Barriers and Facilitators to Choosing Traditional Chinese Medicine among Patients with Degenerative Lumbar Spinal Stenosis in China: A Qualitative Study

Barriers and Facilitators to Choosing Traditional Chinese Medicine among Patients with Degenerative Lumbar Spinal Stenosis in China: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Choosing Traditional Chinese Medicine among Patients with Degenerative Lumbar Spinal Stenosis in China: A Qualitative Study Zhou Yanji, An Yi, Wang Jing, Li Xiaoyue, Cui Zhijie, Yi Liu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8812194/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Purpose This study aimed to qualitatively explore the perceived barriers and facilitators that influence decision-making among patients with degenerative lumbar spinal stenosis (DLSS) in China regarding the use of Traditional Chinese Medicine (TCM) interventions. Methods A qualitative descriptive study was conducted using semi-structured interviews. Through purposive sampling, 26 patients with DLSS were recruited from a tertiary TCM hospital in Beijing. Interviews explored patients' experiences, perceptions, and the reasoning behind their decisions to use or decline TCM interventions (e.g., acupuncture, tuina). Data were analyzed using inductive thematic analysis. Results Patient decision-making emerged as a dynamic process of weighing interlinked factors. Barriers included: (1) skepticism about efficacy and mechanistic distrust; (2) fear and practical concerns about treatment procedures; (3) significant economic and time burdens; and (4) information deficits and knowledge gaps. Facilitators included: (1) a strong desire to avoid surgery; (2) positive direct or vicarious treatment experiences; and (3) cultural affinity and trust in TCM philosophy and practitioners. Notably, cultural trust was found to buffer the impact of practical barriers. Conclusion The choice regarding TCM for DLSS involves a personal calculus where fears and costs are balanced against cultural alignment and experiential positives. To support patient-centered care, a multi-level approach informed by behavioral theory (e.g., the COM-B model) is essential. This includes tailoring communication to bridge information gaps, innovating services to improve access, and leveraging cultural trust within stepped-care discussions to promote the evidence-informed integration of TCM in DLSS management. Lumbar spinal stenosis Traditional Chinese Medicine (TCM) Patient decision-making Barriers and Facilitators Qualitative research Highlights Maps a dynamic decision-making landscape: The study moves beyond listing factors to reveal how Chinese DLSS patients actively weigh interconnected barriers (e.g., cost, fear, doubt) against facilitators (e.g., surgery aversion, cultural trust) in a personal calculus. Identifies cultural trust as a key stabilizer: It uncovers how deep-seated cultural-philosophical alignment with TCM acts as a unique facilitator that can buffer the impact of practical barriers like cost and inconvenience, a finding distinct to indigenous healthcare contexts. Provides a theory-driven roadmap for change: By applying the COM-B (Capability-Opportunity-Motivation-Behavior) model, the findings translate into clear, multi-level intervention strategies for clinicians (tailored communication), service planners (accessible models), and policymakers (insurance reform). Employs rigorous qualitative methodology: The research adheres to high reporting standards (COREQ), using purposive maximum-variation sampling, analyst triangulation, and reflective practice to ensure credible and in-depth insights into patient perspectives. Funding sources: Beijing Tongzhou District Science and Technology Program Project (No.: WS2025004); China Association of Chinese Medicine (Project No.: 202565-001); China National Natural Science Foundation (Nos.: 81803956 and 82374617); Beijing Young Outstanding Talents Program (No.: 2020-4-4195) Clinical trial number: not applicable 1. Background Degenerative lumbar spinal stenosis (DLSS) is a common chronic condition characterized by spinal canal narrowing, which can lead to disabling symptoms such as neurogenic claudication, low back and leg pain, and significant functional impairment [1,2] . As a major cause of pain and functional disability in the elderly, its treatment and management pose significant clinical and public health challenges [3] . International guidelines recommend multimodal conservative therapy as the first-line approach, which may include exercise therapy, physical therapy, analgesics, and traditional Chinese medicine interventions [4,5] . Traditional Chinese medicine therapies (mainly referring to acupuncture and tuina) are widely utilized in the management of DLSS in China and have gained increasing global recognition [6] . Existing evidence suggests that these therapies have potential efficacy in alleviating pain and improving function [7] . However, in clinical practice, there are significant differences in patient acceptance and compliance with TCM treatments, even when clinical indications are clear. Some patients are willing to try, while others who may benefit remain hesitant or refuse [8] . Patient decision-making in chronic disease management is a multifactorial process influenced by knowledge levels, beliefs (perceived benefits/dysfunctions), past experiences, social norms, and healthcare environments [9] . Addressing the driving and hindering factors behind decision-making—i.e., the "deep causes" of choice behaviors—is crucial for achieving a truly patient-centered healthcare model [10] . However, in the context of DLSS, there remains a limited understanding of the factors influencing TCM utilization. Clinicians often lack a detailed map of the perceived barriers (e.g., fear, cost, doubt) and facilitators (e.g., cultural trust, positive experiences) that shape patient decisions. This knowledge gap can lead to ineffective communication, unmet patient needs, and suboptimal utilization of available therapies. Therefore, this study aims to qualitatively analyze the perceived barriers and facilitators faced by China DLSS patients when choosing or rejecting traditional Chinese medicine interventions. The findings will provide a basis for developing more effective clinical communication protocols, personalized patient education measures, and supportive healthcare service policies. 2. Method We adopted a qualitative descriptive research design, conducting in-depth, semi-structured interviews to understand patients' perspectives and experiences. 2.1 Recruitment and Sampling This study employed purposive sampling to select participants from patients visiting the Tuina and Pain Management Department, Dongzhimen Hospital Beijing University of Chinese Medicine between January 2021 and January 2022. To ensure a broad perspective, we employed a maximum variation sampling strategy based on age (< 60, ≥ 60 years), gender, disease duration ( 10 years), and prior treatment history (none, TCM-only, Western medicine-only, both) [11] . Potential participants were recruited through referrals by clinicians and outpatient advertisements. Eligible patients were aged 50–85 years, diagnosed with DLSS according to standard guidelines, fluent in Mandarin, and capable of signing informed consent forms. Patients with severe cognitive impairment or communication difficulties were excluded. Sample size was guided by the principle of information power, which holds that the required number of participants depends on the richness and relevance of the data they provide, considering factors such as study aim and sample specificity [ 12 , 13 ]. This approach prioritizes depth and quality over a predetermined number. Participants (n = 26) were recruited through purposive sampling. Semi-structured interviews were conducted by two experienced researchers (ZYJ & AY), whose expertise in patient-centered dialogue ensured focused and in-depth data collection. Data analysis followed an inductive thematic approach. To enhance rigor, analyst triangulation was employed, with three researchers independently engaging in cross-case analysis to fully explore patterns and variations within the dataset. 2.2 data collection Semi-structured, face-to-face interviews were conducted by two trained researchers (Z.Y.J., male, with a master’s degree in Chinese medicine and 3 years of qualitative research experience; A.Y., male, with a master’s degree in acupuncture and tuina and 3 years of clinical research experience). Both interviewers were not involved in the clinical care of the participants to encourage open expression and minimize social desirability bias. Prior to the interviews, participants were informed that the interviewers were researchers focusing on patient experience, not their treating clinicians. Interviews lasted between 30 to 45 minutes and took place in a private, quiet consultation room at the hospital to ensure confidentiality. Only the interviewer and the participant were present. With the participant’s permission, all interviews were audio-recorded digitally. Researchers also took brief field notes during the interviews to capture non-verbal cues and contextual observations. The interview guide (see Supplementary File 1) was developed based on a literature review and team expertise, and was piloted with two DLSS patients (not included in the final sample) to refine question clarity and flow. The guide covered key domains: illness and treatment journey; perceptions of TCM; decision-making considerations (efficacy, safety, cost, logistics); and expectations for ideal care. All audio recordings were transcribed verbatim into Chinese by a professional transcription service within one week of the interview. To ensure accuracy, one of the interviewers (A.Y.) meticulously verified each transcript by listening to the recording while reading the text, correcting any discrepancies. The verified transcripts were then de-identified, with participants assigned unique study IDs (P1-P26). During the recruitment period, approximately 45 eligible patients were approached by their physicians or via posters. Nineteen patients declined to participate, primarily citing lack of time (n = 11) or a general disinterest in research participation (n = 8). No discernible pattern was noted between those who declined and those who participated regarding basic demographic characteristics available from clinic records. 2.3 Data Analysis Data were analyzed following the inductive thematic analysis framework [14,15] , using NVivo 12 software for data management. The process involved six phases: Phase 1: Familiarizing with the data. The lead analyst (ZYJ) immersed themselves in the data by conducting repeated, active readings of all interview transcripts. This process involved not only reading for content but also noting down initial analytical observations, ideas, and potential patterns, forming the foundation for subsequent coding. Phase 2: Generating initial codes. Two researchers (ZYJ and AY) independently performed line-by-line coding on the first three transcripts to identify the basic segments of meaning relevant to the research question. This inductive coding process aimed to remain open to all features of the data. The two analysts then met to compare their independently generated codes, discussing similarities and discrepancies to collaboratively develop a coherent and comprehensive preliminary coding framework. Phase 3: Searching for themes. In this phase, the researchers worked systematically to collate all codes and relevant data extracts. They examined how different codes could be clustered together to form broader patterns of meaning, thereby constructing initial candidate themes and sub-themes. This involved organizing the coded data into thematic maps to visualize potential relationships. Phase 4: Reviewing themes. The candidate themes were rigorously reviewed and refined at two levels. First, Level 1 review checked if the coded data extracts coherently supported each theme. Second, Level 2 review evaluated whether the entire thematic structure accurately represented the complete dataset in relation to the research objective. This iterative process involved refining, splitting, combining, or discarding themes through sustained team discussion to ensure internal homogeneity and external heterogeneity. Phase 5: Defining and naming themes. For each finalized theme, a clear and concise definition was articulated that captured its essence and central narrative. Precise names were assigned to each theme and sub-theme to immediately convey their core meaning to the reader, moving beyond simple description to interpretive analysis. Phase 6: Producing the report. The final analytic narrative was woven together, integrating compelling data extracts that vividly illustrated each theme. The report contextualizes these extracts within the analysis, clearly demonstrating the link between the raw data and the interpretive conclusions, thereby substantiating the findings. 2.4 Rigor and Trustworthiness To ensure the rigor and trustworthiness of the analysis, multiple strategies were employed in alignment with established qualitative research COREQ criteria [ 16 ]. Analyst Triangulation: Two researchers (Z.Y.J. and A.Y.) independently performed initial coding and theme development. A third senior researcher (W.X.Y.) reviewed the coding framework and participated in cross-case analysis discussions to resolve discrepancies and enrich interpretations. Peer Debriefing: The evolving analysis and thematic structure were periodically discussed with a senior qualitative methodology expert (Y.C.H.) not involved in data collection or coding. This peer challenged assumptions, provided alternative interpretations, and ensured analytical logic. Researcher Reflexivity: All team members maintained reflective journals. Given that several researchers (W.X.Y., Y.C.H.) have clinical training in TCM, we actively discussed how this background might shape our interpretation of data related to ‘efficacy doubts’ or ‘cultural affinity.’ We consciously sought disconfirming evidence and ensured that themes emerged from the data rather than our preconceptions. For instance, when analyzing quotes expressing skepticism, we deliberately avoided defensive interpretations and focused on understanding the patient’s perspective. Audit Trail: A detailed record was maintained, documenting all analytical decisions, iterations of the codebook, meeting notes, and the rationale for theme refinement, merging, or discarding. Data Saturation: We employed the principle of information power [ 12 , 13 ] to guide sample size. Recruitment and analysis proceeded iteratively. After analyzing the 22nd interview, no new substantive themes or insights emerged related to the core research question. The final four interviews were conducted and analyzed to confirm that thematic saturation had been robustly achieved. 2.5 Ethical considerations This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Institutional Review Board of Dongzhimen Hospital Beijing University of Chinese Medicine (Approval No 2018-JYBZZJS090). All participants provided written informed consent. The research process was strictly confidential. 3. Results 3.1 Participant Characteristics We conducted interviews with 26 participants (11 males and 15 females), with a mean age of 65.2 years (SD 7.1) and a mean disease duration of 6.8 years (SD 3.9). Educational backgrounds ranged from elementary school to postgraduate level. Detailed characteristics are presented in table S3 in Supplementary File. 3.2 Theme The analysis identified two overarching themes: barriers and facilitators, comprising seven sub-themes that capture the psychological and practical considerations in patient decision-making. Illustrative quotations are provided in Table 1 . Table 1 Themes, Sub-themes, and Illustrative Quotations on Barriers and Facilitators to Selecting TCM for DLSS theme Sub-theme and code Illustrative Quote (participant ID) Barriers 1. Skepticism regarding efficacy and mechanism of action History of previous ineffective treatment "I had previously tried acupuncture and tuina therapy, but the effects were not significant... Perhaps it was merely a psychological effect." (P07) The need for scientific evidence "I need to see more definitive evidence to be fully convinced." (P12) 2. Fear and Practical Concerns Pain Fear I want it (refer to acupuncture) to work, and it has to be comfortable... The pain is unbearable. Focus on safety/standardization From a professional perspective, my focus is on operational standards, such as infection risk. (P19) Concerns about side effects (herbal medicine) As the saying goes, 'All medicines have some toxicity.' I am always concerned that long-term consumption of traditional Chinese medicine (TCM) may cause liver and kidney damage. (P14) 3. Economic and Time Burden Treatment cost If the cost is too high... I cannot afford it. The insurance has an annual limit. (P10) time cost "Having to attend training sessions multiple times a week makes it difficult to take leave." (P21) 4. Information Gap/Knowledge Deficiency The role in Traditional Chinese Medicine (TCM) remains unclear. "I don't know anything about this disease." (P05) Reliable information is hard to obtain The general public does not fully comprehend; we merely adhere to the physician's recommendations while retaining reservations. (P18) Facilitators 1. Desire to avoid surgery Consider Traditional Chinese Medicine as a Safer Alternative Choosing Traditional Chinese Medicine (TCM) allows me to address health issues while preserving the integrity and original physiological functions of my body, which brings me a sense of reassurance. (P13) Consideration of a Rational Stepwise Nursing Plan My idea is straightforward: to establish a 'staircase' approach. Surgery represents the highest and final step, which should only be considered as a last resort. Traditional Chinese Medicine (TCM) is currently the most systematic non-surgical therapy I can identify. (P09) From a medical perspective, systematic Traditional Chinese Medicine (TCM) treatment is the first rational step for my case. (P15) 2. Direct positive experience remission Pain persists after acupuncture, but has significantly alleviated... Therefore, I will continue the treatment. (P04) enhance treatment comfort "After the tuina, I felt relaxed and experienced improved sleep quality." (P23) 3. Cultural Affinity and Philosophical Compatibility Trust in Holistic/Natural Therapy Trust. I believe Traditional Chinese Medicine (TCM) emphasizes balance rather than aggressive intervention. (P11) I trust this concept of recovery through one's own physiological functions. (P08) Respect the professional expertise of licensed physicians I trust two things: his experience and his character. As the department head, his hair is already white, which clearly indicates his extensive experience. He communicates with me about the patient's condition and treatment methods without exaggeration or intimidation, always being very practical. (P09) Initially, I approached the treatment with skepticism. However, after several sessions, I observed genuine improvement in my symptoms. Upon revisiting the physician's initial statements, diagnosis, and selected therapeutic regimen, I came to recognize the rationale behind each step he took. (P04) 3.2.1 Theme 1: Barriers This theme summarizes the barriers that deter patients from choosing TCM. Subtheme 1: Skepticism about Efficacy and Mechanistic Disbelief This reflects patients 'fundamental skepticism regarding the efficacy of Traditional Chinese Medicine (TCM) in treating DLSS. Some patients lose confidence due to previous ineffective experiences, as exemplified by P07: "I tried acupuncture and tuina before, but the results were not significant... Perhaps it's just a psychological effect." Another group, particularly those with higher education levels, demonstrate a need for scientific evidence, as noted by P12 "I need to see more definitive evidence-based findings to fully trust this approach." Both types of skepticism stem from the conceptual gap between the theoretical framework of TCM and patients' understanding of their own disease. Subtheme 2: Treating Fear and Practical Concerns This involves patients' physiological experiences and perceived risks during Traditional Chinese Medicine (TCM) treatment. The most common concern is the fear of procedural pain, particularly in acupuncture, as described by P06: "I hope it works while also being comfortable... Excessive pain is unbearable." Additionally, there are widespread concerns about safety and side effects, such as herbal toxicity or tuina-induced injuries. Patients with medical backgrounds are more concerned about technical specifications and infection risks, as mentioned by P19: "From a professional perspective, I am concerned about procedural standards, such as infection risks." Subtheme 3: Economic and Time Burden This encompasses the non-clinical costs associated with Traditional Chinese Medicine (TCM) treatment. The primary concern is the financial burden, particularly due to restrictions on medical insurance reimbursement, as highlighted by P10: "If the cost is too high... I cannot afford it. The insurance has an annual limit." Time and travel expenses also pose significant barriers, especially for employed individuals. For instance, P21 noted: "I need to attend multiple treatments per week, making it difficult to take leave." These practical constraints often lead patients to hesitate in balancing the investment in treatment with its potential outcomes. Subtheme 4: Information Deficiency and Cognitive gap This reflects the difficulty patients face in making informed decisions due to the lack of reliable and easily understandable information. Some patients have no basic understanding of the disease or Traditional Chinese Medicine (TCM), as admitted by P05: "I know nothing about this disease." Others feel confused by conflicting information, as expressed by P18: "We ordinary people don't understand; we just follow the doctor's advice, but still have some doubts." This information vacuum hinders patients from accurately assessing other obstacles or facilitators. 3.2.2. Theme 2: Facilitators This theme covers the motivation, experience and belief that promote patients to actively choose TCM. Subtheme 5: Surgical Avoidance Intention The primary driving force is patients 'resistance to surgery and their preference for Traditional Chinese Medicine (TCM) as a preferred alternative. This choice encompasses both emotional fears, such as P09's perception that "surgery... carries significant risks," and rational considerations, as exemplified by P15, who views it as "a reasonable step to first attempt systematic TCM treatment." Consequently, TCM is positioned as a safer and non-invasive therapeutic option. Subtheme 6: Direct or Indirect Positive Experiences The most persuasive facilitators stem from direct or credible evidence of benefits. Even mild symptom relief can strengthen treatment commitment, as demonstrated by P04: "Pain persists after acupuncture, but it has significantly improved... Therefore, I will continue with the treatment." The sense of comfort during the treatment process also enhances the overall experience, as noted by P23: "After the tuina, I felt relaxed, and my sleep quality improved." Additionally, indirect experiences such as others 'success stories can motivate treatment attempts. For instance, P16 was willing to try and trust Traditional Chinese Medicine (TCM) due to a colleague's recommendation. Subtheme 7: Cultural Identity and Professional Trust This demonstrates patients 'deep acceptance of Traditional Chinese Medicine (TCM) based on cultural resonance and professional recognition. Some patients endorse the holistic natural therapy philosophy of TCM, as evidenced by P11's statement that "TCM emphasizes balance, not aggressive intervention." Trust in physicians 'professional competence is equally crucial, with P09 expressing confidence in the physician's "experience" and "integrity," while P04 validated the rationality of the physician's decision through therapeutic outcomes. This cultural affinity and professional trust enhance patients' tolerance for treatment uncertainties. 3.2.3. Interrelationships between sub-themes The sub-themes are not isolated but interconnected and dynamically interrelated. For instance, information deficit (Barrier 4) may exacerbate efficacy doubt (Barrier 1) and treatment phobia (Barrier 2). Conversely, positive direct experience (Facilitator 2) serves as the most potent factor in overcoming barriers, directly alleviating doubts and fears. Cultural affinity (Facilitator 3) can modulate the impact of economic time burden (Barrier 3), making patients more willing to bear associated costs. Surgical avoidance intention (Facilitator 1) often acts as an initial driving force, prompting patients to comprehensively weigh other factors before entering the decision-making process. Table 1 . Themes, Sub-themes, and Illustrative Quotations on Barriers and Facilitators to Selecting TCM for DLSS 4. Discussion 4.1 Main Findings This qualitative study provides an in-depth exploration of the decision-making process among Chinese patients with DLSS regarding TCM interventions. The findings move beyond a simple catalog of factors, revealing a dynamic internal negotiation where patients actively weigh perceived barriers (primarily skepticism, fear, and cost) against facilitators (avoiding surgery, trust in positive experiences, and cultural congruence). This process resonates with the core constructs of the Health Belief Model, where the perceived threat of surgery and the perceived benefits of TCM are balanced against perceived costs and fears [ 17 ]. To systematically translate these insights into actionable guidance for clinical practice and policy, we further employ the COM-B model of behavior change [ 18 ], which posits that behavior (B) requires the conjunction of Capability (C), Opportunity (O), and Motivation (M). The following discussion synthesizes our themes within this framework, drawing deeply on relevant literature to contextualize and explain our findings. 4.1. The Foundation of Decision-Making: Capability Gaps and Their Resolution The decision to consider TCM first hinges on a patient’s psychological capability—their knowledge and understanding. Our study identified a profound information deficit and cognitive gap (Barrier 4) as a foundational barrier. Patients lacked accessible, credible information on how TCM modalities like acupuncture might alleviate DLSS-specific symptoms such as neurogenic claudication. This gap directly fuels skepticism and distrust of efficacy (Barrier 1), manifesting either as a demand for scientific evidence among the educated or disillusionment from past experiences. This aligns with broader CAM literature, where “perceived effectiveness” is a primary determinant of use [ 19 ]. A qualitative study on non-surgical LSS treatment similarly found that understanding and believing in the treatment’s benefit was central to persistence [ 20 ]. Building this capability is therefore paramount. Our data, alongside literature, suggest two potent pathways. First, positive direct or vicarious experience (Facilitator 6) is the most powerful tool. Tangible symptom relief provides irrefutable, personal evidence that can overcome pre-existing doubts, a factor critical for adherence in chronic pain management [ 21 , 22 ]. Second, effective communication must bridge the explanatory model divide. As studies on promoting evidence uptake in TCM note, translating concepts into relatable terms is key [ 23 ]. This requires moving from abstract TCM theory to explanations grounded in the pathophysiology of DLSS (e.g., reducing nerve root irritation). 4.2. The Role of Opportunity: Structural Barriers and Enabling Environments Opportunity encompasses external factors that make a behavior feasible. The economic and time burdens (Barrier 3) we identified are critical physical opportunity barriers. The need for frequent, long-term sessions creates significant cost and logistical challenges, particularly for employed patients. This finding is not unique to TCM; research on implementing community-based pain management programs identifies similar structural hurdles [ 24 , 25 ]. Within China’s healthcare context, limited insurance reimbursement for outpatient TCM and the concentration of specialized care in urban centers exacerbate these barriers [ 7 ], creating an “accessibility filter” that may disproportionately affect lower-income groups. Creating opportunity requires systemic innovation. Policy-level interventions to expand insurance coverage for evidence-based TCM protocols are essential. At the service delivery level, models such as community-integrated TCM clinics and flexible scheduling—explored in the context of integrating acupuncture into mainstream care [ 26 , 27 ]—could mitigate time and travel constraints. Furthermore, fostering positive vicarious experience (Facilitator 6) through peer support groups creates a social opportunity, leveraging trusted community narratives to lower psychological barriers to initiation. 4.3. The Engine of Choice: Reflective and Automatic Motivation Motivation directs and energizes behavior. Our findings reveal a complex motivational landscape. A potent aversion to surgery (Facilitator 5) provides a strong reflective motivation. Patients perceive TCM as a safer, less invasive alternative within a stepped-care model, a rational consideration also observed in studies of chiropractic care for low back pain [ 25 ]. This motivation can initiate the decision-making process. However, it is often countered by strong automatic (emotional) motivations in the form of fears about the treatment process (Barrier 2), such as needle phobia or concern about manipulation injury. This fear, linked to the HBM’s “perceived susceptibility” [ 4 ], is a common barrier to procedure-based therapies, as seen in studies on exercise adherence among chronic pain patients [ 28 ]. The facilitatory theme of cultural affinity and trust in TCM philosophy (Facilitator 7) represents a deep, stable reflective motivation unique to this context. This cultural capital, a pre-existing “trust bias,” fosters acceptance of TCM’s holistic approach and increases tolerance for treatment inconveniences or uncertainties. It provides a compelling explanatory framework for patients, making the intervention personally meaningful [ 29 , 30 ]. This factor crucially differentiates TCM adoption in China from the uptake of complementary therapies in non-indigenous settings. 4.4. Clinical and Policy Implications: A Multi-Level COM-B Intervention Strategy To effectively promote informed TCM use, interventions must concurrently address Capability, Opportunity, and Motivation. Enhancing Capability (C): Clinicians must provide stratified education. For the evidence-seeking patient, referencing high-quality RCT data (e.g., [ 7 ]) is valuable. For others, using visual aids or patient testimonials to explain treatment mechanisms in relatable terms is key. This directly targets information gaps and efficacy doubts. Optimizing Opportunity (O): Healthcare systems should innovate service delivery (e.g., community hubs, tele-support) to reduce logistical barriers [ 24 ]. Policymakers must evaluate financial structures to improve affordability. Building platforms for positive peer sharing can harness social opportunity. Strengthening Motivation (M): Practitioners should proactively elicit and validate the aversion to surgery, framing TCM as a legitimate first-line strategy [ 28 ]. To mitigate treatment fears, transparent communication about sensations and patient-controlled “stop signals” are essential. Most critically, meticulously managing the initial treatment experience to maximize early comfort and perceptible benefit is vital to cementing positive direct experience—the ultimate motivational reinforce [ 21 , 22 ]. 4.5 Advantages and Limitations This study demonstrates the following strengths. First, methodological rigor was ensured by adhering to established qualitative research standards and employing thematic analysis. Second, purposive sampling with maximal diversity preservation enabled comprehensive capture of patient experiences, while data collection continued until reaching robust thematic saturation, thereby enhancing the credibility of findings. Third, credibility was strengthened through triad of analyst validation, peer discussion, and researcher reflective practice, which helped eliminate biases and ensure data-driven thematic analysis. This study also has limitations. First, since the subjects may have a higher baseline acceptance of Traditional Chinese Medicine compared to the broader DLSS population, recruiting participants only from a tertiary TCM hospital in the city center may limit the transferability of findings to primary care settings or regions with less TCM exposure. We attempted to include skeptical voices through purposive sampling, but the influence of the study environment still exists. Second, self-selection and potential social expectation bias may affect the study results. We mitigated this issue by using non-clinical interviewers and emphasizing confidentiality. Third, as a qualitative study, the results have the specific context of the China medical environment and may not be directly generalizable to other settings, but they provide a detailed explanatory framework for future research. 5. Conclusion Patients with DLSS often make decisions regarding Traditional Chinese Medicine (TCM) with personal biases. They weigh practical barriers such as costs and fears, as well as facilitators based on experience, cultural background, and preferences for non-invasive treatments. To enhance the adoption of TCM, it is essential to move beyond a one-size-fits-all approach. By implementing tailored communication strategies addressing specific concerns and fears, coupled with policy measures to reduce structural barriers to access, healthcare providers and the healthcare system can better support patients in making informed and value-aligned choices, thereby achieving comprehensive treatment for lumbar spinal stenosis. Declarations Ethical Approval and Participant Informed Consent: This study was approved by the Institutional Review Board of Dongzhimen Hospital, Beijing University of Chinese Medicine (Approval No. 2018-JYBZZJS090). All participants signed informed consent forms after their initial in-person or online meeting with the investigator or principal investigator (PI). Publication Consent Form Not Applicable Availability of Data and Materials The datasets used and/or analyzed in this study are available from the corresponding authors upon reasonable request. Conflict of Interest No conflict of interest exists. Funding Sources Beijing Tongzhou District Science and Technology Program Project (No.: WS2025004); China Association of Chinese Medicine (Project No.: 202565-001); China National Natural Science Foundation (Nos.: 81803956 and 82374617); Beijing Young Outstanding Talents Program (No.: 2020-4-4195) Author Contributions: ZYJ: Data Processing and Analysis, Drafting AY: Data Processing and Analysis, Review and Editing WJ: Supervision and Guidance, Draft Review and Editing LXY: Data Collection, Processing and Analysis CZJ: Data Collection, Processing and Analysis LY: Data Collection, Processing and Analysis NF: Data Collection, Processing and Analysis FMJ: Resource Provision, Supervision and Guidance JJJ: Resource Provision, Supervision and Guidance LCX: Draft Review and Editing WXY: Draft Review, Editing and Analysis YCH: Conceptualization, Methodology and AnalysisAuthor Disclosure Statement: There are no conflicts of interest requiring disclosure. 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Int J Qual Health Care. 2007;19(6):349–57. 10.1093/intqhc/mzm042 . Jones CJ, Smith H, Llewellyn C. Evaluating the effectiveness of health belief model interventions in improving adherence: a systematic review. Health Psychol Rev. 2014;8(3):253–69. 10.1080/17437199.2013.802623 . Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. 10.1186/1748-5908-6-42 . Published 2011 Apr 23. Chen LC, Cheng LJ, Zhang Y, He X, Knaggs RD. Acupuncture or low frequency infrared treatment for low back pain in Chinese patients: a discrete choice experiment. PLoS ONE. 2015;10(5):e0126912. 10.1371/journal.pone.0126912 . Published 2015 May 28. Pauwels C, Roren A, Gautier A, et al. Home-based cycling program tailored to older people with lumbar spinal stenosis: Barriers and facilitators. Ann Phys Rehabil Med. 2018;61(3):144–50. 10.1016/j.rehab.2018.02.005 . Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444–53. 10.1001/archinternmed.2012.3654 . Wong CHL, Tse JVH, Nilsen P, Ho L, Wu IXY, Chung VCH. Barriers and facilitators to promoting evidence uptake in Chinese medicine: a qualitative study in Hong Kong. BMC Complement Med Ther. 2021;21(1):200. Published 2021 Jul 15. 10.1186/s12906-021-03372-5 Bove AM, Lynch AD, Ammendolia C, Schneider M. Patients' experience with nonsurgical treatment for lumbar spinal stenosis: a qualitative study. Spine J. 2018;18(4):639–47. 10.1016/j.spinee.2017.08.254 . Ampiah PK, Hendrick P, Moffatt F, Ampiah JA. Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study. Disabil Rehabil. 2025;47(6):1465–75. 10.1080/09638288.2024.2374497 . Anderson BJ, Meissner P, Mah DM, et al. Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot. J Altern Complement Med. 2021;27(6):496–505. 10.1089/acm.2020.0394 . De la Ruelle LP, de Zoete A, Myburgh C, Brandt HE, Rubinstein SM. The perceived barriers and facilitators for chiropractic care in older adults with low back pain; insights from a qualitative exploration in a dutch context. PLoS ONE. 2023;18(4):e0283661. 10.1371/journal.pone.0283661 . Published 2023 Apr 12. Li H, Darby JE, Akpotu I, et al. Barriers and Facilitators to Integrating Acupuncture into the U.S. Health Care System: A Scoping Review. J Integr Complement Med. 2024;30(12):1134–46. 10.1089/jicm.2023.0603 . Grande GHD, Vidal RVC, Salini MCR, Christofaro DGD, Oliveira CB. Barriers and Facilitators to Physical Activity and Exercise Among People With Chronic Low Back Pain: A Qualitative Evidence Synthesis. J Orthop Sports Phys Ther. 2025;55(5):312–30. 10.2519/jospt.2025.12905 . Liu S, Wu T, Yu Y, et al. Patients' Preferences Regarding Traditional Chinese Medicine for the Treatment of Chronic Obstructive Pulmonary Disease: Protocol for a Mixed Methods Study. JMIR Res Protoc. 2025;14:e75426. 10.2196/75426 . Published 2025 Dec 2. Hopton A, Thomas K, MacPherson H. The acceptability of acupuncture for low back pain: a qualitative study of patient's experiences nested within a randomised controlled trial. PLoS ONE. 2013;8(2):e56806. 10.1371/journal.pone.0056806 . Additional Declarations No competing interests reported. Supplementary Files WhyDoPatientsChooseorRefuseTraditionalChineseMedicineforLumbarSpinalStenosis0110supl2.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 06 May, 2026 Reviews received at journal 11 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 01 Apr, 2026 Editor invited by journal 20 Mar, 2026 Submission checks completed at journal 17 Mar, 2026 First submitted to journal 17 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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21:44:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27129,"visible":true,"origin":"","legend":"","description":"","filename":"WhyDoPatientsChooseorRefuseTraditionalChineseMedicineforLumbarSpinalStenosis0110supl2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8812194/v1/96f84013e77c6cf9fcc2e003.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Choosing Traditional Chinese Medicine among Patients with Degenerative Lumbar Spinal Stenosis in China: A Qualitative Study","fulltext":[{"header":"Highlights","content":"\u003cp\u003eMaps a dynamic decision-making landscape: The study moves beyond listing factors to reveal how Chinese DLSS patients actively weigh interconnected barriers (e.g., cost, fear, doubt) against facilitators (e.g., surgery aversion, cultural trust) in a personal calculus.\u003c/p\u003e\n\u003cp\u003eIdentifies cultural trust as a key stabilizer: It uncovers how deep-seated cultural-philosophical alignment with TCM acts as a unique facilitator that can buffer the impact of practical barriers like cost and inconvenience, a finding distinct to indigenous healthcare contexts.\u003c/p\u003e\n\u003cp\u003eProvides a theory-driven roadmap for change: By applying the COM-B (Capability-Opportunity-Motivation-Behavior) model, the findings translate into clear, multi-level intervention strategies for clinicians (tailored communication), service planners (accessible models), and policymakers (insurance reform).\u003c/p\u003e\n\u003cp\u003eEmploys rigorous qualitative methodology: The research adheres to high reporting standards (COREQ), using purposive maximum-variation sampling, analyst triangulation, and reflective practice to ensure credible and in-depth insights into patient perspectives.\u003c/p\u003e\n\u003cp\u003eFunding sources: Beijing Tongzhou District Science and Technology Program Project (No.: WS2025004); China Association of Chinese Medicine (Project No.: 202565-001); China National Natural Science Foundation (Nos.: 81803956 and 82374617); Beijing Young Outstanding Talents Program (No.: 2020-4-4195)\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"1. Background","content":"\u003cp\u003eDegenerative lumbar spinal stenosis (DLSS) is a common chronic condition characterized by spinal canal narrowing, which can lead to disabling symptoms such as neurogenic claudication, low back and leg pain, and significant functional impairment\u003csup\u003e[1,2]\u003c/sup\u003e. As a major cause of pain and functional disability in the elderly, its treatment and management pose significant clinical and public health challenges\u003csup\u003e[3]\u003c/sup\u003e. International guidelines recommend multimodal conservative therapy as the first-line approach, which may include exercise therapy, physical therapy, analgesics, and traditional Chinese medicine interventions\u003csup\u003e[4,5]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTraditional Chinese medicine therapies (mainly referring to acupuncture and tuina) are widely utilized in the management of DLSS in China and have gained increasing global recognition\u003csup\u003e[6]\u003c/sup\u003e. Existing evidence suggests that these therapies have potential efficacy in alleviating pain and improving function\u003csup\u003e[7]\u003c/sup\u003e. However, in clinical practice, there are significant differences in patient acceptance and compliance with TCM treatments, even when clinical indications are clear. Some patients are willing to try, while others who may benefit remain hesitant or refuse\u003csup\u003e[8]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatient decision-making in chronic disease management is a multifactorial process influenced by knowledge levels, beliefs (perceived benefits/dysfunctions), past experiences, social norms, and healthcare environments\u003csup\u003e[9]\u003c/sup\u003e. Addressing the driving and hindering factors behind decision-making\u0026mdash;i.e., the \"deep causes\" of choice behaviors\u0026mdash;is crucial for achieving a truly patient-centered healthcare model\u003csup\u003e[10]\u003c/sup\u003e. However, in the context of DLSS, there remains a limited understanding of the factors influencing TCM utilization. Clinicians often lack a detailed map of the perceived barriers (e.g., fear, cost, doubt) and facilitators (e.g., cultural trust, positive experiences) that shape patient decisions. This knowledge gap can lead to ineffective communication, unmet patient needs, and suboptimal utilization of available therapies.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to qualitatively analyze the perceived barriers and facilitators faced by China DLSS patients when choosing or rejecting traditional Chinese medicine interventions. The findings will provide a basis for developing more effective clinical communication protocols, personalized patient education measures, and supportive healthcare service policies.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003eWe adopted a qualitative descriptive research design, conducting in-depth, semi-structured interviews to understand patients' perspectives and experiences.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Recruitment and Sampling\u003c/h2\u003e \u003cp\u003eThis study employed purposive sampling to select participants from patients visiting the Tuina and Pain Management Department, Dongzhimen Hospital Beijing University of Chinese Medicine between January 2021 and January 2022. To ensure a broad perspective, we employed a maximum variation sampling strategy based on age (\u0026lt;\u0026thinsp;60, \u0026ge;\u0026thinsp;60 years), gender, disease duration (\u0026lt;\u0026thinsp;3, 3\u0026ndash;10, \u0026gt;\u0026thinsp;10 years), and prior treatment history (none, TCM-only, Western medicine-only, both)\u003csup\u003e[11]\u003c/sup\u003e. Potential participants were recruited through referrals by clinicians and outpatient advertisements. Eligible patients were aged 50\u0026ndash;85 years, diagnosed with DLSS according to standard guidelines, fluent in Mandarin, and capable of signing informed consent forms. Patients with severe cognitive impairment or communication difficulties were excluded.\u003c/p\u003e \u003cp\u003eSample size was guided by the principle of information power, which holds that the required number of participants depends on the richness and relevance of the data they provide, considering factors such as study aim and sample specificity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This approach prioritizes depth and quality over a predetermined number. Participants (n\u0026thinsp;=\u0026thinsp;26) were recruited through purposive sampling. Semi-structured interviews were conducted by two experienced researchers (ZYJ \u0026amp; AY), whose expertise in patient-centered dialogue ensured focused and in-depth data collection. Data analysis followed an inductive thematic approach. To enhance rigor, analyst triangulation was employed, with three researchers independently engaging in cross-case analysis to fully explore patterns and variations within the dataset.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 data collection\u003c/h2\u003e \u003cp\u003eSemi-structured, face-to-face interviews were conducted by two trained researchers (Z.Y.J., male, with a master\u0026rsquo;s degree in Chinese medicine and 3 years of qualitative research experience; A.Y., male, with a master\u0026rsquo;s degree in acupuncture and tuina and 3 years of clinical research experience). Both interviewers were not involved in the clinical care of the participants to encourage open expression and minimize social desirability bias. Prior to the interviews, participants were informed that the interviewers were researchers focusing on patient experience, not their treating clinicians.\u003c/p\u003e \u003cp\u003eInterviews lasted between 30 to 45 minutes and took place in a private, quiet consultation room at the hospital to ensure confidentiality. Only the interviewer and the participant were present. With the participant\u0026rsquo;s permission, all interviews were audio-recorded digitally. Researchers also took brief field notes during the interviews to capture non-verbal cues and contextual observations. The interview guide (see Supplementary File 1) was developed based on a literature review and team expertise, and was piloted with two DLSS patients (not included in the final sample) to refine question clarity and flow. The guide covered key domains: illness and treatment journey; perceptions of TCM; decision-making considerations (efficacy, safety, cost, logistics); and expectations for ideal care.\u003c/p\u003e \u003cp\u003eAll audio recordings were transcribed verbatim into Chinese by a professional transcription service within one week of the interview. To ensure accuracy, one of the interviewers (A.Y.) meticulously verified each transcript by listening to the recording while reading the text, correcting any discrepancies. The verified transcripts were then de-identified, with participants assigned unique study IDs (P1-P26).\u003c/p\u003e \u003cp\u003eDuring the recruitment period, approximately 45 eligible patients were approached by their physicians or via posters. Nineteen patients declined to participate, primarily citing lack of time (n\u0026thinsp;=\u0026thinsp;11) or a general disinterest in research participation (n\u0026thinsp;=\u0026thinsp;8). No discernible pattern was noted between those who declined and those who participated regarding basic demographic characteristics available from clinic records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed following the inductive thematic analysis framework\u003csup\u003e[14,15]\u003c/sup\u003e, using NVivo 12 software for data management. The process involved six phases:\u003c/p\u003e \u003cp\u003ePhase 1: Familiarizing with the data. The lead analyst (ZYJ) immersed themselves in the data by conducting repeated, active readings of all interview transcripts. This process involved not only reading for content but also noting down initial analytical observations, ideas, and potential patterns, forming the foundation for subsequent coding.\u003c/p\u003e \u003cp\u003ePhase 2: Generating initial codes. Two researchers (ZYJ and AY) independently performed line-by-line coding on the first three transcripts to identify the basic segments of meaning relevant to the research question. This inductive coding process aimed to remain open to all features of the data. The two analysts then met to compare their independently generated codes, discussing similarities and discrepancies to collaboratively develop a coherent and comprehensive preliminary coding framework.\u003c/p\u003e \u003cp\u003ePhase 3: Searching for themes. In this phase, the researchers worked systematically to collate all codes and relevant data extracts. They examined how different codes could be clustered together to form broader patterns of meaning, thereby constructing initial candidate themes and sub-themes. This involved organizing the coded data into thematic maps to visualize potential relationships.\u003c/p\u003e \u003cp\u003ePhase 4: Reviewing themes. The candidate themes were rigorously reviewed and refined at two levels. First, Level 1 review checked if the coded data extracts coherently supported each theme. Second, Level 2 review evaluated whether the entire thematic structure accurately represented the complete dataset in relation to the research objective. This iterative process involved refining, splitting, combining, or discarding themes through sustained team discussion to ensure internal homogeneity and external heterogeneity.\u003c/p\u003e \u003cp\u003ePhase 5: Defining and naming themes. For each finalized theme, a clear and concise definition was articulated that captured its essence and central narrative. Precise names were assigned to each theme and sub-theme to immediately convey their core meaning to the reader, moving beyond simple description to interpretive analysis.\u003c/p\u003e \u003cp\u003ePhase 6: Producing the report. The final analytic narrative was woven together, integrating compelling data extracts that vividly illustrated each theme. The report contextualizes these extracts within the analysis, clearly demonstrating the link between the raw data and the interpretive conclusions, thereby substantiating the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Rigor and Trustworthiness\u003c/h2\u003e \u003cp\u003eTo ensure the rigor and trustworthiness of the analysis, multiple strategies were employed in alignment with established qualitative research COREQ criteria [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnalyst Triangulation: Two researchers (Z.Y.J. and A.Y.) independently performed initial coding and theme development. A third senior researcher (W.X.Y.) reviewed the coding framework and participated in cross-case analysis discussions to resolve discrepancies and enrich interpretations.\u003c/p\u003e \u003cp\u003ePeer Debriefing: The evolving analysis and thematic structure were periodically discussed with a senior qualitative methodology expert (Y.C.H.) not involved in data collection or coding. This peer challenged assumptions, provided alternative interpretations, and ensured analytical logic.\u003c/p\u003e \u003cp\u003eResearcher Reflexivity: All team members maintained reflective journals. Given that several researchers (W.X.Y., Y.C.H.) have clinical training in TCM, we actively discussed how this background might shape our interpretation of data related to \u0026lsquo;efficacy doubts\u0026rsquo; or \u0026lsquo;cultural affinity.\u0026rsquo; We consciously sought disconfirming evidence and ensured that themes emerged from the data rather than our preconceptions. For instance, when analyzing quotes expressing skepticism, we deliberately avoided defensive interpretations and focused on understanding the patient\u0026rsquo;s perspective.\u003c/p\u003e \u003cp\u003eAudit Trail: A detailed record was maintained, documenting all analytical decisions, iterations of the codebook, meeting notes, and the rationale for theme refinement, merging, or discarding.\u003c/p\u003e \u003cp\u003eData Saturation: We employed the principle of information power [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] to guide sample size. Recruitment and analysis proceeded iteratively. After analyzing the 22nd interview, no new substantive themes or insights emerged related to the core research question. The final four interviews were conducted and analyzed to confirm that thematic saturation had been robustly achieved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Ethical considerations\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Institutional Review Board of Dongzhimen Hospital Beijing University of Chinese Medicine (Approval No 2018-JYBZZJS090). All participants provided written informed consent. The research process was strictly confidential.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eWe conducted interviews with 26 participants (11 males and 15 females), with a mean age of 65.2 years (SD 7.1) and a mean disease duration of 6.8 years (SD 3.9). Educational backgrounds ranged from elementary school to postgraduate level. Detailed characteristics are presented in table S3 in Supplementary File.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Theme\u003c/h2\u003e \u003cp\u003eThe analysis identified two overarching themes: barriers and facilitators, comprising seven sub-themes that capture the psychological and practical considerations in patient decision-making. Illustrative quotations are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, Sub-themes, and Illustrative Quotations on Barriers and Facilitators to Selecting TCM for DLSS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003etheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme and code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative Quote (participant ID)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1. Skepticism regarding efficacy and mechanism of action\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of previous ineffective treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"I had previously tried acupuncture and tuina therapy, but the effects were not significant... Perhaps it was merely a psychological effect.\" (P07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe need for scientific evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"I need to see more definitive evidence to be fully convinced.\" (P12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2. Fear and Practical Concerns\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain Fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI want it (refer to acupuncture) to work, and it has to be comfortable... The pain is unbearable.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocus on safety/standardization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrom a professional perspective, my focus is on operational standards, such as infection risk. (P19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcerns about side effects (herbal medicine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAs the saying goes, 'All medicines have some toxicity.' I am always concerned that long-term consumption of traditional Chinese medicine (TCM) may cause liver and kidney damage. (P14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3. Economic and Time Burden\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf the cost is too high... I cannot afford it. The insurance has an annual limit. (P10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003etime cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Having to attend training sessions multiple times a week makes it difficult to take leave.\" (P21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4. Information Gap/Knowledge Deficiency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe role in Traditional Chinese Medicine (TCM) remains unclear.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"I don't know anything about this disease.\" (P05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReliable information is hard to obtain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe general public does not fully comprehend; we merely adhere to the physician's recommendations while retaining reservations. (P18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacilitators\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1. Desire to avoid surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsider Traditional Chinese Medicine as a Safer Alternative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChoosing Traditional Chinese Medicine (TCM) allows me to address health issues while preserving the integrity and original physiological functions of my body, which brings me a sense of reassurance. (P13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsideration of a Rational Stepwise Nursing Plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMy idea is straightforward: to establish a 'staircase' approach. Surgery represents the highest and final step, which should only be considered as a last resort. Traditional Chinese Medicine (TCM) is currently the most systematic non-surgical therapy I can identify. (P09)\u003c/p\u003e \u003cp\u003eFrom a medical perspective, systematic Traditional Chinese Medicine (TCM) treatment is the first rational step for my case. (P15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2. Direct positive experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eremission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain persists after acupuncture, but has significantly alleviated... Therefore, I will continue the treatment. (P04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eenhance treatment comfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"After the tuina, I felt relaxed and experienced improved sleep quality.\" (P23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3. Cultural Affinity and Philosophical Compatibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrust in Holistic/Natural Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrust. I believe Traditional Chinese Medicine (TCM) emphasizes balance rather than aggressive intervention. (P11)\u003c/p\u003e \u003cp\u003eI trust this concept of recovery through one's own physiological functions. (P08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespect the professional expertise of licensed physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI trust two things: his experience and his character. As the department head, his hair is already white, which clearly indicates his extensive experience. He communicates with me about the patient's condition and treatment methods without exaggeration or intimidation, always being very practical. (P09)\u003c/p\u003e \u003cp\u003eInitially, I approached the treatment with skepticism. However, after several sessions, I observed genuine improvement in my symptoms. Upon revisiting the physician's initial statements, diagnosis, and selected therapeutic regimen, I came to recognize the rationale behind each step he took. (P04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 \u003cb\u003eTheme\u003c/b\u003e 1: Barriers\u003c/h2\u003e \u003cp\u003eThis theme summarizes the barriers that deter patients from choosing TCM.\u003c/p\u003e \u003cp\u003eSubtheme 1: Skepticism about Efficacy and Mechanistic Disbelief\u003c/p\u003e \u003cp\u003eThis reflects patients 'fundamental skepticism regarding the efficacy of Traditional Chinese Medicine (TCM) in treating DLSS. Some patients lose confidence due to previous ineffective experiences, as exemplified by P07: \"I tried acupuncture and tuina before, but the results were not significant... Perhaps it's just a psychological effect.\" Another group, particularly those with higher education levels, demonstrate a need for scientific evidence, as noted by P12 \"I need to see more definitive evidence-based findings to fully trust this approach.\" Both types of skepticism stem from the conceptual gap between the theoretical framework of TCM and patients' understanding of their own disease.\u003c/p\u003e \u003cp\u003eSubtheme 2: Treating Fear and Practical Concerns\u003c/p\u003e \u003cp\u003eThis involves patients' physiological experiences and perceived risks during Traditional Chinese Medicine (TCM) treatment. The most common concern is the fear of procedural pain, particularly in acupuncture, as described by P06: \"I hope it works while also being comfortable... Excessive pain is unbearable.\" Additionally, there are widespread concerns about safety and side effects, such as herbal toxicity or tuina-induced injuries. Patients with medical backgrounds are more concerned about technical specifications and infection risks, as mentioned by P19: \"From a professional perspective, I am concerned about procedural standards, such as infection risks.\"\u003c/p\u003e \u003cp\u003eSubtheme 3: Economic and Time Burden\u003c/p\u003e \u003cp\u003eThis encompasses the non-clinical costs associated with Traditional Chinese Medicine (TCM) treatment. The primary concern is the financial burden, particularly due to restrictions on medical insurance reimbursement, as highlighted by P10: \"If the cost is too high... I cannot afford it. The insurance has an annual limit.\" Time and travel expenses also pose significant barriers, especially for employed individuals. For instance, P21 noted: \"I need to attend multiple treatments per week, making it difficult to take leave.\" These practical constraints often lead patients to hesitate in balancing the investment in treatment with its potential outcomes.\u003c/p\u003e \u003cp\u003eSubtheme 4: Information Deficiency and Cognitive gap\u003c/p\u003e \u003cp\u003eThis reflects the difficulty patients face in making informed decisions due to the lack of reliable and easily understandable information. Some patients have no basic understanding of the disease or Traditional Chinese Medicine (TCM), as admitted by P05: \"I know nothing about this disease.\" Others feel confused by conflicting information, as expressed by P18: \"We ordinary people don't understand; we just follow the doctor's advice, but still have some doubts.\" This information vacuum hinders patients from accurately assessing other obstacles or facilitators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. Theme 2: Facilitators\u003c/h2\u003e \u003cp\u003eThis theme covers the motivation, experience and belief that promote patients to actively choose TCM.\u003c/p\u003e \u003cp\u003eSubtheme 5: Surgical Avoidance Intention\u003c/p\u003e \u003cp\u003eThe primary driving force is patients 'resistance to surgery and their preference for Traditional Chinese Medicine (TCM) as a preferred alternative. This choice encompasses both emotional fears, such as P09's perception that \"surgery... carries significant risks,\" and rational considerations, as exemplified by P15, who views it as \"a reasonable step to first attempt systematic TCM treatment.\" Consequently, TCM is positioned as a safer and non-invasive therapeutic option.\u003c/p\u003e \u003cp\u003eSubtheme 6: Direct or Indirect Positive Experiences\u003c/p\u003e \u003cp\u003eThe most persuasive facilitators stem from direct or credible evidence of benefits. Even mild symptom relief can strengthen treatment commitment, as demonstrated by P04: \"Pain persists after acupuncture, but it has significantly improved... Therefore, I will continue with the treatment.\" The sense of comfort during the treatment process also enhances the overall experience, as noted by P23: \"After the tuina, I felt relaxed, and my sleep quality improved.\" Additionally, indirect experiences such as others 'success stories can motivate treatment attempts. For instance, P16 was willing to try and trust Traditional Chinese Medicine (TCM) due to a colleague's recommendation.\u003c/p\u003e \u003cp\u003eSubtheme 7: Cultural Identity and Professional Trust\u003c/p\u003e \u003cp\u003eThis demonstrates patients 'deep acceptance of Traditional Chinese Medicine (TCM) based on cultural resonance and professional recognition. Some patients endorse the holistic natural therapy philosophy of TCM, as evidenced by P11's statement that \"TCM emphasizes balance, not aggressive intervention.\" Trust in physicians 'professional competence is equally crucial, with P09 expressing confidence in the physician's \"experience\" and \"integrity,\" while P04 validated the rationality of the physician's decision through therapeutic outcomes. This cultural affinity and professional trust enhance patients' tolerance for treatment uncertainties.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3. Interrelationships between sub-themes\u003c/h2\u003e \u003cp\u003eThe sub-themes are not isolated but interconnected and dynamically interrelated. For instance, information deficit (Barrier 4) may exacerbate efficacy doubt (Barrier 1) and treatment phobia (Barrier 2). Conversely, positive direct experience (Facilitator 2) serves as the most potent factor in overcoming barriers, directly alleviating doubts and fears. Cultural affinity (Facilitator 3) can modulate the impact of economic time burden (Barrier 3), making patients more willing to bear associated costs. Surgical avoidance intention (Facilitator 1) often acts as an initial driving force, prompting patients to comprehensively weigh other factors before entering the decision-making process.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Themes, Sub-themes, and Illustrative Quotations on Barriers and Facilitators to Selecting TCM for DLSS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Main Findings\u003c/h2\u003e \u003cp\u003eThis qualitative study provides an in-depth exploration of the decision-making process among Chinese patients with DLSS regarding TCM interventions. The findings move beyond a simple catalog of factors, revealing a dynamic internal negotiation where patients actively weigh perceived barriers (primarily skepticism, fear, and cost) against facilitators (avoiding surgery, trust in positive experiences, and cultural congruence). This process resonates with the core constructs of the Health Belief Model, where the perceived threat of surgery and the perceived benefits of TCM are balanced against perceived costs and fears [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To systematically translate these insights into actionable guidance for clinical practice and policy, we further employ the COM-B model of behavior change [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which posits that behavior (B) requires the conjunction of Capability (C), Opportunity (O), and Motivation (M). The following discussion synthesizes our themes within this framework, drawing deeply on relevant literature to contextualize and explain our findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1. The Foundation of Decision-Making: Capability Gaps and Their Resolution\u003c/h2\u003e \u003cp\u003eThe decision to consider TCM first hinges on a patient\u0026rsquo;s psychological capability\u0026mdash;their knowledge and understanding. Our study identified a profound information deficit and cognitive gap (Barrier 4) as a foundational barrier. Patients lacked accessible, credible information on how TCM modalities like acupuncture might alleviate DLSS-specific symptoms such as neurogenic claudication. This gap directly fuels skepticism and distrust of efficacy (Barrier 1), manifesting either as a demand for scientific evidence among the educated or disillusionment from past experiences. This aligns with broader CAM literature, where \u0026ldquo;perceived effectiveness\u0026rdquo; is a primary determinant of use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A qualitative study on non-surgical LSS treatment similarly found that understanding and believing in the treatment\u0026rsquo;s benefit was central to persistence [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuilding this capability is therefore paramount. Our data, alongside literature, suggest two potent pathways. First, positive direct or vicarious experience (Facilitator 6) is the most powerful tool. Tangible symptom relief provides irrefutable, personal evidence that can overcome pre-existing doubts, a factor critical for adherence in chronic pain management [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Second, effective communication must bridge the explanatory model divide. As studies on promoting evidence uptake in TCM note, translating concepts into relatable terms is key [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This requires moving from abstract TCM theory to explanations grounded in the pathophysiology of DLSS (e.g., reducing nerve root irritation).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2. The Role of Opportunity: Structural Barriers and Enabling Environments\u003c/h2\u003e \u003cp\u003eOpportunity encompasses external factors that make a behavior feasible. The economic and time burdens (Barrier 3) we identified are critical physical opportunity barriers. The need for frequent, long-term sessions creates significant cost and logistical challenges, particularly for employed patients. This finding is not unique to TCM; research on implementing community-based pain management programs identifies similar structural hurdles [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Within China\u0026rsquo;s healthcare context, limited insurance reimbursement for outpatient TCM and the concentration of specialized care in urban centers exacerbate these barriers [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], creating an \u0026ldquo;accessibility filter\u0026rdquo; that may disproportionately affect lower-income groups.\u003c/p\u003e \u003cp\u003eCreating opportunity requires systemic innovation. Policy-level interventions to expand insurance coverage for evidence-based TCM protocols are essential. At the service delivery level, models such as community-integrated TCM clinics and flexible scheduling\u0026mdash;explored in the context of integrating acupuncture into mainstream care [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u0026mdash;could mitigate time and travel constraints. Furthermore, fostering positive vicarious experience (Facilitator 6) through peer support groups creates a social opportunity, leveraging trusted community narratives to lower psychological barriers to initiation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3. The Engine of Choice: Reflective and Automatic Motivation\u003c/h2\u003e \u003cp\u003eMotivation directs and energizes behavior. Our findings reveal a complex motivational landscape. A potent aversion to surgery (Facilitator 5) provides a strong reflective motivation. Patients perceive TCM as a safer, less invasive alternative within a stepped-care model, a rational consideration also observed in studies of chiropractic care for low back pain [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This motivation can initiate the decision-making process. However, it is often countered by strong automatic (emotional) motivations in the form of fears about the treatment process (Barrier 2), such as needle phobia or concern about manipulation injury. This fear, linked to the HBM\u0026rsquo;s \u0026ldquo;perceived susceptibility\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], is a common barrier to procedure-based therapies, as seen in studies on exercise adherence among chronic pain patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe facilitatory theme of cultural affinity and trust in TCM philosophy (Facilitator 7) represents a deep, stable reflective motivation unique to this context. This cultural capital, a pre-existing \u0026ldquo;trust bias,\u0026rdquo; fosters acceptance of TCM\u0026rsquo;s holistic approach and increases tolerance for treatment inconveniences or uncertainties. It provides a compelling explanatory framework for patients, making the intervention personally meaningful [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This factor crucially differentiates TCM adoption in China from the uptake of complementary therapies in non-indigenous settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Clinical and Policy Implications: A Multi-Level COM-B Intervention Strategy\u003c/h2\u003e \u003cp\u003eTo effectively promote informed TCM use, interventions must concurrently address Capability, Opportunity, and Motivation.\u003c/p\u003e \u003cp\u003eEnhancing Capability (C): Clinicians must provide stratified education. For the evidence-seeking patient, referencing high-quality RCT data (e.g., [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]) is valuable. For others, using visual aids or patient testimonials to explain treatment mechanisms in relatable terms is key. This directly targets information gaps and efficacy doubts.\u003c/p\u003e \u003cp\u003eOptimizing Opportunity (O): Healthcare systems should innovate service delivery (e.g., community hubs, tele-support) to reduce logistical barriers [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Policymakers must evaluate financial structures to improve affordability. Building platforms for positive peer sharing can harness social opportunity.\u003c/p\u003e \u003cp\u003eStrengthening Motivation (M): Practitioners should proactively elicit and validate the aversion to surgery, framing TCM as a legitimate first-line strategy [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. To mitigate treatment fears, transparent communication about sensations and patient-controlled \u0026ldquo;stop signals\u0026rdquo; are essential. Most critically, meticulously managing the initial treatment experience to maximize early comfort and perceptible benefit is vital to cementing positive direct experience\u0026mdash;the ultimate motivational reinforce [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Advantages and Limitations\u003c/h2\u003e \u003cp\u003eThis study demonstrates the following strengths. First, methodological rigor was ensured by adhering to established qualitative research standards and employing thematic analysis. Second, purposive sampling with maximal diversity preservation enabled comprehensive capture of patient experiences, while data collection continued until reaching robust thematic saturation, thereby enhancing the credibility of findings. Third, credibility was strengthened through triad of analyst validation, peer discussion, and researcher reflective practice, which helped eliminate biases and ensure data-driven thematic analysis.\u003c/p\u003e \u003cp\u003eThis study also has limitations. First, since the subjects may have a higher baseline acceptance of Traditional Chinese Medicine compared to the broader DLSS population, recruiting participants only from a tertiary TCM hospital in the city center may limit the transferability of findings to primary care settings or regions with less TCM exposure. We attempted to include skeptical voices through purposive sampling, but the influence of the study environment still exists. Second, self-selection and potential social expectation bias may affect the study results. We mitigated this issue by using non-clinical interviewers and emphasizing confidentiality. Third, as a qualitative study, the results have the specific context of the China medical environment and may not be directly generalizable to other settings, but they provide a detailed explanatory framework for future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003ePatients with DLSS often make decisions regarding Traditional Chinese Medicine (TCM) with personal biases. They weigh practical barriers such as costs and fears, as well as facilitators based on experience, cultural background, and preferences for non-invasive treatments. To enhance the adoption of TCM, it is essential to move beyond a one-size-fits-all approach. By implementing tailored communication strategies addressing specific concerns and fears, coupled with policy measures to reduce structural barriers to access, healthcare providers and the healthcare system can better support patients in making informed and value-aligned choices, thereby achieving comprehensive treatment for lumbar spinal stenosis.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eEthical Approval and Participant Informed Consent: This study was approved by the Institutional Review Board of Dongzhimen Hospital, Beijing University of Chinese Medicine (Approval No. 2018-JYBZZJS090). All participants signed informed consent forms after their initial in-person or online meeting with the investigator or principal investigator (PI).\u003c/p\u003e\n\u003cp\u003ePublication Consent Form\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in this study are available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003eConflict of Interest\u003c/p\u003e\n\u003cp\u003eNo conflict of interest exists.\u003c/p\u003e\n\u003cp\u003eFunding Sources\u003c/p\u003e\n\u003cp\u003eBeijing Tongzhou District Science and Technology Program Project (No.: WS2025004); China Association of Chinese Medicine (Project No.: 202565-001); China National Natural Science Foundation (Nos.: 81803956 and 82374617); Beijing Young Outstanding Talents Program (No.: 2020-4-4195)\u003c/p\u003e\n\u003cp\u003eAuthor Contributions:\u003c/p\u003e\n\u003cp\u003eZYJ: Data Processing and Analysis, Drafting\u003c/p\u003e\n\u003cp\u003eAY: Data Processing and Analysis, Review and Editing\u003c/p\u003e\n\u003cp\u003eWJ: Supervision and Guidance, Draft Review and Editing\u003c/p\u003e\n\u003cp\u003eLXY: Data Collection, Processing and Analysis\u003c/p\u003e\n\u003cp\u003eCZJ: Data Collection, Processing and Analysis\u003c/p\u003e\n\u003cp\u003eLY: Data Collection, Processing and Analysis\u003c/p\u003e\n\u003cp\u003eNF: Data Collection, Processing and Analysis\u003c/p\u003e\n\u003cp\u003eFMJ: Resource Provision, Supervision and Guidance\u003c/p\u003e\n\u003cp\u003eJJJ: Resource Provision, Supervision and Guidance\u003c/p\u003e\n\u003cp\u003eLCX: Draft Review and Editing\u003c/p\u003e\n\u003cp\u003eWXY: Draft Review, Editing and Analysis\u003c/p\u003e\n\u003cp\u003eYCH: Conceptualization, Methodology and AnalysisAuthor Disclosure Statement: There are no conflicts of interest requiring disclosure.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKatz JN, Zimmerman ZE, Mass H, Makhni MC. 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PLoS ONE. 2013;8(2):e56806. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0056806\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0056806\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbar spinal stenosis, Traditional Chinese Medicine (TCM), Patient decision-making, Barriers and Facilitators, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8812194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8812194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to qualitatively explore the perceived barriers and facilitators that influence decision-making among patients with degenerative lumbar spinal stenosis (DLSS) in China regarding the use of Traditional Chinese Medicine (TCM) interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive study was conducted using semi-structured interviews. Through purposive sampling, 26 patients with DLSS were recruited from a tertiary TCM hospital in Beijing. Interviews explored patients' experiences, perceptions, and the reasoning behind their decisions to use or decline TCM interventions (e.g., acupuncture, tuina). Data were analyzed using inductive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatient decision-making emerged as a dynamic process of weighing interlinked factors. Barriers included: (1) skepticism about efficacy and mechanistic distrust; (2) fear and practical concerns about treatment procedures; (3) significant economic and time burdens; and (4) information deficits and knowledge gaps. Facilitators included: (1) a strong desire to avoid surgery; (2) positive direct or vicarious treatment experiences; and (3) cultural affinity and trust in TCM philosophy and practitioners. Notably, cultural trust was found to buffer the impact of practical barriers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe choice regarding TCM for DLSS involves a personal calculus where fears and costs are balanced against cultural alignment and experiential positives. To support patient-centered care, a multi-level approach informed by behavioral theory (e.g., the COM-B model) is essential. This includes tailoring communication to bridge information gaps, innovating services to improve access, and leveraging cultural trust within stepped-care discussions to promote the evidence-informed integration of TCM in DLSS management.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Choosing Traditional Chinese Medicine among Patients with Degenerative Lumbar Spinal Stenosis in China: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 21:44:30","doi":"10.21203/rs.3.rs-8812194/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-07T00:56:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T18:58:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284379299245305653777389577036396549244","date":"2026-04-06T07:20:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T11:17:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291542249137742373170719678475350258146","date":"2026-04-02T06:24:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T03:18:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T03:06:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T10:27:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T16:15:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2026-03-17T12:15:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"528c5360-8877-4559-8308-6e49d92dbf3d","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-07T00:56:12+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T01:10:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 21:44:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8812194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8812194","identity":"rs-8812194","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}