title: Learning to account for the social determinants of health affecting homeless persons.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada. rmcneil@cfenet.ubc.ca
authors.forename: Ryan
authors.initials: R
authors.lastname: McNeil
authors.forename: Manal
authors.initials: M
authors.lastname: Guirguis-Younger
authors.forename: Laura B
authors.initials: LB
authors.lastname: Dilley
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Turnbull
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Hwang
mesh_terms: D001291:Attitude of Health Personnel; D002170:Canada; D002983:Clinical Competence / Q000592:standards; D006282:Health Personnel / Q000193:education; D006297:Health Services Accessibility; D054624:Health Status Disparities; D006703:Ill-Housed Persons; D006801:Humans; D018794:Problem-Based Learning; D011364:Professional Practice; D011369:Professional-Patient Relations; D020377:Self Efficacy; D011795:Surveys and Questionnaires