Study selection
We identified a total of 12,552 studies. After de-duplication, a total of 7778 title abstract were screened, and 7721 citations were excluded due to wrong outcomes or wrong population, leaving 57 studies for full-text reading, of which 19 studies met the inclusion criteria. The process is illustrated in Figure 1.
Description of included studies
The included studies were published between 2001 and 2020. Four of the 19 studies were undertaken in Australia (21-24), three in the USA (25-27), two in Sweden (28, 29), Norway (30, 31), UK (32, 33), New Zealand (34, 35), and Belgium (36, 37), and one in Malaysia (38). Sixteen studies applied qualitative methods (22-24, 27-31, 33-38), one conducted a survey (26), and two studies applied mixed methods (25, 32). For data collection, semi-structured interviews, focus group interviews, telephone interviews, video recordings, and observations were used. Furthermore, the mixed-methods studies included questionnaires, interviews, and observations. The most frequent investigative methods were content (21, 28-30) or thematic (22, 24, 31, 33, 37) analysis, whereas one study applied a grounded theory approach (27). Of the included studies, there was an underrepresentation of studies including patients with COPD because no studies contained knowledge on the involvement of patients with COPD from the patients´ perspectives and only two from GPs´ perspectives (31, 35). The remaining 17 studies reported on the involvement of patients with type 2 diabetes from either the patients’ (21, 22, 25, 28, 30, 32, 37) or GPs’ (23, 29, 31, 35, 36) views or a combination thereof (24, 26, 27, 33, 34, 38). In Table 2, we present the included studies’ characteristics. The studies comprised 1,132 participants (843 patients and 289 GPs), with 10–322 patients with TD2 per study and 4–67 GPs. Most studies applied purposive or randomly selected sampling strategies.
Table 2. Study characteristics
Author, year of publication, location
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Aim
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Study design
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Inclusion and exclusion criteria
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Design/data Collection method
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Sampling strategy
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Participants´ characteristics (Gender, Age,)
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Data analysis techniqies
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Abdulhadi, 2007 (Sweden)
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To explore the perceptions of td2 patients regarding the medical encounters and quality of interactions with their primary health-care providers.
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Qualitative
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Patients with td2 (n=27)
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Focus group interview
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Purposive sampling
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13 men and 14 women from six primary healthcare centres in Muscat. Median age (range 26-70 years)
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Qualitative content analysis
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Dambha-Miller, 2018 (UK)
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To explore patients views on factors within patient-practitioner interactions that are of signifigance to them after diagnosis and over a 10 year experience of living witht he disase
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Mixed methods
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Patints with td2 (n=311) 1 year follow up. (n=110) 10 year follow up. (n=46) both times.
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Survey - Free text comment.
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?
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1 year follow up: 196 men/ 142 women. Mean age 60 years old. 10 year follow up. 53 men/48 women. mean age 72 years old.
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descriptive analysis. Cross-sectoionally analysis
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Ball, 2016 ( Australia)
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To examine the perpections of patients who have been recently diagnosed with TD2 regarding nutrition care provided by primary healthcare professionals
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Qualitative
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Patients with td2 (n=10)
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Semi-structured telephone interviews
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Purposive sampling
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3 male, 7 female, age range (27-74) years.
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Content analysis and meta-synthesis of findings over time
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Burridge, 2016 (Australia)
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Patients perceptions and experiences of TD2 selfcare and engamgement with Gp-led intergrated diabetes care
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Qualitative
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Patients with td2 (n=30)
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Interviews
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purposeive sampling
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Mean age (60,2) years old. 14 female and 16 male.
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Thematic analysys
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Oftedal, 2020 (Norway)
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How adults with TD2 perceive different attributes of support provided by healthcare practitioners and how various attributes of support can influence peoples motication to self-manage their diseases
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Qualitative
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patients with td2 (n=19)
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Focus group interviews
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purposive sample
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12 male, 7 female. Median age 54, 52, 42
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Content analysis
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Parchman, 2010 (USA)
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To examine a causal model linking participatory decision making to improved clinical outcomes that included patient actitivation and medication adherence.
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Mixed methods
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patients with type 2 diabetes (n=144)
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Observatations and Survery quistionarie.
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?
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Patients: mean age 57,7 years. 61% female and 39 % male.
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LGC curve
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Vermeire, 2003 (Belgium)
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To examine the health beliefs of people living with td2, the way they communicate about it, and the problem they encounter in adhering to therapeutic regimens
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Qualitative
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Type 2 diabetes patients. (n=46)
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Focus group interviews and observations
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Focus groups divided by gender.
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21 male, 25 female. Age range 40-80.
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Thematic analysis
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Abdulhadi, 2013, (Sweden)
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To explore the experiences of primary health-care providers of their encounters with patients with TD2, and their preferenes and suggestions for future improvement of diabetes care
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Qualitative
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General practitioner (n=19)
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Semi-structured interview
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purposive sampling
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8 female, 11 male, age range (29-55) years
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Qualitative content analysis
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Halliwell, 2016 (New Zealand)
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To identify strategies that general practitioners can use to facilitate discussions of prognosis with patients who have COPD
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Qualitative
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General practitioners (n=15)
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Telephone interviews
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Purposive sampling
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GP: 7 women and 8 men. Age range 31-60
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General inductive approach
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Laue, 2016 (Norway)
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To explore the decision-making of general practitioners concerning treatment with antibiotics and/or oral corticosteroids and hospitilization for COPD patients with Exerbations
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Qualitative
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General practitioners (n=53)
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Focus group interview
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purposive sampling
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?
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Thematic analysys
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Shortus, 2013 (Australia)
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To investigate provider perspectives on the role of patient involvement in chronic disease decision making
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Qualitative
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general practitioner (n=19)
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interviews
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purposive sampling
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?
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Grounded theory
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Wens, 2005 (Belgium)
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To examine explicitely the physicians expectations of their diabetes patient compliance/adhernce. Objectives: 1) elicit problem physicians encounter with td2 diabets patients adherende to treatment recommendations; 2) to search for soluations and 3) to discover escape mechanisms in case of frustration
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Qualitative
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general pracitioners (n=40)
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Focus group interviews and observations
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NO
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40 general practitioners. 26 , 14 men. Mean age 45,3. mean years in practice 18,4)
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content analysis
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Dao, 2019 (Australia)
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To explore the factors influencing self-management of TD2 in patients attending general practice in sputh west sydney from both a patient and provider perspective. A secondary aim was to assess how consistent the findigs were with the socio-ecological model
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Qualitative
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Patients with td2 (n=10 General practitioner (n=4)
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semi-structured interviews
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Purposive sampling
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Patient group: 6 female and 4 male. Age range 30-79. GP: 6 female, and 4 male, age range 30-79.
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Thematic analysis
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Dowell, 2018 (New Zealand)
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To observe in detal the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition to identify key ponts on the process where miscommunication might occour
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Qualitative
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Patients with TD2(n=32) General practitioner (n=?)
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video Recording
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purposively samling
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?
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ethnography and interaction analysis
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Grant, 2016 (USA)
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To examine how patients with TD2 and their primary care physicians identify and discuss visits prior to and during visits.
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Qualitative
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Patients with TD2 (n=29) General practitioner (n=67)
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Qualitative interviews and focus group
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purposeive sampling
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Patients: Age range 35-80) 14 kvinder and 15 men. Primary care providers (61% women.
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Modified grounded theory aapproach with a inductive approach
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Heislter, 2003 (USA)
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To assess the extent to which patients wit TD2 agree with their primary care provider on diabets treatment goals and strategies, the factors that predict agreement nd whether greater agreement is associated with better patient self-manamgenet of diabetes
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Survey
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Patients with TD2 (n=123) General practitioner (n=50)
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Survey
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randomly sample
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patient: mean age 65, 81% male. Provider mean age 40, 56% men
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descriptive statistics
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Pooley, 2001 (UK)
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To explore people with td2 and healthcare professionals who deliever their diabetes care. To explore the issues that they perceieve as central to effective management of diabetes, primarily within a primary care setting
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Qualitative
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Patients with type 2 diabetes (n=47) General practitioners (n=7)
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Focus group interviews
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Randomly selected.
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?
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Thematic analysis
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Syed, 2017 (Malysia)
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To investigate whether the use of apatient decision aid for insulin initiation fulfils its purpose of facilitating patient-centered decision-making through identifying how doctors and patients interact when using the PDA during Primary care consultations
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Qualitative
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Type 2 diabetes patients (n=15)general practitioners (n=15)
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Audio recording
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purposive sampling
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?
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?
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Narrative synthesis
Patients’ perspectives
Patients reported the importance of GPs providing them with sufficient time for the consultations and explaining or discussing things with them. It was essential that the GPs not were too rushed and preoccupied with their own agendas under time-pressure constraints (21, 22, 27, 32, 33). The lack of time to deal effectively with patients’ concerns and the beliefs among the patients were repeatedly mentioned (33). Furthermore, the patients stated that their tendency to express their priorities nearer to the end of the visit, which left little time to fully address their concerns, was a consequence of time constraints (27). The patients expressed that they wished for all the time they required and that their GPs were never in a rush and had time to explain and discuss treatment decisions (22). Similarly, the patients stated that an unfriendly environment with poor attention and lack of eye contact with the GP prevented them from asking questions and expressing their concerns during consultations and made the encounters more doctor centered; patients felt overwhelmed by the inability to participate in the medical dialogue or express concerns regarding their treatment. (28). The relational continuity of care was also important to the patients, and they preferred to see the same GP at each consultation. The patients expressed that they would benefit from the continuity in terms of increased familiarity with their circumstances (22, 28, 32, 33). In addition, the patients considered it problematic if they did not see the same GP every time because seeing the same GP would make it easier for them to discuss their problems and be more involved in treatment decisions (32). The patients experienced that GPs differ in their behavior and methods of providing care and information, and the patients preferred to build an ongoing relationship with their GP to increase their ability to be more active in the treatment decision-making (28). This ongoing relationship was considered a partnership (22, 27, 30, 33, 37) that was defined as when the competence of the GPs and the patients’ knowledge complemented each other. The patients wanted to co-operate with their GP but found it highly difficult if their needs were not listened to (30). Furthermore, patients reported that their GPs paid too little attention to their health beliefs and to the opinions and concepts they held on medicine in general, their illness, and on medicine-taking (37). Patients identified key factors that were associated with more effective discussion of their visit’s priorities, including GPs’ willingness to be flexible in the flow of discussion topics, and the extent to which their GPs listened to their concerns (27). It was evident that an active patient/provider alliance was important for engaging the patients in the work of disease management but likely also a critical factor in sustaining the long-term collective work that diabetes management requires (22). Low literacy was mentioned as a barrier for being involved in treatment decisions because the patients believed that they had to accept what has been demonstrated to them. Hence, they felt unable to be more active during consultations (28). However, identifying visits’ priorities in advance of a visit enhanced a proactive and collaborative approach, made it possible for the patients to bring what they wanted to discuss, and did not prevent the GPs from talking about what they wanted to express. Thus, a personalized approach offered by GPs was valued (22), and the patients expressed a wish that the GPs should be better at simply listening in a more holistic approach (30).
General practitioners’ perspectives
High workload was mentioned by GPs as a major problem affecting their interactions with the patients (29) because building good relationships with patients takes time (24). GPs expressed the negative impact of time constraints on the ideal goal of fully electing patient priorities; being in a rush, they often had their own agenda overriding the patient’s agendas (27). A good relationship with patients was considered important in relation to involving them in treatment decisions (24, 29, 31, 35, 36). A long-standing relationship with good rapport facilitates discussions about prognoses, improves rapport, increases the number of topics GP and patients can discuss in more honest detail, and enhances GPs’ likelihood of getting patients to ask more questions (24, 35). The GPs’ knowledge about their patients appeared to be important in assessing whether they could rely on the patient’s own judgment about the necessity for treatment and hospitalization. They believed that the patients were rather good at assessing their treatment and hospitalization needs themselves (31). Some GPs suggested that there should be a personal interest of healthcare providers in the care and to show interest to the patients. Furthermore, they proposed avoiding giving instructions to the patients but, rather, have good communications and respect their concerns; such an approach would be a more useful way to correct the patients’ understanding of their disease and gain their cooperation (29). The GPs indicated that they favored active involvement of the patient’s experiential knowledge due to having lived with the disease (31, 34) not necessarily reflecting a biomedical need but also the requirement for relieving anxiety and meeting challenges in the patients’ social lives. Consequently, there could be discrepancies between the GPs’ and patients’ judgments, which the GPs had to balance. According to the GPs, a lack of patients’ consent to treatment or hospital referral seemed particularly challenging because it could increase their concerns (31).
The GPs reported that treatment in primary care was more effective when patients came prepared, whereas a lack of preparation by the patient tended to create barriers to clinical care due to inefficient time use. GPs noted that a tool to empower patients to help them formulate their top priorities at consultations would be helpful, and the GPs liked the idea of pre-visit preparation (27). The GPs acknowledged that there should be potential for flexibility in the application of guidelines when managing patients’ diseases and that involving patients in decision-making was itself an important consideration in attempting to deliver high-quality care. However, they believed that it was more caring to insist upon treating a patient’s disease than to respect any patient preference and that they should, therefore, endeavor to persuade patients to accept their advice. The GPs saw their main responsibility as doing whatever was necessary to minimize the possibility of achieving less-than-ideal outcomes. GPs often experienced a conflict between the two professional responsibilities of achieving ideal health outcomes for their patients and respecting their patients’ rights to make decisions where compromise is often necessary (31).