Exploring social determinants of health in a Saudi Arabian primary health care setting: the need for a multidisciplinary approach.

BACKGROUND: Action on social determinants of health (SDH) in primary health care settings is constrained by practitioners, organizational, and contextual factors. The aim of this study is to identify barriers and enablers for addressing SDH in clinical settings in Saudi Arabia, taking into consideration the influence of local cultural and social norms, to improve care and support for marginalized and underserved patients. METHODS: We conducted a qualitative study involving individual in-depth interviews with a sample of 17 primary health care physicians purposefully selected based on the inclusion criteria, as well as a focus group with four social workers, all recruited from King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. All interviews were audio-recorded, translated from Arabic to English, transcribed verbatim, and analyzed using thematic analysis following a deductive-inductive approach. RESULTS: According to study participants, financial burdens, challenges in familial dynamics, mental health issues and aging population difficulties were common social problems in Saudi primary health care. Action on SDH in primary care was hindered by 1) lack of physician knowledge or training; 2) organizational barriers including time constraints, patient referral/follow up; 3) patient cultural norms and 4) lack of awareness of physician's role in managing SDH. Enablers to more socially accountable care suggested by participants includes: 1) more education and training on addressing SDH in clinical care; 2) organizational innovations to streamline identification of SDH during patient encounters (e.g. case finding questionnaire completed in waiting room); 3) better interprofessional coordination and clarification of roles (e.g. when to refer to social work, what support is provided by physicians); 4) identifying opportunities for broader advocacy to improve living conditions for marginalized groups. CONCLUSION: Enabling more socially accountable care requires a multipronged approach including leadership from the Ministry of Health, hospital administrations and medical schools. In particular, there is a need for: 1) training physicians to help patients in navigating social challenges; 2) improving clinical/administrative interprofessional teams, 3) mobilizing local communities in addressing social challenges; and 4) advocating for intersectoral action to prevent health inequities before they become more complex issues presenting to clinical care.

Physician experiences and barriers to addressing the social determinants of health in the Eastern Mediterranean Region: a qualitative research study.

BACKGROUND: While it is increasingly recognized that social determinants influence the health of patients and populations, little is known about how doctors in the Eastern Mediterranean Region can help their patients with these issues. Our study aimed to identify common social challenges faced by patients in Eastern Mediterranean countries, to assess what doctors are already doing to address these challenges, and to identify barriers and facilitators for addressing the social causes of poor health in Eastern Mediterranean countries with shedding some light on how does this compare to a developed country like Canada. METHODS: We conducted a qualitative research study employing qualitative descriptive methodology. A purposeful sample as well as snowballing technique were used to recruit 18 physicians who were trained in Eastern Mediterranean countries but have since moved to Canada. Recruitment continued until data saturation was reached. A content analysis was carried out after transcribing the interviews. RESULTS: The main social challenges identified in clinical care in Eastern Mediterranean Regions include poverty, illiteracy, domestic violence, and food insecurity. Doctors attempted to help their patients by providing free medical services and free medications, establishing a donation box, and referring to social workers and support services, where available. Cultural constraints, lack of time, and unavailability of referral resources were often cited as important barriers. Our participants stated that Canada is generally better in dealing with the social challenges than 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 would require educating both health care providers and patients about the importance of discussing the patient's social environment as part of the health care encounter, as well as advocating for broader policy approaches by governments to address the underlying social problems.

St John's wort or sertraline? Randomized controlled trial in primary care.

OBJECTIVE: To compare the change in severity of depressive symptoms and occurrence of side effects in primary care patients treated with St John's wort (SJW) and sertraline. DESIGN: Double-blind, randomized 12-week trial. SETTING: Community-based offices of 12 family physicians practising in greater Montreal, Que. PARTICIPANTS: Eighty-seven men and women with major depression and an initial score of > or = 16 on the Hamilton Rating Scale for Depression (Ham-D). INTERVENTIONS: Patients were randomized to treatment with either sertraline (50 to 100 mg/d) or SJW (900 to 1800 mg/d) in a double-blind fashion. Assessment of depression was done at entry and at 2, 4, 8, and 12 weeks using the Ham-D, the Beck Depression Inventory (BDI), and a questionnaire asking about compliance and side effects. MAIN OUTCOME MEASURES: Changes from baseline in Ham-D and BDI scores and self-reported side effects. RESULTS: There were no important differences in changes in mean Ham-D and BDI scores (using intention-to-treat analysis), with and without adjustment for baseline demographic characteristics, between the two groups at 12 weeks. Significantly more side effects were reported in the sertraline group than in the SJW group at 2 and 4 weeks' follow up. CONCLUSION: The more benign side effects of SJW make it a good first choice for this patient population.