97 Applying a DOI theory-based framework Introduction Shared decision-making (SDM) emerged as a transformative approach in medicine in the past decades, revolutionizing the decision-making process by placing patients at the center. [1] Unlike evidence-based medicine (EBM), which quickly gained traction and transformed medical practice, [2, 3] SDM has faced challenges in achieving widespread adoption. [4, 5] Many studies have reported barriers to SDM implementation and strategies to overcome them. These barriers include the healthcare system being non-supportive for SDM, and lacking time and support for SDM execution. [6-8] Moreover, the complexity of SDM seems to be a significant barrier, including variations in the abilities of both healthcare professionals and patients to engage in the SDM process effectively. [9, 10] To overcome some of these barriers, studies have highlighted the need for changes in the organizational culture and healthcare policies to create an environment conducive to SDM implementation. [7-10] Conversely, various facilitators have been identified to promote SDM implementation. These include increasing awareness and knowledge of SDM among healthcare professionals and patients, providing training and educational programs on SDM, incorporating SDM into clinical guidelines and quality standards, and utilizing decision support tools and aids to facilitate the SDM process. [6-10] Regardless of these efforts, the implementation of SDM remains difficult, laborious, and inconsistent. [4, 6, 10] This suggests that the complexity of SDM implementation is multifaceted, necessitating an all-encompassing approach to understanding the intricate dynamics involved in successfully implementing SDM. [6, 7] To gain more insight into this black box, this study employs the Diffusion of Innovations (DOI) theory, developed by Everett Rogers over 50 years ago, to provide a comprehensive framework for understanding the SDM adoption process in clinical practice. [11] Despite its relative unfamiliarity among medical professionals, the DOI theory has garnered substantial recognition and established itself as credible. Both within and outside the medical and health research domains, numerous studies have successfully utilized DOI models to investigate the introduction of new technologies and ideas. [12-18]. The DOI theory introduces the concept of innovation, which is defined as an idea or technology perceived as new by potential adopters. It also highlights diffusion as the process through which an innovation spreads. [11] The diffusion process encompasses both planned and spontaneous dissemination of ideas, ultimately leading to social change within a given system. [11] The DOI model includes five essential stages for an innovation to succeed: ‘knowledge’, ‘persuasion’, ‘decision’, ‘implementation’, and ‘confirmation’. [11] These stages collectively contribute to the overall adoption process. While all are significant, particular emphasis in our study is placed on the first two stages, knowledge, and persuasion, as they precede the critical decision by any potential adopter to either adopt or reject the innovation. Notably, these stages seem essential in the lack of current SDM adoption in clinical practice. However, surprisingly, these foundational stages have received limited comprehensive attention in the existing literature. 6
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