Demographic characteristics of healthcare providers
Four healthcare providers (HCPs) were interviewed; among them 2 were female nurses and 2 male physicians. The age of HCPs ranged from 30 years to 40 years. All nurses were registered with a diploma of nursing, while all physicians had the postgraduate (MMed) level of education.
Demographic characteristics of patients
Seven participants (3 females and 4 males) whose ages ranged between 46 and 76 years attending diabetic clinic were interviewed. All participants were married, and their education level ranged from standard seven to advanced diploma. Out of three female participants two were housewives and one was self-employed. Two of the four male patients were retired civil servants, one was a driver and the other one was a businessman.
Themes Obtained in the Study
Three themes were obtained in relation to the practices and challenges of participation in shared decision-making between diabetic patients and healthcare providers at Muhimbili National Hospital (MNH). These themes are role of shared decision-making, decision aids and barriers to shared decision-making.
Role of shared decision making
Most participants reported to participate in shared decision making. Healthcare providers reported that they always engage patients with diabetes in decision-making regarding screening and treatment options. They reported that at the diabetes clinic all decisions involve physicians, nurses and patients. Following examples prove this:
“But in my experience, I engage properly my patients through conversations” (#02 D)
“Okay, a patient participates when he comes to look for service and doctor’s explanation on that particular condition or problem.” (#03 D)
“...therefore, I have to agree with my patients that screening is voluntary. I don’t force a patient to screen because we have to discuss and agree with each other” (#01 N)
Healthcare providers reported that they like to involve patients in shared decision making (SDM) because it helps them to determine the patients’ understanding of a disease, to understand their chief complains, to adhere to HCPs’ advice on treatment, to actively participate in self-management at home and it enhances a good relationship between HCPs and patients. One of the doctor’s responses was,
“When a patient participates it helps me to know his/her chief complaint and so that I can decide on the appropriate course of action to be taken. You know diabetic patients are under self-management therefore for them it is very important.” (#02 D)
Most diabetic patients reported that they are engaged in shared decision-making and that it is very important. Participation in decision-making helps health care providers to understand patients’ preferences in the treatment options. Also, it helps health care providers to determine the type of drugs that are suitable for the patient. The following examples proved patient’s participation and its importance.
“Yes, we participate.” (#05 P)
“It is important as the doctor will know which medication or drug works for me and that which doesn’t. Also, it will help him to know drugs that a patient likes and those he or she doesn’t like and why.” (#07 P)
Some few participants reported minimal or partial participation in decision-making. They reported that they do not participate because sometimes providers make decisions on their own. They also reported that only healthcare providers have the right and responsibility of deciding what is best for a patient because they are experts and patients have only to abide on what health care provider decide and plan. They said that:
“For decisions no, but on my date to come like today the doctor is the one to decide which drugs are suitable for me” (#06 P).
Some participants expressed fear of information as one reason for not wanting to engage in discussion regarding medications which are prescribed, citing fear of uncovering adverse reactions which may affect adherence, this participant said:
Unh…it is better I’m not engaged… (Laughing) You know you may be told that the drugs you take are not safe so I, like any human being may say let me stop using them.” (# 06P)
Assessment of decision-making aids
Healthcare providers acknowledged that they use different decision aids to make sure a diabetic patient can know and understand appropriate diet, complications as well as treatment. Decision aids used are face-to-face conversations, pictures, charts, leaflets and other domestic utensils like plates. They sometimes tell patients to search for diabetes information on websites. They said that:
“Okay, in most cases we use them and mind you that when patient comes here, he/she must read them. The important thing that makes you to use them is that some patients prefer to be taught using pictures…” (#01 N)
Healthcare providers expressed concerns that although decision aids facilitate shared decision making, they were no sufficient materials at the clinic as Tanzania Diabetes Association (TDA) and some pharmaceutical companies usually prepare these. They said:
“Leaflets are available, but they are scarce. They are sometimes available and the other times not as we at Muhimbili are not producing them therefore we have to request them from the office of TDA (Tanzania Diabetes Association) or from the pharmaceutical companies.” (#02 D)
Barriers to shared decision-making
Some of the factors reported by participants as barriers to shared decision making included beliefs and values, time, and educational level.
Some patients indicated that they do not participate in a shared decision-making because their beliefs and values do not allow them to. They believe that healthcare providers must be respected and considered the same as local witch doctors. This makes a patient to be resistant to be engaged in decision-making and leads to partial or no shared decision-making. One patient said:
“According to our traditional values you can’t question a witchdoctor, but you have only to comply on what he directs like bringing him a cock or whatever. This applies to our professional doctors as well.” (#08 P)
Healthcare providers and patients with diabetes held that there is shortage of time for active engagement in decision making between health care providers and patients, this was attributed to big number of patients attending each clinic as well as other responsibilities shouldered by health care providers in the hospital, resulting in minimal consultation time and a quick process of decision making. Respondent said:
“You find a patient who I need to stay with at least for 15 minutes but time is very little, and patients are many.” (#03 D)
“The time to talk to a physician satisfactorily is not enough... sometimes you find there are doctors while the number of patients attending is big that patients are already overcrowded.” (#05 P)
Some healthcare providers demonstrated that it is difficult to engage a patient with low level of education in decision-making. They insisted that patients with low education do not understand things quickly and easily. Thus, people who are found in this category are not engaged in decision-making. Therefore, low education level of some patients influences one-sided decision. For example, a doctor indicated that:
“…But you have sometimes to look on the education level of your patients.” (#02 D)