Shared decision-making underutilisation at an outpatient clinic during BMI monitoring in rural Uganda

Introduction

As the world population faces challenges peculiar to their locations, some challenges cut across the globe’s diversity. The global challenge of morbid obesity has had an increase in the past 3 decades (Stenholm et al., 2017). This led to the mandatory inclusion of the measurement of the body mass index (BMI) for adult patients during their hospital visits (Ministry Of Health, 2016). Patients need to know and remember information regarding their BMI for their use. The way the information is shared at hospitals may hinder the recall of instructions (McHale et al., 2016).

Shared decision-making has been defined by several bodies that deal with health and related matters. “The American Medical Association (AMA) defines it as a formal process or tool that helps physicians and patients work together to choose the treatment option that best reflects both medical evidence and the individual patient’s priorities and goals for his or her care” (Godolphin, 2009).“Shared decision-making is a collaborative process through which a healthcare professional supports a person to decide on their care, now or in the future.” The healthcare provider has to work with the patient to arrive at the best options (Bae, 2017). This study used the three-talk model of shared decision-making, which describes a three-step approach to applying shared decision-making. The steps are divided into: “choice talk, option talk, and decision talk”, where the clinician supports deliberation throughout the process (Mathews et al., 2016). Patients are served with various categories of information at hospitals and the hospital may give customised information or follow general guidelines. The information given will either be remembered by the patients or not (Jansen et al., 2008). The concern for the health care team is the communication to be used effectively. The effective use may also mean an effective recall that the patients base on to act (Bae, 2017). During the routine outpatient visits, the patients get their anthropometry measurements taken. The procedure is never complete without feedback from the patients because the feedback is what patients recall (Jansen et al., 2008). “Effective treatments can be rendered useless by poor patient recall of treatment instructions” (Mathews et al., 2016).

Health professionals are thus the task of providing information in a way that it can be “encoded” and retrieved when needed (Bae, 2017). This is a challenge faced when health workers attempt to teach new information. The process of communication will thus not only be affected using the health care provider’s technique; but also by the personal factors of the patient that influence the process (Selic et al., 2011).

Patients remember as little as a fifth of the information discussed and immediately forget 40%- 80% of the content of their medical encounters.” (Dawson et al., 2014). This fact emphasizes the need to improve several approaches to how doctor-patient discussions should have been held a decade ago (Gionfriddo et al., 2013). Subsequent studies have continued to report little improvement in patient-doctor discussion techniques producing poor treatment adherence as the negative outcome (Lewis et al., 2016).

Patients’ recall of medical instructions requires further study to allow improvement on the already existing approaches to clinician-patient discussion. In this study, patient factors were studied to facilitate a patient-based approach that keeps the consumer of health services at the centre of improvements (Ong et al., 1995).

The current way of communicating has not efficiently led to teaching patients the basics of the outcomes of their visits to the hospital. Several patients may not recall what the healthcare providers found out about their health and thus cannot actively participate in the interventions, which leaves them as followers and not active participants (Skinner et al., 2012). The status thus given to patients makes them powerless or with little power to control the likely outcome of the health care intervention (Hoffmann et al., 2014).

Methods

A cross-sectional study design was employed and data was collected by a survey approach. The study was carried out during September 2019 at Comboni Hospital Kyamuhunga a rural hospital in southwestern Uganda. The hospital serves a population of mostly peasant farmers and staff of neighbouring tea estates. The hospital on average attends to about 50 outpatient adults per day. All these patients routinely undergo anthropometry measurements at the outpatient department. Therefore, the outpatient department was used for data collection.

Results

The majority of the study participants were male (58.7%) and aged between 18–37 years 55.43%. with only 17.6% illiterate while the rest were able to read and write. Although most participants were educated only 14.1% of all participants could recall their BMI after attending the outpatient department. This is shown in Table 1 (Banturaki, 2024).

Discussion

The majority of the respondents 79 (85.9%) could not recall their BMI while only 13 (14%) could remember their BMI]. Most times the patients leave the doctor’s room when they don’t know what the doctor said.

Patients need cooperative decision-making during their visits. Enhanced care with patient satisfaction may rise as a result of adherence that results from group decision-making (Fernandez-Lazaro et al., 2019). The study found that demographic factors except gender did not have a significant association with the recall of BMI, while shared decision-making was associated with the recall of BMI. The findings were thus pointing at a situation that is modifiable or can be learnt (shared decision-making). The discussion that follows explains the relationships that were observed during the findings.

Regarding demographic factors, the majority of the patients, 33.7% (31 patients) belonged to the 25 to 35-year category in the study. The findings demonstrated the challenges that youth seeking medical assistance could be facing in terms of recalling medical instructions. However, the age distribution of the sample still relevantly showed that all age groups had difficulty recalling their BMI. Participants’ age was not protective against failing to recall BMI.

The study also measured the level of education for each participant. The findings differed from those of a study in New Zealand which found that mothers who had a university education were more able to recall instructions than those with a lower level of education. This further outlines the differences in communities that may hinder the recall process (Dawson et al., 2014). The current study thus revealed the limitations of the level of education to independently improve recall in the study population.

The third item that was studied was gender and its association with the recall of BMI. It was found to be associated with the recall of BMI. The findings did not match with other studies. Gender may not influence recall (Shiber et al., 2018). Shiber et al. (2018) related their findings to the improved communication by healthcare providers, overshadowing gender differences. Our current study’s observation associates gender with recall. This may underscore the likely poor shared decision-making practices among the health workers at the time of the study. The exact description of gender quality needs further study if it will be used to improve recall of BMI.

This study observed an association between recall of BMI and shared decision-making, as an indicator of varied communication with each patient despite the hospital being the same. Some of the models used in health care include the paternalistic model, informed decision-making model, and shared decision-making model. Poor adherence to treatment due to poor communication is common among the sick. Although these concepts have been known for a long time to improve recall and adherence, decades later they are still measured to be under-utilised such as our study reports. Ley gives us a model decades earlier among other authors that shows that recall follows understanding (Kessels, 2003; Ley, 1989).

Patients’ understanding is crucial since it is the pathway for recall resulting in adherence. A model of decision- making in communication would have to give the patient the most in terms of improving the understanding of therapies. Shared decision-making (SDM) was associated with a better ability to recall BMI (P < 0.001) (Table 3). This showed that regardless of the demographic factors, there was a need for clinician-patient interaction to be done through SDM. The discussions that the health care provider facilitates involving patient, aid recall and understanding of the health instructions. The more the interaction gives preference to the patient for understanding, the better it becomes. 77.2% of the 92 participants reported that no effort was made to help them understand BMI. Patients who had poor recall may not have been exposed to explanations that would aid their understanding and recall of BMI. The explanations may not have been tailored to the patient’s preferences. BMI needs to be explained to the patients. The information that is delivered to the patients about their BMI needs to be provided in a manner that the patients can understand. SDM has been in use for decades but has not implied its vast usage in medical practice in Uganda (Nuwagaba et al., 2021). This calls for more efforts towards its utilisation.

Conclusion

The prevalence of not recalling BMI after the outpatient consultation was high. Patient demographic factors were not associated with the recall of BMI except gender. SDM is likely to improve patients’ recall of BMI when used. The findings point out the role of shared decision-making in monitoring BMI and thus should be considered for continuous medical education at the facility. The country needs more studies at different healthcare facilities to assess the utilisation of shared decision-making.

Ethics and consent

The study protocol was approved by the Research Ethical Committee of Nexus International University on 23^rd March 2019 and Comboni Hospital’s management on 11^th September 2019 before any data collection took place. At the time the study was carried out, Banturaki Amon was a student of Nexus International University, which is why ethical approval was sought from this university. Data were collected at Comboni Hospital, so the hospital also had to give ethical approval before the study was carried out.

All participants were contacted voluntarily and only participants who provided written informed consent were enrolled for the study.

Author contribution

A.B. and D.K. prepared the manuscript and did data analysis and presentation. P.T., and K. A reviewed the manuscript and contributed to the discussion of the results.