Multiethnic Perspectives of Shared Decision-Making in Hypertension: A Mixed-Methods Study

Abstract

Background: Shared decision-making (SDM) has the potential to improve hypertension care quality and equity. However, research lacks diverse representation and evidence about how race and ethnicity affect SDM. Therefore, this study aims to explore SDM in the context of hypertension management.

Methods and results: Explanatory sequential mixed-methods design was used. Quantitative data were sourced at baseline and 12-month follow up from RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) participants (n=1212) with hypertension. Qualitative data were collected from semistructured individual interviews, at 12-month follow-up, with participants (n=36) selected based on their SDM scores and blood pressure outcome. Patients were cross- categorized based on high or low SDM scores and systolic blood pressure reduction of ≥10 or <10 mm Hg. Multinomial logistic regression analysis showed that predictors of SDM scores and blood pressure outcome were race and ethnicity (relative risk ratio [RRR], 1.64; P=0.029), age (RRR, 1.03; P=0.002), educational level (RRR, 1.87; P=0.016), patient activation (RRR, 0.98; P<0.001; RRR, 0.99; P=0.039), and hypertension knowledge (RRR, 2.2; P<0.001; and RRR, 1.57; P=0.045). Qualitative and mixed-methods findings highlight that provider-patient communication and relationship influenced SDM, being emphasized both as facilitators and barriers. Other facilitators were patients' understanding of hypertension; clinicians' interest in the patient, and clinicians' personality and attitudes; and barriers included perceived lack of compassion, relationship hierarchy, and time constraints.

Conclusions: Participants with different SDM scores and blood pressure outcomes varied in determinants of decision and descriptions of contextual factors influencing SDM. Results provide actionable information, are novel, and expand our understanding of factors influencing SDM in hypertension.

Keywords: health equity; hypertension; mixed‐methods; shared decision‐making.

Figure 1. Adapted conceptual framework.

Figure 2. Study flow chart.

BP indicates blood pressure; RICH LIFE, Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone; and SDM, shared decision‐making.

Figure 3. Facilitators, barriers, and corresponding domains related to SDM in the context of hypertension by SDM and BP group.

Black circles: Facilitators discussed by the corresponding group. Black cross: Barriers discussed by the corresponding group. Green circles: Facilitators of patient‐clinician racial and ethnic concordance. Red cross: Barriers of patient‐clinician racial and ethnic discordance. Orange circles: Facilitators mentioned as relevant rather than patient–clinician racial and ethnic concordance or discordance. Blue circles: Participants' own race and ethnicity as a facilitator of participation in SDM. Blue cross: Participants' own race and ethnicity as a barrier of participation in SDM. BP indicates blood pressure; High SDM, CollaboRATE sum score 27; Lower SDM, CollaboRATE sum score ≤26; SBP, systolic blood pressure; and SDM, shared decision‐making. SBP ≥10: reduction in SBP of ≥10 mm Hg; and SBP <10: reduction in SBP of <10 mm Hg.