Health-related decision-making in its personal, social and health service contexts: a critical review of relevant findings from seven publications and consideration of their contribution to understandings of decision-making and the wider field of applied health services research

Abstract

Health-related decision-making, in particular patients’ involvement in decision-making about their treatment and care, has been an important and enduring concern for many practitioners and researchers working in applied health services research and allied fields. This is evidenced by the substantial (and still growing) body of work on ‘shared decision-making’ (SDM). With the aim of advancing understandings of decision-making, and the associated literature, this critical review seeks to situate, present, draw together, and critically consider, relevant findings from work (seven papers) I have first-authored. These papers arose from three applied (qualitative) health services research studies which directly or indirectly explored the experiences of different groups of patients confronted with decisions about their treatment and/or care. I begin my review with a short overview of relevant theoretical and empirical work pre-dating and informing my own research studies and publications, noting some emergent critiques, and highlighting where important gaps in evidence and understanding were said, at the time, to remain. Then, shifting focus to my own work, I introduce the three studies from which the submitted publications arose, detailing their backgrounds, aims, methods and my involvement in each. Next, I reflect on the findings of my submitted papers, noting how individually and collectively they indicate the importance of the context(s) in which health-related decisions are made. Using techniques of qualitative synthesis to identify a series of descriptive and analytic themes, I develop – and evidence – the proposition that health-related decision-making happens in, and is shaped by, its personal, social and health service contexts. This includes detailing the various ways in which different features of context may influence patients’ decision-making. I then consider, critically, how my findings fit with the wider literature. I proceed to argue that, in attending to, and highlighting, the role of context, my papers, synthesis and review provide insights that complement and extend the historic emphasis in SDM scholarship on what goes on within clinical encounters. Reflecting on the focus of more recent SDM literature (publications contemporaneous with or subsequent to work leading to the submitted papers) I note where other authors have similarly gone on to assert the importance of taking a more context-cognisant approach to understanding health-related decision-making. I also consider how other literatures (such as the classic literature of medical sociology and more recent work in psychology) support and might usefully inform this and future thinking about health-related decision-making. Moving the review towards a close, I offer an assessment of the strengths and limitations of my published work and, moreover, of my synthesis and review. I finish by reflecting upon the methodological and other learning I have accrued over the course of undertaking the contributing studies, including preparing the submitted publications, and from the process of producing this critical review