Effectiveness of alternative approaches to integrating SDOH into medical education: a scoping review

What Are We Teaching Medical Students and Physician Learners About the Social Determinants of Health? A Scoping Review

PURPOSE

Curricula about social determinants (drivers) of health (SDOH) are becoming more common in medical education, reflecting increasing expectations from payers and accreditors that health care systems do more to address health-related social needs and close pervasive health equity gaps. Few previous reviews have addressed the content of SDOH-related curricula. This review examines the scope and focus of medical education on SDOH and adjacent concepts.

METHOD

The authors screened 2,442 articles describing curricula delivered in undergraduate, graduate, and continuing medical education settings between 2010 and 2023 using PubMed and 2 field-specific databases, yielding 289 articles. Data on course duration, pedagogic approach, assessment methods, and curricular content were extracted and analyzed. Curricular content was categorized using the National Academies of Science, Engineering, and Medicine's (NASEM's) 5As framework, which recommends 5 key activities health care can undertake to mitigate social risk (awareness, adjustment, assistance, alignment, and advocacy).

RESULTS

A total of 289 articles were included in this review. Curricula covering SDOH-related concepts have increased over time. Of the included articles, 190 (65.7%) referenced at least 1 of NASEM's 5 key activities. Training on social risk screening and other awareness activities were noted most frequently [123 (42.6%)], followed by curricula on helping patients get social care [assistance; 86 (29.8%)] and providing social risk-adjusted health care [adjustment; 81 (28.0%)]. Curricula on system- and policy-level activities, including alignment of health care and social care organizations (alignment), and advocacy (advocacy) were described less frequently [43 (14.9%) and 49 (17.0%), respectively]. Ninety-four articles (32.5%) referenced only general information about SDOH without describing specific actions to adjust care or reduce social adversity.

CONCLUSIONS

NASEM's 5As framework provides a useful construct for characterizing SDOH-related curricula. Medical educators should teach not only the prevalence and pathophysiology of SDOH but also what physicians can do to address these factors.

The role of government chief nursing and midwifery officers in addressing the social determinants of health inequalities in the who European region

Health inequalities continue to exacerbate in the European Region, this underlines the need to strengthen the equity impact of public health policies. Nurses and midwives, professional groups that account for 61.8% of the practicing health professionals, work at the point of care, interdisciplinary and see the effects of health inequalities in their everyday work supporting communities and the environment where they are born, live, work and age. The government chief nursing and midwifery officer (GCNMOs) influence, provide policy advice and lead health systems planning and delivery of services. Further to this, it is increasingly being document that they participate in public health policy and inspire others to commit to the implementation of a new vision to strengthen equity impact on population health outcomes. In 2023, a series of discussions with GCNMOs, multidisciplinary researchers and experts, representing 35 of 53 countries in the WHO European Region explored the implications as to how GCNMOs can contribute to addressing the social determinants of health inequalities. Based on this dialogue, we provide a proposal of public health actions for health equity that will benefit from GCNMOs in delivering co-benefits for better health and inclusive growth. These actions can include equity-responsive health systems and health promotion, universal social protection, secure employment and healthy working conditions, environmental protection, education, decent housing, or urban planning among others. Unless governments facilitate the process where GCNMOs have clear mandates, sufficient authority, recognition, and support to engage in policy advocacy, governments will miss out on building fairer and healthier societies that are truly intersectoral and collaborative.

Towards anti-racist futures: a scoping review exploring educational interventions that address systemic racism in post graduate medical education

Since 2020, brought to the forefront by movements such as Black Lives Matter and Idle No More, it has been widely acknowledged that systemic racism contributes to racially differentiated health outcomes. Health professional educators have been called to address such disparities within healthcare, policy, and practice. To tackle structural racism within healthcare, one avenue that has emerged is the creation of medical education interventions within postgraduate residency medical programming. The objective of this scoping review is to examine the current literature on anti-racist educational interventions, that integrate a systemic or structural view of racism, within postgraduate medical education. Through the identification and analysis of 23 papers, this review identified three major components of interest across medical interventions, including (a) conceptualization, (b) pedagogical issues, and (c) outcomes & evaluation. There were overlapping points of discussion and analysis within each of these components. Conceptualization addressed how researchers conceptualized racism in different ways, the range of curricular content educators chose to challenge racism, and the absence of community's role in curricular development. Pedagogical issues addressed knowledge vs. skills-based teaching, and tensions between one-time workshops and integrative curriculum. Outcomes and evaluation highlighted self-reported Likert scales as dominant types of evaluation, self-evaluation in educational interventions, and misalignments between intervention outcomes and learning objectives. The findings are unique in their in-depth exploration of anti-racist medical interventions within postgraduate medical education programming, specifically in relation to efforts to address systemic and structural racism. The findings contribute a meaningful review of the current state of the field of medical education and generate new conversations about future possibilities for a broader anti-racist health professions curriculum.

Integrating the social determinants of health into graduate medical education training: a scoping review

BACKGROUND

The social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs.

METHODS

A systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded.

RESULTS

The initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum.

CONCLUSION

Applying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force.

Teaching Social Determinants of Health in Nursing Programs: An Integrative Review of Strategies and Effectiveness

BACKGROUND

Incorporating social determinants of health (SDoH) into clinical decision-making can clarify disease causes, enhance care planning, and improve health outcomes. Nurse educators should know which strategies are most effective for teaching SDoH in bachelor of science in nursing (BSN) programs.

OBJECTIVE

This integrative review synthesizes the literature on familiarizing BSN students with SDoH and identifies effective teaching interventions for SDoH in these programs.

METHODS

The researchers searched CINAHL, PubMed, Web of Science, and ERIC databases, and 21 articles met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines were followed for reporting.

RESULTS

The curriculum method, service learning, and international outreach experiences were frequently used teaching strategies. Qualitative evaluation was used to evaluate student outcomes.

CONCLUSIONS

Nurse educators should be mindful of these strategies. Interdisciplinary teamwork can bolster students' understanding of disadvantaged populations while integrating SDoH in nursing curricula. Quantitative evaluations of learning outcomes are needed to determine teaching effectiveness.

Evaluation of a Novel Equity-Focused Curriculum for Early-Stage Medical Students

OBJECTIVES

Medical school curricula have increasingly incorporated topics and content related to health equity and affiliated social determinants of health. However, there is limited literature to guide how programs might measure the success of these initiatives. Previous studies assessed medical student attitudes and perceived knowledge, preparedness, and skills. Based on self-reported measures of these attributes, we compared within-group and between-group differences at the onset of a novel equity-focused curriculum implementation.

METHODS

A multi-component approach to "thread" lectures, panel discussions, and other content dedicated to health equity concepts was assessed using adapted versions of two validated survey instruments of the measured constructs. Baseline data were collected prior to coursework and at follow-up early in students' second year assessed change attributable to the equity-focused curriculum thread, with additional comparison to a cohort of second-year students who had no exposure to the curriculum. Data were collected at the beginning of academic years 2021-2022 and 2022-2023.

RESULTS

The multivariate analysis of variance indicated significant change over time (p < 0.001) with the analyses of variance identifying students' perceived current skills and topic knowledge increasing over time. No significant differences were found between two separate groups of M2 students.

CONCLUSIONS

Students' perceived skills at working with diverse patient populations and knowledge of topics focused on health equity increased across the study, despite a much smaller response rate for the same student cohort at follow-up. Students' perception that they are prepared to care for patients of diverse backgrounds was unaffected. Attitudinal assessment revealed a ceiling effect at baseline, which should be explored further with longitudinal assessment. For the ongoing effort to evaluate the success of equity-focused curricula and programs, this study contributes evidence of change on some but not all outcomes, and can help guide other programs in determining which outcomes best reflect areas of programmatic need and impact.

Experiential Learning as a Path to Critical Consciousness in the Medical Curriculum: A Qualitative Study

OBJECTIVES

Clinical settings are increasingly focused on addressing patients' social needs, thus medical education must prepare future clinicians for this task. Critical consciousness, an awareness that puts health within a broader social, historical, and cultural context, could help shape students' understanding of patient social needs. Our paper explores how experiential learning through participation in a social care intervention deepened students' critical consciousness, or their understanding of the systems and structures that make it difficult for patients to meet their basic needs.

METHODS

We conducted one-on-one semistructured interviews with all 24 students who served as advocates for the intervention. Of the 24 advocates, 75% (n = 18) were first-year medical students, 17% (n = 4) were public health students, and 8% (n = 2) were social work students. Interviews were audiorecorded, transcribed verbatim, and analyzed using framework analysis.

RESULTS

We identified themes informed by critical consciousness, including individual (assumptions and biases), interpersonal (communication and relationship), and structural (organization and power) factors. Within these categories, advocates expressed deeper self-awareness of personal biases (individual), the importance of interpersonal communication to build trust with caregivers (interpersonal), and the identification of the structural factors that influence health, such as housing conditions (structural). The advocates highlighted the importance of experiential learning to help them understand social determinants of health. By witnessing multiple patients experiencing social needs, advocates saw the cascading effects of social needs, the structures that make it difficult to meet basic needs, and the effect on health and healthcare behavior.

CONCLUSION

Students engaged in the intervention demonstrated the development of critical consciousness. Although limited, our findings suggest that when students engage with patients around social needs, students can better understand the broader social context of patients' lives. Experiential learning through social care interventions may have the potential to influence critical consciousness development and shape the practice of future clinicians.

Graphic Novels and Comics in Undergraduate and Graduate Medical Students Education: A Scoping Review

There is an increasing use of graphic novels and comics (GnCs) in medical education, especially-but not only-to provide students with a vicarious learning experience in some areas of clinical medicine (palliative care, difficult communication, and rare diseases). This scoping review aimed to answer questions about how GnCs are used, the theories underlying their use, and the learning outcomes. Twenty-nine articles were selected from bibliographic databases and analyzed. A thematic analysis revealed four many themes: learning outcomes, students' reactions, theories and methods, and use of GnCs as vicarious learning. GnCs can support the achievement of cognitive outcomes, as well as soft skills and professionalism. The reactions were engagement and amusement, but drawing comics was also perceived as a protected space to express concerns. GnCs proved to be a possible way to provide a vicarious experience for learning. We found two classes of theories on the use of GnCs: psychological theories based on the dual concurrent coding of text and images and semiotics theories on the interpretation of signs. All the studies but two were single arm and observational, quantitative, qualitative, or mixed. These results suggest that further high-quality research on the use of GnC in medical training is worthwhile.

Enriching Real-world Data with Social Determinants of Health for Health Outcomes and Health Equity: Successes, Challenges, and Opportunities

OBJECTIVE

To summarize the recent methods and applications that leverage real-world data such as electronic health records (EHRs) with social determinants of health (SDoH) for public and population health and health equity and identify successes, challenges, and possible solutions.

METHODS

In this opinion review, grounded on a social-ecological-model-based conceptual framework, we surveyed data sources and recent informatics approaches that enable leveraging SDoH along with real-world data to support public health and clinical health applications including helping design public health intervention, enhancing risk stratification, and enabling the prediction of unmet social needs.

RESULTS

Besides summarizing data sources, we identified gaps in capturing SDoH data in existing EHR systems and opportunities to leverage informatics approaches to collect SDoH information either from structured and unstructured EHR data or through linking with public surveys and environmental data. We also surveyed recently developed ontologies for standardizing SDoH information and approaches that incorporate SDoH for disease risk stratification, public health crisis prediction, and development of tailored interventions.

CONCLUSIONS

To enable effective public health and clinical applications using real-world data with SDoH, it is necessary to develop both non-technical solutions involving incentives, policies, and training as well as technical solutions such as novel social risk management tools that are integrated into clinical workflow. Ultimately, SDoH-powered social risk management, disease risk prediction, and development of SDoH tailored interventions for disease prevention and management have the potential to improve population health, reduce disparities, and improve health equity.