Exploring the barriers and facilitators towards implementation of shared decision-making in primary healthcare centres in Saudi Arabia

Background: Shared decision making (SDM) is considered as a key component of patient-centred care and has been incorporated into national policy in several countries. The value of SDM has been supported by the research in improving the knowledge of patients about their treatments, improve patients' confidence and coping skills, reducing the number of major surgeries and emergency admissions, and improving patients' health outcomes and satisfaction with the clinical encounter. Despite the benefits of SDM and the policies that support its implementation, SDM is not yet embedded in clinical practice especially in non-Western countries and it confronts many barriers that hinder its implementation. There is a clear need to identify factors that facilitate and hinder the implementation of SDM in Saudi Arabia in order to inform strategies for its effective implementation.

Purpose: The overall aim of this PhD research is to develop an understanding of factors influencing SDM implementation in primary healthcare centres (PHCCs) in Saudi Arabia.

Methods: Four studies have been performed in this PhD project. An umbrella review to obtain an overview of barriers and facilitators to implement SDM (Study 1). A systematic review to identify factors that influence the adaption of SDM in the Eastern Mediterranean Region (EMR) (Study 2). A qualitative study to investigate and explore the factors obstructing and facilitating the implementation of SDM in Saudi Arabia from the perspectives of patients with diabetes (Study 3). A qualitative study to investigate and explore the factors obstructing and facilitating the implementation of SDM from the perspectives of healthcare professionals (Study 4).

Results: The findings of the umbrella review made it clear that there is a need to address the gap in the SDM literature by conducting a systematic review focused on non-Western countries to investigate and better understand the challenges and enablers of implementing SDM in these countries. The systematic review findings indicated that additional exploratory qualitative work on barriers and facilitators to SDM implementation would provide much-needed novel and detailed information. The factors revealed in the qualitative studies in Saudi Arabia are comparable to those reported in Western countries and in the EMR, such as the role of patients and their families, a lack of time and resources, and physician attitudes and behaviours. However, there were some additional important factors specific to Saudi Arabia relating to the healthcare organisations and the health system. All the four studies demonstrated the importance of effective physician-patient communication in the success of SDM.

Conclusions: The major findings in this thesis contribute significantly to the literature on SDM, particularly in terms of factors that influence the implementation of SDM in non-western communities. Although they indicate some key similarities with existing literature, they also reveal that influential factors differ across countries and should be studied in different health systems and countries. SDM implementation necessitates structural, as well as cultural and attitudinal, changes among physicians and patients. Future researchers will be able to develop culture sensitive interventions as a result of these findings.