Exploring the opportunities and challenges to adapt existing shared decision-making strategies and tools in contraceptive counselling for Chinese migrant women living in Australia

Abstract

Shared decision-making (SDM) calls for improved patient-provider communication, through which healthcare decisions are made collaboratively between the patient and the healthcare provider. In Australia, SDM has gained increased momentum in the healthcare policy and research agenda in recent years. Australia is a multicultural country with a large migrant population. Therefore, the need for exploring the opportunities and challenges to extend, adapt and apply such an approach to healthcare decision-making among culturally and linguistically diverse population groups is imperative. Migrants from Chinese ethnicity are among one of the largest overseas-born groups in Australia. Contraceptive method-choice decisions are highly preference-sensitive and are ideal for SDM in clinical settings. SDM can be facilitated and complemented by the use of decision support tools such as patient decision aid (PDA)s. SDM and the use of PDAs are shown to improve women’s knowledge of contraceptive methods and lead to patient-centred contraceptive counselling experiences and informed decisions. However, there is a lack of research into how existing SDM strategies, including the use of PDAs, in contraceptive counselling can be better adapted for Chinese migrant women living in Australia. Aims The overarching aim of this thesis was to explore improved ways to adapt existing SDM strategies and PDAs in contraceptive counselling for Chinese migrant women living in Australia. Using a stepwise approach, the studies (Chapters) contained within this thesis investigated the following specific objectives: i) identify interventions that aimed to improve patient participation in decision-making during patient-provider encounters in non-Western countries and synthesise factors that are influencing their effectiveness (Chapter 2); ii) explore the relationships between individuals’ core cultural and personal attitudinal values and their desire for medical information and self-involvement in medical decision-making in Australia and China (Chapter 3); iii) adapt an existing PDA in contraceptive counselling for Chinese migrant women living in Australia and explore potential strategies to support SDM(Chapter 4); iv) explore Chinese migrant women’s experiences and perceptions of choosing contraceptive methods and their decision-support needs (Chapter 5); v) explore healthcare providers’ experiences with providing contraceptive care for Chinese migrant women and their perceptions of the challenges and opportunities to engage Chinese migrant women in SDM during contraceptive counselling (Chapter 6); vi) explore the perceived usefulness, acceptability, and feasibility of the adapted PDA with both the Chinese migrant women and the healthcare providers (Chapter 7). Methods This thesis comprises studies that applied a variety of research methodologies, including systematic review of literature (Chapter 2), quantitative data analysis (Chapter 3), and qualitative interviews (Chapter 4, 5, 6 and 7). In Chapter 2, eight databases were systematically searched for interventional studies (randomised controlled trials, controlled or uncontrolled before-and-after studies, and interrupted time-series studies) that were conducted in non-Western countries. Included studies were analysed and reported using the narrative synthesis method. In Chapter 3, existing data from Australia and China on medical decision-making and its influencing cultural and personal factors were analysed using structural equation modelling method. In Chapter 4, a detailed description of a 6-stage process for adapting an existing contraceptive method-choice PDA and potential decision support strategies for Chinese migrant women living in Australia was provided. In Chapters 5, 6, and 7, 22 women from Chinese ethnicity who were recently living in Australia and 20 healthcare providers who were experienced in providing contraceptive counselling for Chinese migrants were interviewed. Collected data (audio-recorded transcripts) was analysed using the thematic analysis method (Chapter 5 and 6) and the content analysis method (Chapter 7). Key findings The systematic review findings from Chapter 1 showed that interventions to promote patient participation in healthcare decisions during medical encounters were more likely to be effective in non-Western cultural contexts if the following interventional elements were incorporated. Key interventional elements that were common among studies that reported positive outcomes were patient and/or provider communication skills training, and PDAs which were provided to patients and/or providers who received training on communication skills or briefing on utilising the PDAs. The structural equation model analysis from Chapter 2 found that core cultural values (independence and interdependence) and a personal attitudinal value (health locus of control) similarly influenced individuals’ desire for medical information in both China and Australia. Only one cultural value (power distance) was found to influence individuals’ desire for self-involvement in decision-making in both countries; however, the influence took opposite directions in China versus Australia. In Chapter 4, a six-stage process for adapting an existing encounter PDA (‘Right For Me’ birth control tool) and exploring decision-support strategies for both the Chinese migrant women and healthcare providers was piloted. Those stages involved were: 1) selection and appraisal of source PDA; 2) review by content experts; 3) content validity and usability testing; 4) translation into the Chinese language; 5) decisional needs assessment; 6) acceptability, usability, and perceived feasibility testing of the adapted PDA. Chapter 5 results revealed that there was a strong preference among Chinese migrant women towards ‘natural’ or non-invasive methods such as condoms, withdrawal, or fertility awareness-based methods. At the same time, there was a strong sense of rejection towards methods involving hormones or (Intrauterine devices) IUDs. Most women had not visited or perceived it necessary to visit healthcare providers for contraceptive advice or services. Many women accessed contraceptive related information on Chinese language websites or social networking sites. Chapter 6 revealed that healthcare providers faced unique challenges in communicating and engaging with Chinese migrants during contraceptive counselling sessions. Such challenges included the opportunistic nature of the consultations, language barriers, women’ lack of sexual and reproductive health knowledge, and negative attitudes/beliefs towards methods involving hormones. Chapter 7 results showed that both the Chinese migrant women and healthcare providers perceived the encounter PDA to be of good design, informative, and useful in assisting women’s decision-making about contraceptives. Chinese migrant women suggested not to limit the use of the PDA to the clinical consultation sessions. Healthcare providers’ main concern was the information load of the PDA, which they perceived as potentially overwhelming for women. There were also concerns about and the feasibility of reviewing all pages of the PDA with women during one consultation. Such concerns were likely to ease with the explanation of how to use the PDA effectively. Conclusion: The body of work presented in this thesis adds to the limited yet growing number of literature on SDM with people from diverse cultural and linguistic backgrounds. The findings imply that promoting active patient participation in decision-making during patient-provider encounters is more likely to be feasible if patients and/or providers are provided with communication skills training with or without the provision of PDAs. An individual’s desire for self-involvement in medical decision-making was largely unpredictable by the cultural and personal values that an individual possess both in China and Australia. Therefore, cultural stereotyping individuals’ preference for involvement in medical decisions should be avoided, and individuals should be provided with equal opportunities to be involved in their medical decisions regardless of their cultural background. During contraceptive counselling encounters between the Chinese migrant women and the healthcare providers, the PDA that was adapted using a six-stage framework has the potential to serve as a useful tool to facilitate SDM and informed decisions. To improve the perceived feasibility and potential implementation of the PDA, providing HCPs with training on how to use the PDA might be necessary. The process for adaptation employed in this thesis can serve as an example for future efforts to extend the adaptation of PDAs on various topics for diverse patient population groups in Australia and beyond.