Abstract
Background Family medicine (FM), often known as general practice, is the foundation of sustainable and universal healthcare worldwide. As a new specialty in the Eastern Mediterranean Region (EMR), it must recruit doctors and gain public acceptability, which has traditionally favoured specialists.
Aim This research examined studies on Arab populations' attitudes towards FM to discover the barriers to creating and embracing this vital specialty.
Design & setting This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and encompassed peer-reviewed articles from reputable sources such as PsycNet, Web of Science, PubMed, Embase, Scopus, and grey literature.
Method A comprehensive search was conducted across databases for peer-reviewed studies that explored Arabs' awareness, perceptions, and attitudes towards FM and physicians.
Results After a rigorous selection process, 19 studies were deemed suitable for analysis. These studies encompassed diverse participants, including medical students, physicians, patients, and the general public. The overall perception of FM was positive, but it was noted that few had direct exposure to family physicians during their medical education or in the clinical setting.
Conclusion Our review findings suggest the following five recommendations: (1) an education campaign for the general public about the role of FM; (2) increasing training capacity for family physicians; (3) early exposure to family physicians during medical school; (4) developing a process for continually improving the education and quality of family physicians; and (5) further research on the challenges to FM practice in Arab countries to understand the situation better and work toward its improvement.
How this fits in
Historically, the public and medical students in the Eastern Mediterranean Region (EMR) have favoured care from specialists. As a new specialty in EMR, family medicine (FM) must recruit medical students and residents to choose the specialty. The public must understand the value FM adds to health care. To expand the acceptability of FM by these populations, this review suggests the following: (1) an education campaign for the general public; (2) increasing training capacity for family physicians; (3) early exposure to family physicians during medical school; (4) developing a process for continually improving the education and quality of family physician practice so that they can incorporate the rapid changes in science into the care they provide; (5) further research.
Introduction
Family medicine (FM), often known as general practice in some countries, is the basis of healthcare systems worldwide. It is regarded as the first point of contact for comprehensive, continuous, and coordinated community-based practice that ensures healthcare quality and equity.1 FM is a specialty in primary health care (PHC) and is considered a cornerstone of a sustainable health system. FM cares for all ages, addressing preventive care and managing chronic illnesses. PHC is the most inclusive, effective, and efficient way to improve people’s physical and mental health and social wellbeing.2 Most countries incorporate the FM specialty into their PHC as populations age and face considerable ongoing lifestyle, equity, and chronic illness concerns.3
FM is a relatively new discipline in low-income countries. A period of expansion followed, which included the addition of community practices, medical school courses, residency programmes, and organisational adaptations to empower PHC as early as the 1970s.4 In the Eastern Mediterranean Region (EMR), FM started in the early 1980s and has advanced slowly in most Arab countries compared with other clinical medical specialties.5 A review of FM in 22 countries of the EMR between 2014 and 2016, which was conducted by the World Health Organization (WHO), found that family practice is included in the national health policies of 16 countries (72%), with 13 countries planning to expand it. The review revealed a severe lack of family physicians in the EMR, requiring immediate action. The population density of family physicians ranges from 1.84 per 10 000 to 0.31 per 100 000, significantly below WHO standards, and the production of family doctors fluctuates despite relatively solid political support for family practice programmes.6 The scarcity of doctors to fill open positions has shifted the focus of political and media attention to FM.7 It’s worth noting that most of the doctors providing PHC in the EMR are GPs, representing medical doctors (MDs) who have graduated from medical school and completed a rotating hospital-based internship without any further residency programme in FM.
Ignoring the value of FM and its importance to the rest of the health system and society impedes FM development. FM is gaining recognition in some Arab countries but also confronting specific challenges, such as the dominance of specialist care, varying levels of awareness about the role of family physicians, and differing perceptions of primary healthcare quality.5 Other issues include low professional prestige for family physicians, detrimental policies, and apparent signs of discrimination.8 Population-based initiatives effectively bring about social change against FM discrimination and support the importance of such medical practice to the community.9
Numerous studies have focused on primary care and family physicians, highlighting their benefits and impact.10 Patients tend to bypass PHC centres in favour of specialised medical centres and tertiary institutions, even when it may not be necessary.11 The Arab population has preferred specialised care over FM, possibly owing to a perceived lack of trust in FM physicians' knowledge and competence.12,13
The accessibility of reliable information regarding the Arab community’s awareness and perception of FM as an integral component in PHC may be limited owing to many factors. Generally, funding and research priorities dictate the extent of an investigation. In addition, government regulations and privacy concerns may limit data accessibility, particularly at the community level. Access to comprehensive data on community attitudes may consequently be impeded. Moreover, Arab communities exhibit remarkable diversity, which is evident in the variations observed in socioeconomic status, healthcare systems, and cultural practices. This diversity must be accounted for in research if a comprehensive understanding is to be attained; however, this can present logistical challenges. This research aimed to examine studies investigating community perceptions of FM in Arab countries to identify obstacles that hinder the development and adoption of this crucial practice in Arab countries.
Method
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.14 A search of the PROSPERO database revealed no prior protocol for this review.
Eligibility criteria
Inclusion criteria included all published, peer-reviewed, and any language research between database inception and 20 April 2024. The sample population was mandated to consist of individuals from the Arab community, irrespective of their occupation, which could include medical students and dental students, among others. The review included publications reporting the awareness of, perceptions of, and attitudes towards FM and family physicians in the following Arab countries: Egypt; Bahrain; Iraq; Jordan; Kuwait; Lebanon; Libya; Morocco; Oman; Saudi Arabia; Sudan; Syria; Tunisia; United Arab Emirates; Yemen; Algeria; occupied Palestinian territories; Sudan; Republic of the Sudan; Mauritania; and Comoros Islands. Observational studies (cross-sectional, cohort, and case-control), qualitative designs, and systematic reviews were all included in the search. The article was required to be a primary study or research report. Abstracts and posters were used, but editorials, commentaries, and books were excluded.
Search strategy
An electronic search was undertaken of PubMed, Embase, Web of Science, Scopus, and PsycNet to identify all relevant studies published in peer-reviewed journals. No restrictions were imposed on the language search. Grey literature was examined by locating FM-related organisations in the region and checking their websites for answers to our study topic. The keywords 'Physicians”, “Family”, 'Family Practice', ”General Practice”, “Awareness”, “Attitude”, “Perception”, ”Public Opinion”, “Egypt”, “Bahrain”, “Qatar”, “Iraq”, “Jordan”, “Kuwait”, “Lebanon”, “Libya”, “Morocco”, “Oman”, ”Middle East“, “Saudi Arabia”, “Sudan”, “Syria”, “Syrian Arab Republic”, “Tunisia”, “United Arab Emirates”, “Yemen”, “Algeria”, “West Bank”, “Palestine”, “Gaza strip”, “Sudan”, “republic of the Sudan”, “Mauritania”, and “Comoros Island”, were combined using Boolean operators ('AND' and 'OR').
Eligibility screening
Article details were imported into Mendeley, exported to Covidence (https://www.covidence.org), and duplicates removed. Two authors (BM, ZN) independently screened all titles, abstracts, and articles according to the eligibility criteria; disagreements were resolved by consensus between the two authors.
Data collection process
A comprehensive codebook was developed as per Cooper guidelines.15 Two authors (BM, ZN) extracted data from eligible studies. Categories of coded variables included study identification, research design, funding, source of the article, population features (target population, location, sample size, response rate of surveys), outcomes (the perceptions of the Arab community regarding FM, family practice, and PHC practice in the Arab World, Arab community understanding of the role of the family physician, and the Arab community attitude towards family practice and the FM specialty.
Risk of bias
Two investigators independently assessed the methodological quality of each included cross-sectional study using a quality assessment tool for cross-sectional studies.16 Any disagreement on the quality assessment checklist was resolved by consultation with a third reviewer. The evaluation instrument assessed the sample’s representativeness, sample size and technique, non-response bias, and the acceptability of the measurement instrument. The total score ranged between 0 and 9. Studies scoring 0–3 points were deemed to have a low risk of bias, whereas studies scoring 4–6 points were considered moderate, and studies scoring 7–9 points were deemed to have a high risk of bias. The overall quality of the study was classified as high, moderate, or low.
Qualitative study assessment
The qualitative studies were assessed using a qualitative quality assessment instrument. The present tool was sourced from Hawker et al's research17and consists of nine questions that can each be answered 'good', 'fair', 'poor', or 'very poor'. After using the tool on the studies, we converted the results into a numerical score by giving the answers a range of 1 (very poor) to 4 (good) points. Each study resulted in a minimum of nine points and a maximum of 36 points. The scores correspond to 30–36 points for high quality, 24–29 for medium quality, and 0–19 for low quality.
Data extraction
A data extraction form was created to collect the information required for data synthesis. Pilot tests were carried out before the implementation of this form. Two reviewers extracted the data and analysed it to attain a deeper understanding of the participants' viewpoints toward family medicine, which varied depending on the study’s objectives, ranging from patient satisfaction in centres run by family doctors versus centres run by a GP; and a medical doctor with no formal training in FM to medical students' knowledge and awareness of FM as a specialty. The findings were presented in two separate tables, the first of which included the titles, country of study, goal and study design, sample size, and time of study execution, as well as the net quality. The second represented the study’s inclusion criteria and the study’s outcome. For this paper, FM refers to physicians specialising in FM, and GPs are medical school graduates who complete a year of rotating hospital clerkships without training in FM.
Results
As shown in the data presented in Figure 1, the searched databases yielded 4505 studies and 4480 studies were screened following the removal of 25 duplicate entries. The dataset was subsequently filtered based on the criteria of title and abstract, removing 4417 studies. Out of the total of 63 studies, the researchers retrieved and assessed their eligibility. Among these, 44 studies were deemed ineligible and subsequently rejected. Expressly, 33 reports were excluded based on their out-of-scope measurements. Six studies were excluded from the analysis because they failed to evaluate FM or primary care settings. Additionally, three studies were excluded because their study designs did not allow for concluding perceptions of FM or PHC, and two studies were excluded as their population did not originate from the Arab world. The total number of articles incorporated in the study was 19.
The majority of the studies had a moderate risk of bias, five studies had a low risk of bias, and only one study had a high risk of bias; this latter study was included in the analysis to retrieve potential outcomes (Supplementary Box I).
Most studies employed a cross-sectional design, while two utilised a qualitative approach and one used a mixed-methods design. Some cross-sectional studies utilised an online form in addition to self-reported questionnaires. Ten studies were conducted in Saudi Arabia, two in Egypt, three in Iraq, two in Jordan, one in Oman, and one in Morocco. Numerous studies failed to disclose their funding sources and potential conflicts of interest, as seen in Supplementary Table 1.
The 19 studies targeted different types of populations. Seven studies targeted university students and house officers, two studies targeted physicians, five studies targeted the general population, and six studies targeted PHC clients.
Table 1 summarises the results of studies on students and house officers. Medical students had better knowledge and perception than non-medical. Medical students were aware of the role of family doctors as gatekeepers, delivering holistic and continuity of care. FM was not a preferred career path among medical students owing to concerns regarding its prestige and salary; reasons given by those who were positive about FM included the opportunity for work–life balance in family practice and being an exciting specialty from a research perspective.
Table 2 provides a summary of findings from two research studies conducted on physicians. One of the studies focused on physicians from various specialties, including emergency medicine, obstetrics and gynaecology, paediatrics, internal medicine, surgery, psychiatry, ophthalmology and orthopedics; the other study targeted primary care physicians. Surgeons in obstetrics and gynaecology and medicine were least satisfied with the role of family doctors in the community in Saudi Arabia. Meanwhile, GPs in Iraq agreed on the role of family doctor as the gatekeeper.
As Table 3 shows, Saudi Arabia studies were favourable in assessing the community’s perception of the role of family doctors. Most had heard about FM. However, most did not have regular family physicians, nor did they know where FM practices were located or even understand the difference between a family doctor and a GP.
Primary care clients showed more satisfaction with family doctors than GPs because of their better communication and clinical skills. Having a committed doctor who clarifies issues and informs patients about management plans is important, whether the doctor is an internist or a family doctor (Table 4).
Discussion
Summary
Nineteen studies met the criteria to be included in this review about the perceptions of the specialty of FM in Arab countries. Participants in these studies included medical students (five) and house officers (one), physicians (two), patients (PHC clients; six), and the general public (five). Overall, there was a positive perception of FM and the specialty’s role as a first point of contact or gatekeeper, managing chronic health issues and promoting preventive care. Despite the positive opinions, most responders in the general population studies had not encountered a FM physician or were confused about the difference between a GP and an FM physician.
The two studies that surveyed physician colleagues showed positive regard from GPs and colleagues in other specialties (Salman et al, 2017 and Alzahrani et al, 2020).18,19 While medical students were aware of FM and its role in healthcare delivery and reported finding FM rotations valuable, less than 5% of the students in any of the studies considered it a career choice. Reasons included its low status within the medical profession, limited scientific prestige, and lower salaries. However, house officers and students wanted more exposure to FM early on in their training.
Strengths and limitations
The majority of the studies reviewed exhibited low quality. Only one study employed an instrument characterised by a low risk of bias. This was achieved using a representative sample and a random sampling strategy while minimising non-response. Furthermore, it is worth noting that certain studies have solely focused on a single geographic location, recruited participants exclusively through health centres, or targeted specific medical schools. This approach may have inadvertently added selection bias to the research findings. In addition, social desirability bias may have influenced the optimistic view of FM as questionnaires or interviews were implicitly or explicitly based on a positive view of FM. Hence, there is a lack of clarity on the correct measurement of constructs and the generalisability of findings to the broader population in the analysed countries. Therefore, it is imperative to do rigorous research to understand the variations in how Arab communities perceive the field of FM and its practice on an international scale. Specifically, there is a requirement for qualitative studies that explore various constructs related to this topic. Given that only two qualitative studies and one mixed-method study fulfilled the inclusion criteria, it is imperative to conduct additional qualitative research to obtain a more comprehensive understanding of Arab communities' perspectives on family medicine specialisation and practice. Such research has the potential to illuminate health systems and medical and educational factors that are modifiable and thus may necessitate consideration to improve the practice in this particular medical discipline.
Comparison with existing literature
FM programmes in the Middle East and North Africa were established after adopting the Declaration of Alma-Ata in 1978. Lebanon, Bahrain, and Israel were the first countries to develop FM residency programmes. Other postgraduate programmes were established in the 1980s (Kuwait, Jordan, Turkey), in the 1990s (Qatar, United Arab Emirates, Oman, Saudi Arabia), in the 2000s (Iran), and more recently in 2010 (Palestine) and 2011 (Tunisia). A 2011 survey of FM residency programmes in Arab countries found 31 programmes graduating only 182 residents per year, a low ratio of FM to the population.5 The WHO astern Mediterranean Region and World Organization of Family Doctors (WONCA) publication shows some progress but woefully inadequate numbers to meet the need for adequate primary care access.6
The limited interactions with FM physicians and the limited experience and interest in the medical school reported in our review are most likely a result of the scarcity of family physicians and the absence of FM in medical school curricula. Oman, which has one of the most established FM-based health systems, acknowledged the importance of FM in the healthcare system,20 and stressed the need to retain and attract more FM physicians. This can be done by ensuring that primary healthcare centres have adequate laboratory capabilities and medications and that they use team-based care approaches so that patients with non-communicable diseases can be managed in primary healthcare centres. Legislation should link populations to a primary healthcare catchment area. Robust primary health care ensures that patients’ needs are met and avoids seeking secondary and tertiary services without first accessing primary care.21 It also provides adequate support so that family physicians can make use of the full range of their skills.
Perceptions and attitudes towards FM vary widely among medical students, practising physicians, patients, and the general public. Understanding these perceptions is crucial for addressing challenges in recruiting and retaining FM practitioners and improving the healthcare delivery system. Medical students' attitudes towards FM are influenced by various factors, including curriculum exposure, mentorship, and personal experiences.22,23 Studies indicate that early and positive exposure to FM can significantly enhance students' interest in this field. Studies from Saudi Arabia have shown a positive perception of FM among medical students as there is good curriculum exposure in medical education there. Medical students with substantial primary care clerkship experiences were more likely to pursue careers in FM.22 However, persistent stereotypes and misconceptions about FM negatively impact student interest. Many students perceive FM as less prestigious than surgery or cardiology. Concerns about lower income and perceived lack of specialisation also deter students from choosing FM as a career path.23
Practising family physicians often report high job satisfaction owing to the variety and continuity of care they provide. They appreciate the holistic approach to patient care and the opportunity to build long-term relationships with patients. However, challenges such as administrative burdens, lower reimbursement rates compared with specialists, and high patient loads can lead to burnout and job dissatisfaction.24
Patients generally hold family physicians in high regard owing to their accessibility, comprehensive care, and personal touch.25 Studies have shown that patients value the trust and continuity of care provided by family physicians, contributing to better health outcomes and patient satisfaction.26 However, our results show that some patients may perceive family physicians as less specialised and prefer consulting specialists for specific health issues. This perception can be influenced by the growing emphasis on specialisation within the healthcare system and the belief that specialists offer more advanced care for complex conditions.27
The general public’s perception of FM is shaped by media representation, personal experiences, and broader societal attitudes towards primary care. FM is often viewed positively for providing accessible and patient-centred care. Nevertheless, there is a lack of understanding of the full scope of FM, which can lead to an underappreciation of the specialty’s complexity and the comprehensive training required for family physicians.28
Implications for research and practice
Our review findings suggest the following recommendations: (1) an education campaign for the general public about the role of FM; (2) increasing training capacity for family physicians by increasing residency slots; (3) early exposure to family physicians during medical school and including FM in the curricula; (4) developing a process for continually improving the education and quality of family physician practice so that they can incorporate the rapid changes in science into the care they provide; and (5) further research on the challenges to FM practice in Arab countries to understand the situation better and work towards its improvement.
Other countries with longstanding training in the specialty of FM face similar challenges with engaging medical students.23,24,26 Research in these settings underlines the importance of early exposure of medical students to practising family physicians, including FM in medical school curricula, and family physicians engaged in research so that students understand the full range of family physicians' skills.
Notes
Funding
There was no external funding for this review.
Trial registration number
The research was registered in PROSPERO (Reg ID CRD42023387889).
Provenance
Freely submitted; externally peer reviewed.
Data
Data can be obtained from the corresponding author upon request.
Acknowledgements
We acknowledge the support of Hebron University for providing access to Databases and resources.
Competing interests
The authors declare that no competing interests exist.
- Received May 6, 2024.
- Revision received June 19, 2024.
- Accepted September 2, 2024.
- Copyright © 2025, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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