LITERATURE REVIEW AND THEORETICAL FRAMEWORK
2.4 TREATMENT DECISION MAKING
2.4.4 SHARED DECISION MAKING
Shared decision making is an approach where doctors and patients communicate together using the best available evidence when faced with the task of making treatment decisions. Patients are supported in exploring possible attributes and consequences of various options in an attempt to arrive at an informed preference - making a decision about treatment (Frosch and Kaplan, 1999). It is an approach
encompassing respect for patient autonomy and it is a desired, ethical and legal process (Elwyn, Edwards, Kinnersley and Grol, 2000; Charles, Gafni and Whelan, 1997).
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Shared decision-making is increasingly advocated as an ideal model of treatment decision-making (Frosch and Kaplan, 1999). Charles et al (1997) believe that to date, the concept has been both poorly and loosely defined. In implementing shared decision making, Charles et al (1997) suggest a criteria as follows: (1) that there are at least two participants involved (the physician and the patient) as a minimum; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred
treatment; and (4) that an agreement is reached on the treatment to be implemented.
There is increasing interest in interventions that help patients become involved in decision-making about healthcare choices (Frosch and Kaplan, 1999). Elwyn et al (2008) describe 'decision aids' as interventions that provide those making decisions with information related to the nature and probabilities of various options. These aids may be in the form of paper-based hand outs, videos and / or web links which may be given to patients before, during or after consultations with health professionals. Information they relay should include details on the clinical condition; outcome probabilities tailored to personal risk factors;
descriptions of others' experiences; and guidance in the steps of decision-making and communicating with others.
In their 2008 study An Assessment of Parents’ Decision-Making Regarding Paediatric Cochlear Implants, Cyne Johnston et al incorporate one particular aid that provides a process to facilitate shared decision making - the Ottawa Decision Support Framework (ODSF). This framework is appropriate for decisions that (a) are stimulated by a new circumstance, diagnosis, or developmental condition, (b) require careful deliberation because of the uncertain and/ or value-sensitive nature of the benefits and risks, and (c) need relatively more effort in the deliberation stage than the implementation stage.
The decision parents are required to make in using psycho-stimulants in treating ADHD meets each of these criteria. The ODSF depicts how a family’s decisional needs and decisional qualities influence each other. Decisional needs include (a) elements of the decision, such as timing, stage, and learning, (b) decisional conflict, (c) knowledge and expectations, and (d) values.
The ODSF is however relatively linear in its approach and does not adequately consider the numerous influences, parental cognitions, treatment perceptions, attitudes and beliefs that intertwine in deciding on treatment for an ADHD child. Individual level theories offer us a better understanding of these factors in exploring treatment decision making.
Page 37 of 150 2.4.5 THE HEALTH BELIEF MODEL
The Health Belief Model (HBM) was one of the first, and remains one of the best known social cognition models (Janz and Becker, 1984). Developed by Irwin Rosenstock, it is a health behaviour change and psychological model for studying and promoting the uptake of health services (Rosenstock, 1966).
Originally, the model was designed to predict behavioural response to the treatment received by acutely or chronically ill patients, but in more recent years the model has been used to predict more general health behaviours (Glanz, Lewis and Rimer, 2002). The HBM was one of the first models that adapted and applied theory from the behavioural sciences to health problems (Glanz, 1999). In the 1970’s and 1980’s the model was further developed where amendments to the model were made to accommodate evolving evidence generated within the health community regarding the role of knowledge and perceptions in personal responsibility and decision making (Glanz et al, 2002).
This model proposes that following perceptual factors influence health behaviours (Jiang and Johnston, 2010):
Perceived susceptibility (an individual's assessment of their risk of getting the condition)
Perceived severity (an individual's assessment of the seriousness of the condition, and its potential consequences)
Perceived barriers (an individual's assessment of the influences that facilitate or discourage adoption of the promoted behaviour - perceptions of potential difficulties or obstacles to performing the action chosen)
Perceived benefits (an individual's assessment of the positive consequences of adopting the behaviour).
The HBM suggests that before an individual takes action, the individual must first decide that the behaviour creates a serious problem and that there is susceptibility to health harm. Following this, the individual must recognize that moderating or ceasing the behaviour would be beneficial (Gorin and Arnold, 1998).
The HBM suggests that an individual’s belief in personal threat together with their belief in the effectiveness of the proposed behaviour will predict the likelihood of the individual initiating that behaviour (Petersen, Bhana, Flisher, Swartz and Richter (eds), 2010),
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The HBM is based on the understanding that a person will take recommended action if there is the belief that a negative outcome can be avoided, if suggested recommendations will have a positive outcome and if that person feels they can successfully follow through with the recommended health action. Perceived barriers and / or the potentially negative aspects of a particular health action may act as obstacles to undertaking the recommended behaviour. Often individuals consciously or unconsciously engage in a cost benefit analysis, where the individual weighs the expected effectiveness of the action against perceptions that it may be expensive, dangerous (medication having severe side-effects), or unpleasant - difficult, upsetting, inconvenient and / or time consuming (Gorin and Arnold, 1998; Petersen et al, 2010).
The HBM therefore focuses on two related appraisal processes, the threat and the behavioural response to that threat. Threat appraisal involves consideration of both the individual’s perceived susceptibility to negative consequences and the anticipated severity. Behavioural evaluation involves consideration of the costs and benefits of engaging in behaviours likely to reduce the threat (Glanz et al, 2002).
The HBM helps explain why individual patients may accept or reject preventative health services or adopt healthy behaviours. The HBM suggests that individuals will respond best to recommendations about health promotion when the following four conditions for change exist:
The person believes that he or she is at risk should behaviour not change.
The person believes that the risk is serious and the consequences of developing the condition are undesirable.
The person believes that the risk will be reduced by a specific behaviour change.
The person believes that barriers to the behaviour change can be overcome and managed.
The HBM is a framework for motivating people to take positive health actions using the desire to avoid a negative health consequence as the primary motivation. Appropriate fear-based messages are incorporated to facilitate susceptibility and severity (Glanz et al, 2002).
In addition to the above, the HBM considers factors which prompt action, understanding behaviour to be triggered by a ‘cue to action’ where health-related decisions are triggered by environmental cues (Petersen et al 2010, p. 22).
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Closely linked to this is the proponent that motivation to change behaviour is the result of an individual feeling sufficiently threatened by their behaviour and recognising an ability to behave differently. Further extensions on this model incorporated the concept of self-efficacy – the perception that one has the ability to successfully perform an action (Petersen et al 2010).
Later versions of the model added an additional dimension, the individual’s motivation or readiness to be concerned about health matters. This dimension has the potential to be greatly affected if defense
mechanisms (such as denial as to the existence of a problem) lead to irrational thinking and unwillingness to accept the suggested treatment regime (Gorin and Arnold, 1998).
Adopting the HBM as a theoretical framework has some specific strengths. Included in these are that its common-sense constructs are straightforward to assimilate and apply, making the theory easily understood by non academics. In addition to this, the HBM has focused research attention on psychological
prerequisites of behaviour that are modifiable. Also, the HBM makes testable predictions - large health threats for example might be offset by perceived costs and small health threats by large benefits (Glanz et al, 2002, Gorin and Arnold, 1998).
Despite the identified strengths of the HBM, some significant limitations need to be recognized. Important limitations are that the common-sense framework has a tendency to over-simplify health-related
decisional processes. Closely related to this is that the theoretical components comprising the HBM are broadly / generally defined and may not necessarily be strictly comparable to all circumstances. In addition to this, the HBM does not take into account social and other factors and therefore cannot make testable predictions.
Green and Kreuter (1999) believe that the Theory of Reasoned Action (TRA) addressed some of the limitations of the HBM. This theory focuses on theoretical constructs concerned with individual motivational factors as determinants of the likelihood of performing a specific behaviour.
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