Physician experiences and barriers to addressing the social determinants of health in clinical care in the Eastern Mediterranean Region

Introduction: It has been increasingly recognized that social determinants can impact the health of patients and populations. Although there are a growing number of publications and studies about this topic in industrialized countries, relatively little is published in the Eastern Mediterranean Region. In particular, there is little known about how physicians in this region can help to address the underlying social causes of poor health of their patients. The objectives of this study are: 1) To identify common social challenges faced by patients in Eastern Mediterranean countries, 2) To assess what doctors are already doing to address these challenges, 3) To identify barriers and facilitators for addressing the social causes of poor health in the clinical encounter, and 4). To explore the main similarities and differences between doctors' experiences in Eastern Mediterranean countries as compared to the Canadian context where social accountability is increasingly emphasized in medical education and accreditation standards of health care institutions. Methods: We conducted a qualitative research study employing a qualitative descriptive methodology. A maximum variation purposive sampling approach was used to recruit physicians with a wide range of age groups, genders, countries of origin, types of clinical practice and years since training. A snowball technique was also used to identify additional participants. Recruitment continued until data saturation was reached. In total, semi-structured in-depth interviews were carried out with 18 doctors who were trained in Eastern Mediterranean countries but have since moved to Canada. In this way, all study participants had in-depth understanding and practical clinical experience as health professionals in the Eastern Mediterranean Region, as well as an awareness of the Canadian health care system and context. All interviews were conducted in English, whether in person or over the phone, and transcribed verbatim. A conventional content analysis was used to analyze the data.Results: According to study respondents, the main social challenges of patients in the Eastern Mediterranean Region include poverty, illiteracy, domestic violence, unstable families, and food insecurity. Doctors there have attempted to help their patients by providing free medical services and free medications, establishing a donation box for underprivileged patients and referring to social workers, where available. Barriers to addressing social determinants in this context include cultural constraints, lack of time, unfamiliarity or unavailability of social support organizations, shortages of family doctors, and lack of formal training in how to address social determinants of health. Study participants acknowledged that Canadian health care providers have greater access to a wide range of social support resources, a better developed social security network for patients living with disadvantage, and increasingly more training and awareness about the social determinants of health and social accountability role than in their countries of origin. Conclusions: Most study participants expressed their willingness to help patients in dealing with social challenges, and shared their experiences of tackling such issues, though there were also important barriers reported that would need to be overcome. Participants suggested that better addressing social challenges in clinical care within the Eastern Mediterranean context would require educating both doctors and patients about the importance of discussing the patient's social environment as part of the clinical encounter, as well as advocating for broader policy approaches by governments to address the underlying structural causes of widespread social challenges.

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