Social and structural determinants and their associations with patient experience in the emergency department

Biomedicine and the treatment of difference in a Jerusalem emergency department

Biomedicine has played a key role in the dissemination of modern social norms, such as the emphasis on individual autonomy and the distinction between science and religion. This study examines the way the mostly-Jewish members of the medical staff at an emergency department of a Jerusalem hospital perceive Jewish ultra-Orthodox and Arab patients' behaviors vis-à-vis the existing biomedical norms. We analyzed participants' perceptions in terms of the social constructs they reveal, their meanings, and their implications. Semi-structured in-depth interviews were conducted with 24 staff members and were analyzed using content analysis. The staff described challenges in treating Arab and ultra-Orthodox patients, which they related to both groups' embeddedness in traditional "cultures" and collective identities. According to the participants, in both cases, the patients' cultural affiliations constrained their sense of individual autonomy and rationality. However, in the comparative analysis, two differences emerged. First, while both groups were perceived to diverge from modern norms of individual autonomy, in the case of Arab patients, these characteristics were presented as disruptive and potentially threatening to the hospital staff. By contrast, in the case of ultra-Orthodox patients, adherence to traditional and collective values was more likely to be represented as a risk to the patient, rather than to the staff. Second, staff were more likely to provide accommodations for ultra-Orthodox patients than for Arab patients. These accommodations were often described in the frame of "cultural competency." We suggest that divergences in how staff understood and responded to perceived cultural differences of each group reflect unequal impacts of structural determinants of health, including of political conflict. We recommend moving beyond the conceptual framework of cultural competency to strengthen the staff's structural competency, cultural and structural humility, and critical consciousness.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem

Background

A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance.

Methods

A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days.

Results

There were differences between Jewish and Arab patients’ social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty.

Conclusion

The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Neutrality, conflict, and structural determinants of health in a Jerusalem emergency department

BACKGROUND

Medical neutrality is a normative arrangement that differentiates a zone of medical treatment disconnected from the field of politics. While medical neutrality aims to ensure impartial healthcare for all and to shield the healthcare personnel from political demands, it can also divert attention away from conflicts and their effects on health inequity. This article analyzes how healthcare professionals understand and negotiate the depoliticized space of the emergency department (ED) through their views on neutrality. It also examines how medical staff use depoliticized concepts of culture to account for differences in the health status of patients from disadvantaged groups. These questions are examined in the context of the Israeli-Palestinian conflict.

METHODS

Twenty-four in-depth, semi-structured interviews were conducted with healthcare personnel in a Jerusalem hospital's ED. All but one of the participants were Jewish. The interviews were analyzed using qualitative content analysis and Grounded Theory.

RESULTS

The ED staff endorsed the perspective of medical neutrality as a nondiscriminatory approach to care. At the same time, some medical staff recognized the limits of medical neutrality in the context of the Israeli-Palestinian conflict and negotiated and challenged this concept. While participants identified unique health risks for Arab patients, they usually did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of cultural and behavioral differences. Culture served as a non-controversial way of acknowledging and managing problems that have their roots in politics.

CONCLUSIONS

The normative demand for neutrality works to exclude discussion of the conflict from clinical spaces. The normative exclusion of politics is a vital but under-appreciated aspect of how political conflict operates as a structural determinant of health. Healthcare personnel, especially in the ED, should be trained in structural competency. This training may challenge the neglect of issues that need to be solved at the political level and enhance health equity, social justice, and solidarity.