-engagement with the
transcripts to ensure quotes were placed in context. Finally,
to enhance the quality of reporting, authors used the
COnsolidated criteria for REporting Qualitative research
(COREQ) checklist (Supplement 1).
32
Health Equity Framework
In seeking to understand the role of social determinants of
health upon participant experience of virtual MBSR training,
we drew heavily upon the research framework published by
the National Institute on Minority Health and Health Dis-
parities.
33
Our analysis utilized this structure to consider
factors affecting participant experience by the domain of
influence (social determinant) and the level upon which that
domain exerts influence (individual to societal). Examples of
these factors with relevant participant quotes are presented.
Results
Among 122 eligible participants, 59 completed exit inter-
views. Of 59 participants, 27 were Black or African
American, 41 were female and 45 were unemployed. At least
one third (30.5%) had an annual household income below
$25,000, another 28.8% preferred not to answer, and 40.7%
had an educational attainment of high school or less (Table 1).
All participants were assigned to the intervention arm of the
study. We detail two key themes from exit interviews with
these participants, including (1) the effects of external en-
vironments on participants’program engagement and (2)
their experiences navigating the virtual platform. There were
3 subthemes regarding the effects of the external environ-
ment: comfort, social demands in the home, and sharing
personal spaces. There were 3 subthemes regarding
Table 1. Characteristics of participants completing exit interviews
Category
Number of Patients
n (%)
Total 59
Average age (years) 57
Age range 27-79
Race
American Indian or Alaska native 2 (3.4)
Asian 2 (3.4)
Black or African American 27 (45.8)
Native Hawaiian or Pacific Islander 0 (0)
White 25 (42.4)
Unknown 1 (1.7)
Not reported 2 (3.4)
Ethnicity
Hispanic or latino 1 (1.7)
Not hispanic or latino 56 (94.9)
Unknown 1 (1.7)
Not reported 1 (1.7)
Gender identity
Male 18 (30.5)
Female 41 (69.5)
Not reported other 0 (0)
Highest level of education completed
Less than secondary/high school 1 (1.7)
Some high school 2 (3.4)
High school degree 21 (35.6)
Associate’s/technical degree 13 (22.0)
College degree 11 (18.6)
Doctoral or postgraduate education 11 (18.6)
Annual household income
Less than $10,000 6 (10.2)
$10,00 to $25,000 12 (20.3)
$25,000 - $100,000 21 (35.7)
Over $100,000 3 (5.1)
Prefer not to answer 17 (28.8)
Employment status
Full-time employment 10 (16.9)
Part-time employment 4 (6.7)
Not employed 45 (76.2)
4Global Advances in Integrative Medicine and Health
navigating the virtual platform: ease, struggle, and levels of
support (see Table 2).
Effects of External Environments
The first theme described the effects of the “real world”or
physical space that each person inhabited during the
mindfulness-based group medical visit. Most participants
were in their home; however, a few joined the session from
their yard, a vehicle or a public space. For some partici-
pants, location varied by week, adding uncertainty to the
experience. The space either enhanced or detracted from
each person’s ability to engage with the session. The
subthemes were comfort, social demands, and sharing
intimate spaces.
Comfort: “Just the Very Same in My Home”
Overall, participants valued the opportunity to connect
from home. Participants’social location affected their
degree of comfort or ease with the virtual experience. For
participants employed outside the home, and for whom
private space at home was available, the virtual experience
was often one of comfort and ease. For example, a par-
ticipant noted,
“I felt like I was in person, just the very same. But just to know
that it was done to my convenience. After a long day at work, I
was able to come home. I was able to be a part of the study, just
the very same in my home, in my own space, and everything
where I’m comfortable.”(35-year-old Black, Non-Hispanic fe-
male, ID 8)
An important component of the MBSR curriculum in-
volves practicing meditation at home between classes since
regular practice is associated with improved outcomes.
34
Providing instruction at home enabled participants to learn
mindfulness in the setting where they would be practicing it.
This participant explained,
“If you think about it, you’re using the practice online and you’re
in your own home and that’s where you’re going to practice it.
So, it’s easier to apply instead of going to the office and [saying],
‘oh I’m gonna go home and try this.’” (44-year-old Black, Non-
Hispanic female, ID 6)
Social Demands in Home Setting: “No One Would Let
Me Have It”
By contrast, the home environment detracted from the ex-
perience in some cases. For some participants, the home
lacked space, structure and/or privacy. This introduced a
conflict between being present with others at home and
engaging in the session. Participants’social location affected
their ability to create a home environment conducive to
practicing mindfulness. Participants described attempting to
set boundaries with family and friends and to remove them-
selves to private parts of the home, only to be interrupted by
people asking for their help. These interruptions and caregiving
duties were particularly prevalent during the early evening
when the occupants and the functions of the home were
shifting. This participant described attempting to isolate herself
in one part of the home, only to be repeatedly interrupted by
company: “I’dtellpeopleI’m on Zoom -- and no one would let
me have it. The company was turning over. [It’s just] the time
Table 2. Major themes and subthemes from reflective thematic analysis
Effects of the External Environment
Comfort “I felt like I was in person, just the very same. But just to know that it was done to my convenience. After a long day at
work, I was able to come home. I was able to be a part of the study, just the very same in my home, in my own space,
and everything where I’m comfortable.”(35-year-old black, non-hispanic female, ID 8)
Social demands in
home
“My older kids come in, mom, they did this, why is it doing that? You know, so it was hard to find that quiet peace.”(35-
year-old white, non-hispanic female, ID 20)
Sharing personal
spaces
“I just didn’t feel comfortable in my own room. I just didn’t. I didn’t want to have that stress on my head [of] what they
could see and couldn’t see.”(69-year-old black, non-hispanic female, ID 27)
Navigating the Virtual Platform
Ease “I knew that there wasn’t much to prevent me from being able to look at a phone and talk to people. You know, it’s not
like I had to stand on my head or balance myself on one foot and hold the phone up…you’re not asking a lot.”(58-
year-old black, non-hispanic male, ID 2)
Struggle “When you’re looking at this little teeny, square person on the screen, it’s hard to make connections.”(70-year-old
white, non-hispanic female, ID 26)
Levels of support “I’m new to all this technology and stuff and I’ve just given that up to the staff that I’m working with, you know, for that
part of the job.”(58-year-old black, non-hispanic male, ID 1)
Barnhill et al. 5
of day …somebody would stop by and then run to the room.”
(69-year-old Black, Non-Hispanic female, ID 27)
For participants in smaller living spaces with more oc-
cupants, it was not possible to find a private space. Some
participants joined from outdoors or from their cars to find
privacy. The time of day was particularly problematic for
some participants: “[It] was at dinnertime and there was just
too much confusion in the kitchen and that was really the only
place I could go and sit.”(65-year-old White, Non-Hispanic
female, ID 3)
Another participant described the challenge of prioritizing
attention to the virtual session when interrupted by an in-
person interaction. She could silence a phone call during a
virtual session but turning away from an in-person interaction
evoked loss. The moment juxtaposed what we expect to give
and get in a virtual vs in-person interaction.
“I can always look at my phone and say, ‘I think I can call you
back later’, you know? But then somebody starts knocking at
your door, that makes you stop and see who’s at the door, you
know? …[They] might catch me off guard and we start talking
about something and then lead to something else. And they’re
more people coming in. Before you know it, I forgot what I was
supposed to be doing for myself.”(60-year-old Black, Non-
Hispanic female, ID 12)
Several participants described competing demands which
they attempted to resolve by shifting attention between the home
and the virtual session to meet expectations of both. One par-
ticipant described the tension between her role as a homemaker
and wife and her desire to attend the group from home:
“I don’t really get to see my husband that much because of his
job. And then he’s at home, and to him it’s like, “my goodness,
why you going to be on the phone for such a time”…You know,
I just hate to just close the door. [laughs] So, I was having my
phone on mute, and unmute it and mute it, and unmute it. And I
[said] to him ‘So, honey, this is a class I’m in. I’ll be off in a few
minutes, baby. Give me time, okay. Your food is already fixed,
and I’ll be off soon’.He’s really not used to that because he’s–
when he comes home, I greet him at the door, and it just it wasn’t
quite like that. [laughs]”(70-year-old Black, Non-Hispanic fe-
male, ID 30)
While participants would have weighed social obligations
and opportunities against attendance in both in person and
virtual training, the flexibility inherent in virtual encounters
introduced more opportunities to weigh the benefits and costs
of attendance. For example, this participant described getting
caught up in a series of events that eventually resulted in her
not attending the group. The participant’s quote illustrated the
interconnectedness of family in her social context. For her
this meant that her most important social responsibilities and
demands globally affected her availability to participate but
also provided enduring support –a reason to prioritize them
continually.
“[Some] days when my family come and get me, I had to go to the
doctor’soffice, you know? Then we might be at a restaurant
getting something to eat after we leave the office. You know we
want something to eat. Or somebody wants to stop at Ross you
know, get just some outfits for the kids. I mean, I didn’t try [to
miss the virtual session]. I would be with my family. And then
before you know it, I said, ‘oh, look at the time. My phone is dead
and I have missed the appointment.’” (60-year-old Black, Non-
Hispanic female, ID 12)
This participant described the tension among comfort,
convenience, and distraction stating “the pro was I didn’t
have to find a babysitter. I can be in my house. And the same
time, that’s–you know, the same con. My older kids come in,
mom, they did this, why is it doing that? You know, so it was
hard to find that quiet peace, but it was also nice that I can do it
in my own home …I think if I did it in a doctor’soffice, I
wouldn’t have been able to relax and meditate the way I was
able to do at my home.”(35-year-old White, Non-Hispanic
female, ID 20)
Sharing Intimate Spaces: “People Seeing How I Live”
Some participants did not have a quiet, private or com-
fortable area within the home from which to join the
session, requiring them to move to a more personal space.
This introduced inequity in the level of intimacy involved
in attendance. For example, a participant discussed having
the camera on in their bedroom, “Ijustdidn’tfeelcom-
fortable in my own room. I just didn’t. I didn’twanttohave
that stress on my head [of] what they could see and couldn’t
see. I can see enough right here on your screen that you all
could see enough in my room. And that’s just above your
head, so.”(69-year-old Black, Non-Hispanic female,
ID 27)
With technical assistance, some inequities can be miti-
gated. For example, when the participant was shown how to
blur the background, she felt more comfortable:
Interviewer: If we had been able to teach you [how to blur the
background], do you think that might have helped?”
Interviewee: “Yeah. That would have helped. I like that. Because
it is blurred, you know, as and you don’t know what you’re
looking at. Because in my bedroom I mean, I got everything in
there.”(69-year-old Black, Non-Hispanic female, ID 27)
Leaving the camera off was one way to preserve privacy
and comfort when there were limited options in the home
environment. However, many participants wanted to be seen.
This participant lived with her mother in a small home, and
6Global Advances in Integrative Medicine and Health
she described foregoing comfort and privacy in preference for
being seen on video:
“My space is limited where I’m living, how I’m living. I’m living
with my mother in her house. So, I have one bedroom, and she
doesn’t have like a kitchen table or chairs. Her setup is different.
So, I really had no place to sit in the chair, and it was hard to really
figure out where I was going to put the computer so I could show
up on Zoom. I could have done it the whole time without showing
up on Zoom, but I thought it would be more fun just to be seen
and heard too. So, that was the challenge. The challenge for me
was just my space, my limited space.”(63-year-old Black, Non-
Hispanic female, ID 10)
In summary, there were pros and cons to learning
mindfulness remotely from the home or community setting.
For these participants, many of whom are women who have
caregiving responsibilities, virtual participation was com-
plicated by the multiple competing demands on their time
and attention. The wide variety of social expectations/
relationships and feelings about physical spaces (positive
or negative) variably affected participants’experience of the
program from week to week, adding a mix of uncertainty,
vulnerability and comfort. The differences in participants’
experiences were often related to social determinants of
health as experienced individually, interpersonally and in
community (See Table 3).
Navigating the Virtual Platform
Navigating the virtual platform refers to participants’expe-
riences using technology to engage with others in this po-
tential space that is co-created and mediated by technology.
The virtual space was new to many, but not all, participants.
The most striking finding about participants’experiences
navigating the virtual platform was the heterogeneity of
experiences often influenced by participants’social position.
Subthemes included ease, struggle, and levels of support.
Ease: “It Was Just so Simple”
Many participants commented on their comfort with the
technology and the ease of use. For example, a participant
said, “It was just so simple. You picked up your phone or your
computer or whatever you were going to use, and you did it.
You had the class. It was very, very simple.”(54-year-old
White, Non-Hispanic female, ID 34) Another participant
shared a similar sentiment, “I knew that there wasn’t much to
prevent me from being able to look at a phone and talk to
people. You know, it’s not like I had to stand on my head or
balance myself on one foot and hold the phone up…you’re
not asking a lot.”(58-year-old Black, Non-Hispanic male,
ID 2).
Some participants described value that was added with the
technology. For example, this participant explained, “No, I
don’t mind the camera at all. I think it’s kind of fun sometimes
to see people in their own environment, like in their own
habitat! Like this environment, or even if you’re laying down,
or you know, it’s okay. It makes you more comfortable with
people. I don’t mind it at all.”(63-year-old Black, Non-
Hispanic female, ID 10) For participants who were socially
isolated and unlikely to seek in-person care, virtual access
was largely positive. For example, this participant who is
unemployed and on disability shared, “It felt like I was being
taken care of. It felt like as if I was going to a doctor’s
appointment, but it was so much cooler!”(51-year-old Black,
Non-Hispanic female, ID 35) For some, the virtual envi-
ronment increased comfort and safety in the group setting.
Differences in education level and social skill may have been
less pronounced. One participant noted: “I’m nervous talking
to multiple people. If I’m not there, it’s better if it’sona
telephone, when I’m there in person, my anxiety goes to the
roof. And that’s because I did terrible in school, and ev-
erything reminds of sitting in school and being on spot.”(59-
year-old White, Non-Hispanic female, ID 28). Personality
factors and preferences also played a role in comfort level, as
is highlighted by this participant: “I liked it online, because
I’m kind of a not-a-crowd person. And since I’m not sitting
there looking at people, I felt freer to talk, express my
opinion. But if we were face-to-face, I might be held back
some.”(62-year-old White, Non-Hispanic female, ID 16).
Socialization at a distance was particularly comforting
during the pandemic when the prospect of contagious illness
was a large threat. For participants with weakened immune
systems, the virtual platform expanded access to care: “I liked
it better online and you know, I could see them if they wanted
to be seen, they could see me, but not be close enough to
where if they sneeze, they would not get on me. I mean, I’m
not a germaphobe or nothing like that, but because of COVID
and you know like I said, I had cancer, so my immune system
is down you know from all the treatments, so this was actually
a really fun way to meet the other people, the other ladies and
stuff that were in the group.”(49-year-old American Indian or
Alaskan Native, Non-Hispanic female, ID 11).
Researchers anticipated disparities in virtual access and
provided tablets to participants without virtual access. The
pragmatic clinical trial design also included flexibility to ap-
proximate real-world conditions, such as accommodating
participants who chose to keep their cameras off. This was
important to some participants. As described by one person:
“You had the option to put yourself on video, or if you didn’t
want to be on video. So, that was very calming for me, because
even if I’m talking and I wanted to turn off the video on the
tablet that was provided to me on this study. I had the option to
do so.”(35-year-old Black, Non-Hispanic female, ID 8) The
use of break out rooms where participants interacted in smaller
subsets was a highlight for some: “It was nice to get the
breakout rooms and speak with other people and stuff…And
like I said, everybody was really nice. And it was a nice thing to
do.”(52-year-old Black, Non-Hispanic female, ID 13).
Barnhill et al. 7
Some participants would not have attended the inter-
vention if it were in-person at a clinical site due to heavy
caretaking responsibilities, long travel times and the cost of
hiring a caretaker. For example, this participant whose
daughter is disabled explains, “I was able to do it. If it was not
online and it was in person, I wouldn’t have been able to
because…going somewhere, and having my daughter, get-
ting somebody here to take care of her. And me having to go
somewhere is more time. [It] would take me an hour to get [to
the physical location]. So, that’s an extra 2 h …” (44-year-old
White, Non-Hispanic female, ID 38).
Struggle: “I Don’t Really Want to be Online for Two
Hours With Nobody”
Meanwhile, for other participants, the increased distance
created by the virtual platform felt like a barrier to connection
compared to in-person experiences. This participant lamented
the loss of physical touch: “And also, the ability to feel
connected to the other people. If I were in the same room with
him, I’m just imagining this for a minute. We were sitting in a
circle in the same room. There are probably times during the
discussion that I would have actually touched them, touched
the other people in the group. And that human connection as
simple with touch is part of good communication for me. So,
yeah, we’re robbed. Zoom robs us of at least one aspect of
how we communicate with each other.”(72-year-old White,
Non-Hispanic male, ID 46) The sentiment of having lost out
was commonly expressed, “I would love it to be able to be
there and do this and be with the same people that I was with.
That I was feeling their energy you know to make you want to
really get this done…oh I would love that if that was to ever
happen.”(58-year-old Black, Non-Hispanic female, ID 5)
“There’sdefinitely a difference between doing it in person
and doing it on the [Zoom]. I would think that ideally, it
would be wonderful for people to do that in person. For one
thing, it’s easier for people to share and talk to each other
when they’re in the same room. Even people who are more
Table 3. Framework for analyzing variations in patient experience arranged by social dterminant of health and level of influence
35-37
Social Determinant of Health
Built Environment, eg,
Infrastructure &
Accessibility
Healthcare Access
and Quality of Care
Social and Community
Context, eg, Discrimination
Economic Stability
eg, Jobs, Food,
Housing
Education Access and
Quality
Level of influence
Individual Access to quiet
uninterrupted
space, correct
equipment,
connectivity to
phone and data plan,
eg, “just the very
same in my home”
Access to in-person
mindfulness-based
group medical
visits, eg, “I liked it
better online…I
had cancer so my
immune system is
down.”
Autonomy in home; social
role in home; childcare
or other coverage; belief
systems, acceptance of
nonpharmacologic
treatment, eg, “no one
would let me have it”
[other members of the
household] would not let
me have [access to a
private room]
Cost of Wi-Fi and
cell phone plan;
flexibility and
predictability of
work schedule
Technical skill,
comfort level
learning new skill,
experience of using
technology, eg, “it
was just so simple”
Interpersonal Quality of video,
privacy, eg, “people
seeing how I live”
Role of medical
provider in group
Connection with instructor
and group members, eg,
“if we were face to face I
might be held back
some”
Ability to prioritize
attending group
Prior
experience
interacting online,
prior educational
experiences, eg, “I
love doing zoom
now.”
Family,
community
Time of day and activity
level in shared
spaces, eg, “the
company turning
over [people coming
and going in the
evening]”
Past relationships to
healthcare, eg, “if I
did it in a doctor’s
office, I wouldn’t
have been able to
relax”
Cultural familiarity with
mindfulness terminology
Economic tradeoffs
to attending, eg,
“I’d be with my
family and before
you know it I
missed group.”
Access to mindfulness
education
Society Broadband access Insurance, primary
care workforce
Access to trained MBI
instructors
8Global Advances in Integrative Medicine and Health
hesitant to talk …when you’re looking at this little teeny,
square person on the screen, it’s hard to make connections. It
would really be better if it was done personally. Wherever
possible.”(70-year-old White, Non-Hispanic female, ID 26).
Others commented on the increased level of concentration
and energy expenditure required compared to in-person ex-
periences. For example, this participant found the pace ‘a
little fast’and the cognitive load heavy: “I’ve never had this at
a doctor’soffice, but I don’t know if it will be more effective
in person, maybe, but the thing is, it just felt long. It felt long
to me…and a little fast. If I’m being honest, I don’t really
want to be online for 2 h with nobody.”(52-year-old Black,
Non-Hispanic female, ID 13). Meanwhile, for others, the
energy input was balanced by valuing the experience: “So, for
me to sit on the computer or my phone on a Zoom meeting for
an hour and a half, almost two sometimes, was a lot for me,
but it was worth it.”(67-year-old female, race and ethnicity
undisclosed, ID 4).
Levels of Support: “Where There is a Will, There is a
Way”
Participants had varying levels of experience and comfort
with technology. For many participants, this was their first
experience using video-conferencing technology to attend a
virtual group. Others were well acquainted with the format
through work and social connections, and this contributed to
their positive experience: “I love Zoom now. That’s because
with this pandemic, I belong to a sorority, and we’ve had our
Zoom meetings. I was already in tune on how to use them,
how to get out and go into the breakout room, how to leave
the breakout room, how to stop my video if I needed to, how
to turn up my volume. I didn’t have a problem at all.”
(63-year-old Black, Non-Hispanic female, ID 23). Similarly,
another participant expressed this ease: “Iwasfine with
doing it online. I really was. I also should add, though, I
spent the last 19 years of my working life working remotely
and, in fact, managing it for the last 8 of those years, I was
managing a huge team of people spread all across the
country and had to do it all remotely. It was no change for
me. I mean, it was not a big deal.”(70-year-old White, Non-
Hispanic female, ID 26).
For others, it was essential that technical assistance was
provided. Flexibility and persistence on the part of partici-
pants and researchers was important to support equitable
participation. For example, this participant explained, “Al-
though I haven’t got it on the [screen] –there was a way, and
they would hook me up and make sure I was included. It was
like one way or the other. Wherever there is a will, there is a
way!”(70-year-old Black, Non-Hispanic female, ID 30)
Similarly, this participant noted, “I have no problems with it.
I’m new to all this technology and stuff and I’ve just given
that up to the staff that I’m working with, you know, for that
part of the job…I could be anywhere, and I’ll try this, try
that.”(58-year-old Black, Non-Hispanic male, ID 1).
In summary, participants expressed missing out on in-
person experiences balanced by benefits of the virtual
experience. There was a range of comfort with video-
conferencing technology, with some having “never done a
Zoom thing ever in [their] life”while others having to shift to
online “professionally and personally”and thus “having no
issue with it being online.”Meanwhile, the truly mixed
experience was summed up nicely by one participant: “So,
getting comfortable and not having that real connection that
you do with folks, person to person, there’s that energy,
there’s that feel that you take for it. So, I think that was a part
that I probably missed out on…but it was also nice that I
didn’t have to travel anywhere, there was no stress of parking
or traffic or anything else like that. So, being able to do it in a
comfortable environment and space like that, …it was al-
ways a wash at the end of the day.”(38-year-old White, Non-
Hispanic male, ID 18).
Discussion
In the post-COVID era, more research is being published with
recommendations and guidelines for virtual engagement in a
wide variety of contexts.
38,39
This study included participants
across the socioeconomic spectrum and provided insights
about the contribution of social determinants of health to the
disparities in access and effort required to participate in
virtual group mindfulness trainings (see Table 3).
40
Some of
these disparities were represented by the quotes and themes
explored in this manuscript, while other disparities can be
explored in future work.
This qualitative analysis described the complexity un-
derlying the experience of virtual mindfulness-based group
medical visits. Participants simultaneously navigated varying
external and virtual environments, resulting in differential
obstruction and facilitation of the virtual experience. The
experience of comfort, convenience and ease of use for some
was juxtaposed with technological challenges, competing
demands in the home and a desire for privacy.
Hidden Complexities
Video-conferencing technology presented each participant as
a square on a screen. This flattened context lacked the depth
and subtlety of in-person engagement, where a broader range
of nonverbal communication is available. However, these
interviews suggested a hidden complexity, or dimension, to
virtual groups compared to in-person groups. As Figure 1
illustrates, during an in-person mindfulness-based group
medical visit, participants shared a single external environ-
ment (classroom, break room, etc.) and individual internal
experiences. The virtual experience had an additional layer
for the individual, as each person navigated a separate ex-
ternal environment while participating in the creation of the
virtual session. Ultimately, participants’experiences were
influenced by 3 environments: external, internal, and virtual.
Barnhill et al. 9
This competition for participants’attention may have in-
creased cognitive load. At the same time, learning mind-
fulness in the middle of life with its competing priorities
offered the opportunity to practice present moment awareness
and equanimity while meditating. Equanimity refers to “an
even-minded mental state or dispositional tendency toward
all experiences or objects, regardless of their origin or their
affective valence (see Figure 2).”
By examining the variety of experiences occurring in the
external and virtual environments, researchers saw a more
robust picture of the hidden complexities inherent to this
model. Additional variation was introduced since each per-
son’s virtual environment was mediated by their technology.
Each instance of variation in patient experience was an op-
portunity to consider whether social determinants of health
were at play and whether the variation present could result in
more or less health equity.
One concrete example of the difference between in-
person and virtual groups is to compare the process of ar-
riving to in-person vs virtual group mindfulness training.
There is a paradox here that virtual care is simple and yet its
practice is complex. The discrete process of arriving and
being physically present during in-person mindfulness
training is not replicated in the virtual setting. Complexity
exists in the varied external environments of all participants,
in the movement of concentration and attention among
different stimuli, and in each participant’s relationship with
and response to technology. In-person mindfulness training
sets the stage with a common external environment, that is
arranged to promote attention and focus, whereas virtual
mindfulness training involves sustaining attention toward or
perpetually re-engaging with a shared virtual space. With in-
person mindfulness training, participants experience a
transition - they leave their prior setting and physically
arrive for mindfulness training. Verbal and nonverbal cues
communicate participants’level of engagement. Rather than
investing energy upfront with travel, time, etc., virtual at-
tendance begins in an instant by clicking on a link. The lack
of transition time to reorganize the internal environment and
the lack of a physical transition to mark the start of the
session can collapse the space for mental and physical
preparation for mindfulness training. Attending to one’s
environment to minimize distractions is helpful but is not
always possible. In this manner, virtual mindfulness training
occurs in the “real world”where competing stimuli vie for
one’s attention. Arrival and presence are dynamic factors.
There is an inward movement involved in arriving and
maintaining presence during virtual mindfulness training
that is individualized and largely unknowable by instructors
and other participants. This is another area where virtual
mindfulness training reflects the real world more directly
than in person training, because people are engaging with
mindfulness from their homes. They are in home envi-
ronments when they attend, and they are not removed to a
classroom or retreat center.
Pedagogical Implications
Conveying the work of mindfulness presents a unique
challenge. The process is internal and individual, and the
product is also internal and not easily assessed by an
outside observer. In teaching mindfulness, instructors offer
guidance that alternately brings attention to the internal
and external environments, prompting participants to ex-
plore connections from the liminal space in between. In this
process, participants can begin to conceptualize separately
Figure 1. Complexity introduced by virtual vs in-person group mindfulness training.
42
10 Global Advances in Integrative Medicine and Health
the observed environments (internal and external) and the
place from which they observe. The virtual setting adds a
third dimension to the teaching and practice of group
mindfulness. It challenges present-moment awareness in
specificways–first by removing the teacher/observer from
the physical space which distances the learner from social
cues and accountability, second by an implicit suspension
of day-to-day interpersonal rules, and third, the unac-
knowledged interface (camera, connectivity, and screen)
that filters the experience. An important need for virtual
group mindfulness practice is to provide a structure that
can organize the real and virtual spaces. Naming the
presence of the virtual platform, introducing its role and
function, and accepting interference are key to acknowl-
edging the adaptation. By naming the role and function of
the technology, the instructor can help shift participants’
focus to the supportive role it can play in accessing
and practicing mindfulness. Where interference might
occur, instructors can name the distractions and pitfalls to
virtual instruction and thereby normalize the inevitable
challenges.
Afinal consideration is the language used to discuss a
virtual interface for mindfulness. Technology and personal
devices have the negative connotation of interfering with the
ability to be present and mindful, so resolving the role of
technology in attention and mindfulness practice is important.
Guidance is needed for how to bring focus to the mindful
group space, but not to the device itself or other apps like
internet browsers or social media. Furthermore, instructors
could address the pull of digital tasks and cues while working
via a virtual platform. In addition to outlining individual and
group norms for engagement in this environment, this can
extend mindful awareness to the presence of a virtual space
even outside of the session.
43
Implications for Future Research
The physical space where the participant is located during
the mindfulness training can enhance or detract from the
participants’experience and is vastly different from in-
person programs. The process of arriving and being pres-
ent during in-person mindfulness training differs from
arrival to and participation in a virtual space. Other quali-
tative studies of synchronous virtual group mindfulness
interventions have likewise described the mixed cost/
benefits of remote participation.
41,44
However, to our
knowledge, this paper was the first to explore specific
factors in the physical environment—including physical
comfort and safety, conflicts with other household members
who are unwilling to give up the space, and disruptions from
children and people at the door—that may influence and
integrate with other aspects of the training experience. As
mindfulness training includes acceptance of difficult emo-
tions, thoughts and experiences, its practice in stimulating or
stressful environments may facilitate learning about how to
work with and through these inevitable challenges using
mindfulness. These findings can inform approaches to
teaching mindfulness virtually.
The participant’s internal mindset may influence how they
engage with virtual mindfulness programming, including
their capacity to remain committed in the face of the com-
peting needs of close others in their lives. Some participants
who had caregiver roles for spouses, children, or other family
members described feeling strained when family member
Figure 2. Observing mind and body across physical and virtual environments with equanimity.
Barnhill et al. 11
needs conflicted with the virtual mindfulness training. This
tension may have been more prominent given participants were
physically present with family members during the virtual
mindfulness sessions. Others, meanwhile, seemed to develop a
greater sense of self-compassion through the mindfulness
training. They began to recognize their own needs as valid and
worthy and were better able to maintain the interpersonal
boundaries needed to take care of themselves (eg, hire a sitter to
allow participation). Indeed, self-compassion is implicit in
mindfulness training and entails awareness of one’s own feel-
ings, thoughts, needs in connection with others; self-compassion
is linked to relational authenticity and compromise in conflict (as
opposed to self-subordination or self-prioritization).
19
More-
over, self-compassion has been linked to less pain disability
through greater self-efficacy, making it a measure to include for
future work with participants with chronic pain.
20
The virtual
interface was described by some as a preferred mode of en-
gagement, by others as less optimal compared to in-person
formats, and by a few as a mixed experience with no clear
preference. This preference is influenced by many factors,
including personality traits like interpersonal orientation.
Although not specific to synchronous virtual group MBIs,
previous research suggests individuals who are high in ex-
troversion and/or agreeableness prefer group-based inter-
vention, while those who are more introverted prefer more
structured and/or one-on-one intervention formats.
45
In this
study, the virtual group format provided a buffer for some
presumably more introverted participants, who found greater
ease in interacting with others. Meanwhile, some who are
energized by interpersonal interaction found the virtual in-
terface an obstacle to connection and perceived needing to
exert greater effort to remain engaged. Future work is needed
to explore the range of individual, community and systemic
factors that moderate outcomes in the virtual vs in-person
formats. This may allow participants and referring providers
to make an informed choice about which format is best suited
to each person.
On the one hand, video-conferencing platforms can create
more access for historically marginalized groups by de-
creasing cost, transportation, and time barriers. On the other
hand, without an overt strategy in place to address other
barriers, this intervention’s expansion is unlikely to sub-
stantially decrease health disparities. For example, the eq-
uitable large-scale implementation of virtual MBSR training
in primary care settings would require accommodation for
differing effects of social determinants of health across
multiple levels of influence (as presented in Table 2). Some of
these accommodations include greater access to internet
services, technical support for all users, sufficient interper-
sonal trust, and reliable access to primary care.
Limitations
This reflexive thematic analysis told part of the story, but it is
not the complete story. Exit interviews were collected from
59 out of 122 participants. Participants who declined to be
interviewed could have additional vantage points not re-
flected in this sample. On a few occasions, participants knew
the researcher conducting the interview, which could affect
what participants disclosed. There is also more analysis to be
completed to better understand how socioeconomic status
affected participant experiences. The main study outcomes
are not yet available, so it is not currently possible to link
qualitative interview themes with quantitative results. The
OPTIMUM study included only virtual groups due to the
pandemic, thus this project cannot compare in-person vs
virtual MBSR. We conducted fidelity assessments and found
that the MBSR groups were engaging to participants, and key
features of MBSR were consistently included in sessions.
46
Completion of the parent study and analysis of primary study
endpoints will also inform future qualitative analysis.
Despite these limitations, this analysis of 59 exit inter-
views contained rich content and the results of the thematic
analysis contribute new insights into the complexity of virtual
MBSR training and the ways in which a person’s social status
may affect their experience. As virtual delivery of MBSR
continues to develop, understanding these differences in
patient experience will help inform program development.
Conclusion
This analysis highlighted how virtual settings are simple and
complex, mirroring the practice of mindfulness. A virtual
setting appears with the press of a button. However, on closer
look, there are multiple variables at play that differentially
affect how participants interact with the virtual setting.
Similarly, in essence, mindfulness involves simply being
present in the present moment. On closer examination,
holding one’s attention in the present moment is complicated.
Key themes were ‘effects of the external environment’and
‘navigating the virtual platform.’Within the external envi-
ronment, subthemes were comfort, social demands in the
home setting, and sharing personal spaces. With regards to
the virtual environment, subthemes were ease, struggle, and
levels of support. Where possible, differences in participant
experience were analyzed by considering the role of social
determinants of health and the level of influence (individual
to society). In this manner, researchers developed a frame-
work to evaluate the health equity implications of virtual as
opposed to in-person MBSR training.
Acknowledgments
OPTIMUM Community Advisory Board members: Nicole Elam,
Amy Goldstein, Demond Hamer, and Sarah Kirshenbaum. National
Center for Complementary and Integrative Health. Dr Paul Mihas,
Odum Institute, University of North Carolina at Chapel Hill for
qualitative analysis consultation. The Community Advisory Board
for the OPTIMUM study. The National Institute for Complementary
and Integrative Health.
12 Global Advances in Integrative Medicine and Health
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article:This work
was supported within the National Institutes of Health (NIH)
Pragmatic Trials Collaboratory through the NIH HEAL Initiative
under award number UG3/UH3 AT010621 administered by the
National Center for Complementary and Integrative Health. This
work also received logistical and technical support from the PRISM
Resource Coordinating Center under award number
U24AT010961 and UG3 AT010621 from the NIH through the NIH
HEAL Initiative. The content is solely the responsibility of the
authors and does not necessarily represent the official views of the
[Institute, Center, or Office providing oversight] or the NIH or its
HEAL Initiative.
Ethical Statement
Ethical Approval
University of Pittsburgh Institutional Review Board
STUDY20110378.
Consent to Participate
Participants gave verbal consent to participate in the exit interviews.
ORCID iDs
Jessica L. Barnhill https://orcid.org/0000-0003-3360-4217
Paula Gardiner https://orcid.org/0000-0002-3663-000X
Carol M. Greco https://orcid.org/0000-0002-3078-2918
Graham Dore https://orcid.org/0000-0001-9444-4822
Natalia E. Morone https://orcid.org/0000-0002-8405-5396
Data Availability Statement
The data is not publicly available as the main trial is ongoing.
Supplemental Material
Supplemental material for this article is available online.
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