Shared Decision Making Among Racially and/or Ethnically Diverse Populations in Primary Care: A Scoping Review of Barriers and Facilitators

Dear Editor,

We have read with interest the recent article by Anaya et al. (1), which presents a scoping review examining barriers and facilitators to shared decision making (SDM) among racially and ethnically diverse patient populations in primary care. We are writing as a family physician and an independent researcher based in Spain, where multicultural patient populations are becoming increasingly common in local health centers. The insights offered by the authors resonate with many observations from daily practice in Spanish primary care settings, and we believe that adapting and extending their findings can enhance both clinical outcomes and patient satisfaction in our own context.

One aspect of the article we find particularly noteworthy is the extensive description of communication barriers within the clinical encounter. As Anaya et al. discuss, language discordance often compromises the exchange of crucial information, creating mutual misunderstandings and reducing opportunities for patient participation. While their findings are drawn primarily from the United States and Canada, many Spanish health care centers also face significant linguistic and cultural challenges that influence SDM. A substantial number of patients in Spain speak limited Spanish or come from cultural backgrounds that differ markedly from that of their clinicians. Although law and health policy in many autonomous communities recommend or even mandate professional interpretation services, such services are not always readily available, nor are they uniformly trained in medical terminology. This logistical gap can restrict the degree to which SDM is carried out in practice, consistent with prior research indicating that limited language proficiency is a core impediment to patient-centered care (2). We suggest, therefore, that additional resources be allocated within Spanish primary care to train and hire certified interpreters and to ensure that clinicians possess at least foundational language skills in the most commonly spoken languages of their patient population.

Anaya et al. also highlight how prejudices, both explicit and implicit, significantly diminish patient trust and can derail the shared decision-making process. Their findings align closely with published evidence that cultural competence and patient-centeredness are key elements of high-quality care (3). In Spain, many family physicians note that patients from specific immigrant communities might harbor a sense of mistrust toward the health system. This mistrust often emerges from broader societal experiences of discrimination and from unfamiliarity with how health care is delivered in Spain. In line with Anaya et al.’s recommendations, we believe it would be highly beneficial to implement regular bias-awareness training for physicians, nurses, and administrative staff. Such training, informed by evidence-based interventions, has shown promise in helping health care professionals recognize and mitigate biases in clinical practice (4). Where possible, these trainings should be integrated into continuing education programs, and strategies to sustain the learning—such as recurring workshops and structured feedback—should be put in place to promote ongoing cultural sensitivity.

We particularly appreciate the authors’ emphasis on the importance of family involvement in health decisions. Their review demonstrates that patients often discuss treatment options with relatives, which can affect adherence to medical advice in ways that clinicians sometimes misunderstand. Our experience in Spanish primary care echoes this: an older patient from a rural community, for instance, may rely heavily on the counsel of adult children or other kin before committing to any treatment plan. Similarly, patients from certain cultural backgrounds may defer major decisions to a senior family member, whom they view as a gatekeeper for health decisions. As Mead and Bower (5) have observed, family-centered discussions not only strengthen adherence but also show patients that their cultural preferences and familial dynamics are valued. We believe this evidence underscores a need to encourage clinicians to explore how the patient’s immediate network might influence decision making and to welcome supportive relatives when appropriate. However, we acknowledge the complexity of family engagement and the necessity of balancing patient autonomy with inclusive family participation.

Another issue that Anaya et al. underline is the vital role that empathy and honest, humanistic communication play in bridging cultural gaps. Their review reports that patients who felt listened to, validated, and respected were more willing to engage in SDM. This finding is consistent with broader studies suggesting that trust grows when patients perceive a genuine interest in their personal history (6). We have observed that Spanish family physicians could further strengthen such trust by adapting basic communication strategies—e.g., asking open-ended questions, reflecting on patient statements, confirming that the patient’s perspective has been understood—particularly when serving patients who may feel marginalized or disoriented in a new cultural setting. Moreover, we propose that medical curricula incorporate communication skills training with a special focus on cross-cultural empathy, allowing young practitioners to develop the capacity to handle sensitive discussions early in their careers.

A prominent limitation of the scoping review by Anaya et al. is its almost exclusive focus on African American and Latino/x/e populations in North America. Although these findings are relevant as starting points, Spanish health centers must also consider a wide spectrum of groups: individuals from North Africa, Eastern Europe, Sub-Saharan Africa, South Asia, and Latin America, among others. The extent to which these communities differ not only linguistically but also in religious beliefs, health literacy, and perceptions of the medical system may vary significantly. We recommend future research in Spain to systematically examine how these diverse cultures perceive physician-patient relationships and the extent to which they feel empowered to engage in SDM. The results could guide the development of locally tailored guidelines, ensuring that they reflect not only a bilingual but a truly multicultural society.

We also agree with Anaya et al. on the importance of structural facilitators that promote SDM, such as having enough consultation time and reducing administrative burdens that shorten patient appointments. Many Spanish physicians face strict scheduling that allocates no more than a few minutes per patient, posing a significant challenge to the in-depth conversations required for a meaningful SDM process. Recent professional debates in Spain, spurred by calls for a more patient-centered approach, emphasize that short consultation times prevent clinicians from exploring patients’ concerns in a way that fosters shared decisions. Echoing the authors’ recommendations, we believe policymakers and health managers should recognize the need for sustainable staffing policies. By allowing sufficient time per consultation, clinicians can offer detailed explanations, address patient doubts, and respect cultural nuances, all of which are necessary for effective SDM (2,5).

In the context of diverse patient populations, another practical challenge in implementing shared decision making is the frequent lack of access to complete clinical histories and family health information, especially in the case of tourists and recent immigrants. These patients often arrive at consultations without formal medical documentation, previous test results, or comprehensive knowledge of their family’s health background. This limitation can hinder the clinician’s ability to contextualize current symptoms, assess risks, and discuss diagnostic or treatment options in depth (7). Furthermore, certain patients may be unfamiliar with the importance placed on family history in Western medicine or may not perceive it as relevant, which can lead to underreporting or uncertainty during the consultation. While this situation is understandable given the structural and personal barriers involved, it makes the establishment of trust and the development of tailored treatment plans more complex. Clinicians must often rely on approximations, ask clarifying questions with sensitivity, and be prepared to revisit decisions as more information becomes available or as patients feel more comfortable sharing details over time.

Moreover, from our perspective as a family physician and an independent researcher, the article’s discussion on the post-visit dimension is particularly compelling. Patients frequently incorporate the opinions of extended family, community elders, or religious advisors after leaving the clinic. This “invisible” decision-making phase can either reinforce or challenge the decisions reached in the consulting room. Encouraging patients to return or contact the clinic with any emerging questions is a practical method to ensure they remain engaged and informed. Instituting follow-up methods—such as phone calls, text messages, or nurse-led check-ins—may maintain communication and thus preserve the integrity of SDM. Indeed, Beach and Sugarman (8) have shown that sustainable shared decision-making efforts are those that persist beyond the initial office visit and integrate well with patients’ lives at home and in their communities.

Finally, the authors’ call for further studies is also pertinent for Spain. While the review by Anaya et al. offers a valuable framework, additional research is necessary to assess how extensively SDM is practiced in Spanish primary care and to identify which interventions meaningfully improve outcomes for diverse patients. Large-scale investigations could measure the impact of cultural competence training or extended consultation times on both patient satisfaction and clinical indicators, confirming whether the variables highlighted in North American contexts resonate in Spanish settings. Future research might also clarify whether structural differences within Spain’s regional health services (Servicio Vasco de Salud, Servicio Madrileño de Salud, Servicio Andaluz de Salud, etc.) lead to variation in how SDM is approached.

In conclusion, the review by Anaya et al. represents a thorough examination of how patients from different racial and ethnic backgrounds experience SDM in primary care. From our vantage point, many of their findings have potential applications in Spain, where the cultural landscape is also evolving. The barriers and facilitators described—ranging from adequate time and trustworthy interactions to professional interpretation and family involvement—are all factors that Spanish clinicians and health authorities should address proactively. By incorporating these insights into targeted reforms, we can strengthen our commitment to accessible, equitable, and person-centered care. We appreciate the effort the authors invested in elucidating these complex processes, and we strongly advocate for continued scholarly and policy attention to ensure that SDM becomes a cornerstone of health care for diverse communities in Spain and beyond.

REFERENCES

1. Anaya Y, Do D, Christensen L, Schrager S. Shared Decision Making Among Racially and/or Ethnically Diverse Populations in Primary Care: A Scoping Review of Barriers and Facilitators. Ann Fam Med. 2025 Mar 1;23(2):108–16.

2. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med. 2012 Oct 1;27(10):1361–7.

3. Saha S, Beach MC, Cooper LA. Patient Centeredness, Cultural Competence and Healthcare Quality. J Natl Med Assoc. 2008 Nov 1;100(11):1275–85.

4. Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain. Soc Sci Med. 1998 Nov 1;47(10):1573–88.

5. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002 Sep 1;48(1):51–61.

6. Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control. 1999 Feb 1;3(1):25–30.

7. Tenajas R, Miraut D. Addressing Hidden Histories of Donor-Conceived Adults. Ann Fam Med. 2025;23(1):eLetter.

8. Beach MC, Sugarman J. Realizing Shared Decision-making in Practice. JAMA. 2019 Sep 3;322(9):811–2.