Call for shared decision making in Iran ; Future directions

Shared decision making (SDM) is a systematic procedure by which patients and health care professionals collaborate to make informed value-congruent decisions. During the procedure, patients are empowered to make decisions based on accurate evidence-based information and what matters most to them with collaboration of health providers. In spite of its importance and proven benefits in different contexts and countries, its implementation in Iranian health system is absent. Here, I will give a brief introduction on SDM and its tools and benefits, along with some directions for its implementation in Iran.

Shared decision making (SDM) is a systematic procedure by which patients and health care professionals collaborate to make informed value-congruent decisions.During the procedure, patients are empowered to make decisions based on accurate evidence-based information and what matters most to them with collaboration of health providers.In spite of its importance and proven benefits in different contexts and countries, its implementation in Iranian health system is absent.Here, I will give a brief introduction on SDM and its tools and benefits, along with some directions for its implementation in Iran.
SDM was used for the first time in 1972 by Veatch as "sharing of decision making". 1 SDM is a systematic process of deciding about diagnosis, treatment or follow-up along with patient when more than one medically reasonable option is available, and when there is no best option.In order to specify what falls or does not fall within the boundaries of SDM, Charles et al. identified and introduced some of its minimum and necessary key characteristics as following: "(i) that at least two participants (i.e.physician and patient be involved); (ii) that both parties share information; (iii) that both parties take steps to build a consensus about the preferred treatment; and (iv) that an agreement is reached on the treatment to implement". 2 Afterwards, other authors complimented it with further characteristics and explanations.Paternalistic model of decision making which we see mostly in relationship between patients and physicians in Iran, is a one-way information exchange which medical information is passed from the health care provider to the patient, and they decide on treatment options alone or with limited or no input from the patient.In contrast, in informed patient choice model patient alone decide on options, and patient alone makes the final treatment choice.SDM is the middle point of paternalist and informed patient choice.It is a two-way information exchange and deliberation process whereby a decision is made by the patient and health care provider altogether (Figure 1).Patient decision aids are SDM tools that help patients to be involved in decision making.They are evidence-based tools designed to help patients make specific and deliberated choices among health-care options.Patient decision aids could be in different forms such as leaflets, videos, webbased tools, or grids such as the Option grid. 4,5They are designed to complement, rather than replace, counselling from a health practitioner. 5They help to identify the decision that needs to be made, provide information about the options and outcomes based on the best evidence, and clarify personal values. 6n order to help individuals and organizations to use/develop decision aids, a group of researchers, practitioners and stakeholders from around the world established an internationally-approved set of criteria called International Patient Decision Aid Standards (IPDAS) for determining the quality of patient decision aids.7 In spite of the proven benefits of decision aids, they are rarely used in Iran since some physicians believe that the use of decision aids could lead to patients perceiving the physician less reliable (or decisive), or to less patient satisfaction.8 While, studies have shown a positive attitude toward the use of decision aids among Iranian patients.[8][9][10] SDM tools have been demonstrated to increase patients' knowledge, reduce decisional conflict, and reduce the proportion of patients who are passive in the decision making process or remain undecided.11 The implication is that for Iran, realistically, SDM tools need to be developed, tested, and implemented that are consistent with the culture of Iranian patients and clinicians.However, different barriers have been identified for implementation of SDM in Iran 12 which should be addressed.In the following, we will discuss more in details what the future directions are in order to implement SDM in Iran.

Increasing knowledge and awareness among
patients: lack of knowledge and awareness among patients, 13 including lack of awareness about their rights, is a barrier in implementing SDM in Iran. 12Therefore development of strategies to increase general public' awareness and knowledge seems necessary.Social media for example, Telegram, a popular mobile application designed for texting and transferring videos, has great potential for changing citizens' attitudes and increasing their awareness and knowledge about SDM.Besides, not all of the Iranian patients are educated to be able to well contribute in the SDM procedure and decide about their treatment options.Using eHealth technologies (such as telephone, films, and videos) in support of SDM may be an effective way to introduce SDM to patients with lower levels of literacy. 12vercoming cultural barriers: In Iran, there are cultural barriers on the part of both patients and providers to implement SDM.For example, some Iranian physicians think that asking for the patient's opinion about a decision will be interpreted as an indication of the physician's lack of knowledge and experience, or the common culture of hiding bad news from patients which usually insisted by patients family is another cultural barrier.Required is educating patients, their families and health care providers of the benefits of SDM.For instance, educating public about benefits of patients themselves knowing about the "news" (good or bad) as well as about the possible options may make a difference.Social media could have a great impact with this regard.
Health care system and resource management: Such as other countries, lack of time which may be due to high numbers of referrals and inappropriate distribution of human resources 13 seems one of the main barriers among Iranian health care professionals in implementing SDM in regular basis.Therefore, required is further support from government in increasing and better management of resources in hospitals and other health care organizations.

Development of training programs:
Greater patients' involvement depends on changing health professionals' skills and attitudes. 14onsidering reports, Iranian healthcare providers seem unfamiliar with the principles of SDM.Very little studies have been done with this regard, and very little SDM tools have been developed in the country.Therefore, in order to move SDM into clinical practice, pre-and post-licensure healthcare professionals need to be trained in SDM.
Government support: Lastly required are new policies, both in government and in the medical education system, that promote SDM among health professionals and public.
SDM activities need to be given much higher priority at all levels of policy, education, and within further professional development strategies.
Besides, for successful implementation of SDM in the country, it is important to strengthening collaborations among patients, health professionals, academics, and policy makers nation-wide.

Figure 1 .
Figure 1.Patient-Physician relationship types SDM: Shared decision making