Patient Education and Counseling 104 (2021) 1933–1944 Contents lists available at ScienceDirect Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou Review Article Healthcare professionals’ behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review María José Hernández-Leala,b , María José Pérez-Lacastaa,c , María Feijoo-Cidd,e , Vanesa Ramos-Garcíaf,g , Misericòrdia Carles-Lavilaa,b,c,* a Department of Economics, Universitat Rovira i Virgili, Spain b Centre de Recerca en Economia i Sostenibilitat (ECO-SOS), Spain c Research Group on Statistics, Economic Evaluation and Health (GRAEES), Spain d Department of Nursing, Faculty of Medicine, Universitat Autónoma de Barcelona, Spain e Group de REcerca Multidisciplinar en SAlut i Societat (GREMSAS), (2017 SGR 917), Spain f Evaluation Unit of the Canary Islands Health Service (SESCS), Spain g Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Spain A R T I C L E I N F O A B S T R A C T Article history: Objective: To explore the barriers to and facilitators of healthcare professionals’ implementation of SDM Received 24 February 2020 regarding screening programmes. Received in revised form 22 January 2021 Method: A systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The Accepted 27 January 2021 barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves. Keywords: Results: Eight studies were selected: seven related to cancer screening. The most significant facilitators Shared decision-making were literacy and interest in active participation, both of which have their origins in patients. The most Participation in preventive health Screening programmes significant barriers identified for the first time in a systematic review were legal conflict, lack of Healthcare professional remuneration and lack of flexibility in clinical guidelines in screening programmes. Conclusion: The results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts. Practical implications: The authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals’ behaviour within the context of the uncertainty of screening programmes. © 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Contents 1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1934 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1934 2.1. Study design . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1934 2.2. Literature search and data sources . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 2.3. Inclusion and exclusion criteria . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 2.4. Study selection . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 2.5. Data extraction and quality appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 2.6. Data analysis and synthesis . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 * Corresponding author at: Department of Economics, Universitat Rovira i Virgili, Avenida Universitat 1, 43204, Reus, Spain. E-mail addresses: mariajose.hernandez@urv.cat (M.J. Hernández-Leal), mariajose.perez@urv.cat (M.J. Pérez-Lacasta), Maria.Feijoo@uab.cat (M. Feijoo-Cid), vanesa.ramosgarcia@sescs.es (V. Ramos-García), misericordia.carles@urv.cat (M. Carles-Lavila). https://doi.org/10.1016/j.pec.2021.01.032 0738-3991/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 3.1. Description of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1935 3.2. Barriers to SDM application in screening programmes (Table2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1937 3.2.1. Healthcare professionals’ perceptions factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1937 3.2.2. Patients’ attributes factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1937 3.2.3. Healthcare system performance factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1938 3.3. Facilitators of SDM application in screening programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1938 3.3.1. Healthcare professionals’ perceptions factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1938 3.3.2. Patients’ attributes factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1939 3.3.3. Healthcare system performance factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1939 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1939 4.1. Perception of healthcare professionals’ factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1940 4.2. Patients’ attributes factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1940 4.3. Healthcare system performance factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1940 4.4. Experience of other countries in SDM for screening programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1941 5. Practice implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1941 6. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1942 7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1942 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1942 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1942 1. Background actions to adopt healthier lifestyle changes, consumption of drugs to reduce the risk of some diseases - such as statins [17] - and The chief function of screening programmes is the early screening. The SR of Gravel, et al. [6] includes some of these detection of diseases [1]. Nevertheless, the unwanted effects of scenarios, even though a specific study for screening has not been screening programmes have been dealt with in scientific carried out. Having specific studies in this area is important since in discussions over the past few decades. The most discussed effects recent decades, experts have discussed the difficulty of knowing include overdiagnosis, false positives, false negatives, and over- the magnitude of overdiagnosis, which causes uncertainty about treatment [2–4]. This increasing emphasis in literature is one of its main adverse effects. In other words, the main adverse associated with an increase in the uncertainty of screening effect of screening involves treating a disease unnecessarily, while programmes, which arises the need for a change in the in other preventive activities the adverse effects are different and decision-making model. This need could be satisfied by shared are focused on those derived from the medication. Therefore, decision-making (SDM), which allows healthcare professionals barriers and facilitators other than those derived from already and patients to arrive at a joint decision based on the knowledge of studied in other SRs [6]. the risks and benefits of screening programmes and also considers Moreover, there is evidence from the SDM professionals’ the patient’s values and preferences [5]. perspective also in various health contexts [18], but it has not been SDM has been employed since the 1970s, especially in European done exhaustively in screening contexts either, as this is an countries, Canada, and the United States [6,7]. Elwyn et al. (2010) increasingly frequent practice within the actions of their profes- defined SDM as a model in which ‘professionals and patients share the sion. In this context, the decision does not include discussing best available evidence when making a decision. Patients are supported various options, but rather participating -or not- in the screening, to consider the options available, and thus be able to make an informed which sometimes means that this discussion can be confused with decision’ [8]. In other words, it seeks to improve people’s Informed Consent [19]. participation in the health-disease process through a horizontal Thus, for example, other countries have focused on the relationship between patients and healthcare professionals [9]. In implementation of SDM in screening programs through patient contrast to the paternalistic model, in which the patient plays a decision aids (PtDAs) with the collaboration of public and private passive role, and the interventions are proposed by the healthcare institutions [14,20–22]. Examples include Canada, Germany, the professional [10]; the SDM approach considers the patient’s values, United Kingdom, and the United States [23]. Specifically, the Swiss beliefs, and preferences as well as the risks and benefits associated Medical Association in Switzerland contends that SDM is the ideal with therapeutic options [11]. Evidence supports the fact that model for a preventive approach [7] and has conducted research on patients prefer to be active participants in the conversation in which colon cancer screening programs [24–26]. healthcare professionals provide the necessary information; Despite the aforementioned research, we have no knowledge patients report greater satisfaction with the care process when about other systematic review (SR) which has emphasised effective and reliable communication is established [12,13]. healthcare professionals’ perspectives regarding the application Based on the previous literature, the main barriers to the of SDM in screening programmes and the possibility of overcoming implementation of SDM from the perspective of professionals barriers. Accordingly, this SR explored the barriers to and include deficiency of time during clinical encounters, and patient’s facilitators of healthcare professionals’ implementation of SDM characteristics and current health situation. The factors that in the context of screening programmes. facilitate SDM include professionals’ motivation and the belief that SDM can have a positive impact on specific health outcomes [14]. 2. Methods However, the use of SDM has not been generalised in the clinical context [15] or screening programmes [12]. 2.1. Study design SDM has been studied in various health contexts [14], from therapeutic -patients who are sick and seek, their disease to be A SR was conducted based on the recommendations of the treated- to preventive -people who are in a healthy condition and Cochrane Manual for Systematic Reviews of Interventions, version seek to avoid falling into disease [16]. Preventive activities include 5.1.0 [updated March 2011] [27]. 1934 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 2.2. Literature search and data sources dissertation documents (n = 101), were excluded. Other studies were excluded: studies on the perceptions of administrative The search was performed between April and May 2019 in four personnel, students, or patients (n = 315); studies pertaining to databases—PubMed, Cochrane Library, Cumulative Index to person-centred medicine (n = 123); studies that did not assess Nursing and Allied Health Literature, and PsycInfo, using the screening programmes (n = 204) and studies that, while encom- keywords ‘shared decision-making’, ‘screening’, ‘health personnel’, passing SDM did not delve into its barriers and facilitators or only ‘barriers’, and ‘facilitators’ with their variants in each database. The evaluated the implementation of PtDAs (n = 98). search was not limited by language or year (Fig. 1). Disagreements concerning the inclusion and exclusion criteria were resolved through discussion with another researcher pair 2.3. Inclusion and exclusion criteria (MC-MJP). Original research articles with quantitative, qualitative, or 2.5. Data extraction and quality appraisal mixed methodologies that referred to the facilitators of and barriers to SDM in the context of screening by healthcare One researcher (MJH) extracted the following data from the professionals who performed direct clinical care were included. selected articles: title, authors, year of publication, journal of We also included studies that did not explicitly define SDM but publication, country of study, type of study, study methodology, incorporated a balanced discussion of the benefits and adverse participants’ characteristics, study screening type, degree of effects of screening programmes to facilitate an informed decision. acceptance of SDM, and evidence quality (Table 1). Some publications were excluded, for example, those involving Two researchers (MJH-MC) independently used the QualSyst combined perceptions of professionals and patients and which [36] tool to determine the quality of the studies. The studies were lacked clarity regarding the person who issued the answers. assigned values between 0 and 1, with lower numbers representing poor quality study. The corresponding author of the study was 2.4. Study selection contacted in case of methodological doubts. Discrepancies in evaluation were resolved by a third researcher (MJP). The database search was conducted by three teams of researchers (MJH-MJP, MC-MF, and MJH-VR), each of which 2.6. Data analysis and synthesis applied the inclusion and exclusion criteria in the three phases of the process: reading the title (n = 977), reading the abstract The selected articles presented heterogeneous methodologies. (n = 748), and reading the full text of each article (n = 106). For this reason, we chose to analyse individual study results. They Duplicate studies (n = 128) and studies that did not report original were not considered representative of the sum of their statistical research, such as SRs, bulletins, theses, posters, and conference or measures as a whole, that is, only thematic synthesis was conducted (Table 2). Thematic synthesis [38] employed an inductive process. Three researchers (MJH, MC, MJP) independently read the papers and structured the analysis using the steps proposed by Strauss and Corbin [36]. First, in the citations included in the retrieved articles, they identified sections where healthcare professionals mentioned their perceptions of the difficulty or ease of SDM implementation. Second, the citations were grouped into codes (units that revolve around the same idea) and finally into categories (higher-grade units). Third, the categories were identified as barriers and facilitators. Barriers and facilitators were classified according to three factors based on their origin (who or what influenced the perception or attitude of the healthcare professional): the professional him/herself, patients, or healthcare system perfor- mance [38]. Once the researchers (MJH, MC, MJP) independently structured the categories into barriers and facilitators, the results were compared, and discrepancies were discussed until an agreement was reached. Subsequently, the articles selected for this SR were classified according to the percentage of adherence to SDM [29,30,33–35]. Thus, according to Pollard, Bansback, and Bryan’s classification, four categories were identified [39]: Strong support for SDM (>80 % adherence to SDM), Mild support for SDM (60 %–80 % adherence to SDM), Indifference towards SDM (40 %–60 % adherence to SDM), and Lack of support for SDM (<40 % adherence to SDM). Articles that did not present a percentage or degree of adherence were not categorized [31]. 3. Results 3.1. Description of included studies Fig. 1. Search strategy. Each item was combined with the Boolean term OR and among items with the The first database search yielded 977 studies: 30 in PubMed, Boolean term AND. 265 in PsycInfo, 393 in the Cumulative Index to Nursing and Allied 1935 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Table 1 Characteristics of the articles (n = 8). Article Authors Year Journal Country Aim / purpose Type of Methodology Participants (n) Screening Acceptability Qualsyst study SDM in screening ** Are Physicians Discussing Guerra C., 2007 Journal of General USA To identify factors that either Qualitative In-depth, semi- Health professionals (18) = Prostate Indifference 0,75 Prostate Cancer Jacobs S., Internal Medicine facilitate or prevent discussion structured interviews. internal medicine (14) and cancer toward SDM Screening with Their Holmes J. & about prostate cancer screening The Walsh and McPhee family medicine (4) Patients and Why or Shea J. Systems Model of Clinical physicians Why Not? A Pilot Study Preventive Care as a [28] conceptual framework Physicians’ attitudes Davis K., 2011 Family Medicine USA To assess both attitudes and Quantitative Surveys Health professionals (135) Prostate Indifference 0,72 about shared decision Haisfield L., factors which influenced on the = primary care physicians; cancer toward SDM making for prostate Dorfman C., SDM process for primary care academic clinicals (16), cancer screening [29] Krist A. & providers (PCPs) using internes/residents (84), Taylor K. participative practices in prostate community clinicians (35) cancer screening Prenatal screening for Légaré F., St- 2011 Prenatal Diagnosis Canada To assess both women and their Quantitative Surveys. Control- Participants (50) = Prenatal Mild support 0,77 Down syndrome: a Jacques S., family physicians’ willingness Preference Scale based on pregnant women (9) and screening for SDM survey of willingness in Gagnon S., (FPs) to engage in shared OPTION scale, and the family medicine for Down women and family Njoya M., decision-making (SDM) in degree to which family physicians (41) syndrome physicians to engage in Brisson M., prenatal Down-syndrome physicians involved shared decision- Frémont P. & screening and the factors that women in shared- making [30] Rousseau F. might influence on their decision making related willingness to do so to prenatal screening Early detection of G. Malli 2013 Das Austria To explore factors which help to Qualitative Focus group and deep/ Health professionals (42) = Prostate Not reported 0,7 prostate cancer by PSA Gesundheitswesen know GPs’ counselling about the further interviews general (38) and internal cancer testing: the results of a prostate specific antigen test medicine (4) physicians 1936 qualitative study on barriers caused by physicians in Austria implementing informed decision making* [31] Physician decision Lewis C., 2013 Journal of General USA To analyze whether physicians Quantitative Surveys by a research Health professionals (276) Colon Indifference 0,53 making for colorectal Esserman D., Internal Medicine engage elderly patients in team. Not validated = family medicine (158) cancer toward SDM cancer screening in the DeLeon C., individual decision making for and internal medicine elderly [32] Pignone M., colorectal cancer screening (118) physicians Pathman D. assesssment & Golin C. Patient Education and Counseling 104 (2021) 1933–1944 Primary care physicians’ Volk R., 2013 Annals of Family USA To examine the use of Quantitative Surveys. Beliefs related to Health professionals (246) Prostate Strong 0,86 use of an informed Linder S., Medicine prescreening and discuss on cancer screening and = family medicine cancer support in decision-making Kallen M., potential benefits and harms of identified by Purvis physicians favor of SDM process for prostate Galliher J., prostate cancer screening by Cooper et al. A group of 17 cancer screening [33] Spano M. primary care physicians. Analise indicators were found in Mullen P. & the role of physicians’ beliefs in the literature Spann S. prostate cancer screening efficiency, and the contextual factors related to the harms and benefits discussion Are Providers Prepared to Martinez K., 2018 Journal of women USA To assess readiness to engage Quantitative Surveys Health professionals (220) Breast Strong 0,65 Engage Younger Deshpande 's health younger women in SDM for = nurse practitioners (11), cancer support in Women in Shared A., Ruff A., mammography internal medicine (100) favor of SDM Decision-Making for Bolen S., and family medicine (54) Mammography? [34] Teng K. & physicians Rothberg M. M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 Health Literature, and 289 in the Cochrane Library. After applying the inclusion and exclusion criteria in the different phases, eight 0,95 - “not reported”: Some of the studies do not mention the tools used in the survey, so one of the researchers (MJH) contacted the corresponding author to clarify this information. However, no response was obtained. articles (28–35) were selected (Fig. 2). Seven of these were in English [28–30,32,34,35] and one was in German [31]. The articles support for were published between 2007 and 2018. Six studies were *Original title: Früherkennung von Prostatakrebs mittels PSA test: Ergebnisse aus einer qualitativen Studie zu arztseitigen Barrieren bei der Umsetzung der informierten Entscheidungsfi ndung in Österreich. performed in the USA [28,29,32–35], one in Austria [31], and Lack of SDM one in Canada [30]. Four studies focused on screening for prostate cancer [28,29,31,33], and one for breast cancer [34], cervical cancer [35], colon cancer [31], and Down syndrome [30]. Five used Health professionals (10) = Cervical cancer quantitative methodologies [30,31,33,33,34,35], while the remain- ing three were qualitative studies [28,31,35]. The eight analysed articles included 988 healthcare professionals, of which 76.7 % (1), obstetrics/gynecology/ internal/family medicine nurses’ practitioners (4), were physicians. The quality of the articles was valued between public health (1), family internal medicine (3), preventive medicine/ 0.53 and 0.95 (range: 0–1) with an average of 0.74 (standard deviation 0.12) points on the QualSyst [37] (Table 1). Barrier codes (n = 45) were more than the facilitator codes practice (1) (n = 30). Overall, most of the barrier codes were related to the health system (n = 14), while the facilitator codes generally corresponded to the patients’ attributes (n = 14) (Table 2). All the selected studies reported at least one facilitator [28–35]. However, one study did not mention any barriers [30]. Deeply, semi-structured 3.2. Barriers to SDM application in screening programmes (Table 2) 3.2.1. Healthcare professionals’ perceptions factor interviews Healthcare professionals’ attitudes and beliefs served as obstacles when they did not consider themselves to be experts in SDM [31] or when they were reluctant to accept some aspect of the screening process. In such scenarios, they potentially forgot to To explore health care providers’ qualitative recommend screening during clinical meetings [28], held negative perceptions of diagnostic tests [28,31], argued that clinical experience was more useful than scientific evidence with regards to managing screening [33], or maintained their own beliefs facilitators for cervical cancer regarding the effectiveness of screening [31]. perception of barriers and The lack of knowledge about screening and communicative screening in American competence was a significant professional barrier [31]. Reportedly, Vietnamese women 31.3 % of healthcare professionals were unaware of the risks and benefits of screening [29] and did not have enough information about critical values related to diagnosis [33]. Concerning breast cancer, 21 % and 16 % overestimated and underestimated the risks of screening, respectively [34]. Additionally, 48 % of the healthcare professionals reported inadequate communicative competence to involve patients in their health-related decisions, and only 8 % of those who believed that they possessed these competencies felt USA sufficiently qualified to implement them [34]. On the contrary, the benefits were over-evaluated in prostate cancer as compared to the risks; thus, early detection substantially reduced mortality [33]. Transcultural Journal of 3.2.2. Patients’ attributes factor Nursing Healthcare professionals’ aversion to incorporating SDM into screening could be due to certain characteristics of their patients. According to healthcare professionals, some patients preferred a 2018 paternalistic model and disease-centred care [29,30,32,33,35] or had a passive attitude toward their care. This passivity could be D., Lee-Lin F., Le T., Tang J., Hsiao C., Vy Hassouneh explained by a lack of motivation to get involved in the decisions Truong C., Truong A. Nguyen- Vu M. & [31]. Additionally, healthcare professionals identified the health - SDM: Shared Decision Making. state of the patient as a factor in SDM implementation. About 91 % Barriers and Facilitators Vietnamese American of the healthcare professionals initiated the discussions when their Health Care Providers’ patients were in a good health condition, which decreased to 44 % to Cervical Cancer Perspectives on otherwise [31]. Multi-morbidity is also a barrier [29,33], especially Women [35] Screening in in people with mental health pathologies [28]. Finally, healthcare professionals mentioned patients’ socio- demographic characteristics as a barrier. Poor health literacy or patients’ lack of knowledge regarding screening or SDM posed major barriers to SDM implementation [28,33,35]. Specifically, 1937 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 Table 2 Barriers and facilitators for the SDM practice in screening programs. Factors Barriers Articles Facilitators Articles Healthcare professionals’ Attitude and beliefs Attitude and beliefs perceptions Negative attitude towards screening [28,31] Positive attitude towards screening [28,30] Poor competence in SDM [31,34] The professional opinion does not influence [28,34] adherence to screening Not contemplate the application of screening [31,34] Subsequent regret when the patients are not [33] involved in the decision Discussion discourages adherence of patients [29] The uncertainty treatment allows evaluating the [33] best alternative Skills and competences Skills and competences Lack of knowledge in screening [28,30,32,33] Long working experience [29,34] Lack skills in SDM [30,33] Family-medicine training [34] Lack of knowledge in SDM [33] Same nationality or language [35] Trustful relationship [35] The patient’s attributes Prescribed attitude Open attitude Passive patients [28,31] Interest patients in involved in the decision [28–31] Comorbidity patients removes the focus of preventive [28,32] Patients with longer life expectancy evaluate the [28,32] care future profits and losses Assuming a priori the patients' s decision on screening [28,33] Personal history of risk sensitizes discussion [28] No decision-making is required when there is a reduced [28] Family history of risk sensitizes discussion [28] life expectancy patient Disease-centered care [28] Sociodemographic Sociodemographic Limited literacy in patients makes difficult to [25,28,30,32] High literacy patients make easy to understand [28,29,33,35] understand risk and benefits factors risk and benefits factors Impaired physical and cognitive function in elderly age [25,32] High socioeconomic status increased discussion [28] tools Different language makes communication difficult [26,32] Risky age sensitizes discussion [28] Male sex patients are less participatory [32] Healthcare system Structural-organizational Structural-organizational performance Lack of assistence time [28,29,31,34,35] Assistance time increase [28] Lack of remuneration to new decision-making activities [29,31] Referral to specialized staff o competent [28] professionals Complaints and legal conflict [28,29] Reminders system about participation in [28] Including more activities given the high workload [28] screening. Complexity of screening [29] Public politics Public policies Rigid clinical guides in the application criteria screening [28] Focus on a preventive care [28] Lack of scientific consensus for the customization of [28] Solid Scientific evidence for the purpose of offer [33] complex screening programs alternatives to screening Standardized screening adherence in at-risk population [33] - Qualitative methodology uses an inductive process to agglutinate the main units in complex conceptual [37]. In this case, the “codes” are the phrases that are located in each box associated with the articles that have been mentioned. The “categories” grouped the codes were represent in the title to each box. The categories, according to the healthcare professional perceptions are organized in barriers or facilitators around three factors: patients attributes, healthcare system performance or own healthcare professional perceptions. - Articles [28,30,31,33] were categorized in barriers or facilitators in their original researcher. healthcare professionals considered that patients did not have healthcare professionals requested exams without considering adequate knowledge about SDM [28] or the benefits and harms of patients’ opinions. Additionally, 38.2 % of clinicians, 11 % of interns/ screening programmes [33,35]. Then, healthcare professionals also residents, and 18.8 % of academicians [29] considered the lack of doubted the patients’ ability to understand concepts such as false remuneration for SDM activities as another barrier [29,31]. positives [31], false negatives [30], specific symptoms, risk factors, The barriers related to public policies included guidelines and risk estimation [31,35]. They also mentioned that older age, related to the healthcare system and scientific community. About male gender [28], and idiomatic differences with the interlocutor 95.5 % of healthcare professionals believed that the current [35] made SDM more complicated. healthcare system is focused on treatment [29] instead of prevention. This was reflected in screening requests being 3.2.3. Healthcare system performance factor considered as indicative of care quality, regardless of the patient’s From the perspective of healthcare professionals, some opinion [33] to meet coverage goals. Nevertheless, another study elements of the structure and organisation of health management identified the general lack of consensus on specific recommenda- could become barriers. The lack of time to apply SDM was the most tions in clinical guidelines as a barrier [28], for example in colon frequently mentioned barrier [28,30,32,34], accounting for 80.5 % cancer screening [32]. [29]. For example, more than 77 % of healthcare professionals spent less than five minutes of the clinical meeting discussing possible 3.3. Facilitators of SDM application in screening programmes therapeutic options with patients [34]; this is the main limitation to increasing patients’ participation in their healthcare [31]. Legal 3.3.1. Healthcare professionals’ perceptions factor elements were also seen to impact care styles. In two studies According to the healthcare professionals, if they exhibited performed in the US, the legislative system was mentioned as a favourable attitudes and beliefs towards screening, patients felt threat [28,29]. In one study, this was because 49.6 % of the encouraged to engage in a discussion about whether to undergo participants felt responsible and neglectful if a patient refused to screening [28,31]. Therefore, healthcare professionals had to be undergo screening, resulting in late diagnosis [29]. Consequently, aware of all the possible unfavourable outcomes [33]. They also 1938 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 Fig. 2. Selected article flowchart. Patient decision aids (PtDAs). stated that the decision to implement SDM should be independent identified some socio-demographic elements that influenced of their personal beliefs [29], even though 21.8 % believed that a patients’ participation in health decisions. discussion could decrease programme adherence [29]. Addition- High literacy was observed to be a significant facilitator [28]; ally, failing to adequately facilitate discussions of the decision 51.9 % of the healthcare professionals believed that knowledge is a regarding screening generated feelings of remorse in some of them key factor [29]. Access and exposure to information make patients [33]. more aware of the implications of screening, thereby facilitating It was observed that healthcare professionals’ communicative discussions [35]. According to healthcare professionals, patients skills and competencies concerning the promotion of SDM had the who recognised that screening could lead to the early detection of capacity to lay the foundation of a relationship based on trust, diseases were more open to SDM [33]. Additionally, healthcare closeness, and sensitivity to cultural beliefs, establishing an professionals stated that patients considered to be at high risk [28] optimal space for patients to expose their fears and allowing and who had a high socio-economic level [28] also favoured the joint decisions [35]. Thus, being a specialist in family medicine implementation of SDM. [34], belonging to the same nationality as the patient [35], and having work experience [29,34] of at least five years [35] were 3.3.3. Healthcare system performance factor factors that facilitated SDM. One study reported that academics Elements related to political and scientific guidelines that and community medicine specialists showed a greater degree of encourage participation in the healthcare system have been acceptance of SDM than residents or internal medicine physicians classified into public policies. Concerning prostate cancer, scien- [34]. Nevertheless, 96 % of the latter believed that PtDAs are tific evidence and clinical guidelines support routine screening beneficial during clinical encounters [29], compared to their more regardless of the patient’s opinion [33]. Nevertheless, another experienced colleagues (73.5 %) [29]. study reported the opposite: scheduled preventive visits enabled periodic meetings that facilitated discussion and access to more 3.3.2. Patients’ attributes factor specialised health resources [28]. The open attitude facilitator corresponded to codes in which the Screening reminders in the clinical file for high-risk patients, professionals considered the patient’s attempts to engage in a consulting more experienced healthcare professionals and having detailed discussion about the decision as indicative of a proactive extra time, were facilitating factors under the organisational attitude. For example, 69.9 %(29) of the professionals considered structure category [28]. patient’s interest as one of the pillars of improving participation, leading to a shared decision [28–31]. Those with a family medical 4. Discussion report of the disease [28], risky behaviour (e.g., smoking) [28], and a medium/long life expectancy [28] of more than two years [32] This is the first SR to explore the elements that influence showed a greater demand for SDM. Healthcare professionals also healthcare professionals’ decisions to implement SDM in screening 1939 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 programmes. Eight original research articles were analysed [28– beginning of the relationship because it can vary from passive to 35], with most of the results pertaining to cancer screening active or vice versa during an interview [50,53]. Additionally, if [28,29,31,29–35]. Based on the number of articles assigned to each healthcare professionals are aware of the patients’ preferences at of the codes, time constraints [28,29,31,34,35] and healthcare the outset, it could be easier for them to adapt to their needs, professionals’ lack of knowledge about the benefits and harms of resulting in greater satisfaction and reducing anxiety and screening [29,31,33,34] were identified as the principal barriers. confusion [54]. Regarding the facilitators of SDM, high patient literacy [28–33,35] and interest in participation or having a proactive attitude [28–31] 4.3. Healthcare system performance factor were the most notable ones [16,40]. Unlike other aspects of clinical care, in which patients are unhealthy, on the contrary, they are The healthcare system exerts its influence not only through its healthy people who take preventive measures to maintain their structure and organisation but also through the health policy. In healthy condition. Therefore, the application of SDM differs in our case, lack of time was shown to be a major obstacle to the clinical and screening contexts. To identify these differences, we implementation of SDM [28,30,31,34,35]. While there is no analysed these three factors together with both barriers and consensus regarding whether SDM involves a greater time facilitators. investment [18], previous studies have reported that it requires an extra 2.6 min [12] beyond 10 15 min reserved for the usual care 4.1. Perception of healthcare professionals’ factor [55,56]. Thus, 18 20 min would be optimal for an outpatient care meeting [55]. The literature mentions the need to extend the time Health professionals consider aspects of attitude for SDM [28– devoted to clinical meetings, especially in 18 countries, where 31,33,34] such as the belief that discussion can discourage every patient receives a maximum of five minutes of the healthcare adherence [29], while others do not see any relationship professional’s time [57]. Such short durations, apart from being [28,33]. On the other hand, some studies find that CDT tends to insufficient to correctly assess a patient’s condition and establish a increase adherence to screening [41]. In any case, the focus of SDM doctor-patient relationship, increase the risk of not detecting is not adherence to screening, but making the decision jointly by symptoms or pathological conditions. Additionally, existing the actors. The health professional has the role of informing in a evidence supports the inclusion of PtDAs in clinical encounters balanced way about risks and benefits, and in this way promoting to improve the quality of care. the patients’ autonomy [42]. Even if there are different opinions An outstanding element in our work revealed that healthcare between the health professional and the patient, the patient’s professionals’ fear of malpractice accusations [28,26] leads to autonomy should always be respected and the integrity of the defensive medicine. Therefore, healthcare professionals employ professional preserved [43]. more screening, without considering the adverse effects [58]. The A SR, 2019, described that patients with cancer decided on an literature has established that if patients are involved in the oncologic treatment. The most significant barriers to the implemen- decision and consider it their own, they do not take legal actions tation of SDM are related to clinical professionals’ specialities and [59]. miscommunications [44]. Thus, patients should establish horizontal Regarding economic incentives, the studies included in our SR communicative relationships with healthcare professionals, and did not specify why they were considered as barriers [29,31]. To healthcare professionals should consider patients’ preferences [45]. date, the payment system has focused on improvements in the These results are consistent with our findings [28–32]. remuneration of professionals who incorporate new strategies or achieve better biometric results, which could sometimes be a 4.2. Patients’ attributes factor perverse incentive for professionals (to report better health indicators than the real ones or use invasive procedures to obtain In our SR, healthcare professionals’ beliefs about their patients’ good results) or, on the contrary, be beneficial as it would behaviour influenced SDM [28–33] Our results confirm the encourage professionals to create more effective methodologies to findings of the previous study [44]. In screening studies there keep patients healthy [60]. Another point is that the payment are should be a higher concern about adverse effects, since their system in the health sector has been changing; in the National uncertainty, as well as adverse effects in treatments, which have Health Service in Britain, indicators incorporating the effect of been studied more rigorously [46]. interventions on well-being and life expectancy are used [61]. In the SR mentioned above [44], the concerns of the patients However, in the screening context, SDM is focused on facilitating about the adverse effects of cancer treatment were analogous to participatory decisions rather than on adherence, or the lack of it, our results. However, despite the fact that the adverse effects of to screening programmes [62]. Therefore, remuneration related to screening are known by the scientific community, it has been really the objective of implementing SDM should be adjusted by difficult to transmit balanced information to the population, since evaluating patient participation in decision-making rather than it tends to give greater relevance to the benefits (overestimation of health outcomes. However, for professionals to consider this benefits) than to the risks (underestimation), which is known as an function as a part of their work, it should be introduced as an optimistic bias [47]. In cancer medical treatments both profes- ethical and legal professional role [18] right from university sionals and patients are more aware of the risks. training. Previous studies support our results regarding patients’ While clinical health guidelines based on the effectiveness of attributes that facilitate SDM, for example: young age [48–50], screening tests are a framework shared by healthcare professio- high educational level [49,50], higher socioeconomic level [50], nals, they sometimes do not reflect their effectiveness. Therefore, and existing risk factors (smoking) [51]. Regarding gender, males evidence-based practice (EBP) should not only result into an seemed less participative; this result aligns with the findings of improvement of biometric or population parameters (such as low another study [52], in which females had a more active role [49]. mortality in screening) but also focus on the patient’s preferences However, another study found no such association (51). Another because it is, first and foremost, patients who are responsible for element found in our study was that active participation indicated their care and who must evaluate the gains and losses they are the patient’s interest in being the protagonist in the clinical willing to bear in each specific case [62]. Thus, the best option is encounter [28–31]. Therefore, previous studies recommended that discussing guideline recommendations with patients and making a the patient’s desired role should be explicitly explored at the shared decision using EBP and PtDAs [63,64]. 1940 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 4.4. Experience of other countries in SDM for screening programmes [67], for breast cancer screening and cardiovascular diseases. However, this has not guaranteed its full implementation; Countries that have developed SDM in screening programmes therefore, different organizations have been willing to promote emphasize the development of public policies to overcome system it [68], including universities that train undergraduate students or (legal) and professional (professional training) barriers besides postgraduate programs [67], responding to the barriers of the taking advantage of professional facilitators (PtDAs). professionals’ factor. We highlight Switzerland, whose success is also due to the Other countries have also started programs in this direction. training of professionals in SDM in undergraduate and graduate Ottawa Hospital [23] describes and evaluates many of them. (See studies of general internal medicine [26]. Additionally, a study Table 3). raised the possibility of incorporating practice assistants (PAs) who are healthcare professionals and have administrative and clinical 5. Practice implications functions to overcome some of the barriers described in the system category [26]. The United States government has also promoted the Based on the results of this study, together with those reported implementation of a more participatory model, especially since the previously, some proposals can be introduced to overcome the enactment of the Law of 2010 (The Patient Protection and barriers in applying SDM. First, training in SDM should be Affordable Care Act). In this law, the use of PtDAs is recognized introduced at the undergraduate level [15,29,69,70]. Consideration statewide for the first time and legally protects physicians from should also be given to providing training in communicative skills negligence lawsuits when they choose to use certified PtDAs, a [65,71], empathy [71], strategies to respond to emotional signals concern that was referred to in our results as a system barrier [65]. [72], active listening [18,58,70], nonverbal language [59,71], and PtDAs have been developed for breast, colon, lung, melanoma, supportive care [70]. Early training would make it possible to prenatal, and prostate cancer screening, among others [23,66]. generate a paradigm shift in the healthcare model, strengthening Finally, research recognizes the need to make professionals aware patients’ position as active entities who are invested in their health of the controversies and benefits of screening and to increase SDM and are aware of the benefits and adverse effects of preventive strategies for screening, especially for a more participatory model measures such as breast cancer screening. [66], which coincides with our results. Finally, Canada has a Second, by incorporating PtDAs [15,64,73], professionals can growing interest in considering SDM in the Canadian healthcare effectively involve patients in their health-related decisions [9,53], system. CanMEDS calls on physicians to not only inform patients which would allow the optimisation of the limited time available but also actively facilitate their learning for a better physician- during clinical meetings. PtDAs have been developed in different patient relationship. Physicians have a legal obligation to allow formats [12,64]: brochures, booklets, videos, DVDs, web pages, and patient participation, which has prompted the creation of PtDAs interactive programmes for online or in-person use [12,73,74]. Table 3 Summary of PtDAs reported at The Ottawa Hospital. Country Screening PtDAs Year Argentina Breast Cancer Detección precoz del cáncer de mama. Herramienta para la toma de decisiones compartidas. / 2020 Early detection of breast cancer screening. A tool for shared decision making. Australia Breast Cancer Should I Continue Having Mammograms to Screen for Breast Cancer? A decision aid for women 2005 aged 70 and older at their next screening mammogram Cervical Cancer Screening Making Choices: A decision aid for women with a mildly abnormal pap smear. 2006 Colorectal Cancer Making decisions: Should I have a screening test for bowel cancer? 2006 Prostate cancer Prostate cancer screening: Decisions for men with a family history of prostate cancer. 2014 Brazil Prostate Cancer Apoio à decisão no rastreamento do câncer de próstata. [Decision aid for prostate cancer 2019 screening.] Canada Prenatal Testing What are my options regarding prenatal screening tests?; Quelles sont mes options concernant 2017 le test de dépistage prénatal? Prostate cancer Le dépistage du cancer de la prostate : une décision qui VOUS appartient! [Prostate cancer 2013 screening: It's YOUR decision!] Prostate Cancer Screening, Choosing Whether or Not to Screen; Dépistage du cancer de la 2019 prostate, choisir de faire ou de ne pas faire le test de dépistage. Germany Breast Cancer Entscheidungshilfe Mammographie-Screening [Decision Aid for Mammography Screening] 2015 United Kingdom Melanoma Melanoma: follow-up with regular CT scans - yes or no? 2015 United States Aortic Aneurysm Abdominal Aortic Aneurysm: Should I Get a Screening Test? 2015 Breast Cancer Breast Cancer Screening and Dense Breasts: What Are My Options? 2015 Breast Cancer Screening Decision Support Tool. 2017 Breast Screening Decisions 2016 Breast Cancer Screening: When Should I Start Having Mammograms? 2016 Colorectal Cancer Colon cancer: Which screening test should I have? 2015 Health Screening Health Screenings: Should I Buy Commercial Tests? 2016 Lung Cancer Is Lung Cancer Screening Right for Me? A Decision Aid for People Considering Lung Cancer 2016 Screening With Low-Dose Computed Tomography Lung Cancer Screening Decision Support Tool. 2017 Lung Cancer: Should I Have Screening? 2019 Melanoma Melanoma: follow-up with regular CT scans - yes or no? 2015 Prenatal Testing Pregnancy: Should I Have Screening Tests for Birth Defects? 2015 Prostate Cancer Prostate Cancer Screening with PSA Testing 2012 Prostate Cancer Screening: Making the Best Choice 2014 Prostate Cancer Screening: Should I Have a PSA Test? (Healthwise) 2016 Prostate cancer screening: Should you get a PSA test? (Mayo Clinic) 2015 The table only shows the results of the PtDAs reported and evaluated by The Ottawa Hospital. Therefore, countries and PtDAs may be omitted, this does not mean that any of them are not in development [23]. 1941 M.J. Hernández-Leal, M.J. Pérez-Lacasta, M. Feijoo-Cid et al. Patient Education and Counseling 104 (2021) 1933–1944 More recently, the hypothetical goal board model, wherein the Funding objectives are established to guide and strengthen decision- making are aligned with the patient’s priorities and values through This study was funded by Instituto de Salud Carlos III through a practical and realistic approach, has been introduced [56]. The the project PI18/00773 (co-funded by the European Regional evaluation of PtDAs has been effective in empowering patients, Development Fund) and the European Union’s Horizon 2020 reducing their decision-making conflict [73–78], achieving effec- research. Innovation programme under the Marie Skłodowska- tive patient-clinician communication [16], improving patients’ Curie grant agreement No. 713679 from the Universitat Rovira i knowledge related to their health condition [75,78], and resulting Virgili (URV). 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