Review
What are the external influences on information exchange and shared decision-making in healthcare consultations: A meta-synthesis of the literature

https://doi.org/10.1016/j.pec.2008.09.025Get rights and content

Abstract

Objective

To review the literature to identify external influences on information exchange and shared decision-making in healthcare consultations and conceptualise how information is used both outside and within a consultation.

Methods

A ‘meta-study’ approach (meta-data-analysis, meta-theory, meta-method, and meta-synthesis) was used to locate, review, synthesise and summarise the findings, methodology, theoretical orientation and interpretation of qualitative research papers.

Results

In a model of external influences on information exchange within healthcare consultations, practitioner influences were: receptiveness to informed patients and patient choice, lack of knowledge of cultural difference, patient centredness vs. stereotyping. Patient influences were: motivation to seek and engage with information; the appraisal of information before a consultation, expression of cultural identity, and ways of managing the risk of poor information. Shared influences were: differing illness notions, role expectations and language. Empowerment, disempowerment and non-empowerment were outcomes of information exchange and health literacy was a mediator of external influences and empowerment.

Conclusion

This meta-study provides a conceptualisation of external influences on information exchange in shared decision-making where health literacy mediates patient related influences and is also an influence on empowerment.

Practice implications

Our model can inform the development of interventions aimed at improving information exchange and shared decision-making, potentially contributing to more equitable healthcare encounters.

Introduction

The nature of the relationship between those with expert medical knowledge and patients has been the subject of a long-standing debate in medical sociology. The traditional doctor–patient relationship has been characterised as the doctor assuming a dominant position with a high level of control and the patient assuming a more subordinate position with a low level of control [1]. Medical professionals are said to have a “social monopoly of expertise and knowledge” through which they maintain their position of power in medical consultations [2]. One feature of ‘late modern’ society [3] is a shift towards a consumerist society, bringing about a need for the transfer of expert knowledge from the professional to the client. According to Giddens, a ‘reflexive consumer’ has emerged, one who is able to evaluate and even challenge ‘expert knowledge’ [4]. The lay knowledge of a patient and the expert knowledge of a medical professional are important aspects of information exchanged in medical consultations. However, conflict can occur between a medical professional and a patient as ‘lay perspectives’ of patients sometimes conflict with the ‘expert knowledge’ of medical professionals and are not encouraged or accepted [4]. In order to counteract this, a partnership and shared distribution of power is important and encouraged [4]. It has been suggested that as a consequence of consumerism, patients’ expectations of their role in decision-making in health care consultations have changed to one where patient involvement and patient choice are usually desired [5], [6]. However, one alternative perspective to consumerism is that medical consultations are not ‘units of consumption’, but units of production. Medical professionals and patients can become ‘co-producers’ in the process of reaching some understanding of the patients’ problems and possible solutions. Hence a partnership is created and the provision of information from both parties is important in sustaining the partnership [7].

There is a general acceptance in the medical profession that patients should be more involved in making decisions about their own health and treatment [8]. Patient involvement in decision-making is widely advocated for a number of reasons; firstly, it has been accepted as an ethically appropriate form of practice that promotes veracity and patient autonomy [9]. Secondly, it has been associated with improvements in the standards of health care [10] and thirdly, it has been associated with greater adherence to treatment and improved health outcomes [11]. The concept of shared decision-making has been devised where doctors and patients jointly participate in a treatment decision-making process and come to some negotiation of which treatment is chosen and implemented [6]. However, shared decision-making has been inconsistently achieved in practice, partly because patient preferences for involvement in shared decision-making tend to be varied [12], [13], and practitioners do not always implement shared decision-making [14]. Yet, these reasons only offer a partial explanation.

To explore the reasons for shared decision-making not being implemented widely, we need to examine the different elements of the process. The shared decision-making process involves three phases: information exchange; deliberation; and treatment decision [15]. Adequate information exchange is important to healthcare practitioners for formulating diagnoses and prescribing treatment, and to patients in order to help reduce uncertainty and alleviate concerns [16]. Furthermore, it can help reduce an imbalance of power in a medical consultation, giving a patient the opportunity to make choices about their treatment options and participate as information-givers and not merely passive recipients of ‘medical facts’ [17], [18]. However, there is relatively little research examining the processes in practice, and in particular to understand the potential limitations of information exchange in the shared decision-making context.

All too often, medical consultations and doctor–patient relationships are represented as independent or ‘self-contained units of analysis’ or ‘de-contextualized encounters’, overlooking a wider set of social influences [19]. Research on shared decision-making often conceptualises the process as a ‘one-off dyadic encounter’ that occurs within the space of a consultation room [20]. Influences on communication in medical consultations have been found to be mostly “inherent” to both doctors’ and patients’ beliefs (such as expectations of information needs and role expectations) and environmental factors that are present at the time of the consultation. For example, Bugge et al. [21] identified a number of key reasons for the non-disclosure of information were that were based on the internal environment of the consultation and beliefs about the needs, desire and potential value and use of the information for the other party. Influences on the disclosure of information and failures in information exchange appeared to be encapsulated in the particular time and space of the consultation or experience of a prior consultation. There was no evidence regarding wider socio-cultural factors or external factors that may either facilitate or inhibit information exchange.

Rapley [20] argues that decisions can be shaped over time and influenced by knowledge or information acquired through encounters with others and beyond the time and space of a single health care consultation. Engagement with alternative information sources also influences communication in healthcare consultations [22]. One example is the rich source of information and expert knowledge that is available to patients through the internet [23]. A range of other external information sources also influence communication in healthcare consultations, i.e. the patient's family, the doctor's social network, continuing medical education, data from evidence based medicine, independent consumer organisations, patient groups, the media (TV, magazines, newspapers) [24]. Yet, little is known of how these factors influence information exchange as it may affect the shared decision-making process.

Longo [25] developed a conceptual model of information use, based on survey data from women with breast cancer. The model explains contextual and personal influences on the progression of information seeking and use for making health care decisions (Fig. 1). In Longo's model, which is set in the context of breast cancer, the potential outcomes of information seeking and use for the patient are: empowerment, a locus of control, satisfaction, and activities of daily living and health outcomes. Although the model integrates concepts, processes and outcomes of information seeking and use aimed at making healthcare decisions, it does not focus on information that is used or exchanged for shared decision-making within the medical consultation. Furthermore, there is no description of how the influences impact on both information use and healthcare decision-making.

A literature review of information seeking and use for early stage breast cancer found that human sources of information (physician, family, and friends) were common. Age, income, education also influenced which information sources were used [26]. However, the influence of language, culture and healthcare structure on information seeking and use, as suggested in Longo's model, were found not to be supported [26]. Similarly, the relationship between information seeking and use and locus of control and empowerment and activities of daily living as suggested by Longo's model were also not supported. These unsupported influences and outcomes need further testing and development. There is a need for a comprehensive model to understand the nature, type and source of health information used in shared decision-making [26]. Low information is exchanged in health care consultations and particularly where there may be opportunities for enhanced shared decision-making.

After an initial scoping of the literature we decided that quantitative papers were unlikely to help us answer the research question in sufficient depth. Thus, we adopted a methodology that would help us review the literature on external influences on information exchange and shared decision-making in healthcare consultations by identifying, synthesising and summarising the findings, methodology, theoretical orientation and interpretation of available qualitative research papers. We did this within an interpretative framework, aiming to develop a model of external influences on information exchange that provides a stronger, more complete and theoretically grounded interpretation than is evident in the literature to date.

Section snippets

Introduction to meta-study

The research design was a meta-study [27], [28], an analysis and synthesis of qualitative research papers. The data for analysis and synthesis were the texts of the research papers (findings, discussion and conclusions). Three stages of analysis precede a final meta-synthesis of the primary studies included: meta-data analysis (analysis of content of primary studies), meta-method (analysis of method), and meta-theory (analysis of theory) [see Fig. 2].

Search

A search strategy was devised based on three

Results

A total of 11,949 citations were retrieved, 135 full papers were read and seven papers were included for data extraction. Three research themes (across seven studies) were identified as examining external influences on information exchange in shared decision-making health care encounters. These were on internet information use [31], [32], [33] studies on cultural difference in intercultural consultations [34], [35], [36] and one study on the influence of the women's health movement [37]. The

Motivators and barriers to information exchange

Some studies from our search of influences on information exchange on shared decision-making had focused on the influence of internet use and the exchange of information derived from the internet [31], [32], [33]. This meta-study has described a number of characteristics associated with internet information use, for example, barriers to the exchange of internet information enforced by healthcare practitioners, how patients manage internet information in terms of its risks and how they regulate

Conclusion

A more comprehensive conceptualisation of external influences on information use and information exchange in medical consultations is proposed. Patients’ motivation to seek information, the management of that information and its risks and information exchange in consultations can lead to empowerment. Health literacy as an influence on all these stages can be a mediator of empowerment. However, the receptiveness of healthcare practitioners to informed patients is also crucial to information

Acknowledgement

This research is supported by the Gerry Stimson studentship, awarded by the Foundation for the Sociology of Health and Illness.

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