Shared decision-making in the management of Type 2 Diabetes Mellitus in Malaysia: an exploration of the perspective of patients and health care professionals

Abstract

Background: Decisions regarding the management of Type 2 Diabetes mellitus (T2DM) are complex as the management of this chronic illness requires a multifaceted approach. Shared decision-making is a patient-centred care approach in which the patients and their healthcare professionals (HCPs) collaboratively make a health decision, not only using the best available evidence, but also reflecting patients‘ needs, preferences and values. While there is growing evidence of the effectiveness of shared decision-making in supporting T2DM patients‘ involvement in the decisions across the world, potentially contributing to the improvement of their overall well-being, little is actually known about patient involvement in the decisions and particularly about shared decision-making in the Malaysian context. Aims: This study explores the experiences and perspectives of patients and HCPs on patient involvement in decision-making in the management of T2DM in Malaysia. Methods: A qualitative research design is employed in this study. Data were collected in the outpatient setting of three health facilities in the urban area of Malaysia. Face-to-face in-depth interviews were conducted, over a period of six months, with 19 HCPs (including three specialists, five medical officers, five diabetes educators/nurses, four dietitians/nutritionist and two pharmacists) and 24 T2DM patients. Thematic analysis and constant comparative method were used to analyse the data. Findings: The data highlighted a range of interpretations of shared decision-making. While patients described shared decision-making as a way for their concerns, preferences and values to be heard and addressed by their HCPs, the HCPs emphasised their patients‘ agreement and compliance with their recommendations. The types of decisions made, despite professed patient involvement would seem to remain largely in the hands of the HCPs. The extent to which patients are generally involved is subtle, whereby the decision is not necessarily shared and the decision-making for T2DM extends outside the face-to-face clinical encounter. This study also highlights that patient involvement in their decision is mainly influenced by patients and HCPs characteristics, values, beliefs, culture and past experience; their interpersonal relationship and communication; and role expectations in the healthcare field. Using Bourdieu‘s work to shape analysis showed that these factors intersect with each other and create a multifaceted patient-HCP power dynamic in making the decision. By including different groups of HCPs, this study also has provided valuable insight into the struggle among the non-physicians, who perceived to have limited decision-making power in managing patients with T2DM despite being the HCPs who were found to be more encouraging of patient involvement in the decisions. This is an addition to the struggles that are generally faced by all groups of HCPs, including their dilemma to balance their ethical foundation of beneficence and respecting patients‘ autonomy; their limited opportunity for involving patients due to constraints on the resources available at their facilities; and the language barrier. Conclusion: In conclusion, this study highlights the benefit of integrating the shared decision-making approach with some additional emphases on facilitating patient involvement in the decisions. These emphases include (1) inclusion of problem identification as one of the element of shared decision-making; (2) reducing the power gap and struggle by explicitly addressing the power issue and improving patients‘ cultural health capital; (3) strengthening of patient-HCP interpersonal relationship and communication skills; (4) allowing experimentation of different options that suit patients‘ condition; (5) integration of other approaches including motivational interviewing, support for self-management and interprofessional collaboration.