The Integration of Social Determinants of Health learning into UK Medical School Curricula Introduction A 2018 Public Health England publication detailed a health profile for England, describing a social gradient in health where “Between the most and least deprived tenths of England, the absolute difference in life expectancy is 9 years for males and 7 years for females”. 1 Such disparities are underpinned by wider determinants of health such as race, gender identity, socioeconomic status, age and region. 2 Social determinants of health (SDH) are defined by the World Health Organization (WHO) as the “conditions in which people are born, grow, live, work, and age”. 3 Evidence supports the impact of social factors on an individual’s health. 4 It is also well established that increases in health inequities means those requiring medical care the most are least attended to by health services. 5 An understanding of SDH can affect clinical practice and be applied by doctors in their daily decision-making and organization of services. 6 Additionally, it could lead to increased documentation of risks associated with patients. 7,8 It helps doctors to advocate for more holistic interventions. It also enables partnerships with community organizations and initiatives such as social prescribing. 9 Overall considerations of SDH may improve doctor-patient relations and equip doctors to feel confident in delivering optimal care, especially in underserved areas. Addressing SDH can reduce burnout by increasing job satisfaction, particularly for those working in deprived areas. 6 The World Health Organization has previously linked the role of positive rural clinical experience to higher retention rates of postgraduate professionals in those areas. 10
Transcript
The Integration of Social Determinants of Health learning into UK Medical
School Curricula Introduction
A 2018 Public Health England publication detailed a health profile for England, describing a
social gradient in health where “Between the most and least deprived tenths of England, the
absolute difference in life expectancy is 9 years for males and 7 years for females”.1 Such
disparities are underpinned by wider determinants of health such as race, gender identity,
socioeconomic status, age and region.2 Social determinants of health (SDH) are defined by
the World Health Organization (WHO) as the “conditions in which people are born, grow,
live, work, and age”.3 Evidence supports the impact of social factors on an individual’s
health.4 It is also well established that increases in health inequities means those requiring
medical care the most are least attended to by health services.5
An understanding of SDH can affect clinical practice and be applied by doctors in their daily
decision-making and organization of services.6 Additionally, it could lead to increased
documentation of risks associated with patients.7,8 It helps doctors to advocate for more
holistic interventions. It also enables partnerships with community organizations and
initiatives such as social prescribing.9 Overall considerations of SDH may improve
doctor-patient relations and equip doctors to feel confident in delivering optimal care,
especially in underserved areas. Addressing SDH can reduce burnout by increasing job
satisfaction, particularly for those working in deprived areas.6 The World Health Organization
has previously linked the role of positive rural clinical experience to higher retention rates of
postgraduate professionals in those areas.10
The General Medical Council’s Tomorrow’s Doctors11 outlines the standards of good medical
practice expected of medical students and highlights the place and importance of public
health. The inclusion of such outcomes has strengthened medical school curricula. However
the implementation of public health teaching, when and how it is taught is and outcomes are
varied across medical schools. The main method of teaching in one study was 93.3%
through lectures, followed by small group tutorials and e-learning.12 However across UK
medical schools, health inequalities within the core curriculum is limited.13 Alongside this,
there is a need for medical schools to not just teach about SDH but offer opportunities for
students to gain the necessary skills to address them.14
Medical schools play a significant role in shaping both knowledge and attitudes of future
doctors. Exposure to health inequalities through the curriculum can influence student’s
perceptions of delivering health care.15 This can be done through the core curriculum or
elective programs.16 There is also evidence that shows that placement encourages the
return of students to rural areas following completion of the medical degree.17
This study aims to explore how such appreciation for SDH can be appropriately incorporated
into the undergraduate medical curriculum. It also discusses if its inclusion on the curricula
will guarantee application of the concepts and how can this be best evaluated. The research
was based on two schemes initiated by the University of Sheffield medical school. One of
these being a masterclass in health inequity through a combination of learning activities
including discussion, reflection and small group debate. The other scheme was a Student
Selected Component (SSC) in primary care with a focus on health inequalities. It involved
attachment to a General Practice (GP) surgery and third sector organisation in a
disadvantaged area, the Deep End.18
Research methods
Search methods
A literature search was performed to provide a review of current referable literature in fields
relevant to our study. Search terms included: social determinants, health, health inequalities,
inequities, public health and medical curriculum. The search databases used were PubMed,
StarPlus and Google Scholar.
Research design
Focus groups were the chosen method of data extraction for this qualitative study. The
sample included two separate single focus groups.19 One group consisted of students who
had completed a masterclass in health inequities in the Academic Unit of Primary Medical
Care (AUPMC), while the other consisted of students who had completed the Deep End
SSC. Two separate groups allowed for homogeneity so themes could be explored by those
with a similar experience.
The use of human participants required formulation of an ethics proposal for the project as
consent is central to such research. Ethical approval was granted by the University of
Sheffield before any progression with the methodology. The ethical review and approval was
on behalf of the University of Sheffield’s Research Ethics Committee and in accordance with
the University’s ethics review procedure. Upon receiving approval, students were
approached by email with a brief introduction to the research projects. Respondents
received a further email with a consent form and more detailed information sheet. All
participants were provided with informed consent prior to their involvement in the study.
Method of data collection
To elicit optimal information, a clear and specific research question was developed.
Following this, a concise topic guide was created to provide structure in conducting the focus
groups. Themes were outlined in a logical order, starting with an initial general question to
open the discussion. Focus groups were audio recorded using a digital recorder and a
mobile device. Additional observational data of non verbal communication was noted during
the focus group. This accounted for facial expressions and overall body language of the
participants.
To increase the value of this method, questions were open ended to promote discussion and
to avoid participant bias. The same topic guide was used for both groups to avoid method
error confounding the results. To preserve anonymity participant numbers were allocated
from P1 to P5 and PA, PB , PC for each of the respective groups where n=5 and n=3.
Participants were asked to state this number when speaking or referring to one another.
Method of data analysis
Both focus groups were completely transcribed. Thematic analysis enabled report of
patterns within the data.20 This form of analysis permits methodical rigour in order to yield
useful results. Braun and Clarke’s framework 21 was used to guide the process of analysis
(see Table 1). Direct quotes were drawn from the data and are described within the results
section.
Considerations in protecting data included use of a password protected laptop and restricted
access to transcription documents. Emails to participants were sent as blind carbon copies
to comply with General Data Protection Regulation (GDPR) regulations of identifiable
personal data.
Results
In total, 8 medical students participated across the two focus groups (n=5 and n=3). Only in
one case could one individual not attend due to conflicting timetables. During each group
there were 2 researchers present where one asked questions and the other took notes. The
sessions took on average 40 minutes. Four dominant themes emerged from our study and
are outlined below.
Style of learning/ Method of teaching
Students appreciated smaller groups (between 4-5) with consistency of supervisor. Majority
agreed the best facilitator would be GP’s or experts either in public health or third sector
organisations. This method of teaching was quoted as being “really useful to get you
engaged” (Masterclass). Masterclass students spoke of debates allowing them to share
ideas and oftentimes challenging their own opinions. Deep End SSC students felt their small
group meetings also encouraged exchange of experiences as a method of learning and
would have liked more of an opportunity to teach. Both groups stated the masterclass/SSC
had exceeded their expectations.
When to implement learning
Masterclass students spoke of the need to have a good grounding in the earlier years which
they developed within 4-5 sessions. All agreed they learnt SDH early on but had no way of
applying it. One student is quoted as follows: “first and second year you're not really getting
any clinical experience, so that's one of the reasons why it doesn't feel as relevant. 3A,
(clinical phase) I think it's still a good idea to introduce it earlier if possible but I think people
are more receptive to it after 3 years” (Masterclass). There was disagreement about
integrated teaching of health inequalities as opposed to a block of designated teaching. All
SSC students stated implementation in preclinical years would be too much and that after
the first Objective Structured Clinical Examination (OSCE) exam would be a better time so
that students have a greater appreciation for the topic.
Evaluation of learning
A major subtheme identified was attitudes. Majority of students agreed formal examination
would be the least preferred option. About half of the group referenced the difficulty in
assessing attitudes or mindsets: “so how can you prove you’re a better person than you
were before? Because I think that's more what it is its an attitude” (Masterclass).
“because you have to face reality that fundamentally you can't change someone's
personality and you can't change their opinions directly but if you give them the tools to
change their own opinion you can hope, but you can't measure it” (Masterclass).
Majority of the students across both groups were in agreement with the use of reflective or
formative assessment. The masterclass students agreed an essay based question would be
a welcome and suitable method of assessing their learning. All SSC students agreed it
should not be examined but rather a reflection.
Impact on student - student perceptions
The subthemes included the application of their learning and future careers. A masterclass
student quoted this: “I think it was about how we put our knowledge of a person and situation
into use.” Students liked that they could identify different barriers with access to healthcare
for different patient groups e.g. language. One student said “its being able to adapt your
practise to understand that patient no matter what group of patients you’re talking about”
(Masterclass) supporting another point of it challenging preconceptions of why patients don’t
attend appointments. SSC students identified the differentiating factor of their experience in
it being a “really unique opportunity to apply the theoretical learning” (Deep End SSC). In
terms of future career choices, for a minority their health inequality learning increased their
likelihood of going into public health. For about half it increased their desire to be a GP and
for a few there was no major impact on their future career choice.
Any additional/ unexpected findings
Choosing had to do with having an interest in the subject “a lot of us had a background or
were already interested” (Masterclass). Both the masterclass and SSC were optional and
most students had a general or strong interest in the topic when choosing.
Masterclass students were more enthusiastic about their learning and seemed to highly
value the class. This was unexpected as comparatively and in line with previous studies, we
assumed students who had experience out in the Deep End would have had more
enthusiasm.
Discussion
Health inequalities need action from medical schools. The curriculum plays a role in shaping
both knowledge and attitudes of future doctors.22 There are many ways in which schools can
promote equity including a selection process in recruiting students from disadvantaged areas
or those with an interest in the topic and the content in the curriculum.16 Our study explores
the latter alongside the theme of the optimal time to implement teaching, as some have
found perception decreases over time due to medical culture.16
Our findings support existing evidence that incorporating SDH and health inequality
education into medical school curricula is significant.14,23 Students voiced advantages in the
application of their learning into clinical practice. Beyond this there was a running theme of
the teaching impact on their mindsets and improving their ability to identify barriers while at
times addressing unconscious bias. Students discussed the importance of an appropriate
facilitator for these sessions of health inequality teaching. While most suggested a GP,
students also found external speakers from third sector organisations also helpful. This could
help build stronger partnerships between medical schools and community based
organizations. This may provide training and development opportunities for GP’s within any
locality in regards to teaching SDH. This could also promote interdisciplinarity in providing
optimal care.
One major consideration of our study was the effect of health inequality learning continuing
into future practice. While further study would be required to validate this, looking at the
theme of student impact we can see there is significant impact on future careers and student
perceptions. These perceptions support increased cultural competence as students found
they considered external factors and barriers that they would otherwise not have identified.
Community based teaching and activities have previously been found to be effective in
addressing bias.24
Reflective evaluation as the best measure of student’s learning can act as a good marker of
behavioural change. It also allows students to discuss levels of confidence and self belief in
the capabilities when working with patients from underserved areas.25 Unlike traditional
assessment focused on the specificity of answers, this method of evaluation would give
students an overall appreciation for SDH in practice. It also relates to their development of a
holistic approach to primary care, linking with other elements of teaching in clinical years.
Limitations
A major limitation to our study was the limited length of time (6 weeks) and small sample
size. For future studies, more focus groups would be advantageous. It may be useful to
include groups with little or no interest in health inequalities and students enrolled through
widening participation schemes. A weakness may exist in the reliability of the data as we did
not make use of an independent researcher to cross check our thematic analysis.
In terms of the sample population, our study only looked at student reviews and perceptions.
We did not look at educator’s feedback as some other studies have.12 This may have offered
additional perspectives relating to delivering the teaching. We did not go into great depth into
considering the logistics of implementing curricular changes and potential barriers in terms of
time and funding. These limitations have been noted and emphasise the potential place for
further research.
Conclusions
There are gaps in the literature concerning teaching health inequalities in the medical
curriculum, especially in the UK. This study highlighted four dominant themes: teaching
style, when to implement learning, evaluation of learning and impact on students. One of the
major contributions of our work is that it allows for the restructuring of the curriculum to
include small group debates and case scenarios in early clinical years. Our work validates
the importance, place and need for more teaching within the curriculum regarding health
inequalities. Such teaching will impact individuals not just as students but as future health
care professionals and crucial members of any community. Incorporating more health
inequality teaching demands the social responsibility embedded within the role of doctors
providing patient centred care. Prioritizing health inequalities in medical education promotes
overall improvement in care. Future research studies should aim to validate our conclusions
and replicate results with a larger sample size and a more diverse population.
Reflexivity Statement
This research was based in the AUPMC, which provides teaching, research and training
opportunities. AUPMC research uses a range of methods with a focus on primary and
community care. I, the author, am a phase 2a medical student and this is my first study
based in AUPMC with no previous affiliations. I have an interest in health inequalities and
education and had prior knowledge of social determinants of health.
Word count - 2541
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