An International Consensus Definition for Contextual Factors: Findings from a Nominal Group Technique

Emerging literature suggests contextual factors are important components of therapeutic encounters and may substantially influence clinical outcomes of a treatment intervention. At present, a single consensus definition of contextual factors, which is universal across all health-related conditions is lacking. The objective of this study was to create a consensus definition of contextual factors to better refine this concept for clinicians and researchers. The study used a multi-stage virtual Nominal Group Technique (vNGT) to create and rank contextual factor definitions. Nominal group techniques are a form of consensus-based research, and are beneficial for identifying problems, exploring solutions and establishing priorities. The 10 international vNGT participants had a variety of clinical backgrounds and research specializations and were all specialists in contextual factors research. The initial stages of the vNGT resulted in the creation of 14 independent contextual factor definitions. After a prolonged discussion period, the initial definitions were heavily modified, and 12 final definitions were rank ordered by the vNGT participants from first to last. A sixth round was used to identify a final consensus, which reflected the complexity of contextual factors and included three primary domains: 1) an overall definition; 2) qualifiers that serve as examples of the key areas of the definition; and 3) how contextual factors may influence clinical outcomes. Our consensus definition of contextual factors seeks to improve the understanding and communication between clinicians and researchers. These are especially important in recognizing their potential role in moderating/mediating clinical outcomes. ### Competing Interest Statement Antoine Bailliard, Joel Bialosky, Elisa Carlino, Luana Colloca, Jorge Esteves, Dave Newell, Alvisa Palese, William Reed,Giacomo Rossettini, Jennifer Plumb Vilardaga report no competing interests and nothing to declare. Chad Cook receives honoraria from book sales and continuing education courses, and is a consultant for Revenite and the Hawkins Foundation. None of the honoraria or consulting work has a competing interest with the work provided in this paper. ### Funding Statement WR, CC Project Number U24AT011969-01 Administering Institutes or Centers NATIONAL CENTER FOR COMPLEMENTARY & INTEGRATIVE HEALTH The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Institutional Review Board of Duke University, Durham, North Carolina, USA, approved the study (ro00111522-INIT-1.0). We obtained verbal and written consent from participants using Form M0345 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All relevant data are within the manuscript and its Supporting Information files.