Study Selection and Characteristics

Our literature search retrieved 9,509 records (Figure 1). After removing duplicates, we screened the titles and abstracts of 5,522 records for eligibility. Two additional records were identified through searching the references of studies identified for inclusion in the review and underwent screening. We thus screened 5,524 records.

Figure 1.

PRISMA Flow Diagram

PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Ultimately, 39 studies met all of the inclusion criteria.5,12-43,48-53 Their characteristics are summarized in Table 1 and detailed in Supplemental Table 2. Thirty-eight of the studies were conducted in the United States; 1 was conducted in Canada.28 Most had a qualitative study design.5,12-43 Fully 35 studies focused on decision making among African American/Black and Latino/x/e patients.5,12,13,15-27,29-43,48-50,53 Ten pertained to decision making on the management of chronic illnesses,20,26,32,34-37,39,40,49 8 to decision making about cancer screening,12-14,21-24,33,41,43,53 6 to contraceptive decision making,15,16,18,19,30,48 and 3 to mental health treatment.17,23,38

Table 1.

Summary Characteristics of the 39 Studies

Main Themes

We identified 5 overarching themes of SDM in diverse populations during our review: factors regarding the decision-making process during the clinical encounter, clinician practice characteristics, trust in the clinician and health care system, cultural congruence, and extrinsic factors affecting the decision-making process. These themes and related subthemes are detailed in Table 2 and discussed further below.

Table 2.

Overarching Themes and Subthemes, and Examples From Studies

Factors Regarding the Decision-Making Process Encounter

Many of the studies described factors that affected the use of SDM during a clinical encounter (Table 2). Patients discussed their ability to participate in the decision-making process with the clinician.18,30,31,38,40,41,49,50,52-54 Specific factors that affected ability to participate included the way in which the clinician shared information,16,25,30,31,34,35,37,49,50 whether the clinician made a recommendation,18 and how the clinician encouraged the patient to share information.32,34,37 Patients also prioritized the ability to ask questions that enhanced their self-efficacy within the clinical visit.30,31,35

Clinician Practice Characteristics

Several studies discussed the role that various aspects of clinician-patient communication play in SDM (Table 2).5,20,30,34,35,37,50-52 The importance of humanistic communication was frequently described, as was clear and honest communication.5,20,51,52 In one study, effective communication, described as a relationship in which the clinician seeks to know and understand the patient and family, was foundational to tailored communication and decision making.53 Clinician time constraints were a barrier to SDM.17,18,20,51,52 Studies additionally highlighted how clinicians disliked being questioned, how they became impatient or dismissive when the patient attempted to ask questions, and how patients reported making accommodations for the clinician, prioritizing harmony with the clinician over their own care.17,28,36,52

Trust in the Clinician and Health Care System

Trust and factors impacting trust were often mentioned in the studies reviewed (Table 2). Facilitators of patient trust in SDM included clinician interpersonal skills; honesty and information sharing; promoting of patient sharing; medical skills and technical competence; and a balance of power.35,37,50,51 Barriers to patient trust included physician racial bias, cultural discordance between the clinician and patient, experiencing prejudice from the clinician, past experiences of health care discrimination, and invalidation of illness experiences and concerns.31,37,38,50 Mistrust (of the medical profession generally and of clinicians specifically) was an additional factor that affected SDM, as was suspicion of the effect of recommended medications on health, of clinician motives and intent, and of clinicians overall.20,32,50,51

Cultural Congruence

Studies described how not sharing racial, ethnic, cultural, and/or social background with one’s clinician was a barrier to developing patient-clinician SDM relationships, whereas having a clinician with similar lived experiences or sharing the same racial and/or ethnic identity promoted relationship building (Table 2).17,31,36,37 In addition, patients valued having culturally sensitive clinicians and interactions.39 Language barriers between patients and clinicians were identified as a barrier to engaging meaningfully in SDM.39,51,52 Patients noted the need for improved language competence by their clinicians and lamented the lack of high-quality interpreter services.39 Language barriers impeded in-depth treatment discussions, and patients indicated that translators did not always fully or accurately translate.28,39,52

Extrinsic Factors Affecting the Decision-Making Process

Factors outside of the encounter and clinician-patient relationship, including family members’ or peers’ past experiences with similar conditions or treatments, also affected SDM (Table 2). Several studies described the importance of family members in the decision-making process during or outside the visit.5,27,52 Some patients valued input of their family on health care–related decisions, and others added that incorporating family could facilitate adherence and engagement.5,27,52 Studies described how decisions about care occur subsequent to the encounter, whereby a patient responded to a clinician’s recommended treatment plan behaviorally, by adhering or not adhering to the recommendations.31,34 For patients, what could be viewed as nonadherence by clinicians was appropriate decision making about care occurring outside of the clinical encounter based on incorporating information gained through discussions with family and friends.34

Thematic Framework

In total, our analysis identified 8 barriers and 15 facilitators for SDM (Table 3). All have implications for clinical practice, and most can be modified with strategies and interventions at the clinician and/or health system level, seen in the table.

Table 3.

Barriers and Facilitators for Shared Decision Making and Their Practice Implications

The overall thematic framework for our findings is shown in Figure 2. This framework outlines the 3 phases of the decision-making process (previsit, visit, and postvisit) at which barriers and facilitators can impact the SDM process and relationship for better or worse.

Figure 2.

Thematic Framework for Shared Decision Making