Socio‐economic differences in patient participation ...

Health Expectations. 2019;00:1–12. | 1wileyonlinelibrary.com/journal/hex

Received:27February2019 | Revised:30July2019 | Accepted:1August2019DOI: 10.1111/hex.12956

O R I G I N A L R E S E A R C H P A P E R

Socio‐economic differences in patient participation behaviours in doctor–patient interactions—A systematic mapping review of the literature

Sarah Allen BSc, (Hons), MSc, MBPsS1 | Simon N. Rogers FDS, RCS, FRCS, MD2,3 | Rebecca V. Harris BDS, PhD1

ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginalworkisproperlycited.©2019TheAuthorsHealth ExpectationspublishedbyJohnWiley&SonsLtd

1DepartmentofHealthServicesResearch,InstituteofPopulationHealthSciences,UniversityofLiverpool,Liverpool,UK2Evidence‐BasedPracticeResearchCentre(EPRC),FacultyofHealthandSocialCare,EdgeHillUniversity,Ormskirk,UK3ConsultantRegionalMaxillofacialUnit,UniversityHospitalAintree,Liverpool,UK

CorrespondenceSarahAllen,BSc(Hons.)MScMBPs,DepartmentofHealthServicesResearch,InstituteofPsychologyHealthandSociety,UniversityofLiverpool,Room111,1stfloor,BlockB,WaterhouseBuilding,1‐5BrownlowStreet,LiverpoolL693GL,UK.Email:[email protected]

Funding informationThisworkwassupportedbyTheNationalInstituteforHealthResearchCollaborationforLeadershipinAppliedHealthResearchandCareNorthWestCoast(NIHRCLAHRCNWC).SarahAllenisaPhDstudentattheNIHRCLAHRCNWC.Theviewsexpressedarethoseoftheauthor(s)andnotnecessarilythoseoftheNHS,theNIHRortheDepartmentofHealth.

AbstractBackground: Thedegreetowhichpatientsparticipateintheircarecanhaveaposi‐tiveimpactonhealthoutcomes.Thisreviewaimedtomapthecurrentliteratureonpatient participation behaviours in interactionswith physicians and the extent towhichdifferences in thesebehaviours canbeexplainedby socio‐economic status(SES).Search strategy: Fourelectronicdatabasesweresearchedfrom1980onwardsusingkeywordsrelatedtosocio‐economicstatusandpatientparticipationbehaviours.Study selection: Titles,abstractsandfulltextswerescreenedbytworeviewers,withthesecondreviewerscreening20%ofallentries.Data extraction: Dataonyearofpublication, country, patientpopulation, setting,patientparticipationbehaviourstudied,andSESmeasureusedwereextracted.Main results: Forty‐ninestudieswereincludedinthereview.Moststudieswerecon‐ducted intheUnitedStates,andthemostcommonlystudiedpatientparticipationbehaviourwas involvement in decisionmaking.Most studiesmeasuredSESusingeducationasanindicator,withveryfewstudiesusingoccupationasameasure.Manystudies did not report onparticipants’medical conditionor study setting. Patientparticipation in theirhealth‐careappointment increasedwith increasingSES in24studies,althoughin27studiesnosignificantassociationwasfound.Discussion and conclusions: Current literaturewasfoundtobemainlyUS‐centric.Manystudiesdidnotspecifyparticipants’medicalconditionorinwhatsettingthestudywasundertaken.Morestudiesareneededonlesscommonlystudiedpatientparticipation behaviours. Itwould be helpful for further studies to also include awiderrangeofSESindicators.

K E Y W O R D S

communication,Doctor–patientrelationship,inequalities,patientparticipation,socio‐economicstatus

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2 | ALLEN Et AL.

1 | INTRODUC TION

Patient‐centredcarehasbeenassociatedwithbeneficialoutcomessuchasagreateradherencetotreatment,satisfactionandimprovedqualityof life.1‐4The InstituteofMedicinedefinespatient‐centredcareasprovidingcarethat is respectfulofandresponsiveto indi‐vidualpatientpreferences,needsandvalues,ensuringthatpatientvaluesguideallclinicaldecisions.5Thus,theextenttowhichpatientsparticipateindiscussionsduringtheirhospitalorclinicvisitsisseenasanimportantbarometerofpatient‐centredcare.Althoughthereisnouniversallyapplieddefinitiononwhattypeofbehavioursconsti‐tutespatientparticipationinclinicalvisits,6moststudiesfocusingonpatientparticipationbehavioursinvolvearangeofbehaviourssuchasquestionasking,raisingconcerns,andexpressingopinions,pref‐erencesandemotions.7

Often‘patientparticipationbehaviours’aredescribedasagen‐eralgroupofbehaviours thatcharacterizedoctor–patientcommu‐nication,ratherthandescribingindetailthedifferentwayspatientparticipationcanbemeasuredorothercomponentpartsofdoctor–patient communication behaviour which are classified in a differ‐entway.Forexample,animportantprevioussystematicreviewbyVerlindeetal8focusedmoregloballyondoctor–patientcommunica‐tionbehaviours,withtheelectronicsearchtermsbasedon‘doctor–patientcommunication’and‘physician–patientrelations’.Thereviewreportedevidenceshowingthatasocialgradientindoctor–patientcommunicationexistsandclassifiedthisaccordingtothefollowingclassification:verbalbehaviourincludinginstrumentalandaffectivebehaviour, non‐verbal behaviour and patient‐centred behaviour.Although the reviewfound thatpatientswith lowsocio‐economicstatus(SES)tendedtoparticipatelessactivelyintheircare,thestudyanditssearchstrategywereinsufficientlysensitivetoallowidenti‐ficationastowhethercertainpatientparticipationbehavioursweremoreresearchedormoreimportantthanothers,sincethefocusofthestudywasdoctor–patientcommunicationingeneral.

The Verlinde et al8 review also limited identification of litera‐tureexploringthesocialgradientindoctor–patientcommunicationand social gradient, to studies reporting the ‘social class relatedconceptsof’educational level, incomeoroccupation.Confusingly,threeofthestudiesincludedinthisreviewmeasuredSESusing‘so‐cialclass’,althoughtheauthorsdidnotspecifyexactlyhowthiswasdefined.However, thereareseveralother indicatorsofSESwhichmayalsobeassociatedwithpatientparticipationbehaviours suchas thepatients’health insurancestatusor receiptofbenefits,andalsoarea‐levelmeasuresofdeprivationrelatedtothepatients’homeaddress(IndicesofMultipleDeprivation),whichmaynothavebeencapturedpreviously,andmaystillberelevant.9Bearinginmindthepotentialimportanceofthisareaanditslikelyrelationshiptobenefi‐cialhealthoutcomes,weundertookasystematicmappingreviewtoidentifywhatresearchhadbeendonewhichspecificallyexaminedhowpatientparticipationbehavioursindoctor–patientinteractionsare related todifferences inawide rangeofpossiblemeasuresofsocio‐economicstatus.

Wechosetoconductasystematicmappingreview,assuchre‐viewsareusefulfordetectingpatternsinalargebodyofliteratureinordertoidentifyareasforfutureresearch.Assuch,detailsoftheincludedstudiesaresummarizedwithoutqualityassessmentorpre‐sentingstatisticalanalyses.10,11

2 | PURPOSE

Our research question was as follows: How and why does ten‐dencytoanddesireforpatientparticipationbehavioursinhealth‐careconsultationswithphysiciansvaryaccordingtoSESandwhatmeasuresofSEShavebeenexplored?Forthepurposeofthisre‐view,wedefinedpatientparticipationbehavioursasconsistingofquestion asking, raising concerns, involvement in decision mak‐ing,rapportbuilding,andexpressionofopinions,preferencesandemotions.

3 | DATA SOURCES

Anelectronic searchwasundertakenof the followingdatabases:Medline,CINAHL,PsychINFOandWebofScience.Literaturewassearchedfrom1980to2018;sincepriorto1980,therewasmuchlesselectronic indexing.Apilotsearchwasconductedto identifypotentiallyeligiblepapers,assesstheamountofrelevantliteraturein the field and identify suitable search terms. At this stage,wefound that including screening appointments and emergency ad‐missionsmadethescopeofthereviewfartoobroadandunman‐ageable;therefore,wedecidedtointroducelimitsintheelectronicsearchtermsregardingongoingdoctor–patient relationships.Theelectronic search contained free text and subject headings in‐cluding patient‐centred care, question asking, raising concerns,involvement in decision making, building rapport, expression ofpreferences,emotionsoropinions,educationalstatus,income,oc‐cupational status, employment, social class and socio‐economicfactors.ThiswasmodifiedasnecessaryforeachdatabaseandcanbefoundinAppendixS1.

Inclusioncriteriaforthereviewwereasfollows:

• Studies involving patient perspectives on actual and desiredquestion asking, raising concerns, involvement in decisionmak‐ing,rapportbuilding,orexpressionofopinions,preferencesandemotions.

• SESgradientmeasuredintheformofeducation,income,occupa‐tionor‘othermeasures’whichincludedpatients’healthinsurancestatus, incomeindicatorsofstatebenefitsandarea‐basedmea‐suresrelatingtothepatients’homeaddress.

• Publishedin1980onwards.• Studiesinvolvingadultpatients.• Onlystudieswhichfocusedondoctor–patientinteractions.• WritteninEnglishlanguageonly.

| 3ALLEN Et AL.

Studieswereexcludedif:

• Theyincludedonlyhealth‐careprofessionalperspectivesonpa‐tientparticipation.

• Patientsunder18orparentsofpatientsonlywererecruited.• Adult patient perspectives of childhood experiences werecollected.

• ThestudywasconductedinacountryontheOECDsDevelopmentAssistanceCommitteelistofOfficialDevelopmentAssistancere‐cipients.12Thiswas inorder to limit literature tohigher incomecountrieswherethehealth‐caresystemswerelikelytobesimilar.

• Theappointmentinvolvedemergencyattendancesorscreening.• The interactionswerewithhealth‐careprofessionalswhowerenotmedicaldoctors.

• Theywereopinionarticles.• Theyweresystematicreviews.

4 | STUDY SELEC TION

Onereviewer(SA)screenedalltitlesandabstractsidentifiedthroughelectronicsearches,and20%oftheentriesweredoublescreenedbyasecondreviewer(DH).Allfull‐textarticleswerethenscreenedbyonereviewer(SA),and20%ofthefulltextsweredoublescreenedbyasecondreviewer (DH). If the tworeviewersdisagreedonanypapers,thiswasresolvedbydiscussionwithtwootherindependentreviewers(RHandSR).

5 | DATA E X TR AC TION

Data extraction was independently conducted by both review‐ers and the following informationwasobtained: year published,country the studywas conducted in, studymethod and design,

F I G U R E 1 PRISMAdiagramRecords identified through

database searching

(n = 4718)

Records screened

(n = 4350)

Duplicates removed

(n=368)

Records excluded

(n=3989)

Full text articles assessed for eligibility

(n = 361)

Full text articles excluded

(n = 312)

Conducted in country on OECD DAC ODA list (n = 2)

Focus on doctor behaviours (n = 1)

Not in English (n = 13)

No patient participation behaviours measured (n = 151)

Patient participation behaviours not compared by SES (n = 75)

No SES data collected (n = 37)

Study protocol (n = 1)

Review (n = 5)

Unable to obtain paper (n = 18)

Not medical doctors (n = 3)

About childhood/adolescent experiences (n = 1)

Screening appointment (n = 5)

Studies included in systematic mapping review

(n = 49)

Iden

tific

atio

nSc

reen

ing

Elig

ibili

tyIn

clud

ed

4 | ALLEN Et AL.

TAB

LE 1

Characteristicsofincludedstudiesandreporteddirectionofassociationbetweensocio‐economicstatusandpatientparticipationbehaviours

Aut

hor

Coun

try

St

udy

popu

latio

nM

etho

dsN

umbe

r of

part

icip

ants

Soci

o‐ec

onom

ic s

ta‐

tus (

SES)

mea

sure

Patie

nt p

artic

ipat

ion

beha

v‐io

urs m

easu

red

Dire

ctio

n of

ass

ocia

tion

1.Aasenetal

(2012)34

Norway

End‐stagerenaldisease

patients

Qualitative

interviews

11Education

Involvementindecisionmaking,

questionasking,andexpres‐

sionofopinions

Nostatisticalanalyses

performed

2.Ackermansetal

(2018)35

The Netherlands

Patientswithosteoarthritis

ofthehiporknee

Questionnaire

142

Educationand

employment


andexpressionofopinions,

preferencesandemotions

Noassociations

3.Adamsetal

(2001)

26Australia

Asthmapatients

Questionnaire

128

Income,education,

employment,receipt

ofbenefits,and

housingsituation

Involvementindecisionmaking

Positiveassociationwithedu

‐cationonly

4.AlHaqwietal

(2015)36

SaudiArabia

Adultfamilypractice

patients

Questionnaire

236

Education


Positiveassociation

5.Aroetal

(2012)37

Estonia

AdultICUpatients

Questionnaire

166

Education


Negativeassociation

6.Aroraetal

(2000)38

USA

Hypertension,diabetes,

congestiveheartfailure,

myocardialinfarctionand

clinicaldepressionpatients

Questionnaire

2197

Education,incomeand

employment


Positiveassociationwithedu

‐cationonly

7.Attanasioetal

(2015)39

USA

Womenaged18‐45who

gavebirthinUShospitals

Questionnaire

2400

Educationand

insurance

Questionasking

Positiveassociationfor

education

Negativeassociationforinsur

‐ancetype

8.Beauchampet

al(2015)40

Australia

Patientsattendingchronic

diseaseservices

Questionnaire

813

Insuranceand

education


Noassociations

9.Belletal

(2001)

15USA

Patientsreportinganewor

worseningproblem,orwor

‐riesaboutseriousillness

Questionnaire

909

Education,employ

‐ment,incomeand

insurance

Raisingconcerns

Noassociationforeducation

andincomeonly,otherSES

variablesnotanalysed

10.Bozecetal

(2016)23

Fran

ce Headandnecksquamous

cellcarcinomapatients

Questionnaire

200

Educationand

occupation

Expressionofpreferences

Noassociations

11.Chungetal

(2012)41

USA

Patientsadmittedtoa

generalinternalmedicine

service

Questionnaire

8308

Education


andexpressionofpreferences

Positiveassociationforin‐

volvementindecisionmaking

only

12.Cohenetal

(2013)

22USA

Patientsadmittedtohospital

forhematopoieticstemcell

transplantation

Longitudinal

qualitative

interviews

60Educationand

occupation



performed

13.Dangetal

(2017)

21USA

Newpatientsattendinga

HIVclinic

Longitudinal

qualitative

interviews

21Occupation

Questionaskingandinvolve‐

mentindecisionmaking


performed

(Continues)

| 5ALLEN Et AL.

Aut

hor

Coun

try

St

udy

popu

latio

nM

etho

dsN

umbe

r of

part

icip

ants

Soci

o‐ec

onom

ic s

ta‐

tus (

SES)

mea

sure

Patie

nt p

artic

ipat

ion

beha

v‐io

urs m

easu

red

Dire

ctio

n of

ass

ocia

tion

14.DelasCuevas

etal(2014)42

Spain

Outpatientpsychiatric

patients

Questionnaire

846

Education


Noassociations

15.Deenetal

(2011)13

USA

Communityhealthcentre

patients

Intervention‐

pilotstudy

252

Education


Noassociations

16.Durandetal

(2016)43

UK

Chronickidneydisease

patients

Questionnaire

492

Education


Noassociations

17.Ellingtonetal

(2006)44

USA

Generalpopulation(some

hadcancer)

Focusgroups

55Educationand

employment




performed

18.Friisetal

(2016)16

Denmark

Patientswithdiabetes,car

‐diovasculardisease,COPD,

musculoskeletaldisorders,

cancer,ormentaldisorders

Questionnaire

29,473

Education

Questionasking,raising

concerns,andexpressionof

opinions,preferencesand

emotions

Positiveassociations

19.Garfieldetal

(2007)

27UK

Patientswithtype2diabe

‐tesorrheumatoidarthritis

Questionnaire

516

Socialclass(composite

measure)



20.Gleasonetal

(2016)28

USA

Olderadultswithhyperten‐

sion,arthritis,cholesterol,

diabetes,cancer,heart

diseaseordepression

Questionnaire

277

Education,financial

strain,andfinances

attheendofthe

month


Nosignificantassociations

21.Henselmans

etal(2015)45

The Netherlands

Patientsdiagnosedwitha

somaticchronicdisease

Questionnaire

1314

Education


questionasking,andexpres‐

sionofopinions,preferences

andemotions


22.Jacobs‐

Lawsonetal

(2009)46

USA

Lungcancerpatients

Questionnaire

100

Incomeandeducation



Nosignificantassociationsfor

educationonly,incomenot

enteredintoanalysis

23.Janzetal

(2004)

17USA

Breastcancerpatients

Questionnaire

101

Education,employ

‐mentandincome

Involvementindecisionmak

‐ing,questionasking,raising

concerns,andexpressionof


emotions

Positiveassociationbetween

educationandinvolvementin

decisionmakingonly


forincomeandemploy

‐ment,andotherparticipation

behavioursnotenteredinto

analysis

24.Jonsdottiret

al(2016)47

Icel

and

Patientswhoreportedand

consultedforchronicpain

Questionnaire

754

Educationandincome



TAB

LE 1

(Continued)

(Continues)

6 | ALLEN Et AL.

Aut

hor

Coun

try

St

udy

popu

latio

nM

etho

dsN

umbe

r of

part

icip

ants

Soci

o‐ec

onom

ic s

ta‐

tus (

SES)

mea

sure

Patie

nt p

artic

ipat

ion

beha

v‐io

urs m

easu

red

Dire

ctio

n of

ass

ocia

tion

25.Luetal

(2011)14

USA

Underservedwomennewly

diagnosedwithbreast

canc

er

Intervention‐

pilotstudy

231

Education


questionasking,andraising

concerns

Positiveassociationforques‐

tionaskingonly

Nosignificantassociationsfor

othervariables

26.Lubetkinetal

(2010)48

USA

Patientsattendingurban

healthcentres

Questionnaire

454

Education


Positiveassociation

27.Magnezietal

(2015)

19Israel

Generalpopulation

Questionnaire

508

Educationandincome


rapportbuilding,andexpres‐

sionofpreferences

Negativeassociationsforrap

‐portbuildingandexpression

ofpreferencesonly

Involvementindecisionmak

‐ingnotenteredintoanalysis

28.Malyetal

(2008)18

USA

Breastcancerpatients

Questionnaire

257

Educationandincome

Questionasking,raisingcon

‐cerns,involvementindecision

making,andexpressionof


emotions


29.Manderbacka

(2005)

20Fi

nlan

d Coronaryheartdisease

patients

Qualitative

interviews

30Occupationand

employment



performed

30.Merceretal

(2016)24

UK(Scotland)

PatientsattendingaGP

practice

Questionnaire

659

ScottishIndicesof

MultipleDeprivation


Positiveassociation

31.Moiseetal

(2017)49

USA

Patientswithuncontrolled

hypertension

Questionnaire

195

Educationand

insurance


Positiveassociationforeduca

‐tiononly

32.Moretetal

(2017)

25Fr

ance

Gynaecology,orthopaedic,

internalmedicine,and

emergencymedicinehospi‐

talinpatients

Questionnaire

255

Deprivation(EPICES

scoreandperceived

socialstatus),

education,and

employment


Positiveassociationfordepri‐

vationonly

Othervariablesnotentered

intoanalysis

33.Morishigeet

al(2017)

50Japan

Inflammatoryboweldisease

patients

Questionnaire

1035

Income,educationand

employment


Noassociations

34.Morrisonetal

(2003)51

Australia

Generalpopulation

Questionnaire

1297

Educationandincome



Negativeassociations

35.Murrayetal

(2007)

52USA

Generalpopulation

Questionnaire

3177

Education,incomeand

insurance


Positiveassociationsforedu

‐cationandincomeonly

36.Nijmanetal

(2014)53

The Netherlands

Generalpopulation

Questionnaire

1432

Educationandincome



37.Olsonetal

(2010)54

USA

Hospitalinpatients

Questionnaire

89Educationand

insurance


Noassociations

TAB

LE 1

(Continued)

(Continues)

| 7ALLEN Et AL.

Aut

hor

Coun

try

St

udy

popu

latio

nM

etho

dsN

umbe

r of

part

icip

ants

Soci

o‐ec

onom

ic s

ta‐

tus (

SES)

mea

sure

Patie

nt p

artic

ipat

ion

beha

v‐io

urs m

easu

red

Dire

ctio

n of

ass

ocia

tion

38.Overgaardet

al(2012)

55Denmark

Lowriskwomenreceiving

midwiferyunitorobstetric

unitcare

Questionnaire

375

Educationand

employment


Noassociations

39.Phippsetal

(2008)56

USA

AfricanAmericancancer

patientswhoreceived

chemotherapy

Questionnaire

26Incomeandeducation


Noassociations

40.Rademakers

etal(2012)57

The Netherlands

Patientswithrheumatoid

arthritis,spinaldischernia

‐tion,ormalignantorbenign

breastabnormalities

Questionnaire

1019

Education


andquestionasking


41.Skolaskyetal

(2011)58

USA

Communitydwellingmulti‐

morbidadults

Questionnaire

855

Educationandincome


Positiveassociationforeduca

‐tiononly

42.Smithetal

(2016)

59USA

Generalpopulation

Questionnaire

3400

Incomeandeducation



43.Spiesetal

(2006)

60Germany

Patientsattendingachronic

painclinic

Questionnaire

341

Income,employment

andeducation


andquestionasking

Positiveassociationsforedu

‐cationonly

44.Steplemanet

al(2010)

61USA

Multiplesclerosispatients

Questionnaire

199

Educationand

employment



45.Tarimanetal

(2014)

62USA

Symptomaticmyeloma

patients

Questionnaire

20Employment,educa‐

tion,andincome


Noassociations

46.Tsimtsiouetal

(2014)63

Greece

Hospitalizedpatients

Questionnaire

454

Educationandincome


andquestionasking

Positiveassociationsfor

educationonlyIncomenot

enteredintoanalysis

47.vandenBrink‐

Muinenetal

(2011)64

The Netherlands

Patientsdiagnosedwitha

somaticchronicdisease

Questionnaire

2423

Education


Noassociation

48.Yeketal

(2017)

65Singapore

Patientsattendinga

pre‐operativeevaluation

clinicforelectivesurgical

procedures

Questionnaire

364

Education,employ

‐ment,insuranceand

inco

me


andquestionasking


education,employment,and

insuranceonly

Incomenotenteredinto

analysis

49.Yeo(2016)66

USA

Generalpopulation

Questionnaire

2297

Education,employ

‐ment,incomeand

insurance


andquestionasking

Negativeassociationsforedu

‐cationandincomeonly


insuranceEmploymentnot

enteredintoanalysis

TAB

LE 1

(Continued)

8 | ALLEN Et AL.

populationrecruited,studysetting,samplesize,howSESismeas‐ured,whatpatientparticipationbehavioursarereportedandkeyresults.

6 | RESULTS

Thetitleandabstractsof4718articleswereimportedintoEndnote,and368duplicateswereremoved.Thisleft4350entries,ofwhich3989 articles were excluded leaving 361 entries. After screeningall361full‐textarticles,thetworeviewersdisagreedon11papers.Followingdiscussion,sevenpaperswereexcluded.Afterscreening,49studieswereincludedinthereview.ThePRISMAdiagramcanbefoundinFigure1.

Detailsofthecharacteristicsofthe49includedstudiescanbefound inTable1.Overall,39 (79.6%)of the includedstudieswerepublishedinthelast10years,withonly10beingpublishedbefore2008. Most of the studies were conducted in the United States(46.9%), with the Netherlands being the second most common(10.2%).TherewereonlythreestudiesconductedinAustralia,andonly threeconducted in theUK. ‘Other’ countries includedSpain,Estonia,Germany,NorwayandFinland(Figure2).

The majority of studies used questionnaires to collect data(75.5%),withonlyfivestudiesusingqualitativetechniquessuchasinterviewsorfocusgroups,andonlytwostudies13,14wereinterven‐tions.Bothinterventionswerepilotstudieswithnocontrolgroup.The most commonly studied condition was cancer (20.4%), withfourstudiesrecruitingarthritispatients,andfourstudieswithdia‐betespatients.Moststudiesdidnotspecifywhatcondition(ifany)theirparticipantshad (36.7%). ‘Other’conditions includedasthma,chronicpain,HIV,multiplesclerosisandinflammatoryboweldisease(Figure3).NoneofthethreeUKstudiesrecruitedcancerpatients.

Themostcommonsettingforstudiesinvolvedsecondaryorter‐tiary care (44.9%),with primary care being the setting in only 11studies.Unfortunately,16studiesdidnotspecifywhichsettingtheirresearch referred to when collecting data from participants. Themostcommonlystudiedpatientparticipationbehaviourwasinvolve‐mentindecisionmaking(46studies),whereasfivestudiesexaminedraising concerns,14‐18 and only one study looked at rapport build‐ing.19Question asking and expression of opinions, preferences oremotionswasmorecommonlystudied,featuringin13and12stud‐ies, respectively.The rapportbuildingstudy recruitedparticipantsfromthegeneralpopulationandsotherewasalackofstudieswhichfocusedonrapportbuildingwhichinvolvedparticipantsinahealthsetting.Threeoftheraisingconcernsstudieswerewithbreastcan‐cerpatients(Table2).

Themostcommonlyusedmeasuretoexplorerelationshipsbe‐tween patient participation behaviours and SES was educationallevel (45 studies).Only four studiesusedoccupationasan indica‐torofSES,20‐23andonlytwostudiesusedacompositemeasureofdeprivation.24,25Onestudymeasuredhousingsituationandreceiptofbenefits,26oneusedacompositemeasureofsocialclass,27 and onelookedatfinancialstrainandfinancesattheendofthemonth.28

It isalsoimportanttonotethatmanystudiesexaminedmorethanonetypeofpatientparticipationbehaviourorusedmorethanonemeasureofSES.Moststudies(33)usedmorethanonemeasureofSES,whereasonly18studiesexaminedmorethanonetypeofpa‐tientparticipationbehaviour(Table2).

Table1showsthedirectionofassociations reported in the in‐cludedstudies.Ofthe49 includedstudies,5didnotperformsta‐tistical analyses as they had employed qualitativemethodologies.Positive associations between SES and patient participation be‐haviours (PPBs) were reported by 24 studies, while 5 studies re‐ported negative associations. Twenty‐seven studies reported noassociationbetweenatleastsomeoftheirvariables.ElevenstudiesreportedassociationsofdifferingdirectionsfordifferentmeasuresofSESordifferentPPBswithintheirstudy.Sincethestudiesweresomixedintermsofdesign,participants’condition,outcomesandsetting,itwasnotappropriatetoundertakeanymeta‐analyses.

Ofthe23studiesconductedintheUnitedStates,13reportedapositiveassociationbetweenSESandPPB,2reportedanegativeassociation,and14reportednoassociationbetweenatleastsomeoftheirvariables.Threestudiesdidnotperformstatisticalanalyses,and9studiesreportedassociationsofdifferingdirectionsfordiffer‐entmeasuresofSESandPPB.

Ofthe10studiesconductedwithcancerpatients,4reportedapositiveassociationbetweenSESandPPB,7reportednoassocia‐tionbetweenatleastsomeoftheirvariables,and2reportedassoci‐ationsofdifferingdirectionsfordifferentmeasuresofSESandPPB.Onestudydidnotperformstatisticalanalyses.

7 | DISCUSSION

Althoughthegoalofsystematicreviewsearchesistoidentifyallrel‐evantstudiesonatopic,itisnecessarytobalancecomprehensivelycoveringatopic(orsensitivityofasearch)withhowmanageableitiswithin resources available.11On theotherhand, awider searchmayreduceprecision(identifyingnon‐relevantarticles),whichwhilemorecomprehensive,maybemoredifficulttosummarizebecausetypesofstudiesmayvaryquitewidely.Systematicmappingreviewshelpbyamethodtooverviewa largerareasothatgapsto informfutureresearchcanbeidentified.10,11

Ourstudyshowsthatwhileanearliersystematicreviewexplor‐ing literatureon the social gradient indoctor–patient communica‐tion had a relatively broad search strategy, this included only 20papers,8whereasourstudyfocusingpurelyonpatientparticipationbehavioursandSESdifferencesidentified49studies.Althoughthismay indicate an expanding area of research, thismay also be be‐causeourstudyusedawidersetofSES indicators thanhadbeenused previously. Our research is particularly informative becauseit focused in detail on thepatient‐sideof the clinical interactions,whereasotherreviewshavehadamainfocusonbehavioursintheconsultation.8,29

WefoundthatthemostcommonlyusedmeasureofSESinstud‐iesofthistypewaseducationallevel,whilemeasuresofparticipants’

| 9ALLEN Et AL.

occupationhavebeenmuch lessfrequentlyused. Incomeandem‐ployment status were not as commonly measured as educationallevel,althoughtheywerestillusedinsomestudies.OccupationisakeyindicatorofSESandlikelytohaveanimportantinfluenceonthedoctor–patient relationship,30andso it issurprisingtofindsofewpreviousstudiesusingthismeasure.

Wefoundthatthemostfrequentlystudiedpatientparticipationbehaviourwasinvolvementindecisionmaking,whereasraisingcon‐cernsandbuildingrapportwerecomparativelyrelativelyneglected.

Incontrast,Verlindeetal8foundfewerstudiesonjointdecisionmak‐inganda largernumberofstudies involvingother typesofpatientparticipationbehaviours.Perhapspatient‐orientatedcommunicationstudieshavehadmorefocusondecision‐makingaspectsofcommu‐nication, whereas doctor‐orientated communication studies focusonotheraspectsoftherelationship—orourmorespecificelectronicsearchtermswhichincluded‘decisionmaking’,meantthatwecouldbetterreflecttheamountofresearchwhichhasbeenundertakeninthisfield.

F I G U R E 2 Countriestheincludedstudieswereconductedin

0

5

10

15

20

25

USA UK The Netherlands Australia Other

F I G U R E 3 Diagnosesofrecruitedparticipants

02468

101214161820

Cancer Diabetes Arthri�s None specified Other

TA B L E 2 SummaryofSESvariablesandpatientparticipationbehavioursusedinincludedstudies

Patient participation behaviours

Involvement in decision making Question asking Raising concerns

Rapport building

Expression of opinions, pref‐erences or emotions

SESmeasure

Education 1,2,3,4,5,6,8,11,12,14,15,16,17,20,21,22,23,24,25,26,27,28,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49

1,7,18,21,23,25,28,40,43,46,48,49

9,18,23,25,28 27 1,2,10,11,17,18,21,22,23,27,28,34

Employment 2,3,6,17,23,29,32,33,38,43,44,45,48,49

23,43,48,49 9,23 2,17,23

Income 3,6,22,23,24,27,28,33,34,35,36,39,41,42,43,45,46,48,49

23,28,43,46,48,49 9,23,28 27 22,23,27,28,34

Occupation 12,13,29 13 10

Insurance 8,31,35,37,48,49 7,48,49 9

Deprivation 30,32

Receiptofbenefits

3

Housingsituation

3

Socialclass 19

Financial strain

20

Financesatendofmonth

20

Note: EachstudyinTable1wasassignedanumber,whichcorrespondswiththenumbersinthistab.

10 | ALLEN Et AL.

Althoughpreviousstudieshavefoundthatrapportbuilding inthedoctor–patientrelationshipcanhaveanumberofpositiveout‐comes, including treatment satisfaction, understanding health in‐formation,copingandadherencetotreatment,1,3,31onlyonestudywas identifiedwhich lookedathowthisbehaviourwasrelatedtoSESdifference,andsofurtherresearch inthisarea isparticularlyneeded.

Most studies used more than one measure of SES which insome cases allowed a comparison of the effects of each differ‐entmeasure,althoughinsomeofthese,notalltheSESvariableswereentered into theanalysisbutweresimplyusedtodescribethesample.Theobjectiveofourstudywastomaptheliteratureinthisarearatherthantoproduceasynthesisacrossseveraltypesofstudies;however,weextracteddatafromincludedstudiesonwhether a statistically significant association between SES andPPB had been reported. This indicated that although PPB wasfoundtobe related toSES inabouthalfof thestudies, inabouthalf, theywerenot.Summarizingresultsaremademoredifficultby the heterogeneitywhich exists between studies in this area,and the range of different measures of SES and indicators ofPPBwhichhadbeenused.Forexample,althoughseveralstudiesshowed an association with education and patient participationbehaviours,asmanyas17studiesfoundnostatisticallysignificantassociationbetweenthetwovariables;andsotherelationshipislikelytobecomplex.Ontheotherhand,fewstudiesseemtohavefoundasignificantassociationbetweenpatientparticipationbe‐haviours and employment or income. Larger andmore sophisti‐cated studies are needed, using a rangeof SES indicators and amorein‐depthdescriptionofpatientparticipationbehaviours,andthesettinginvolved.

Whilethemostcommonconditionstudiedwascancerandthemost common settingwas secondary or tertiary care, 36.7% ofstudies did not specifywhat condition (if any) their participantswerediagnosedwithorwhathealth‐caresettingtheirquestionsregardingpatientparticipationreferredto.Thisispotentiallyim‐portantinformationwhichismissingfromthesestudies,assettingand condition which the patient is consulting for can influencea patient's preferred and experienced level of participation in aconsultation.7,32,33

Most studies included in the review were conducted in theUnitedStates,makingthecurrentresearchinthisareaveryUS‐cen‐tric.Thismaylimitthegeneralizabilityoftheresultsofthesestudies,asothercountrieshavedifferentlystructuredhealth‐caresystemswhichmight influencepatient participationbehaviours. There is aneed formorestudiesonpatientparticipationbehavioursoutsideoftheUnitedStates.

8 | CONCLUSION

Inconclusion,ourfindingssuggestthatmostpatientparticipationre‐searchreliesoneducationasanindicatorofSESandmainlyexploresinvolvementindecisionmakingasthepatientparticipationbehaviour

ofinterest.MostpreviousstudieshavebeenundertakenintheUnitedStates,butmanylackimportantinformationonthesettingorthepa‐tients’condition.Morestudiesonspecificpatientparticipationbehav‐iourssuchasrapportbuildingandraisingconcernsareneeded,andotherstudiesundertakenoutsidetheUnitedStates.UseofawiderrangeofSESmeasuressuchasoccupation,housingsituation,receiptofbenefitsandhouseholdfinanceswouldbeusefuladditionaldata.

ACKNOWLEDG EMENTS

TheauthorswouldliketoacknowledgetheworkofDanielleHewittassecondrevieweronthismappingreview.

CONFLIC TS OF INTERE S T

None.

DATA AVAIL ABILIT Y S TATEMENT

Datasharingisnotapplicabletothisarticleasnonewdatawerecre‐atedoranalysedinthisstudy.

ORCID

Sarah Allen https://orcid.org/0000‐0003‐1194‐3584

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How to cite this article:AllenS,RogersSN,HarrisRV.Socio‐economicdifferencesinpatientparticipationbehavioursindoctor–patientinteractions—Asystematicmappingreviewoftheliterature.Health Expect. 2019;00: 1–12. https://doi.org/10.1111/hex.12956

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