Multilevel barriers and facilitators of shared decision-making in chronic illness management: a social ecological model approach

Abstract

Background: Shared decision-making is central to patient-centered chronic illness care, yet patients’ participation often remains constrained in physician-driven systems. Therefore, this study applied the Social Ecological Model to explore how multilevel barriers and facilitators influence patient–doctor communication and shared decision-making among patients with chronic illnesses. Methods: We conducted an interpretive qualitative study in South Korea using semi-structured, in-depth interviews guided by the Social Ecological Model. Sixteen adults diagnosed with hypertension, diabetes mellitus, chronic kidney disease, or heart disease for more than 12 months were purposively sampled. Interviews (75–115 min) were transcribed verbatim and analyzed using qualitative content analysis informed by grounded theory approaches. Codes were inductively developed through open coding and organized across multiple ecological levels (individual, interpersonal, institutional, societal). Analytical rigor was enhanced through independent coding, iterative discussions, and triangulation. Results: Twelve themes were identified across multiple levels. At the individual level, patients’ illness-specific perceptions, health literacy, and psychological distress strongly influenced engagement. At the interpersonal level, physician authority, limited and selective information provision, and patients’ own communication styles shaped relational dynamics, which together determined trust and willingness to participate. The institutional level was marked by hospital capacity and continuity challenges, outdated or inaccessible educational resources, and rigid scheduling and coordination processes that constrained dialogue. Cultural expectations of deference to physicians, entrenched hierarchical medical culture, and financial uncertainty (including lack of transparent cost information) further limited autonomy at the societal level. Across levels, empathetic provider communication and supportive information environments functioned as key facilitators. Conclusions: Shared decision-making in chronic illness care is not solely a patient–provider exchange but the product of interacting personal, relational, organizational, and societal forces. Effective promotion of shared decision-making requires multilevel interventions: strengthening patients’ knowledge and self-efficacy, fostering empathetic two-way communication, ensuring institutional continuity and educational support, and addressing structural and cultural barriers. By aligning strategies across these levels, health systems can enable patients to participate as informed and autonomous partners in decision-making, ultimately improving care quality and outcomes. Clinical trial registration: Not applicable.