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

Background Shared decision-making (SDM) is central to patient-centered chronic illness care, yet patients’ participation often remains constrained in physician-driven systems. This study applied the Social Ecological Model (SEM) to explore multilevel barriers and facilitators shaping SDM among patients with chronic illnesses. Methods We conducted semi-structured in-depth interviews with 16 adults diagnosed with hypertension, diabetes mellitus, chronic kidney disease, or heart disease for more than 12 months. Interviews (60–90 minutes) were transcribed verbatim and analyzed using grounded theory methods. Codes were inductively developed and organized by SEM levels (individual, interpersonal, institutional, societal). Rigorous analytic techniques—including independent coding, iterative discussions, and triangulation—ensured reliability. Results Twelve themes were identified across the SEM levels. At the individual level, patients’ illness-specific perceptions, health literacy, and psychological distress strongly influenced engagement. At the interpersonal level, relational dynamics were shaped by physician authority, limited and selective information provision, and patients’ own communication styles, 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 The institutional level was marked by hospital capacity and continuity challenges, outdated or inaccessible educational resources, and rigid scheduling and coordination processes that constrained dialogue. At the societal level, cultural expectations of deference to physicians, entrenched hierarchical medical culture, and financial uncertainty—including lack of transparent cost information—further limited autonomy. Across levels, empathetic provider communication and supportive information environments functioned as key facilitators. Conclusions SDM 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 SDM 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.