Factors influencing implementation of a patient decision aid in a developing country: an exploratory study

Evaluation of the implementation of an insulin patient decision aid for patients with type 2 diabetes in an academic primary care clinic in Malaysia: a mixed method study

BACKGROUND

Literature surrounding patient decision aid (PDA) focus on testing effectiveness such as measuring patient or practice outcomes, while few studies looked into evaluation of implementation outcomes. It is important to assess implementation outcomes because in order for PDA to deliver its intended effects, they should first be effectively implemented. This study aimed to evaluate the implementation of an insulin PDA in an academic primary care clinic specifically measuring implementation outcomes.

METHODS

A mixed-methods sequential explanatory design was used. This study was conducted at a primary care clinic in an academic hospital from April - November 2018. The insulin PDA was implemented using a tailored implementation intervention, which comprised of 11 strategies aiming to overcome 13 prioritised implementation barriers. Evaluation data were collected from: healthcare administrators such as the head of department, the clinic coordinator, and the nursing officer who oversees the clinic operations, doctors whose tasks were to deliver the insulin PDA to patients, nurses who were responsible for making sure the insulin PDAs were available, and patients with type 2 diabetes who were offered the insulin PDA. The study commenced with the quantitative approach to assess 'Reach', 'Adoption', 'Implementation' and 'Maintenance'of the insulin PDA. Subsequently, qualitative approach was employed and qualitative interviews were conducted with the relevant stakeholders to explain the quantitative outcomes. A total of six IDIs and six FGDs were conducted with healthcare providers (healthcare policymakers: 3, doctors: 35, and staff nurses: 5), and 62 IDIs were conducted with patients.

RESULTS

For 'Reach', 88.9% (n = 48/54) of doctors and 55% (n = 11/20) of nurses attended the insulin PDA training workshops. This was attributed to their self-motivation and the mandate from the Head of Department. The PDA reached 387 patients and was facilitated by the doctors who delivered the PDA to them and their own desire to know more about insulin. Doctors' 'Adoption' of the PDA was high (83.3%, n = 45/54) due to the positive personal experience with the usefulness of the PDA. Only 65.7% (n = 94/143) of patients who received the PDA read it. The degree of 'Implementation' of the PDA varied for different tasks (ranged from 19.2 to 84.9%) and was challenged by patient and system barriers. For 'Maintenance', 80% of the doctors were willing to continue using the PDA due to its benefits.

CONCLUSION

This study highlighted that the implementation of an insulin PDA in a primary care setting is promising. Addressing the issues of social hierarchy, and healthcare providers' roles and responsibilities can further improve implementation outcomes.

Shared decision-making in type 2 diabetes: a systematic review of patients' preferences and healthcare providers' perspectives

BACKGROUND

Shared decision-making (SDM) is crucial for type 2 diabetes mellitus (T2DM) management due to the complexity of treatment options. This systematic review sought to understand T2DM patients' preferences and diabetes care providers' perspectives regarding SDM, and the barriers and facilitators to SDM.

METHODS

Five databases were searched from 2000 to 2023 (Medline/PubMed, Web of Science, Scopus, PsycINFO, and Embase). All included papers were quantitative and qualitative studies regarding preferences of patients with T2DM for SDM, perspectives of providers on SDM, and their barriers and facilitators to SDM. Quantitative findings were extracted as percentages, and qualitative findings were extracted as presented in the original research paper. Study selection was carried out independently by two authors, with discrepancies resolved by consensus and by consultation with the supervisor. The Joanna Briggs Institute Checklist for Qualitative Research and for Cross Sectional Studies was used to evaluate the risk of bias of included papers.

RESULTS

Thirty-four studies were included in this review; 22 focused on T2DM patients' decision-making preferences, 7 focused on perspectives of diabetes care providers, and 5 addressed both. Of the 27 studies of T2DM patients, 20 (ten quantitative and ten qualitative studies) reported that respondents preferred and valued SDM and wanted to make decisions in collaboration with a provider. Of the 12 studies of providers, only 5 reported that providers had positive views towards SDM and preferred to involve patients in decision-making. A comprehensive list of SDM facilitators and barriers included patient factors (facilitators like higher health literacy and motivation, and barriers like blind trust in physicians and poor health), provider factors (facilitators like a physician's information-giving behavior and medical knowledge/technical skills, and barriers like a paternalistic attitude and poor interpersonal style), and context factors (facilitators like physician accessibility and availability, and barriers like a lack of system support and low continuity).

CONCLUSION

Although SDM is important for most patients living with diabetes, the evidence from included studies suggest that providers in diabetes practice do not universally express positive views towards SDM. Because T2DM patients and their providers need to work together to implement the SDM approach satisfactorily, there is a need to encourage more providers to do so.

Examining cancer patient preferences during three stages of decision making and family involvement: a multicenter survey study in China

BACKGROUND

Medical decision-making is a complex multi-stage process. Chinese cancer patients' preference for participation in decision-making stages, family involvement and influencing factors remain unclear.

METHODS

A total of 1,422 cancer patients from four tertiary hospitals in China were included in the cross-sectional survey. Patient Expectation for Participation in Medical Decision-making Scale was used to measure patients' information, deliberation and decisional control preferences. The patient-family Control Preferences Scale was used to measure expected and actual levels of family involvement. Generalized estimation equation was performed to explore factors associated with patients' preferences.

RESULTS

93.0% of patients had a high preference for information exchange, 95.8% for treatment deliberation, and 61.7% for decisional control. Equal participation was most common in family involvement in decision-making, followed by family-led and patient-led. 15.5% of patients reported a discrepancy between expected and actual family involvement. Age, education, marital status, number of adult children, occupation, family income, regular residence, health insurance and time since diagnosis were related to patient preference. Compared to patients with other cancer sites, those with breast [odds ratio (OR) 2.02, 95%CI: 1.47-2.77] and thyroid cancer [OR 2.37, 95%CI: 1.82-3.10] had higher information preference, those with breast [OR 2.98, 95%CI: 2.73-3.26] and esophagus cancer [OR 2.86, 95%CI: 1.13-7.22] had higher deliberation preference, and thyroid cancer patients [OR 1.50, 95%CI: 1.07-2.10] had higher decisional control preference. Patients who expected or experienced equal participation had higher preference at all stages of decision-making than those with family-led involvement. Patients with inconsistent expected and actual family involvement had lower preferences for the deliberation [OR 0.53, 95%CI: 0.36-0.77] and decisional control stages [OR 0.67, 95%CI: 0.56-0.79].

CONCLUSIONS

Chinese cancer patients generally have high preference for information exchange and treatment deliberation, but varied preferences for decision control, influenced by patients' sociodemographic factors, cancer types, time since diagnosis and family involvement. The findings underscore the importance of tailoring medical decision-making processes to individual patient preferences and ensuring family involvement aligns with patient expectations to enhance patient-centered care in China.

Developing an implementation intervention, and identifying strategies for integrating health innovations in routine practice: A case study of the implementation of an insulin patient decision aid

BACKGROUND

Implementation, which is defined as the process of getting evidence-based innovation to be utilised is critical in ensuring innovation is being integrated into real-world practice. The way an implementation intervention (i.e., a bundle of strategies to facilitate implementation) is developed has an impact on the types of strategies chosen, and whether they are relevant to the implementation setting to exert their effects. However, literature pertaining to development of intervention or detailed descriptions of implementation processes are scarce. This study aims to report the development of an implementation intervention to integrate the use of an evidence-based innovation in routine practice, using a Malaysian insulin patient decision aid (PDA) as an exemplar.

METHODS

The development of the insulin PDA implementation intervention was divided into two phases, incorporating step 3 and 4 of the Action Cycle in the Knowledge to Action framework. In Phase 1, barriers to the insulin PDA implementation was explored through qualitative interviews using an interview guide developed based on the Theoretical Domains Framework. In Phase 2, prioritisation of the barriers was conducted using the multivoting technique. Next, potential strategies that can address the barriers were identified based on understanding the clinic context, and evidence from literature. Then, the selected strategies were operationalised by providing full descriptions in terms of its actor, action, action target, temporality, dose, implementation outcome affected, before they were embedded into the patient care pathway in the clinic. The implementation intervention was finalised through a clinic stakeholders meeting.

RESULTS

In Phase 1, a total of 15 focus group discussions and 37 in-depth individual interviews were conducted with: healthcare policymakers (n = 11), doctors (n = 22), diabetes educators (n = 8), staff nurses (n = 6), pharmacists (n = 6), and patients (n = 31). A total of 26 barriers and 11 facilitators emerged and they were categorised into HCP, patient, organisational, and innovation factors. The multivoting exercise resulted in the prioritisation of 13 barriers, and subsequently, a total of 11 strategies were identified to address those barriers. The strategies were mandate change, training workshop, involve patients' family members or caretakers, framing/reframing, inform healthcare providers on the advantages of the insulin PDA use, define roles and responsibilities, place the insulin PDA in the consultation room, provide feedback, systematic documentation, to engage patients in treatment discussions, and juxtapose PDA in preferred language with patient's PDA in their preferred language to help with translation.

CONCLUSION

This study highlights main barriers to PDA implementation, and strategies that can be adopted for implementation. The steps for intervention development in this study can be compared with other intervention development methods to advance the field of implementation of evidence-based innovations.

A scoping review, novel taxonomy and catalogue of implementation frameworks for clinical decision support systems

BACKGROUND

The primary aim of this scoping review was to synthesise key domains and sub-domains described in existing clinical decision support systems (CDSS) implementation frameworks into a novel taxonomy and demonstrate most-studied and least-studied areas. Secondary objectives were to evaluate the frequency and manner of use of each framework, and catalogue frameworks by implementation stage.

METHODS

A scoping review of Pubmed, Scopus, Web of Science, PsychInfo and Embase was conducted on 12/01/2022, limited to English language, including 2000-2021. Each framework was categorised as addressing one or multiple stages of implementation: design and development, evaluation, acceptance and integration, and adoption and maintenance. Key parts of each framework were grouped into domains and sub-domains.

RESULTS

Of 3550 titles identified, 58 papers were included. The most-studied implementation stage was acceptance and integration, while the least-studied was design and development. The three main framework uses were: for evaluating adoption, for understanding attitudes toward implementation, and for framework validation. The most frequently used framework was the Consolidated Framework for Implementation Research.

CONCLUSIONS

Many frameworks have been published to overcome barriers to CDSS implementation and offer guidance towards successful adoption. However, for co-developers, choosing relevant frameworks may be a challenge. A taxonomy of domains addressed by CDSS implementation frameworks is provided, as well as a description of their use, and a catalogue of frameworks listed by the implementation stages they address. Future work should ensure best practices for CDSS design are adequately described, and existing frameworks are well-validated. An emphasis on collaboration between clinician and non-clinician affected parties may help advance the field.

Decision aids for cancer survivors' engagement with survivorship care services after primary treatment: a systematic review

PURPOSE

To elucidate existing decision aids (DAs) in supporting cancer survivors' decisions to engage in cancer survivorship care services after primary treatment. Secondary objectives are to assess the DA acceptability, impact of DAs, and implementation barriers.

METHODS

Databases (PubMed, Embase, PsycINFO, CINAHL) were searched to collect publications from inception through September 2021. Studies describing the development or evaluation of DAs used for survivorship care services after primary cancer treatment were included. Article selection and critical appraisal were conducted independently by two authors.

RESULTS

We included 16 studies that described 13 DAs and addressed multiple survivorship care domains: prevention of recurrence/new cancers in Hodgkin lymphoma survivors and breast cancer gene mutation carriers, family building options, health insurance plans, health promotion (substance use behavior, cardiovascular disease risk reduction), advanced care planning, and post-treatment follow-up intensity. The electronic format was used to design most DAs for self-administration. The content presentation covered decisional context, options, and value clarification exercises. DAs were acceptable and associated with higher knowledge but presented inconclusive decisional outcomes. Implementation barriers included lack of design features for connectivity to care, low self-efficacy, and low perceived DA usefulness among healthcare professionals. Other survivor characteristics included age, literacy, preferred timing, and setting.

CONCLUSIONS

A diverse range of DAs exists in survivorship care services engagement with favorable knowledge outcomes. Future work should clarify the impact of DAs on decisional outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

DA characterization and suggestions for prospective developers could enhance support for cancer survivors encountering complex decisions throughout the survivorship continuum.

A Voice-Annotated Digital Decision Aid to Promote Child Influenza Vaccination: A Feasibility Study

(1) Background: Child influenza vaccine uptake is suboptimal due partly to vaccine hesitancy. A voice-annotated digital decision aid, Flu Learning Object (FLO), was developed to facilitate parental decision-making. This study assessed parental views on FLO’s usability and utility and determined its preliminary effectiveness in increasing vaccine intention and uptake; (2) Methods: A single-center mixed method study was conducted in a public primary care clinic in Singapore. Parents of children aged 6 months to 5 years who were unvaccinated in the preceding year were recruited. In-depth interviews explored their views of using FLO. Pre- and post-FLO questionnaires assessed their vaccine intention and perceived usability using the System Usability Scale (SUS); (3) Results: 18 parents were recruited. They became more aware of benefits and potential complications, distinguished influenza from the common cold, and recognized recommendations by National Childhood Immunisation Schedule. FLO addressed parents’ concerns and supported their decision-making process. FLO has good usability with a mean SUS score of 79.3, ranked at approximately the 85th percentile. The usage of FLO significantly increased vaccine intention from 55.6% to 94.4% (p = 0.016) with an actual vaccine uptake rate of 50%; (4) Conclusions: Parents generally accepted FLO, which positively influenced their intention to vaccinate their child against influenza.

Healthcare professionals' views on factors influencing shared decision-making in primary health care centres in Saudi Arabia: A qualitative study

OBJECTIVE

To describe the perspectives of healthcare professionals regarding the implementation of Shared decision-making (SDM) in primary healthcare centres (PHCCs) in Saudi Arabia.

METHODS

Qualitative semi-structured interviews were conducted with a purposive and snowball sample of healthcare professionals in PHCCs. Interviews have been recorded, transcribed, translated and thematically analysed. Themes were mapped to the COM-B model.

RESULTS

Sixteen healthcare professionals were interviewed. The data analysis identified six themes and 14 sub-themes. The six themes are patient related factors, health professional related factors, environmental context and resources, patient-physician communication, patient-physician preferences toward SDM and physicians' perceived value and benefits of SDM. Physicians are unlikely to practice SDM in the context of time pressures, shortage of physicians, lack of treatment options, and decision-making aids. The findings also underscored the importance of building a trustworthy physician-patient relationship through the use of effective conversation techniques.

CONCLUSIONS

There are multiple barriers to SDM in primary care. Unless these barriers are addressed, it is unlikely that physicians will effectively or fully engage in SDM with patients.

Development of a Patient Decision Aid to Help People Living with Inflammatory Bowel Disease

BACKGROUND: Patient decision aid (PDA) is a tool, which helps the improvement of shared decisionmaking and is a part of the paradigm shift from physician-centered decisions to patient-centered shared decision making. In this study, we aimed to describe the process used to develop a PDA for facilitating shared decision-making about treatment in patients with inflammatory bowel disease (IBD) who need medication (corticosteroid, azathioprine, anti-TNF, and infliximab) or surgery. METHODS: The development process of PDA included: 1) The development of a prototype based on literature review and interview 2) 'Alpha' testing with patients and clinicians 3) 'Beta' testing in real conditions and 4) The production of a final version. This process took about 12 months (2019-2020). The participants were adult patients with IBD, gastroenterologists, and nurses. RESULTS: The final PDA contains four important sections: 1) Introduction about IBD disease, the purpose of developing PDA, and emphasis on shared decision-making 2) Benefits and risks of main medicines 3) The success rate as well as the incidence of complications after surgery, and 4) The conclusion about patients' satisfaction with PDA to choose the treatment options. Besides, PDA evaluation in the real world setting showed that 100% of physicians (n=4) and 86% of patients (n=12) were completely satisfied with the content of the PDA and considered it applicable and useful. CONCLUSION: This PDA can help patients participate in the shared decision-making process and select the best medical and surgical treatment methods. The feedback received from clinicians and patients showed their satisfaction with using the PDA.

Barriers and facilitators to patient-centred care in pharmacy consultations: A qualitative study with Malaysian hospital pharmacists and patients

BACKGROUND

Patient-centred care (PCC) has been suggested to provide benefits such as improved patient-healthcare provider communication and better disease self-management to patients. The practice of PCC should involve all healthcare professionals, including pharmacists who are well-positioned in providing pharmaceutical care to patients. However, a better understanding of the factors that can affect the practice of PCC in pharmacists' consultations is needed.

OBJECTIVE

To explore the perceptions of Malaysian hospital pharmacists and patients on the barriers and facilitators of a PCC approach in pharmacist consultations.

DESIGN

This study employed a qualitative, explorative semi-structured interview design.

SETTING AND PARTICIPANTS

Interviews were conducted with 17 patients and 18 pharmacists from three tertiary hospitals in Malaysia. The interviews were audiotaped and transcribed verbatim. Emerging themes were developed through a constant comparative approach and thematic analysis.

RESULTS

Three themes were identified in this study: (i) patient-related factors (knowledge, role expectations, and sociocultural characteristics), (ii) pharmacist-related factors (personalities and communication), and (iii) healthcare institutional and system-related factors (resources, continuity of care, and interprofessional collaboration). Pharmacists and patients mentioned that factors such as patients' knowledge and attitudes and pharmacists' personality traits and communication styles can affect patients' engagement in the consultation. Long waiting time and insufficient manpower were perceived as barriers to the practice of PCC. Continuity of care and interprofessional collaboration were viewed as crucial in providing supportive and tailored care to patients.

CONCLUSION

The study findings outlined the potential factors of PCC that may influence its implementation in pharmacist consultations. Strategic approaches can be undertaken by policymakers, healthcare institutions, and pharmacists themselves to address the identified barriers to more fully support the implementation of PCC in the pharmacy setting.

A Patient Decision Aid for Anticoagulation Therapy in Patients With Nonvalvular Atrial Fibrillation: Development and Pilot Study

Background

Atrial fibrillation (AF) is one of the most common predisposing factors for ischemic stroke worldwide. Because of this, patients with AF are prescribed anticoagulant medications to decrease the risk. The availability of different options for oral anticoagulation makes it difficult for some patients to decide a preferred choice of medication. Clinical guidelines often recommend enhancing the decision-making process of patients by increasing their involvement in health decisions. In particular, the use of patient decision aids (PDAs) in patients with AF was associated with increased knowledge and increased likelihood of making a choice. However, the majority of available PDAs are from Western countries.

Objective

We aimed to develop and pilot test a PDA to help patients with nonvalvular AF choose an oral anticoagulant for stroke prevention in the local setting. Outcomes were (1) reduction in patient decisional conflict, (2) improvement in patient knowledge, and (3) patient and physician acceptability.

Methods

We followed the International Patient Decision Aid Standards (IPDAS) to develop a mobile app–based PDA for anticoagulation therapy in patients with nonvalvular AF. Focus group discussions identified decisional needs, which were subsequently incorporated into the PDA to compare choices for anticoagulation. Based on recommendations, the prototype PDA was rendered by at least 30 patients and 30 physicians. Decisional conflict and patient knowledge were tested before and after the PDA was implemented. Patient acceptability and physician acceptability were measured after each encounter.

Results

Anticoagulant options were compared by the PDA using three factors that were identified (impact on stroke and bleeding risk, and price). The comparisons were presented as tables and graphs. The prototype PDA was rendered by 30 doctors and 37 patients for pilot testing. The mean duration of the encounters was 15 minutes. The decisional conflict score reduced by 35 points (100-point scale; P<.001). The AF knowledge score improved from 10 to 15 (P<.001). The PDA was acceptable for both patients and doctors.

Conclusions

Our study showed that an app-based PDA for anticoagulation therapy in patients with nonvalvular AF (1) reduced patient decisional conflict, (2) improved patient knowledge, and (3) was acceptable to patients and physicians. A PDA is potentially acceptable and useful in our setting. A randomized controlled trial is warranted to test its effectiveness compared to usual care. PDAs for other conditions should also be developed.

Decision-making for Risk-reducing Salpingo-oophorectomy (RRSO) in Southeast Asian BRCA Mutation Carriers With Breast Cancer: A Qualitative Study

BACKGROUND

The uptake of risk-reducing salpingo-oophorectomy (RRSO) in Asian countries is variable despite being the most effective option for ovarian cancer risk reduction in BRCA mutation carriers. Exploration of factors which may impact the RRSO decision-making of BRCA mutation carriers from Malaysia, a developing country in Southeast Asia, was undertaken.

METHODS

In-depth interviews with 28 Malaysian BRCA mutation carriers with a history of breast cancer were conducted in addition to observing their RRSO decision-making consultations in the clinic.

RESULTS

The decision-making considerations among the carriers were centered around the overarching theme of "Negotiating cancer risk and womanhood priorities," with the following themes: (1) risk perception, (2) self-preservation, (3) motherhood obligation, and (4) the preciousness of marriage. Cognitive knowledge of BRCA risk was often conceptualized based on personal and family history of cancer, personal beliefs, and faith. Many women reported fears that RRSO would affect them physically and emotionally, worrying about the post-surgical impact on their motherhood responsibilities. Nevertheless, some reported feeling obliged to choose RRSO for the sake of their children. For some, their husband's support and approval were critical, with emotional well-being and sexuality reportedly perceived as important to sustaining married life. Despite reporting hesitancy toward RRSO, women's decisions about choosing this option evolved as their priorities changed at different stages of life.

CONCLUSIONS

Recognizing during clinic encounters with Malaysian women that RRSO decision-making involves negotiating the likelihood of developing cancer with the societal priorities of being a woman, mother, and wife may serve to support their decision-making.

Practising shared decision making in primary care

Making healthcare decisions collaboratively between patients and doctors can be challenging in primary care, as clinical encounters are often short. Conflicts between patients and doctors during the decision-making process may affect both patient and doctor satisfaction and result in medico-legal consequences. With the increasing recognition of the importance of patient empowerment, shared decision making (SDM) can serve as a practical consultation model for primary care doctors (PCDs) to guide patients in making informed healthcare choices. Although more research is needed to find effective ways to implement SDM in the real world, the 6-step approach presented in this paper can guide PCDs to practise SDM in their daily practice. Implementation of SDM can be further enhanced by incorporating SDM training into undergraduate and postgraduate curricula and using evidence-based tools such as patient decision aids.

Shared decision-making between health care providers and patients at a tertiary hospital diabetic Clinic in Tanzania

Background

Patients’ participation in decision making regarding their treatment is defined in ethical, legal and human rights standards in the provision of care that concerns health providers and the entire community. This study was conducted to document experiences of patients and health care providers on shared decision making.

Methods

This study employed a phenomenological study design using in-depth interview technique. Study participants were diabetic patients visiting the clinic and healthcare providers working at Muhimbili National Hospital. Data was collected using the semi-structured interview guide with open-ended questions using an audio digital recorder. Content analysis method was used during analysis whereby categories were reached through the process of coding assisted by Nvivo 12 software.

Results

Participants in this study expressed the role of shared decision-making in the care of patients with diabetes, with report of engagement of patients by health care providers in making treatment decisions. Participants reported no use of decision-making aids; however, health education tools were reported by participants to be used for educating patients. Limited time, patient beliefs and literacy were documented as barriers of effective engagement of patients in decision making by their healthcare providers.

Conclusion

Engagement of patients in decision-making was noted in this study as experienced by participants of this study. Time, patient beliefs and patient literacy were documented as barriers for patients engagement, therefore diabetic clinic at Muhimbili National Hospital need to devise mechanisms for ensuring patients involvement in treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06041-4.

Patients' Involvement in Decision-Making During Healthcare in a Developing Country: A Cross-Sectional Study

PURPOSE

Patient autonomy and participation have a significant impact on patient satisfaction and compliance with treatment. We aimed to establish and describe the level of shared decision-making (SDM) among the patients in a developing country. Uganda is a low resource country with a 2019 GDP of 35.17 billion US dollars. In some regions, over 60% of Ugandans live below the national poverty line and most of them depend on the underfunded health care system.

METHODS

A cross-sectional, quantitative study was carried out among the outpatients attending Kisenyi Health center IV, Kampala, Uganda. An interviewer-administered questionnaire with a 5-point Likert scale was used to assess patients' SDM. All statistical analysis was performed using STATA 15 software.

RESULTS

A total of 326 patients participated in this study. Majority of the participants were females (n=241, 73.9%) and aged 18-35 years (n=218, 66.9%). Only 22 (7%) of the participants knew the name of their consulting doctor. Most of the participants, 84% were given enough time to narrate their symptoms. Overall, only 11.3% (n=37) of the participants had adequately participated in SDM. The overall mean score of participation in SDM was 2.7 (SD:0.8). Participants who knew the name of their consulting doctor were approximately 11 times more likely to participate in SDM (OR: 10.7, 95% CI: 4.2-27.0, P<0.0001).

CONCLUSION

The majority of patients attending Kisenyi Health Center IV did not adequately participate in SDM. Continued medical education should be organized for healthcare professionals to promote SDM.

Patient decisional needs when considering treatment intensification for type 2 diabetes: A qualitative study in China

AIMS

This study explored decisional needs of patients with type 2 diabetes in China when considering treatment intensification to achieve good glycemic control, from both the patient's and practitioners' perspectives.

METHODS

Interviews were conducted with 35 patients, and individual interviews and focus groups with 28 practitioners in Beijing, China. Topic guides based on the Ottawa Decisional Support Framework were modified for the Chinese context. Two interviewers independently extracted and coded transcripts of their notes into-overarching themes. Content analysis was performed to analyze participants' responses.

RESULTS

Patients (34/35) reported having tried different medications and some (15/35) visited multiple hospitals and consulted different doctors. Patients' knowledge of medications was suboptimal (26/35), and most patients were not aware of their glucose levels (23/35). Although most were receptive to add-on medications, both patients and practitioners reported a range of uncertainty about the decision, and patients wanted more reliable information. Patients (15/35) and practitioners (19/28) recognized the importance of a trusting relationship when adding medications. Both reported similar values and preferences, but these were rarely discussed when adding medications. Although most patients (32/35) reported that they were capable of making a decision on adding medications, few practitioners (6/28) perceived their patients were capable.

CONCLUSIONS

Findings suggest a need for reliable information, more discussion about values and preferences and decision support to help engage patients and practitioners in a shared decision-making process. Decision support tools may facilitate the process for patients with type 2 diabetes in China considering add-on medications.

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review

INTRODUCTION

Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review.

METHODS

The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 th April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed.

ETHICS AND DISSEMINATION

The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal.

REGISTRATION NUMBER

PROSPERO 2020 CRD42020176939.

What will make patients use a patient decision aid? A qualitative study on patients' perspectives on implementation barriers and facilitators

RATIONALE, AIMS, AND OBJECTIVES

Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting.

METHODS

This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach.

RESULTS

Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it).

CONCLUSIONS

Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.

Cultural adaptation of a patient decision-aid for insulin therapy

INTRODUCTION

Patient decision-aids (PDAs) support patients in selecting evidence-based treatment options. PDA is useful only if the user understands the content to make personalised decisions. Cultural adaptation is a process of adjusting health messages so that the information is accurate, relevant and understandable to users from a different population. A PDA has been developed to assist Malaysian patients with secondary drug failure to initiate insulin therapy to control their type 2 diabetes mellitus (T2DM). Likewise, patients with T2DM in neighbouring Singapore face similar barriers in commencing insulin treatment, which a PDA may facilitate decision-making in selecting personalised therapy.

OBJECTIVE

The study aimed to explore the views and perceptions of Singaporean primary care providers on the Malaysia PDA to initiate insulin therapy and described the cultural adaptation process used in the design and development of a new PDA, which would be trialled in a Singapore primary healthcare institution.

METHOD

Qualitative research method was deployed to conduct one-to-one in-depth interviews of the healthcare providers at the trial site (SingHealth Polyclinics-SHP), including six primary care physicians and four nurses to gather their views and feedbacks on the Malaysian PDA. The interviews were transcribed, audited and analysed (standard content analysis) to identify themes relating to the content, layout, concerns of the original PDA and suggestions to the design of the new SHP PDA.

RESULTS

Cultural adaptation of the new PDA includes change to the overall design, graphics (including pictograms), presentation styles, additional contextualised content (personalisation, subheadings, cost and treatment option), modified phrasing of the subtitles and concerns (choice of words) relevant to the new users.

CONCLUSION

A PDA on insulin therapy underwent cultural adaptation before its implementation in another population in a neighbouring country. Its relevance and effectiveness will be evaluated in future research.

Interprofessional communication in a socio-hierarchical culture: development of the TRI-O guide

Objectives

Interprofessional education (IPE) and collaborative practice are essential for patient safety. Effective teamwork starting with partnership-based communications should be introduced early in the educational process. Many societies in the world hold socio-hierarchical culture with a wide power distance, which makes collaboration among health professionals challenging. Since an appropriate communication framework for this context is not yet available, this study filled that gap by developing a guide for interprofessional communication, which is best suited to the socio-hierarchical and socio-cultural contexts.

Materials and methods

The draft of the guide was constructed based on previous studies of communication in health care in a socio-hierarchical context, referred to international IPE literature, and refined by focus group discussions among various health professionals. Nominal group technique, also comments from national and international experts of communication skills in health care, was used to validate the guide. A pilot study with a pre–posttest design was conducted with 53 first- and 107 fourth-year undergraduate medical, nursing, and health nutrition students.

Results

We developed the “TRI-O” guide of interprofessional communication skills, emphasizing “open for collaboration, open for information, open for discussion”, and found that the application of the guide during training was feasible and positively influenced students’ perceptions.

Conclusion

The findings suggest that the TRI-O guide is beneficial to help students initiate partnership-based communication and mutual collaboration among health professionals in the socio-hierarchical and socio-cultural context.

The state of shared decision making in Malaysia

Shared decision making (SDM) activities in Malaysia began around 2010. Although the concept is not widespread, there are opportunities to implement SDM in both the public and private healthcare sectors. Malaysia has a multicultural society and cultural components (such as language differences, medical paternalism, strong family involvement, religious beliefs and complementary medicine) influence medical decision making. In terms of policy, the Ministry of Health has increasingly mentioned patient-centered care as a component of healthcare delivery while the Malaysian Medical Council's guidelines on doctors' duties mentioned collaborative partnerships as a goal of doctor-patient relationships. Current research on SDM comprises baseline surveys of decisional role preferences, development and implementation of locally developed patient decision aids, and conducting of SDM training workshops. Most of this research is carried out by public research universities. In summary, the current state of SDM in Malaysia is still at its infancy. However, there are increasing recognition and efforts from the academic institutions and Ministry of Health to conduct research in SDM, develop patient decision support tools and initiate national discussion on patient involvement in decision making.