A socioecological framework for physician advocacy: motivators, enablers, and barriers

BACKGROUND: Advocacy is a professional competency for Canadian physicians, yet adoption into medical education, academic medicine, and physician practice varies. We sought to explore perspectives on why and how physicians integrate health advocacy into their professional identity and to develop a model framework. METHODS: We used a phenomenological approach to develop a socioecological framework. Using purposeful and chain sampling, we conducted semi-structured interviews with physician advocates of diverse backgrounds, clinical specialties, and advocacy interests from across Canada. We used thematic analysis to identify themes, which we then mapped onto the socioecological model. RESULTS: We interviewed 27 participants. We derived 7 themes: intrinsic motivation, role synergy, peers and institutions, external incentives, positionality, advocacy training, and strategic mindset. Themes layered onto or between 4 levels of the socioecological model. Within the intrapersonal level, identity, lived experiences, and exposures to injustice shaped advocacy commitment. Within the interpersonal level, patient relationships and moral injury motivated action; professional responsibility informed advocacy tactics. Within the organizational level, institutional constraints, political considerations, limited academic recognition, and fear of polarization and backlash were barriers; peer and institutional support were enablers. Within the community and society level, physicians described a tension between insider versus outsider roles and efficacy and needing to balance rapid public engagement with long-term institutional influence. Participants emphasized hands-on learning, mentorship, and a hidden curriculum. INTERPRETATION: Physician advocates are influenced by lived experiences and perceived injustice, empowered by training and mentorship, constrained by perceived political and institutional barriers, and fear backlash. Formal curricula and aligned institutional culture support physicians in their role as advocates.