title: Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis.
abstract: BACKGROUND
  Increasing patient engagement in healthcare has become a health policy priority. However, there has been concern that promoting supported shared decision-making could increase health inequalities.
  
  
  OBJECTIVE
  To evaluate the impact of SDM interventions on disadvantaged groups and health inequalities.
  
  
  METHODS
  Systematic review and meta-analysis of randomised controlled trials and observational studies.
  
  
  METHODS
  CINAHL, the Cochrane Register of Controlled Trials, the Cochrane Database of Systematic Reviews, EMBASE, HMIC, MEDLINE, the NHS Economic Evaluation Database, Open SIGLE, PsycINFO and Web of Knowledge were searched from inception until June 2012.
  
  
  METHODS
  We included all studies, without language restriction, that met the following two criteria: (1) assess the effect of shared decision-making interventions on disadvantaged groups and/or health inequalities, (2) include at least 50% of people from disadvantaged groups, except if a separate analysis was conducted for this group.
  
  
  RESULTS
  We included 19 studies and pooled 10 in a meta-analysis. The meta-analyses showed a moderate positive effect of shared decision-making interventions on disadvantaged patients. The narrative synthesis suggested that, overall, SDM interventions increased knowledge, informed choice, participation in decision-making, decision self-efficacy, preference for collaborative decision making and reduced decisional conflict among disadvantaged patients. Further, 7 out of 19 studies compared the intervention's effect between high and low literacy groups. Overall, SDM interventions seemed to benefit disadvantaged groups (e.g. lower literacy) more than those with higher literacy, education and socioeconomic status. Interventions that were tailored to disadvantaged groups' needs appeared most effective.
  
  
  CONCLUSIONS
  Results indicate that shared decision-making interventions significantly improve outcomes for disadvantaged patients. According to the narrative synthesis, SDM interventions may be more beneficial to disadvantaged groups than higher literacy/socioeconomic status patients. However, given the small sample sizes and variety in the intervention types, study design and quality, those findings should be interpreted with caution.
authors.affiliation: Centre for Lifespan and Chronic Illness Research, University of Hertfordshire, Hatfield, United Kingdom.
authors.forename: Marie-Anne
authors.initials: MA
authors.lastname: Durand
authors.affiliation: Centre for Lifespan and Chronic Illness Research, University of Hertfordshire, Hatfield, United Kingdom.
authors.forename: Lewis
authors.initials: L
authors.lastname: Carpenter
authors.affiliation: Centre for Lifespan and Chronic Illness Research, University of Hertfordshire, Hatfield, United Kingdom.
authors.forename: Hayley
authors.initials: H
authors.lastname: Dolan
authors.affiliation: School of Nursing, Pontificia Universidad Catolica de Chile, Santiago, Chile.
authors.forename: Paulina
authors.initials: P
authors.lastname: Bravo
authors.affiliation: Support Unit for Research Evidence, Cardiff University, Cardiff, United Kingdom.
authors.forename: Mala
authors.initials: M
authors.lastname: Mann
authors.affiliation: Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, United Kingdom.
authors.forename: Frances
authors.initials: F
authors.lastname: Bunn
authors.affiliation: The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, United States of America.
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
mesh_terms: D003657:Decision Making; D003695:Delivery of Health Care / Q000379:methods* / Q000706:statistics & numerical data; D019983:Guideline Adherence; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D012959:Socioeconomic Factors
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