A CROSS-SECTIONAL ASSESSMENT OF SHARED-DECISION MAKING AMONG PATIENTS VISITING PUBLIC HEALTHCARE INSTITUTE OF QUETTA CITY, PAKISTAN

HIRA WAHEED1, SAJJAD HAIDER1, QAISER IQBAL1, ADNAN KHALID2, MOHAMED AZMI HASSALI3, MOHAMMAD BASHAAR4 AND FAHAD SALEEM1* 1Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan 2Combined Military Hospital, Quetta, Pakistan 3School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia 4Health Policy Analyst, SMART Afghan International Trainings & Consultancy, Afghanistan

In the United Kingdom, the MAGIC (Making good decision in collaboration) programme aims to embed SDM in daily clinical practice. In this programme, posters in waiting rooms advise patients to ask these three questions: "What are my options?", "What are the benefits and harms?" and "How likely are these?". Rising patients' self-efficacy will improve their intent to share in DM (Gagnon et al. 2010). In the United States, the SDM has become an important element in health policy discussions (Center for Shared Decision Making 2018). To further strengthen this initiative several projects are in pipeline by the Foundation for Informed Medical Decision Making, alike at the Palo Alto Medical Foundation (Frosch et al. 2011;Informed Medical Decision Foundation 2018). Likewise, in Canada the SDM initiative has been used in healthcare, and further public plans are underway at various administrative levels (Légaré et al. 2011).
In Pakistan, as in many non-Western cultures, decisions about a patient's health care are often made by the family or the doctor (Jafarey and Farooqui 2005;Moazam 2000). A study conducted in Pakistan hospitals reported that majority of residents practiced SDM in their wards (Jameel, Noor and Ayub 2012). However, there is scarcity of information in general. Therefore, the aim of this cross-sectional survey is to employ SDM-Q-9 to measure the SDM process in patients attending the cardiac and medicine ward of tertiary hospital in Quetta, Pakistan.

Study Design and Setting
A questionnaire-based, cross-sectional survey was conducted. Data was collected from patients attending the cardiac and medicine outpatient departments (OPDs) of Sandeman Provincial Hospital (SPH), Quetta, Pakistan. This hospital is the biggest government hospital of Quetta City and provides major healthcare facilities to the general population. Established in 1939 and located in the centre of the city, SPH is a tertiary care, teaching institute. Additionally, being public in nature, SPH is normally the institute of choice for majority of the local residents (Shahzad et al. 2018).

Sampling Strategy, Study Population and Inclusion Criteria
All patients suffering from chronic illness and attending the outpatient department of cardiac and medicine department of SPH Quetta were targeted for the study. Patients who were not willing to participate, those cannot read or write Urdu (official language of Pakistan) and immigrants, were excluded from the study. By keeping confidence interval of 95%, 5% margin of error and response distribution of 50%, 392 patients were initially needed for the study. However, keeping a response rate of 20%, final sample of 470 participants were included in the study (Daniel 2010

Study Instrument
Permission was taken from the developer to use the existing English version of SDM-Q-9 (patient version) (Kriston et al. 2010) and was translated in Urdu (National language of Pakistan) by a linguistic expert, the questionnaire was back translated into English by another expert to avoid any discrepancy in the two versions. Face and content validity was established by four physicians and four pharmacists, their opinion were taken into consideration before the pilot study. The questionnaire was subjected to pilot analysis comprising 30 participants. The questionnaire was declared reliable with an acceptable alpha value of 0.8 consequently used for the study.

Data Analysis
SPSS version 21 was used to perform data analysis. Mann-Whitney U test was used for dichotomous variables that reported a significant association between gender and all items of SDM-Q-9. For variables other than dichotomous in nature, the Jonckheere-Terpstra test was used to find the trend of association. In addition, Kendall's Tau coefficient was used for interpretation of the significant relationship that revealed significant, weak association (r < 0.3) among all items of SDM-Q-9 and education.

Ethics Approval
Departmental Ethics Committee at the Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta approved the study. In addition, permission was also taken from the medical superintendent of SPH. Prior to data collection, the patients were informed about the research initiatives, confidentiality of their responses and their right to withdraw from the study with no penalty or effects on their treatment. Written consent was also taken from the patients.

Demographic Characteristics of the Study Respondents
Data was collected from 465 chronically ill patients with the response rate of 98.93% as shown in Table 1. Majority (63.4%) of patients were above the age of 47. The cohort was dominated by women (314, 67.5%). Ninety-two percent of the respondents were married and majority (404, 86.9%) was not involved in any decision regarding their treatment during their consultation.
Malay J Pharm Sci, Vol. 18, No. 1 (2020): 15-29 Response to SDM-Q-9 As shown in Table 2, majority of patients completely disagreed to all items of SDM-Q-9 with response ranging from 79.6%-84.3%. Only 19 (4.1%) of the patients agreed that their physician asked for the treatment option they will prefer. Additionally, different treatment options were weighed by the physicians and patients in only 20 (4.3%) of the cases. In only 5% of the cases, the patients were informed about different treatment options available for their condition and mutual consensus on how to proceed was agreed by 26 (5.6%) of the participants. 9 My doctor and I reached an agreement on how to proceed. CD = completely disagree; SD = strongly disagree; SWD = somewhat disagree; SWA = somewhat agree; SA= strongly agree; CA= completely agree

Association between SDM and Demographic Characteristics
The association between demographic variables and SDM-Q-9 items was carried out through non-parametric analysis. The Mann-Whitney U test was used for dichotomous variables that reported a significant association between gender and all items of SDM-Q-9. The mean rank interpretation revealed that men were more involved in SDM regarding their treatment when compared with women. However, no significant association was reported between SDM-Q-9 and other dichotomous variables. For variables other than dichotomous in nature, the Jonckheere-Terpstra test was used to find the trend of association. Education was significantly associated with SDM-Q-9. The Kendall's Tau coefficient was used for interpretation of the significant relationship that revealed significant, weak association (r < 0.3) among all items of SDM-Q-9 and education. Hence it is concluded that with an increase in education, there are possibilities of increase in SDM. In addition, significant association between first six items of SDM-Q-9 and monthly income of patients was also reported. Weak association (r < 0.3) was reported revealing involvement in shared-decision process with an increase in income (Table 3). My doctor precisely explained the advantages and disadvantages of the treatment options. 5 My doctor helped me understand all the information. 6 My doctor asked me which treatment option I prefer. 7 My doctor and I thoroughly weighed the different treatment options. 8 My doctor and I selected a treatment option together. 9 My doctor and I reached an agreement on how to proceed.

DISCUSSION
SDM is a central to shaping effective healthcare system and at patient level; it has the potential to save lives through safety and quality of health services (WHO 2016). Therefore, in this study we examined the effect of SDM on healthcare quality in Quetta among patients using SDM. However, considering the impact of SDM of healthcare quality, unfortunately, our results showed that majority of cohort was not involved in any decision regarding their treatment during their consultation, which is similar to prior studies, where patient involvement in DM is poor worldwide (Deber et al. 2007;McKinstry 2000). But in reality, patients prefer to be offered choices and to be asked their opinions in regards to their disease/treatment (Levinson et al. 2005). Research conducted in Malaysia reveals that most of the patients preferred SDM (Ambigapathy, Chia and Ng 2016; Nies et al. 2017). In Japan and United States, majority of patients with cancer preferred SDM (Bruera et al. 2001;Schaede et al. 2017;Singh et al. 2010). Therefore, active advocacy at all levels even at patient level (self-advocacy) is necessary to ensure SDM, patient's empowerment (Elwyn, Tilburt and Montori 2013;Shay and Lafata 2014) and healthcare quality.
Malay J Pharm Sci, Vol. 18, No. 1 (2020): 15-29 So the question is, if the governments are committed towards health quality at policy level, then why patients are not or less involved in DM process? Literature has identified three main barriers towards SDM: time constraints (Stacey et al. 2006;Whelan et al. 2003), lack of applicability due to patient characteristics/preferences (Cabana et al. 1999) and the clinical situation (Légaré et al. 2008). Therefore, it is imperative that while developing or structuring SDM, it is advised that healthcare providers should keep the individual differences in patient preferences in consideration (Arora and McHorney 2000; Robinson and Thomson 2001) and employ DM models. Research revealed that despite existing barriers there are multiple facilitators to SDM like provider motivation, positive impact on the clinical process and patient outcomes (Légaré et al. 2008). Literature review shows that physicians have positive attitudes toward SDM in their clinical practice (Pollard, Bansback and Bryan 2015). That is why SDM and production of SDM training programmes as an effective tool gaining acknowledgement and growing fast in diverse cultures and healthcare setting, in Asia (Légaré et al. 2008) and rest of the world (Diouf et al. 2016).
Significant association was reported between gender and all items of SDM-Q-9 in our study. More men were involved in SDM regarding their treatment when compared with women. Past research has shown that DM could be influenced by personal and social attributes, such as gender, since women can't share their preferences with doctor as compared to men (Street Jr 1991;Willems et al. 2005). However, gender differences in communication styles between doctors and patients have been hypothesised to impact patient care, but the degree remains unclear (Sandhu et al. 2009). Other researchers believe that both, men and women cautiously process information, think logically about the alternatives, predict results, evaluate the consequences, solve the problems and examine all the decision stages (Sanz de Acedo Lizárraga et al. 2007) and there is no influence of gender on DM (Uzonwanne 2016). In the Asian culture, the DM is often left purely to the doctors or other family members despite of gender differences. In Pakistan still the paternalistic model of DM is a trend. Similarly, literature from Kashmir and Japan reveals that patients are willing to accept what their doctors choose for them and the doctors are pleased with their role as decision-maker (Miyashita et al. 2006;Yousuf et al. 2007). Moreover, researchers from Hong Kong feel that patients and doctors to be more enthusiastic to acknowledge the role of families in DM (Chan 2004).
During statistical analysis, we found a significant association between education and SDM-Q-9, which reveals that increase in education, can improve the SDM. Past research has shown that patients with less educational report less interest in SDM (Kiesler and Auerbach 2006). The importance of education interventions were found effective at increasing the implementation of SDM (Chen et al. 2016). Insufficient health literacy and poor physicianpatient communication are two major healthcare challenges adversely affecting DM and consequently contributing to poor treatment decision, drug adherence and high healthcare costs (Kindig, Panzer and Nielsen-Bohlman 2004). Similarly, there is a strong correlation between quality of physician-patient communication and patient satisfaction and positive health outcomes (Stewart 1995). One of the past studies demonstrated that perceived lack of knowledge is a major barrier to SDM (Belcher et al. 2006) and another study revealed that statistical (numbers) illiteracy hampers SDM (Gaissmaier and Gigerenzer 2008). Previous studies indicated that low literacy skills are strongly associated with lower educational levels (Kim et al. 2001). An economically sound and literate population, properly trained doctors and commitment towards SDM are essential prerequisites for establishing DM in healthcare facilities. Therefore, these findings suggest that health literacy is the cornerstone in effective DM. The health literacy definitions focus on individual skills to obtain process and understand health information and services necessary to make appropriate health decisions (Sørensen et al. 2012). In a nutshell, the SDM model is well-suited and appropriate within real-world healthcare systems (e.g. nursing, over-the-counter consumer purchases, emergency, chronic illness management and mental illnesses) and thus patients can expect further individualised and personal treatment plans (Tay, Massaro and Vlaev 2017). With all these advances in techniques and tools to encourage patient participation in SDM, challenges still exist in developing tools for patients with lower literacy, poor health knowledge, limited involvement in health decisions and poor health outcomes (McCaffery, Smith and Wolf 2010). SDM practices at clinical level have direct impact over healthcare quality. Therefore, the health care providers and policy makers should strive to strengthen and promote the SDM at primary, secondary and tertiary healthcare settings.

CONCLUSION
As part of healthcare services, SDM should not be limited to chronic, emergency medical situation or where multiple choices are considered. Respect and access to critical information is the right of both doctor and patient. In SDM, the doctor, patient and family are obligated to give one another realistic information about the illness and treatment plan. The policy maker and healthcare providers should put SDM into practice and for the low literacy population, specific and tailored shared medical DM programmes must be developed. For implementation and success of SDM the political and institutional will and support is needed.

FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST
No funding was received for the study. The authors have no conflict of interest to declare.