Family medicine viewed through the public lens: A national cross-sectional study in Lebanon

ABSTRACT

Background:

Family medicine (FM) is a medical specialty that provides continuing, comprehensive health care for the individual and the family. This study aimed to describe Lebanese citizens’ knowledge, attitudes, and practices toward FM as a specialty.

Methods:

This is a national cross-sectional phone-based survey targeting the knowledge of the public about FM and its scope of practice. Questions were asked whether participants had primary health care doctors and their specialties

Results:

A total of 373 participants were included, with a response rate of 85.2%. Two-thirds were aware of the specialty of FM, while only 16.6% of the participants had previously visited a family physician. Most participants (69.7%) had a doctor they regularly consulted. One-third of participants had a general practitioner as their regular doctor. More than 80% of the participants agreed that FM physicians treat all family members with common and chronic diseases. Around 60% to 75% of participants knew that family physicians provide medical care to children, treat patients with psychiatric impairments, and perform minor surgeries. There was a significant gap in the participants’ knowledge of FM physicians’ role in managing obstetric or gynecologic patients.

Conclusion:

Despite public awareness of FM, limited understanding and system challenges hinder its utilization in Lebanon. Educational campaigns, government-supported FM practices, and collaborations with public health initiatives are crucial to bridging the knowledge gap and establishing FM as the cornerstone of primary care. This knowledge gap challenges the specialty’s identity and necessitates promoting FM as the cornerstone of primary care, potentially requiring a system-wide endorsement.

Introduction

Primary health care offers health equity,[1] which leads to positive health outcomes[1] and provides cost-effective care.[2] Literature has shown that regular primary care visits are associated with regular participation in cardiovascular screening for hypertension, diabetes, and hyperlipidemia in low and higher socio-economic status communities.[3] Although the World Health Organization (WHO) has called for health systems reform in countries that do not adopt primary health care,[4] primary health care is still not the key element of many health care systems worldwide and specifically in Lebanon. Across different countries, primary health care is offered by many specialists, such as general practitioners, family medicine (FM) physicians, and internists.

As a specialty, FM struggles for a clear identity, which is an essential component of health system reorganization.[5] FM training in the European Union and the United States (US) requires a minimum of 3 years of postgraduate training.[6] In the Arab world, such as Lebanon, a general practitioner refers to a medical school graduate who enters clinical practice without advanced postgraduate training. In contrast, a family medicine physician is a medical doctor who has finished four years of postgraduate training in FM.[6]

While primary health care is essential to the health care systems, implementing these systems is quite challenging due to the suboptimal numbers of primary health care practitioners including FM physicians. Furthermore, fewer physicians choose FM as a career.[7] The relatively low number of FM specialists is a prevalent problem worldwide[8] and it is even more pronounced in the Arab region.[5,9] Lebanon was among the first Arab countries to develop an FM program at the American University of Beirut in 1979.[8,9] Currently, there are five FM residency programs in Lebanon, but the number of practicing FM physicians is still limited. According to a survey conducted in Lebanon in 2010, there were 96 family physicians practicing in all Lebanon. Of these, 98.2% received their FM degree from Lebanon, including 52.6% from the University of Saint Joseph and 45.6% from the American University of Beirut. Two-thirds (63.2%) practiced in an urban area, 7% in a rural area, and 29.8% in a mixed area.

While the attitudes of medical students, subspecialists, and FM residents as well as the perceptions of patients have been well studied[10,11,12,13] little is known about the public’s understanding. This study aims to describe the levels of knowledge, attitudes, and practices about the specialty of FM within one country in the Arab region, Lebanon, to help implementing a well-structured primary care model.

Materials and Methods

Study design

This is a national cross-sectional study performed in 2014 among Lebanese citizens using a phone-based survey to measure FM physicians’ knowledge, attitudes, and practices. The Institutional Review Board (IRB) committee at the American University of Beirut Medical Center received and approved the proposal. The IRB number is FAM.MR.03. We used the last edition of the Lebanese landlines phone directory published by the government to select telephone numbers in a systematic manner. The directory was stratified by the six districts of Lebanon: Beirut, Mount Lebanon, North Lebanon, South Lebanon, Nabatieh, and Bekaa. Contacting mobile phone numbers was excluded because it limited the number of participants from each district; it did not allow us to identify the district associated with the number. Every seventh number on the list was called, and the participant was asked if they would like to participate in the research. The following seventh telephone number was chosen if the phone call was not picked up. Phone calls were made between 5 PM and 8 PM on weekdays to contact the participants after returning from work, increasing the chance of reaching them at home. Inclusion criteria included Lebanese citizens 18 years and older, and exclusion criteria included eligible individuals who declined to partake in the survey. Informed consent was obtained verbally from all subjects.

Study subjects

A sample size of 360 participants was needed based on the assumption that 50% of the individuals would visit a family physician, with a margin of error of 5% and a confidence level of 95%; the sample was distributed equally among the six districts. This assumption will lead to the highest sample number-especially since we do not have similar studies in the literature for comparison. Our objective was to calculate a sample number associated with significant results.

Measurements

The phone-based survey included general demographics, knowledge about the FM specialty, and attitudes and practices toward visiting an FM physician. The survey’s questions were based on the definition of FM specialty and its scope of practice. The primary researcher, a FM resident at that time, completed the necessary CITI training course before conducting the research, built the questionnaire, and ran the phone calls.

Statistical analysis

The statistical package SPSS IBM23 was used. A descriptive analysis of the demographics was conducted using percentages for categorical variables. Bivariate analysis was conducted to assess the association between the participant’s knowledge about the specialty of FM and the various demographics using Chi-square. The cut-off value for significant differences was defined as a P value of <−0.05.

Results

A total of 438 people were contacted by phone. Of those, 373 participants answered the questionnaire [Table 1]. However, 65 people refused to participate in the study due to inconvenience or lack of interest. The sample included a good representation of all ages except the very young. The majority were females (70.4%). Almost one-third (35.4%) of the participants did not have any medical insurance [Table 1].

Table 1.

Demographic of the participants

Demographics	n 373 (100%)	P
Age		P<0.001
18–24	34 (9.2)
25–35	57 (15.4)
36–45	87 (23.6)
46–55	91 (24.7)
>65	100 (27.1)
Gender		P<0.001
Female	263 (70.4%)
Male	110 (29.6%)
Education		P<0.001
Illiterate	19 (5.1)
School	189 (50.9)
University	135 (36.4)
Postgraduate	14 (3.8)
Technical	14 (3.8)
Insurance		P<0.001
Private	51 (14.0)
Government-based	184 (50.5)
None	129 (35.4)
Employment		P=0.79
Unemployed	180 (49.3)
Employed	185 (50.7)
Place of residence		P<0.001
Village	80 (30.0)
Town	33 (12.4)
City	154 (57.7)
District		P=0.998
North	60 (16.1)
South	62 (16.6)
Mountain	65 (17.4)
Nabatieh	61 (16.4)
Bekaa	64 (17.2)
Beirut	62 (16.4)

Note: Values are presented as numbers and percentages (%). P value by Chi-square test

Two-thirds (63.3%) were aware of the FM specialty. They had heard about it from the media (44.7%), friends and relatives (36.9%), exposure to FM as part of living abroad (11.7%), other doctors (4.9%), or referrals from an insurance company (1.9%). Only 16.6% of the participants had visited an FM doctor in the past. The main reasons were the lack of knowledge about the specialty and the unavailability of FM physicians [Table 2]. Few participants (11.1%) preferred to visit a specialist. Participants proposed media and lectures when asked how to promote FM as a specialty.

Table 2.

Reasons for participants not visiting a family doctor (n=297)

Reasons	n (%)
No reachable family doctor in my residency area	63 (21.2)
I have my own doctor	61 (20.5)
I do not know what family medicine is	61 (20.5)
I do not have medical problems	47 (15.8)
I prefer a specialist	33 (11.1)
I do not need a family doctor	26 (8.8)
Others:	6 (2.1)
I think it is a luxury.
It is not a trend in Lebanon.
I dislike doctors

The participant’s knowledge of FM was assessed by several questions that address the broader scope of practice [Table 3]. More than 80% of the participants knew that FM physicians treat all family members for the most common illnesses and chronic diseases. To a lesser extent, 60% to 75% of participants were knowledgeable about the FM’s scope to provide medical care to children, treat patients with psychiatric impairments, and perform minor surgeries. There was a significant gap in the participants’ knowledge of FM physicians taking care of obstetric or gynecologic patients [Table 3].

Table 3.

Knowledge of Lebanese citizens about the scope of the practice of a family physician (n=103)

Feature of FM	Yes, n (%)	No, n (%)	Do not Know
Treat all family members	96 (93.2%)	7 (6.8%)	-
Treat 80% of common diseases	84 (83.2%)	16 (15.8%)	1 (1.0)
It deals with prevention	87 (86.1%)	11 (10.9%)	3 (3.0)
Treat chronic diseases	81 (80.2%)	17 (16.8%)	3 (3.0)
Treat most diseases and refer when needed	74 (73.3%)	27 (26.7%)	-
Follow up on children and vaccination	74 (74.0%)	22 (22.0%)	4 (4.0)
Do minor surgeries	63 (62.4%)	33 (32.7%)	5 (5.0)
Treat some psychiatric diseases	61 (60.4%)	34 (33.7%)	6 (5.9)
Deals with genetic diseases	63 (62.4%)	31 (30.7%)	3 (6.9)
Family medicine is not a specialty	60 (60.0%)	38 (38.0%)	2 (2.0)
Perform gynecological exam	27 (26.7)	68 (67.3%)	6 (5.9)
Perform pap smear	24 (23.8%)	71 (70.3%)	6 (5.9)
Insert intrauterine device (IUD)	13 (12.9%)	75 (74.3%)	13 (12.9)
Perform normal vaginal delivery	32 (32.3%)	62 (62.6%)	5 (5.1)
Follow up uncomplicated pregnancy	45 (45.0%)	46 (46.0%)	9 (9.0)

There was a positive association between knowledge of FM and age (P < 0.001), as well as the educational level (P < 0.001). There was an association between one’s understanding of FM and type of insurance (P < 0.001); 50.9% of those who had government-based insurance knew what FM was compared to 14% of those who had private insurance and 35.4% of those who did not have any insurance. People living in the city were more likely to know compared to those residing in towns and villages (P < 0.001) [Tables 1 and 3].

Most participants (69.7%) had a regular doctor they consulted for their medical care. Participants had as their primary care practitioner a general practitioner (33.3%), an internist (16.2%), a surgeon (8.8%), or an FM physician (7.2%). The choice of the regular doctor they visited was influenced by many reasons [Table 4]. The top reasons were trusting the physician’s medical expertise and having a good relationship. An association between the choice of the regular doctor and districts was found (Chi-square, P < 0.001). FM physicians were mainly chosen in the Beirut district. Surgeons, as traditional physicians, were familiar among the North and South districts. There was also an association between the choice of the regular doctor and age (Chi-square, P = 0.001). Participants 46 years of age and older were more likely to visit specialists than younger participants.

Table 4.

Reasons to choose a doctor as their regular doctor irrespective of his/her specialty (n=260)*

Reasons	n (%)
Trust his/her medical experience	151 (58.1)
Good relationship	101 (38.8)
Refer me to the right doctor	38 (14.6)
Easy accessibility	17 (6.5)
My relative	16 (6.1)
My problem is relevant to his/her specialty	13 (5.0)
Lesser fees	8 (3.1)
Others:
Short waiting time (2)	4 (1.5)
The popularity of the physicians (2)

*More than one answer was possible, so the total number does not add up to 100%

Discussion

This is a national study to explore Lebanese citizens’ knowledge, attitudes, and practices toward FM. Most of the participants knew of FM, only one-third knew what FM is, and very few had visited a family physician. Participants who were younger, more educated, and lived in cities were more likely to have heard of this specialty.

Despite the implementation of a network of primary care health care centers by the Lebanese government, universal health coverage is not provided. Therefore, the health care system is a free market where ambulatory care is managed by the unregulated and fragmented private sector.[14] In our study, only a minority of participants visited an FM doctor. This finding is aligned with previous literature about FM in Lebanon, which found that only 20% of the population visits family physicians.[14] The participants in this study visited a regular doctor irrespective of the physician’s specialty. Patients were more interested in having a good relationship with their physicians and benefiting from their medical expertise. Similarly, a comparison between patients in the US who visited Internal Medicine and those who visited FM physicians demonstrated that patients were not aware of the specialty of their physicians; what mattered most were the communication skills and exemplary care their physicians provided.[15]

Unlike Lebanon, many European countries and a selected few neighboring countries have implemented the primary care model. In Germany, the vast majority of the population (95%) had a regular doctor.[16] Although participants were knowledgeable about the FM physician’s scope as a comprehensive practitioner for acute and chronic conditions across all ages, only a minority of participants were aware that these physicians also managed gynecologic and obstetric patients[16] which is similar to our study. We think the variability in FM Physicians’ practice and preferences in dealing with obstetric and gynecological complaints influenced the public knowledge in Lebanon and similarly in Germany.

In Saudi Arabia where they have a primary care system the public experience is not positive and one-third of the population in one study reported that they will not seek care in primary care clinics and rather prefer to visit the emergency department which also emphasizes public awareness about FM is still wanting in the middle east region.[17] In India, however, has a very complex and variable health care system. A recent survey conducted in a private primary care clinic showed that patients had positive feedback regarding the doctors and care provided. They consider their family physicians as the first to contact, however, they seek specialist care in pediatrics, obstetrics issues, and complaints of chest pain.[18]

In Lebanon, patients do not see the FM physician as an exclusive physician. This has imposed a significant challenge to the widespread acceptance of FM practice unless the national health care system mandates it. Our results showed that knowledge about FM was positively associated with the participants’ education levels and that participants residing in cities were more likely to learn about FM than participants living in towns and villages. The latter finding could be related to the fact that most FM physicians in Lebanon were practicing in the urban area, reflecting public awareness and knowledge. The overall scarcity of family physicians in Lebanon is another important factor that we think plays a major role. In addition, the Lebanese health care system’s lack of FM physician utilization affects the public’s exposure to FM physicians.

The scarce knowledge about FM and insufficient access to this doctor in the participant’s place of residence were the most common reasons for not visiting an FM physician. These findings call for an imperative need to promote the scope of care of the FM physicians and their specialty, particularly amongst populations residing in rural areas with a low level of education. This goal can be achieved by structuring a government-based FM practice in these areas. The literature stresses the importance of innovative ways to promote the social image of FM physicians.[19] A study from Cuba’s FM-based health care system has shown that a developing country has achieved health outcomes like a developed country.[20,21,22] These findings make a case for an increased emphasis on FM in the Lebanese health care system. A nationwide continuing medical education (CME) pilot program was conducted in Lebanon to promote the image and principles of FM as a specialty.[23] The program ran over two years and fostered an image of skilled FM physicians. The expansion of these programs, coupled with an increase in awareness of the Lebanese public and medical community regarding FM practice, is necessary to solidify the primary care profession in Lebanon.[24] The low awareness and utilization of family medicine identified in the study can be a hurdle for FM physicians in establishing themselves as the cornerstone of primary care. These findings can guide FM physicians to improve the public understanding of family medicine through educational campaigns, collaborations with public health initiatives, or incorporating informational materials in waiting rooms.

Our study is the first study that addresses the population’s perspective on FM in all districts of Lebanon in a systematic manner. This study can provide a solid foundation for researching the topic further and taking additional steps toward involving more FM physicians to build up primary care in Lebanon. One limitation of the study is the fact that the medical history of the participants was not assessed; we think an inquiry about medical history that is chronic diseases may be an important line of questioning that should have been included in the survey that may affect the population knowledge about FM and/or visiting a family physician.

Conclusion

This study explored Lebanese citizens’ understanding of FM and revealed a critical gap between public awareness and utilization. While a majority had heard of FM, only a small portion actively sought care from family physicians. Factors like education level, location, and health care system structure contributed to this disparity. Our findings highlight the need for a multi-pronged approach to strengthen FM in similar health care systems such as public awareness campaigns, educational materials in health care settings, and partnering with public health programs to promote FM and its benefits. Unless health care systems endorse a mandatory primary care approach, the FM specialty will continue to suffer from an identity crisis.

Abbreviations

FM = Family medicine

US = United States

WHO = World Health Organization

CME = Continuing medical education program

IRB = The Institutional Review Board

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.