Living in conditions of poverty increases the risk of developing chronic illness [1
]. People living in poverty are at greater risk of experiencing deteriorating health, of developing chronic illnesses and, consequently, of dying prematurely [3
]. Added to this is the fact that poor people are the least well-served in terms of health care services (inverse care law
]: they are among those least likely to have a family physician [7
], and they more often report having had unmet health needs, compared with people who are more well-off [8
]. Finally, they often have negative health care experiences and sometimes feel judged by the physicians who treat them [8
This last point is very important, because the quality of the therapeutic relationship between physicians and patients is a key factor in the effectiveness of care [10
]. In particular, a good therapeutic relationship contributes to patients' empowerment for the self-management of chronic illness. Unfortunately, physicians and people living in poverty inhabit very different social milieux, and this social distance hinders the development of a therapeutic alliance. On one hand, people living in poverty find it difficult to understand the language used by physicians, as well as their recommendations, which are often expressed in biomedical terminology [15
]. Conversely, physicians have a hard time understanding poor people and are frustrated when these patients do not follow their recommendations. This results in a negative attitude among physicians [17
], who tend to be more directive with these patients, spend less time with them, and give them less information on treatments[17
] Physicians also feel overwhelmed and ill-equipped in these consultations because these patients accumulate many health problems [21
In brief, it is difficult for physicians to establish good therapeutic relationships with their patients when there is a significant social divide between them. To overcome this social divide, physicians need "social competence". Social competence is a process based on knowledge, skills and attitudes that support effective interaction between the physician and the patient despite the intervening social distance. It enables physicians to better understand their patients' living conditions and to adapt care to patients' needs and abilities.
Physicians dealing with people living in poverty
The literature reports that physician behaviours vary according to patients' socio-economic status [24
]. Studies on physicians' experiences with low-income patients have generally concentrated on the influence on medical practice of patients' individual characteristics (e.g. attitudes, language, etc.) [25
]. In addition, physicians spend less time with low-income patients, give them less information, and put less effort into encouraging their compliance [17
]. They also experience frustration, which leads them to develop a negative attitude toward people living in poverty [21
Health professionals, particularly physicians, have very little understanding of their low-income patients' social situation. This lack of knowledge about poverty, as well as the mistaken perceptions of poverty held by health professionals, affects the quality of clinical interactions [25
]. According to a study conducted among residents in medicine, 25% thought that poverty was a consequence of laziness, 50% thought that the poor were more likely to abuse the health care system, and 50% thought that the poor were less attentive to their health than the rest of the population [26
]. Health care providers, who are close to patients' personal and day-to-day experiences, occupy an important position that has a major impact on people's lives [27
People living in poverty, dealing with physicians
According to a recent study, people who are vulnerable in terms of health and people who see themselves as poor tend to report less satisfactory health care experiences and more unmet needs [28
]. People with low incomes are particularly sensitive to physicians' attitudes and to what physicians say in medical consultations. They are more receptive to advice coming from their physician than from any other source (other professionals, media, brochures, etc.) [24
Recent studies report that poor patients feel stigmatized because of their social status and perceive a lack of sensitivity among health professionals regarding their living conditions [10
]. One of these studies, conducted among low-income Canadians, emphasized that the lack of empathy, compassion and respect they experienced from health care providers had a negative impact on their utilization of services [30
]. A recently published book of biographical accounts of women living in poverty reveals that these women, in addition to experiencing deterioration in their health, encountered a lack of understanding, of sensitivity, and of respect among some of their physicians [31
]. These women considered that inadequate health care (not having access to a physician's care and feeling judged during health care encounters) had exacerbated their health status. These data confirm the importance of providing physicians with the tools they need to adapt better to the needs of patients living in poverty.
Limitations of studies and of conceptual approaches
The majority of studies that have looked at relationships between physicians and patients present certain limitations. First, in terms of methodology, they are most often based on quantitative approaches [30
]. Using questionnaires can limit the ability to explore in depth certain avenues that can, however, be explored in detail by using qualitative interviews [22
]. In terms of theoretical perspective, few studies have looked at health care relationships as an interpersonal class process
]. Thus, according to Allman, theoretical models, and the studies based on them, do not allow for consideration of the whole picture within which health care is provided [35
]. Finally, to our knowledge, while there exist models and studies on cultural competence, to date there is no conceptual model on social competence.
Theoretical approach and conceptual model for social competence
One of this study's premises is to consider the physician-patient relationship as a tracer for the interpersonal experience of social class. Thus, physicians who look after people living in poverty encounter a social distance because they occupy a privileged and prestigious position in our society. As mentioned above, the literature indicates that this difference in social class creates relational difficulties not only for the physician but also for the patient. Our central research premise holds that these difficulties can be overcome by adequate care that requires a social competence process among physicians.
There is currently no model of the physician-patient relationship in a context of social differences, such as, for example, between physicians and people living on unemployment benefits, where the social distance is very great [22
]. Moreover, the growth in the phenomenon of cultural diversity in the United States has given rise to a proliferation of studies that have produced models of care in an intercultural context. Examples include Bennett's (1986) model of the development of intercultural sensitivity and, more recently, Campinha-Bacote's (2002) cultural competency model [37
]. Bennett's model has six levels (denial, defense, minimization, acceptance, adaptation, integration) for categorizing the physician's position according to his or her openness to taking cultural differences into account when treating a patient. Campinha-Bacote's model deals with cultural competence and has five dimensions: 1) cultural awareness; 2) cultural knowledge; 3) cultural skill; 4) cultural encounters; and 5) cultural desire. Cultural competence is conceived as a process that is acquired over time and with motivation. We have retained the model of Campinha-Bacote (2002) because of its relevance for the study of care processes where there are social class differences or a social distance.
We define social competence as a process based on knowledge, skills and attitudes that support effective interaction between the physician and patient despite the social distance that separates them. We take the five dimensions of Campinha-Bacote's cultural competence model and adapt them to the context of social difference: 1) social awareness; 2) social knowledge; 3) social skill; 4) social encounter; and 5) desire and motivation. Social awareness refers to the physician's consciousness of his class situation and of the prejudices and assumptions that exist about people living in poverty. Social knowledge includes acquiring, researching and obtaining information on social conditions, as well as on beliefs and values related to health. Social skill represents the capacity to adapt interventions in order to take into account the situations, needs and capacities of people on low incomes. Social encounter is the willingness to engage in a process of care with persons living in poverty. Finally, desire and motivation are affects (emotions) in the care process. They refer to the fact that the physician wants and is ready to engage in this care process in order to respond in a socially appropriate way to the needs of people coming from socially different circumstances.
Figure presents the model of the social competence process that we will use to guide our data collections. The diagram presents how social competence takes shape in the context of person-centred care. At the centre is social competence, which allows the physician to get closer to the patient. This competence makes it possible to narrow the social gap between them. This diagram includes the organizational and social environments and the larger social context that are part of the social factors that come into play in the provision of care. However, our study will be limited to examining those factors among physicians (i.e., professional ideologies, organizational context, social context).
Model of the social competence process (adapted from Campinha-Bacote, 2002; Stewart, 2003).
The aim of this project is to explore social competence among physicians providing primary care to people living in poverty. We want to understand the experience of physicians who provide care, on a daily basis, to people with low incomes who have at least one chronic illness. Our aim is to identify, from these physicians, the knowledge, skills and attitudes that support the social competence process.