{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T23:18:30Z","timestamp":1791328710824,"version":"4.3.1"},"reference-count":56,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T00:00:00Z","timestamp":1785974400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Ministry of Health and Welfare of Republic of Korea","award":["RS-2023-KH142275"],"award-info":[{"award-number":["RS-2023-KH142275"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Shared decision making (SDM) is fundamental to patient-centered care, yet dominant frameworks have been developed within dyadic patient\u2013provider models grounded in Western individualistic assumptions. Prior research from East Asian, Sub-Saharan African, and Latin American contexts has documented that medical decision making is frequently family-centered and that caregivers function as recognized actors in clinical encounters. Building on this evidence base, this study examines how caregiver participation is enacted and constrained within the Korean chronic care context, contributing a multilevel reinterpretation rather than a discovery of caregiver involvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted four semi-structured focus group interviews between June and September 2024 with 20 family caregivers of patients diagnosed with hypertension, diabetes mellitus, chronic kidney disease requiring dialysis, or heart disease. Disease-specific groups were formed to enable contextually grounded discussion. Participants were recruited through a Seoul-based research agency and were, on average, highly educated. Using inductive qualitative content analysis, we identified key themes and interpreted the findings through the Social-Ecological Model. Interviews were conducted in Korean, and selected quotations were translated by bilingual researchers through consensus-based reconciliation. Analytic adequacy was assessed in terms of thematic sufficiency.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>At the individual level, caregivers experienced emotional strain and decision-related uncertainty, prompting self-directed information seeking. At the interpersonal level, participation was shaped by hierarchical communication with physicians and role-based constraints with nonphysician staff. At the organizational level, fragmented care pathways and standardized information formats constrained access to guidance. At the societal level, culturally embedded deference to medical authority and normalized expectations of family responsibility framed involvement as obligation rather than a formally recognized role. Caregivers simultaneously described aspirations for participatory legitimacy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Consistent with prior non-Western literature, caregiver involvement is not exceptional but routine; the contribution lies in jointly examining the individual, interpersonal, organizational, and societal conditions through which involvement is simultaneously expected and constrained.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0353308","type":"journal-article","created":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T17:44:51Z","timestamp":1786038291000},"page":"e0353308","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Whose voice counts? Family caregivers\u2019 roles in shared decision making for chronic illness in urban South Korea: A qualitative study"],"prefix":"10.1371","volume":"21","author":[{"given":"Go Eun","family":"Bae","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-1585-7744","authenticated-orcid":true,"given":"Jinyoung","family":"Lee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9030-1365","authenticated-orcid":true,"given":"Sang-Ho","family":"Yoo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2265-4753","authenticated-orcid":true,"given":"Sou 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(or it takes at least two to tango)","volume":"44","author":"C Charles","year":"1997","journal-title":"Soc Sci Med"},{"issue":"10","key":"pone.0353308.ref022","doi-asserted-by":"crossref","first-page":"1361","DOI":"10.1007\/s11606-012-2077-6","article-title":"Shared decision making: a model for clinical practice","volume":"27","author":"G Elwyn","year":"2012","journal-title":"J Gen Intern Med"},{"key":"pone.0353308.ref023","doi-asserted-by":"crossref","first-page":"1729","DOI":"10.1200\/GO.20.00306","article-title":"Parent Engagement and Agency in Latin American Childhood Cancer Treatment: A Qualitative Investigation","volume":"6","author":"MF Olarte-Sierra","year":"2020","journal-title":"JCO Glob Oncol"},{"issue":"7","key":"pone.0353308.ref024","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1177\/0269216313486953","article-title":"A multicenter survey of Hispanic caregiver preferences for patient decision control in the United States and Latin America","volume":"27","author":"S Yennurajalingam","year":"2013","journal-title":"Palliat Med"},{"key":"pone.0353308.ref025","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2018-0516J","article-title":"Cross-cultural Interactions and Shared Decision-making","volume":"142","author":"SF Derrington","year":"2018","journal-title":"Pediatrics"},{"key":"pone.0353308.ref026","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1186\/s13012-016-0480-9","article-title":"Implementing shared decision-making: consider all the consequences","volume":"11","author":"G Elwyn","year":"2016","journal-title":"Implement Sci"},{"issue":"1","key":"pone.0353308.ref027","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1186\/s13012-021-01142-y","article-title":"Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review","volume":"16","author":"A Waddell","year":"2021","journal-title":"Implement Sci"},{"issue":"11","key":"pone.0353308.ref028","doi-asserted-by":"crossref","first-page":"100586","DOI":"10.1016\/j.apjon.2024.100586","article-title":"When western concept meets eastern culture: Exploring the impact of Confucianism on shared decision-making in China","volume":"11","author":"M Meng","year":"2024","journal-title":"Asia Pac J Oncol Nurs"},{"key":"pone.0353308.ref029","article-title":"Social policy preferences in South Korea: individual and family-related perspectives [doctoral dissertation]","author":"M Lee","year":"2020","journal-title":"Oxford: University of Oxford"},{"key":"pone.0353308.ref030","article-title":"Medical service experience survey (in Korean). Sejong: Ministry of Health and Welfare and Korea Institute for Health and Social Affairs","author":"H Lee","year":"2023"},{"issue":"6","key":"pone.0353308.ref031","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1215\/03616878-2007-040","article-title":"Family caregivers: a shadow workforce in the geriatric health care system?","volume":"32","author":"A Bookman","year":"2007","journal-title":"J Health Polit Policy Law"},{"key":"pone.0353308.ref032","unstructured":"Korea Disease Control and Prevention Agency. 2024 status and issues of chronic diseases (in Korean). Cheongju: Korea Disease Control and Prevention Agency. 2024. https:\/\/www.kdca.go.kr\/board\/board.es?mid=a20501010000&bid=0015&act=view&list_no=726772"},{"key":"pone.0353308.ref033","unstructured":"National Health Insurance Service, Health Insurance Review & Assessment Service. 2024 national health insurance statistical yearbook. Wonju: NHIS and HIRA; 2025. https:\/\/www.hira.or.kr\/bbsDummy.do?pgmid=HIRAA020045020000&brdScnBltNo=4&brdBltNo=2322"},{"issue":"4","key":"pone.0353308.ref034","doi-asserted-by":"crossref","first-page":"1878","DOI":"10.1111\/jan.14726","article-title":"Shared decision-making in dialysis choice has potential to improve self-management in people with kidney disease: A qualitative follow-up study","volume":"77","author":"J Finderup","year":"2021","journal-title":"J Adv Nurs"},{"issue":"7","key":"pone.0353308.ref035","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1037\/0003-066X.32.7.513","article-title":"Toward an experimental ecology of human development","volume":"32","author":"U Bronfenbrenner","year":"1977","journal-title":"Am Psychol"},{"issue":"3","key":"pone.0353308.ref036","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1177\/1090198111418634","article-title":"Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions","volume":"39","author":"SD Golden","year":"2012","journal-title":"Health Educ Behav"},{"key":"pone.0353308.ref037","doi-asserted-by":"crossref","first-page":"1483758","DOI":"10.3389\/frhs.2025.1483758","article-title":"Facilitators and barriers in managing older chronic heart failure patients in community health care centers: a qualitative study of medical personnel\u2019s perspectives using the socio-ecological model","volume":"5","author":"Y Lou","year":"2025","journal-title":"Front Health Serv"},{"issue":"1","key":"pone.0353308.ref038","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1111\/1467-9566.ep11347023","article-title":"The methodology of focus groups: the importance of interaction between research participants","volume":"16","author":"J Kitzinger","year":"1994","journal-title":"Sociol Health Illn"},{"key":"pone.0353308.ref039","first-page":"159","article-title":"Focus groups: method or madness?","volume-title":"Challenge and Innovation","author":"J Kitzinger","year":"2013"},{"key":"pone.0353308.ref040","unstructured":"Statistics Korea. 2023 Income (earnings) of wage and salary employment. Daejeon: Statistics Korea. 2025. https:\/\/mods.go.kr\/board.es?mid=a10301010000&bid=11113&act=view&list_no=435195"},{"issue":"9","key":"pone.0353308.ref041","doi-asserted-by":"crossref","first-page":"1277","DOI":"10.1177\/1049732305276687","article-title":"Three approaches to qualitative content analysis","volume":"15","author":"H-F Hsieh","year":"2005","journal-title":"Qual Health Res"},{"key":"pone.0353308.ref042","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.nedt.2017.06.002","article-title":"Methodological challenges in qualitative content analysis: A discussion paper","volume":"56","author":"UH Graneheim","year":"2017","journal-title":"Nurse Educ Today"},{"key":"pone.0353308.ref043","volume-title":"The discovery of grounded theory: strategies for qualitative research","author":"BG Glaser","year":"1967"},{"key":"pone.0353308.ref044","article-title":"Criteria for assessing naturalistic inquiries as reports. Paper presented at: Annual Meeting of the American Educational Research Association","author":"YS Lincoln","year":"1988","journal-title":"New Orleans, LA"},{"issue":"1","key":"pone.0353308.ref045","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1177\/1525822X05279903","article-title":"How many interviews are enough? 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