A Multinational Study of Patient Preferences for How Decisions Are Made in Their Care

Inadequate consideration has been given to patient preferences for patient-centered care (PCC) across countries or cultures in our increasingly global society. We examined what 1,698 participants from the United States, Hong Kong, Philippines, and Australia described as important when making health care decisions. Analysis of frequencies following directed content coding of open-ended questions revealed differences in patients’ preferences for doctor behaviors and decision-making considerations across countries. Being well informed by their doctor emerged as most important in decision-making, especially in Hong Kong. Participants in Australia and the United States wanted their doctor to meet their emotional needs. The safety and efficacy of treatments were the most common consideration, especially for Hong Kong. Findings suggest that doctors should focus on information exchange and identifying patient concerns about efficacy, lifestyle impact, cost, and recovery speed. Rather than assuming patients prefer shared decision-making, doctors must assess patient’s decision control preferences.


Background
Patient-centered care (PCC) focuses on how patients' needs, experiences, and preferences are incorporated into medical care, thereby pushing beyond existing biomedical, diseaseoriented models (Eklund et al., 2019). PCC is now the predominant model of care in most Western countries and is typically associated with positive outcomes such as patient satisfaction, treatment adherence, and enhanced prevention (Deen et al., 2011). Non-Western cultures are increasingly adopting PCC. However, evidence demonstrating the benefit and applicability of PCC for non-Western patients is lacking (Pun et al., 2018). Furthermore, the term patient-centeredness does not exist in some languages, suggesting an absence of this construct in some regions (Setlhare et al., 2014). Two foci of PCC have been provider behaviors and shared decision-making (SDM).
A large portion of PCC research has been on the behaviors that providers, including doctors, employ to involve patients in care. For example, in a scoping review of PCC approaches, Constand et al. (2014) found that sharing information, compassionate and empowering care provision, sensitivity to patient needs, developing a relationship, and managing patient cases effectively were important components of provider care. Although some studies conducted within non-Western countries have probed patient preferences for their care (e.g., De Guzman et al., 2019;Ting et al., 2016), the majority of reviews summarize studies conducted in English-speaking, Western countries, mainly the United States and Canada (Constand et al., 2014;Jackson et al., 2013;Rathert et al., 2013). Thus, little is known about patient preferences for care outside of these countries.
PCC research has also focused on SDM between providers and patients. Stiggelbout et al. (2015) assert that SDM should occur through the provider (a) informing the patient about an important decision to be made, (b) explaining options, (c) supporting a discussion of the patient's preferences, and (d) discussing the patient's wishes regarding making the decision or deferring the decision and any follow-up. However, the authors state that this rarely occurs in practice. Western perspectives assume that patients desire SDM and the focus has been on ensuring that doctors know how to involve patients in decisions. However, there has been limited consideration of whether patients in non-Western countries desire the same level of involvement in medical decision-making (Jolles et al., 2019). A few studies have demonstrated differences in patient preferences for medical decision-making across two countries (i.e., desire for medical information and SDM in Australia and China, Dolan ,Alden, et al., 2019; desire for information and power-sharing in Japan and the United States, Alden et al., 2015). Furthermore, one study that considered differences across multiple countries (Australia, China, Malaysia, India, South Korea, Thailand, and the United States) showed differences in preferences for who is involved in and ultimately makes decisions (i.e., family members or the individual) and cautioned against East-West stereotypes (Alden et al., 2018). More research should consider differences across multiple countries, particularly as global mobility increases.
The increasing global mobility of both doctors and patients inevitably leads to increased intercultural doctorpatient encounters, thereby increasing the importance of considering differences in patient preferences across countries. For example, in 2011, less than half of all doctors practicing in Australia were Australian-born, with many recruited from South and Southeast Asia (Negin et al., 2013). The situation is similar across the world as countries manage doctor shortages with increased reliance on overseas-trained doctors. In addition, Michalski et al. (2017) found that international medical graduates from non-English-dominant countries were unfamiliar with SDM and had challenges with PCC, which demonstrates a discrepancy in care delivery models.

New Contribution
Given cultural differences in who makes decisions and the paucity of cross-country evidence on preferences for SDM, we argue the applicability of Western conceptualizations of PCC, and SDM in particular, has not been adequately probed across cultures. Thus, this study aims to explore patient preferences for how care decisions are made and their expectations for how their doctor should provide care in Hong Kong/ China, the Philippines, Australia, and the United States. We posed the following research questions: Findings from these questions will contribute to the current evidence in two main ways. First, findings will increase our understanding of PCC across countries. Second, findings will provide practitioners across countries with a better understanding of patient expectations. This can help providers to facilitate decision-making experiences that are integral to patient satisfaction and high-quality care.

Conceptual Framework
The

Health Care Systems Overview
The Hong Kong health care system is primarily public. Public hospitals provide approximately 90% of medical services and 29% of outpatient medical services, with little to no out-ofpocket costs to the patient. People in Hong Kong may also opt for private health insurance, which has higher out-of-pocket costs but allows for personalized choices and more accessible, timely services. The health care system in the Philippines is complex, with approximately 40% of hospitals in the public sector, with funding sources coming from patient fees, donors, and government taxes. Approximately 30% of people have private health insurance and PhilHealth is a government social health insurance, providing coverage for most of the population, particularly low-income patients. Community healers are also common. The health care system in Australia includes universal public health insurance through Medicare. However, similar to Hong Kong, many people opt for private health insurance to increase personalized choices and accessible, timely services. There is no universal health care coverage in the United States. Instead, most people purchase private health insurance and others qualify for one of the six different public insurance programs covering some health care costs for people who are 65 years or older, have a disability, some forms of chronic disease, prior military service, or very low income (The Commonwealth Fund, 2020).

Participants and Procedure
As part of a larger study investigating whether preferences for multiple facets of PCC differed by country, data were collected in Hong Kong/China, the Philippines, Australia, and the United States. Institutional review board approval was obtained from the University of California, Santa Barbara Institutional Review Board, and the Griffith University Ethics Committee. Participants were required to be above 18 years, currently residing in one of the countries, and speak English, Tagalog, or Cantonese. Surveys were translated into Tagalog and Cantonese using a professionally qualified translation service. All participants in the United States, Australia, and the Philippines responded in English. In Hong Kong, 38.62% (n = 112) of participants responded in Cantonese.
Participants (N = 1,698) were recruited between March 2020 and December 2020. A convenience sample of community members was recruited using Amazon Mechanical Turk (MTurk) in the United States and email and/or social media (i.e., Facebook) in Australia, Hong Kong, and the Philippines. MTurk participants received US$2, participants in the Philippines and Australia could enter a prize draw to win gift vouchers, and those in Hong Kong received a coffee voucher. A university student sample was also recruited in all four countries. Students received course credit or a coffee voucher for participation. Participants recruited from Hong Kong included participants who resided in Mainland China but worked/studied in Hong Kong. Participant characteristics are in Table 1.
Participants completed an online survey comprising validated measures of several PCC facets (see Sheeran et al., 2022 for further information). The survey also contained open-ended questions designed to capture preferences for care and decision-making not assessed by existing measures of PCC. The open-ended questions asked participants to think about, when they had an appointment with their doctor, "What are the most important things that your doctor should say or do?" and "What would you say is most important to you about the way decisions are made about your care?" Participants also responded to demographic questions indicating their gender identity, ethnicity, education level, age, religion, occupation, and presence of a chronic illness. Participants could choose "other" and write in their free-response.

Analysis
Data were analyzed in Microsoft Excel using directed content analysis (Hsieh & Shannon, 2005). R.P. began the analysis by identifying all instances where a participant described something they found important or valued in decisionmaking, or any doctor behaviors. R.P. and A.P. worked together to develop the initial codes in consultation with the research team. Codes were generated both inductively and deductively, with Eklund et al.'s (2019) PCC model providing a basis for creating categories. A.P. then undertook coding of all responses, with R.P. and N.S. reviewing coding to ensure rigor. Finally, R.P. and N.S. returned to the data to refine codes, which included separating codes about the way decisions were made from responses about key considerations when making decisions. A.H.P. and Y.B.J. also coded a small portion of the data to ensure further rigor. All responses written in Cantonese were coded by Y.B.J., who is proficient in Cantonese. Y.B.J. translated a selection of coded Cantonese responses into English, which R.P. and N.S. then reviewed. Moreover, all researchers met monthly to discuss the coding interpretation, including discussions of situating findings within health care systems. All discrepancies were resolved through discussion until consensus was reached. A response by one participant could be coded into more than one category. The presence and absence of each code for each participant were entered into IBM SPSS (version 27) and frequencies were calculated. Chi-square was used to test for significant differences in frequencies of each code across countries.

Results
In the following results, country listings after quotations indicate the participant's ID, location (HK = Hong Kong/ China, PHIL = Philippines, AUS = Australia, USA = United States of America), gender identity (W = woman, M = man, TRANS/NB = transgender or nonbinary), and age in years. The percentages below were calculated by dividing the number of people in each country who reported a consideration or behavior by the number of participants in that country. We first outline behaviors that participants stated they desired from their doctor and then key considerations when making decisions about their care and the decisionmaking process.

RQ1: Important Doctor Behaviors
We identified six categories of behaviors that participants thought were important for their doctors to say or do. Behavior 1, recognize and meet my emotional needs, referred to doctors providing reassurance, comfort, and showing empathy while providing care. The next three categories were behaviors that showed the doctor was active and engaged in the interaction. Behavior 2, listen attentively and communicate clearly, referred to doctors listening to their patients, showing genuine interest without rushing patients, and ensuring communication was comprehensible. Behaviors 3 and 4 pertain to questioning within interactions. Behavior 3, ask me questions, referred to patients wanting their doctors to ask questions about why they were there, how they were feeling, what their concerns were, and to generally engage them in the consultation by asking them questions. Behavior 4, allow me to ask questions, referred to doctors allowing space for and/or inviting the person to ask questions and ensuring that all questions had been answered. Behavior 5, be transparent and honest, referred to the patient's desire for the doctor to communicate honestly about their experience, knowledge, and the patient's prognosis, even if it was not good news (i.e., poor prognosis or having limited experience as a doctor). Behavior 6, advise on my lifestyle, referred to people wanting their doctor to enquire about and advise on their lifestyle more broadly (rather than on medical issues specifically), including prevention of illness, diet, sleep, and well-being in the long term. We present results in order of those most commonly to least commonly reported in the total sample and discuss between-country differences below (see Table 2).

Recognize and Meet Emotional Needs.
Around 28% of participants stated that it was important for their doctor to provide reassurance and comfort and to show empathy and care for them. However, there were significant differences across countries, χ 2 (3, N = 1698) = 65.59, p < .001, with participants in Australia (38.9%) and the United States (30.6%) reporting this more frequently than participants in the Philippines (20.9%) and Hong Kong (12.8%). Examples of responses included "the doctor shall show care and concern" (P1487, PHIL, M, 47) and "Be empathetic in concerns and questions" (P202, HK, W, 41). Many other participants stated it was important that their doctor make them feel comfortable. One participant stated, "just make me feel comfortable because talking about my body is an intimate thing" (P1246, USA, W, 20). Others wanted the doctor to show empathy and acknowledge their feelings, "listen, show empathy and compassion, acknowledge feelings and concerns" (P1273, AUS, W, 21). Responses included in this category also highlighted the importance of the doctor establishing rapport with the patient. One participant stated, "build rapport with me so I could feel comfortable talking with him or her" (P1401, PHIL, W, 22). Allow Me to Ask Questions. Around 10% of participants felt it was important that doctors allowed space for and/or invited the person to ask questions and ensured that all questions had been answered. There were significant differences between the countries, χ 2 (3, N = 1698) = 57.09, p < .001, with those in the United States (15.6%) and Australia (12.1%) wanting to ask questions significantly more than those in Hong Kong (3%) and the Philippines (2.4%). For some, this involved the doctor ensuring they felt comfortable asking questions, for example, ". . . create a safe environment for patients to ask personal questions" (P1566, USA, W, 19). For others, this involved the doctor inviting or allowing them to ask questions: "allow me to ask questions and for them to be properly answered when I am unsure" (P162, AUS, W, 23) and "ask if you have questions" (P142, USA, W, 20). However, some participants noted that it was important that they could ask questions, even the "stupid ones": "I usually choose a doctor who is approachable-a doctor whom we can ask even "stupid" questions" (P1200, PHIL, M, 53).

Maintain Transparency With Honest Communication.
Nearly 18% of participants wanted their doctor to be honest with them, to "tell the truth" (P210, HK), and to "be In addition to honesty about their condition, participants stated it was important for doctors to be honest about their own knowledge and experience, even if it was limited. One participant said, . . . I would rather have a Dr. tell me that "I am sorry, I really don't know what is going on, but together we will figure it out together" than have them lie to me, as that makes me all the more madder and distrust them. I do realize that they are not gods and do not know everything. (P514, USA, W, 60) Some participants recognized that honesty was bidirectional. One participant stated, "I believe that there should be nothing but complete honesty between patients and their doctors when making decisions about the patient's care" (P1175, AUS, W, 18).
Recognize and Advise on My Lifestyle. Less than 5% of participants reported that they wanted the doctor to address their lifestyle habits to improve their health and prevent disease in the long term. However, there were significant differences between countries, χ 2 (3, N = 1698) = 78.46, p < .001. Apart from one participant in the Philippines, two participants in Australia, and five in Hong Kong, only participants in the United States mentioned this doctor behavior (9.9%). For example, one participant stated, "make sure about my health and proper nutrition to take to avoid some illness" (P1283, USA, M, 41), and another said, "make sure you're getting enough rest, exercising and eating well" (P1296, USA, W, 26). Some participants even mentioned wanting their doctor to suggest alternative treatments that did not involve medication: for example, "how to maintain my health without medication like exercise and yoga" (P1398, USA, W, 25).

RQ2: The Way Decisions Are Made
In answering the question about what people felt was important in the way decisions were made, participants responded by describing key considerations when making a decision (38.9%) and outlining the process by which decisions should be made (41.2%). We identified five key considerations when making decisions: (a) the safety and efficacy of treatment, (b) impact on their personal lifestyle, (c) decisions were in their best interest, (d) cost of treatment, and (e) speed of recovery. The process for making the decision was on a continuum, from decisions being made autonomously made by the patient to decisions being made exclusively by the doctor. To explore differences between countries, responses were coded into three categories: doctor decides, SDM, and I decide. However, the most important facet of how decisions were made was the patient being well informed.
Being Well Informed. Nearly 60% of participants reported it was important to be well informed when decisions about their care were made. However, there were significant differences between countries, χ 2 (3, N = 1698) = 66.91, p < .001. Significantly more participants in Hong Kong (76.3%), compared with those in Australia (64.5%), followed by those in the Philippines (51.6%) and the United States (50.3%), reported that information was important. Participants wanted to receive all available information from their doctor to have a complete understanding and ability to make the best decision: for example, "That I'm fully informed of my own conditions, the options that I have and the consequences (including side effects) of those options taken" (P1118, HK, M, 45). Participants expected that the doctor would provide them with information, stating, "Fully inform me of my condition; explain the why/what about any tests/treatments they perform on me" (P1099, USA, W, 20). Participants also felt that they should be made aware of all their available options: "I want them [the doctor] to explain my options and make sure I'm fully informed" (P330, USA, W, 18). Providing information was central to the doctor's role.

Key Considerations When Decisions Are Being Made
Safety and Efficacy of Treatments. Nearly 20% of participants stated the ". . . safety and effectiveness of recommended treatment. . ." (P332, PHIL, M, 44) were important considerations when making health care decisions. Participants also referred to the expertise and ability of their doctor. Safety and efficacy of treatments were significantly more important to participants in Hong Kong (38%) compared with the other countries, χ 2 (3, N = 1698) = 72.42, p < .001. Participants wanted to know the risks and benefits of their treatment. One participant said, I believe that the most important was for decisions to be made about my care is to have all the facts. Get the doctor to outline the pros and cons of that particular decision so that you adequately choose what's best for you. (P1612, AUS, W, 18) Participants especially wanted information about side effects: for example, "藥物效果同副作用 (does it work and what are the side effects)" (P731, HK, M, 29). Safety and efficacy information also included participants wanting to know about treatments' scientific legitimacy and reliability, especially if the recommended treatment was experimental or had not been previously tested. Participants stated that it was important that treatments are "reliable and be seen to work on others" (P482, AUS, W, 18) and that "all facts should be presented and backed with science before making decisions about my care" (P1168, PHIL, W, 26).

Impact on Their Personal
Lifestyle. Around 9% of participants considered treatment "impact on daily life" (P810, AUS, M, 35) and their personal lifestyle important. Impact on their personal lifestyle was particularly important for participants in Australia (13.7%) compared with participants in the United States and Hong Kong, χ 2 (3, N = 1698) = 23.22, p < .001. One participant stated, "That the decision is known to work on previous patients and tries to disrupt my life outside of my health as little as possible" (P45, AUS,M,19).

Decisions Were in My Best
Interest. Around 8% of respondents indicated that decisions must be made for their personal benefit and with their "best interests in mind" (P1160, HK, M, 20). This category was more commonly reported by participants in Australia (10.7%) and the United States (9.8%) compared with participants in the Philippines (4.9%) and Hong Kong (5.8%), χ 2 (3, N = 1698) = 11.35, p = .01. Participants mentioned that it was important to know "if the decision is for my benefit; that it will help me" (P574, PHIL,W,19). Some participants clarified that they felt some apprehension and even mistrust regarding motivations for treatments from the medical system (i.e., financial gain). For example, one participant stated that it was vital to them "that no financial implications or, worse, profit motivations are taken into consideration. This is particularly important as much of health care is privatized" (P1379, HK, M). Similarly, some participants were concerned that third-party industries would benefit: for example, "what is in my best interest, and not that of the pharmaceutical company" (P1451, AUS, M, 32).
The Cost of Treatment. Around 5% of participants stated the financial cost of their treatment options was important when making care decisions, especially when they did not have adequate health care coverage: for example, "Since I often do not have health insurance, I would like to be aware of the most cost-effective means of treatment" (P174, USA, M, 36). This code was mentioned significantly more frequently by participants in Hong Kong (12.4%, "Need to consider the cost as well" P879, HK, M, 58) and the Philippines (7.3%, "Considering expenses" P915, PHIL) than in Australia (2.6%), and in Hong Kong (12.4%) more than the United States (3.8%), χ 2 (3, N = 1698) = 38.02, p < .001. In particular, participants in Hong Kong who chose to take the survey in Cantonese stated that knowing information about both "錢與療效 (cost and efficacy)" (P1699, HK, W, 23) was of high importance to them.
Speed of Recovery. The speed of recovery and convenience of treatment were also important to a small number of participants (2.7%), with participants in Hong Kong (5.8%) and the Philippines (4.5%) mentioning this category significantly more frequently than those in the United States (1.3%), χ 2 (3, N = 1698) = 21.71, p < .001. One participant said, "fast recovery is usually important for me because I never have time to be sick" (P7, HK, W, 19).

The Process of Making Decisions
SDM. Around 20% of the total sample described wanting a collaborative decision-making process with their doctor. This process included discussing their doctor's expert opinion and their experiences of their own body and needs before jointly making a decision. However, there were significant differences between countries, χ 2 (3, N = 1698) = 43.68, p < .001. Around 40% of participants in Australia stated that they desired SDM, which was significantly more than the 20% to 25% of those in the United States and Philippines. HK (10%) was significantly lowest. Some participants desired for the process to be fully collaborative, with equal input from doctor and patient, for example, "facilitate a model of joint decision making" (P960, AUS, M, 23) and "makes decisions with you, not for you" (P642, USA, M, 33). One participant described the collaborative process by stating, "tell me everything I need to know about my condition and treatment and collaborate with me on my choice of treatment" (P47, PHIL, W, 22). A few participants stated they desired for a trusted family member to have input in the collaboration: "A mix of doctor's advice, my current state and wants, and opinions of a trusted family member should be considered as well before decisions are made" (P867, USA, W, 20). Other participants desired collaboration that had more input from their doctor than from themselves. One participant stated, "Make sure it's the best option for my situation and make sure I am on board with it" (P928, USA, W, 20).
Doctor Decides. Instead of valuing autonomy and wanting their doctor to share power, around 10% of participants in each country wanted to be told what their diagnosis was, how to treat it, and how to prevent it. We found no significant differences across countries, χ 2 (3, N = 1698) = 2.91, p = .406. Responses from participants who wanted the doctor to direct care suggested a high trust in medical professionals, who were seen as experts, and a low need for control and decision-making power in their care. For example, "I think the doctor should make the decisions, not the patient" (P945, USA, W, 20). Participants often used verbs that suggested the patient viewed their role in medical consultation as a passive decision-maker whose job was to follow the doctor's guidance. For example, "告訴我我應該做什麼 (Tell me what I shall do)" (P1689, HK, W, 27). Here, the action verb "tell" is directive. Similarly, another participant in Hong Kong stated, "if the decision is made by professional doctors, I will follow" (P1164, HK, M, 25).

I Decide.
A smaller number of participants (8%) stated that they wanted to ultimately make the decisions in their health care. We found no significant difference across countries, χ 2 (3, N = 1698) = 4.60, p = .204. Some responses described a role for the doctor. For example, one participant said they wanted their doctor to "Give me the treatment I want, if they agree with my assessment" (P938, AUS, W, 25), suggesting the doctor may disagree. The doctor was often relegated to providing support in the process rather than being an active participant: "That decisions are made by me with all the information and support of medical staff" (P282, AUS, M, 30). Similarly, the doctor was seen as someone who provided information so that the patient could decide, rather than being an active participant in the process: Other responses more clearly positioned the patient as the person with ultimate power in most circumstances, with one also noting that doctors should not be able to overrule the patient: "Unless my decision is going to harm me (or others) in the long run, doctors should not be able to veto my decisions" (P584, USA, W, 20). Others focused on bodily autonomy, stating, ". . .at the end of the day you have autonomy over your body, and should you decide on something the doctor recommends against, you have every right to treat yourself as fit, even if it kills you" (P655, AUS, M, 24).

Discussion
This multinational, multilingual study explored three important and distinct facets of PCC: behaviors that people feel are important for their doctors, key considerations that people think are important when making decisions about their health care, and their preferences for how decisions are made. Our findings offer implications for health care delivery and our understanding of PCC by highlighting both similarities and differences in patient preferences across countries.
Notably, the majority of people from each country felt that being well informed was integral to the process of making decisions. Providing information was seen as central to the doctor's role. Having access to information about decisions was a minimum expectation for patients, especially in Hong Kong, where over three quarters of participants stated this in their responses. Wanting to be well informed when making decisions aligns with the vast body of literature across medical, bioethical, and psychological disciplines, which highlights the importance of patients engaging in informed decision-making and informed consent (e.g., Schenker et al., 2011). Being well informed has also been found to be important across cultures. For example, a study on patient-centered communication conducted in Nepal found that along with being treated in a friendly and respectful manner and having enough time (akin to our theme of listening actively), being fully informed was most important to patients attending an outpatient department in rural Nepal (Moore, 2008). Research also suggests that doctors underestimate patients' desire for information (Strull et al., 1984).
In contrast to responses from those in Hong Kong and the Philippines, responses from those in Australia and the United States were more varied and were more likely to mention specific doctor behaviors. About 30% to 40% of participants in Australia and the United States (compared with 12%-20% in Hong Kong and the Philippines) felt providing emotional support was an important part of the doctor's role and a quarter to a third (compared with 7%-10%) wanted the doctor to listen actively, suggesting that expectations of doctors are different across countries. Another example of this is the finding that 10% of those in the United States expected their doctor to advise on their lifestyle. Research has explored the importance of doctors encouraging emotional expression and patients' preferences for this in units such as neonatal intensive care units (Jones et al., 2018). However, our study and other studies conducted in non-Western countries suggest this is not universal. For example, in a study of PCC in Nepal, researchers found that patients did not expect to talk about their feelings or life more broadly in discussions about their health (Moore, 2008). More research is needed to understand differences in talking about feelings across cultures.
The expectation that doctors ask the patient questions was similar across countries. Although perhaps not surprising, this finding does indicate that patients across countries expect to be invited to interact by the doctor through questions. Conversely, the expectation that the doctor would allow them to ask questions differed significantly across the countries, with very few people in Hong Kong and the Philippines holding this expectation, compared with the 12% to 15% in Australia and the United States. Together, these findings raise questions about how people in different countries position themselves relative to their doctors and how they view their doctors. Although beyond the scope of this project, our findings suggest that participants in Hong Kong and Philippines may see themselves as less active participants, perhaps lower status, where they are primarily given information by the doctor and are, hopefully, asked questions to contribute to the consultation.  highlighted that communication skills training for patients and providers from countries where participation is less active can increase patient participation and involvement in health care decisions. However, even with coaching, Kim et al. (2003) found that patients felt it was important that explicit permission or endorsement be given by providers for patients to speak up and ask questions.
Consistent with Anglo-American medical ethics, we found that approximately a quarter of those in the United States felt doctor transparency and honesty were important compared with less than 10% of those in Hong Kong and the Philippines. This finding is consistent with research that suggests that in many parts of the world, the cultural norm is the protection of the patient from the truth (Brown et al., 2016). Aligning with this cultural norm, patients in some cultures may not expect transparency and honesty from their doctor. However, previous research has also suggested that even when patients want honesty and transparency from their doctors, the doctors from some cultures may be reluctant to provide information (Obeidat et al., 2013). Similarly, we found that participants wanted to know about their doctor's level of expertise. There is growing interest in the United States about how doctors honestly and transparently communicate medical uncertainty. For example, some research has found that openly communicating uncertainty about the best course of cancer treatment was associated with decreased decision satisfaction, particularly for those patients who were more involved in SDM (Politi et al., 2011). Participants particularly reported wanting to know their prognosis, stating this was important even if it was grim. Similar to communicating medical uncertainty, training on delivering bad news is common for medical professionals (e.g., Baile et al., 2016). We suggest future research should explore the tension between patients wanting honesty and transparency and, therefore, being exposed to dissatisfactory uncertainty.
Consistent with prior research that states that once both parties are aware that a decision needs to be made, SDM includes information exchange, deliberation and discussion about alternative options, and reaching agreement on a decision (Stiggelbout et al., 2015). Up to 40% of participants provided an example of something they felt must be considered when making a decision. The safety and efficacy of treatment were the most important consideration for participants in each country, although the proportion differed significantly across countries. Of note was that nearly 40% of participants in Hong Kong felt that the safety and efficacy of treatment were key considerations when making decisions, with other countries ranging from 14% to 18%. The cost of treatment was the second most common consideration for those in Hong Kong, which was something rarely mentioned in the United States and Australia (2%-4%). Although health care in Hong Kong is publicly available, many people turn to private providers to avoid long wait times, which may explain this finding. However, the lack of United States participants mentioning this, given the cost of treatment for un-or underinsured people, is somewhat surprising. Our data did not provide information about what type of cost was of concern (i.e., costs of prescriptions or other out-of-pocket costs), nor did we collect information about health insurance status.
The second most common consideration for those in the Philippines and Australia was how treatment would affect their lifestyle. Hong Kong and the Philippines were similar in their concern around recovery speed, perhaps linked to the financial impact of taking time off work. Australia and the United States were similar in their concern that decisions were made in their best interest, perhaps highlighting medical mistrust in these countries (Benkert et al., 2019). These results suggest that it is worthwhile for doctors to know what is most highly considered by their patients to target their use of their time with the patient. The different fears and concerns of people are likely related to the social and health systems in each country, although further research is needed to unpack this.
Of the 40% of participants who expressed preferences for how decisions were made, the majority expressed a preference for SDM. However, we again saw significant differences between countries, wherein only 26% of those in Hong Kong described a preference for how decisions were made. SDM was important to a third of participants in Australia and 20% to 25% of those in the Philippines and United States, but only 10% of those in Hong Kong. Previous research in Nepal and Japan has similarly shown that patients in non-Western countries are not as concerned with sharing power and control as patients in the United States (Alden et al., 2018;Moore, 2008).
Around 10% of participants wanted their doctor to decide on the treatment. Previous research investigating decisional control preferences has found that up to 20% of older culturally diverse patients in the United States prefer that doctors make their medical decisions (Chui et al., 2015). Given our sample was younger, our finding may indicate that preferences for a more patriarchal model of care are changing. However, as 60% of people did not mention decision-making processes in their response, our finding may be an underestimate, as we did not explicitly ask, "Who should make the medical decisions?" A physician-focused model of care is often positioned as the opposite of PCC and as out of date (Qidwai, 2003). However, the doctor providing traditionally paternalistic care because the patient has a low need for decisional control may be patient-centered if that is what the patient prefers for their provider to do. A critical question for medical practitioners is whether they employ a patriarchal model of care because it is their preferred style or change their style to match the patient's needs (as is intended with PCC, Eklund et al., 2019).

Limitations and Future Directions
We used open-ended questions that may have been interpreted differently across countries. Prior cross-cultural research with translated surveys has highlighted that the intended meaning does not always translate directly into different languages (Hunt & Bhopal, 2004). The variation in responses across countries may reflect different interpretations of the questions. Moreover, although open-ended questions access information that is most readily available to that person (and theoretically thus most important), different results may emerge if people respond to structured measures about the importance of behaviors. Second, we did not collect information about participants' health insurance coverage, which may affect their perceived decisional control and, therefore, their preferences. We also did not collect information about which participants were students with access to student health services. Third, although preferences varied considerably within countries, our study could not explore why. Further research should explore individual-, group-, and system-level factors influencing PCC and SDM preferences. We also acknowledge that both parties influence consultations between doctors and patients. As such, future research should examine patients in situ to explore the interplay between the parties. Finally, although understanding information about care preferences across countries could assist with receipt of higher quality care and, by extension, improved patient outcomes, our data did not focus on health disparities. Future work that collects data across countries could take a more focused approach to improve health care disparities by understanding patient preferences.

Conclusion
Our study explored the similarities and differences between what people from different countries felt was important when seeking care from their doctor. We found that most people expected doctors to provide information and engage in information exchange. However, expectations of what else the doctor would do varied considerably within and across countries. Given this variability, it is paramount that doctors practice true PCC that is culturally informed, whereby they adapt their style and manner of interacting to meet the patients' needs (Eklund et al., 2019). In being culturally informed, doctors should first examine their own culture and values, including assumptions they may hold, and reflect on how they affect the way they relate to others. Findings from this study highlight the variation of cross-country preferences and place the onus on doctors to consider whether their practice is truly patient-centered, rather than assuming that Westernized notions of PCC and SDM are favored by all.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.