BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.
Med Educ. 2013 May;47(5):485-94. doi: 10.1111/medu.12132.
Intersecting social determinants of health constrain access to care and treatment adherence among homeless populations. Because clinicians seldom receive training in the social determinants of health, they may be unprepared to account for or address these factors when developing treatment strategies for homeless individuals.
This study explored: (i) clinicians' preparedness to provide care responsive to the social determinants of health in homeless populations, and (ii) the steps taken by clinicians to overcome shortcomings in their clinical training in regard to the social determinants of health.
Qualitative interviews were conducted with doctors (n = 6) and nurses (n = 18) in six Canadian cities. Participants had at least 2 years of experience in providing care to homeless populations. Interview transcripts were analysed using methods of constant comparison.
Participants highlighted how, when first providing care to this population, they were unprepared to account for or address social determinants shaping the health of homeless persons. However, participants recognised the necessity of addressing these factors to situate care within the social and structural contexts of homelessness. Participants' accounts illustrated that experiential learning was critical to increasing capacity to provide care responsive to the social determinants of health. Experiential learning was a continuous process that involved: (i) engaging with homeless persons in multiple settings and contexts to inform treatment strategies; (ii) evaluating the efficacy of treatment strategies through continued observation and critical reflection, and (iii) adjusting clinical practice to reflect observations and new knowledge.
This study underscores the need for greater emphasis on the social determinants of health in medical education in the context of homelessness. These insights may help to inform the development and design of service-learning initiatives that integrate understandings of the social determinants of health, and thus potentially improve the readiness of clinicians to address the complex factors that shape the health of homeless populations.
健康相关社会决定因素会限制无家可归人群获得医疗服务和治疗依从性。由于临床医生在健康相关社会决定因素方面接受的培训很少，因此，在为无家可归者制定治疗策略时，他们可能无法考虑或解决这些因素。
本研究探讨了：（i）临床医生准备为无家可归人群提供响应健康相关社会决定因素的护理的情况，以及（ii）临床医生为克服其临床培训中健康相关社会决定因素方面的不足而采取的措施。
在加拿大六个城市对医生（n=6）和护士（n=18）进行了定性访谈。参与者至少有 2 年为无家可归人群提供护理的经验。使用恒定性比较方法分析访谈记录。
参与者强调了他们在首次为该人群提供护理时，不准备考虑或解决影响无家可归者健康的社会决定因素的情况。但是，参与者认识到必须解决这些因素，以便将护理置于无家可归的社会和结构背景下。参与者的描述表明，体验式学习对于提高响应健康相关社会决定因素的护理能力至关重要。体验式学习是一个持续的过程，包括：（i）在多个环境和背景下与无家可归者接触，为治疗策略提供信息；（ii）通过持续观察和批判性反思评估治疗策略的效果，以及（iii）调整临床实践以反映观察结果和新知识。
本研究强调了在无家可归背景下，医学教育中更加重视健康相关社会决定因素的必要性。这些见解可能有助于为服务学习计划的制定提供信息，这些计划整合了对健康相关社会决定因素的理解，从而有可能提高临床医生解决影响无家可归人群健康的复杂因素的准备程度。
