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Social Determinants of Health Training in U.S. Primary Care Residency Programs: A Scoping Review

Gard, Lauren A. MPH; Peterson, Jonna MLIS; Miller, Corrine MLIS; Ghosh, Nilasha MD; Youmans, Quentin MD; Didwania, Aashish MD; Persell, Stephen D. MD, MPH; Jean-Jacques, Muriel MD; Ravenna, Paul MD; O’Brien, Matthew J. MD, MSc; Sanghavi Goel, Mita MD, MPH

Author Information
doi: 10.1097/ACM.0000000000002491


Social determinants of health (SDH) are defined by the World Health Organization (WHO) as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”1 Previous research has estimated that up to 60% of preventable mortality is attributable to social and economic circumstances.2 Given how inextricably linked these socioeconomic factors are to health,3 the need for providers to recognize SDH as potential root causes for health outcomes is increasing.4 Medical training has traditionally focused on the proximate determinants of health5 and on modifying the behavior of individual patients to prevent disease6; however, this approach is insufficient if it does not consider the contextual factors that affect a patient’s ability to make healthy choices.7,8 Studies of interventions designed to address SDH at the clinical level have demonstrated marked improvement in community9 and individual health,10,11 and other studies have found that providers who know how to ask about social and economic challenges are more likely to help patients address those issues.12 To build provider capacity, the WHO Commission on Social Determinants of Health has recommended that medical training include SDH curricula.13 The National Academies of Sciences, Engineering, and Medicine has also issued a report recommending that medical education include training on the effects of SDH.14

Medical schools are increasingly incorporating SDH topics into their curricula,15 but residency training presents an important opportunity to learn and consolidate clinical skills related to SDH. In particular, primary care providers (those in internal medicine, family medicine, and/or pediatrics) are uniquely positioned to address SDH given their longitudinal relationships with patients, which facilitate learning about the barriers their patients face when managing their health.

The body responsible for accrediting residency programs in the United States and Canada, the Accreditation Council for Graduate Medical Education (ACGME), has vague SDH-related requirements across specialties. For example, internal medicine core competencies allude to understanding SDH (e.g., responding to each patient’s unique characteristics and needs, having professional and respectful interactions with patients, communicating effectively with patients and caregivers, identifying forces that affect the cost of health care, and practicing cost-effective care).16 No requirements explicitly incorporate SDH, and recent research indicates that fewer than 1 in 5 internal medicine programs specifically cover SDH in their core or elective curricula.17,18 Moreover, residents in a national survey reported that they lacked sufficient knowledge about SDH and felt inadequately prepared to address them with patients.17 Experts have called on the medical education community to work collaboratively across specialties to train the future workforce to mitigate the effects of SDH.19 While some residency programs have incorporated curricula that address SDH, the effects on residents’ practices and on population outcomes are not known.

We conducted a systematic scoping review of existing curricula designed to teach primary care residents about SDH. Our objectives were as follows: (1) to identify how SDH curricula are developed, (2) to understand how these curricula have been implemented, and (3) to ascertain how these curricula have been evaluated.


Study design

We performed a literature review following PRISMA guidelines.20 We conducted a scoping synthesis, rather than meta-analysis, because of the anticipated heterogeneity in the existing literature.21,22 Our study questions were as follows: (1) How are SDH curricula being developed for primary care residency programs? (2) How are educators implementing or delivering their curricula and over what time span (i.e., duration)? (3) What methods of evaluation, if any, are educators using to determine the effects of their curricula?

We conducted our initial literature search in January 2017, and searched MedEdPORTAL in March 2017. Our team of medical librarians (J.P., C.M.) and experienced educators (A.D., M.S.G., P.R., M.J.-J.) came to a consensus on what key databases to search:

  • Medline via PubMed,
  • Embase,
  • Scopus,
  • MedEdPORTAL,
  • ProQuest,
  • ERIC via EBSCOhost, and
  • the Cochrane Library.

We refined search terms for Medline via PubMed by (1) incorporating search terms from previous, related review articles; (2) interviewing educator and clinician team members who are experts in SDH (A.D., M.S.G., P.R., M.J.-J., M.J.O., and S.D.P.); and (3) identifying Medical Subject Headings and key phrases from formative references. The resultant search strategy included overarching terms such as “social determinants of health,” “health disparities,” “health equity,” “graduate medical education,” and “primary care,” as well as specific types of social determinants, including those related to health literacy, access to healthy food, and socioeconomic factors. We based our search strategies for all databases on the terms used for PubMed (see Supplemental Digital Appendix 1, available at In addition to electronic searching, we identified relevant articles by scanning reference lists of key review articles.

Eligibility criteria

We excluded articles from further review if they were published over 10 years ago (prior to January 2007) or after January 2017, were not in English, were based outside the United States, lacked a description of a curriculum, were not relevant to SDH, did not target residents in primary care fields, or were not relevant to our study questions. We chose a 10-year cutoff to capture the most relevant curricula for current educational needs. We included articles that described at least one curriculum, regardless of whether or not the authors evaluated the program; we also included publications that were in the form of abstracts rather than full articles.

Article review

Once we removed the duplicates, we uploaded the search results to Rayyan (Qatar Computing Research Institute, Doha, Qatar), a reference management software program used to conduct systematic reviews.23 Prior to conducting our initial screening, we selected a random sample of 100 references to test reviewer interrater reliability. We calculated reviewer agreement for determining eligibility after reading the title and abstract using Fleiss’s kappa.24 The level of agreement among the four of us acting as independent reviewers (L.A.G., M.S.G., Q.Y., N.G.) was substantial25 (κ = 0.75; 95% confidence interval, 0.68, 0.82). Based on the large number of references in the initial screening phase and our high interrater reliability, we divided the references among the four of us and independently screened the articles for eligibility, using titles and abstracts, or full-text articles when abstracts were not available. After the initial screening was complete, we uploaded the full text of the included articles into EndNote X8 (Clarivate Analytics, Philadelphia, Pennsylvania).

We developed a standardized form to confirm eligibility during the full-text review. In pairs (L.A.G./N.G. and M.S.G./Q.Y.), we read each article, and when a pair could not reach consensus, a third reviewer (M.J.O.) determined eligibility.

After confirming eligibility, we used an internally developed, standardized review form to extract relevant data from each article. We adapted the tool from Cochrane Review26 and previous systematic reviews.14,27 We piloted the tool with a sample of five articles and revised it accordingly before applying it to the remaining items. We (L.A.G., Q.Y., N.G., M.S.G.) extracted data regarding the following: learners and settings, curriculum objectives, specific curriculum content, teaching methods, study design, evaluation method, and bias assessment.

Data synthesis

We examined general features of each curriculum including targeted learners (whether they were in internal medicine, family medicine, or pediatrics); targeted postgraduate year (PGY); curricular topic(s); educational strategies; instructors; and duration.

We also focused on the development, implementation, and evaluation of each curriculum. We organized data to align with two widely accepted approaches to curricular design and assessment: Kern’s six-step approach to developing a medical curriculum28 and Moore and colleagues’ taxonomy of outcomes.29 Guided by Kern’s model, we highlighted programs that clearly described the development of goals and objectives, educational strategies, implementation, and evaluation. For articles that reported outcomes, we organized the results using Moore and colleagues’29 taxonomy. Moore and colleagues’ taxonomy of outcomes ranges from measuring participation in learning activities to measuring the effect of the curriculum on community health.

Quality assessment

We used the Medical Education Research Study Quality Instrument (MERSQI) to appraise the quality of the quantitative research studies.30,31 Scores range from 5 to 18; higher scores indicate higher quality. Previous researchers have used MERSQI to appraise both full-text articles and abstracts.32 Three of us (L.A.G., N.G., and Q.Y.) independently scored each article, and then we met in pairs (L.A.G./N.G. and L.A.G./Q.Y.) to discuss and reconcile any discrepancies; a third reviewer (M.S.G.) adjudicated decisions when needed.


Of the original 5,523 references identified, 43 (< 1%) met inclusion criteria (Figure 1).33–75 We identified no curricula from MedEdPORTAL that met study eligibility. We summarized study characteristics and examined results by (1) curricular content development, (2) implementation, and (3) evaluation.

Figure 1
Figure 1:
Summary of the literature search and review process. The authors of the systematic review excluded most articles because they did not provide a description of the curriculum content, because targeted learners were not medical residents in a primary care specialty, and/or because the content of the training was not relevant to the study questions. Content that was not directly related to their search included curricula focused on health policy or campaigning strategies.

Study characteristics

Of the 43 articles and abstracts, 27 (63%) were published between 2012 and 2017. Over half of the articles (n = 26; 60%) were full-length articles; the remaining 17 (40%) were abstracts.

Twenty-nine curricula (67%) targeted internal medicine residents, and 31 (72%) provided learning for interns. Programs varied by the type of content they covered. Thirty-two (74%) programs taught SDH broadly by reviewing multiple topics (e.g., food insecurity, housing conditions, barriers to care). In contrast, 11 curricula (26%) focused on specific types of SDH such as health literacy, poverty, or domestic violence. Table 1 summarizes the characteristics of all 43 articles and abstracts we reviewed and the curricula they describe. In addition, we have provided a summary of all programs included in this literature review in Supplemental Digital Appendices 2 and 3, available at We have summarized each publication by resident specialty (internal medicine, family medicine, or pediatrics); PGY level; curricular topic(s) described (e.g., SDH or cultural competency); implementation or delivery; duration; and instructor characteristics.

Table 1
Table 1:
Characteristics of 43 Curricular Programs Focused on Training Primary Care Residents About the Social Determinants of Health

Curriculum development

Across all 43 publications, 27 (63%) did not report how the curriculum was developed; 2 (5%) reported that the curriculum was developed based on literature reviews60,64; 2 (5%) used input from expert faculty33,37; 2 (5%) used input from resident focus groups43,53; 6 (14%) used multidisciplinary teams, including community partners34,39,44,50,56,69; and 4 (9%) developed their curricula using existing frameworks.47,52,70,74 Here we have highlighted two programs that clearly described their development process.

Willis and colleagues (2007)50 collaborated with 13 community agencies, parents, public schools, and other academic institutions to develop their pediatric community health curriculum. Faculty leveraged preexisting relationships to identify community partners. In addition, some staff members from community-based organizations served as cofaculty for the curriculum and provided community-based sites for sessions. Collectively, community partners identified their community assets and then divided into curriculum subgroups, each of which met monthly for one year. The subgroups worked together to develop a curriculum designed to prepare pediatric residents to address SDH, collaborate with community organizations, and learn the basics of child advocacy. An external evaluator reviewed the curriculum to confirm appropriateness to the community and validity of the design. The final curriculum was a mandatory four-week rotation that included (1) interactive sessions with parents and families, (2) activities with community-based organizations, and (3) child advocacy in the form of participation in community initiatives. The majority of residents who completed the program reported that they felt substantially prepared to advocate for children in their communities and able to communicate effectively with patients and families.

MacNamara and colleagues (2014)70 drew from two existing conceptual frameworks to develop their curriculum focused on providing quality care for recently resettled immigrant populations. The first framework emphasized the notion of “cultural humility” so that residents could reflect on their own culture instead of marginalizing the patient’s culture as “other.”76 The second framework focused on transnational competence, which prepares learners to care for ethnoculturally diverse patients using a comprehensive set of skills from five unique domains: analytical, emotional, creative, communicative, and functional.77 The final curriculum consisted of the following: (1) online resource sheets describing the sociopolitical and health care considerations for recently resettled immigrant populations; (2) three 2- to 3-hour faculty-facilitated seminars, integrated into a 36-hour mandatory training for interns in psychosocial medicine, that focused on the use of interpreter services and reflections on cultural awareness; and (3) clinical visits for newly resettled refugees with interns. To evaluate the program, residents participated in focus groups to discuss its effect. Qualitative results indicated that the curriculum improved residents’ perceptions of their care for recently resettled patients and for patients overall.


Across the 43 curricula, 2034,37,44,46,48-50,53-56,60,61,65,66,68-72 (47%) provided SDH training in short (less than six months) or one-time sessions, and were typically integrated into existing one-month rotations. Fifteen programs33,35,36,38,39,41–43,45,51,52,57,73–75 (35%) were longitudinal (lasting six months or longer). The remaining 8 publications (19%) did not specify the length of training. Fifteen (35%) programs were elective,36,44,45,48,49,52,57,59–61,63,67,70,72,74 17 (40%) were required,33,34,37,38,41,42,46,50,51,53,54,56,65,66,68,69,73 and the descriptions of the remaining 11 did not specify. Nearly three-quarters of the SDH curricula (n = 32; 74%) used didactics to deliver content, and 22 (51%) incorporated some experiential (i.e., patient-based, clinical, or service) learning. Notably, these two groups were not mutually exclusive; in fact, most curricula used a combination of delivery methods (n = 38; 88%). Two programs40,67 relied exclusively on online modules. Below, we have highlighted two studies—one using a longitudinal curriculum; the other, a brief, intensive curriculum—that described multiple delivery methods.

Stewart and colleagues (2012)39 described their four-year, longitudinal, multimethod approach to training residents working in urban health. The program leveraged existing relationships with community health centers to provide residents with both experiential learning and didactic sessions. Residents were placed in continuity clinics at community health centers that serve patients who are typically underserved and who use an existing “access partnership” to increase access to specialists and procedures. At the continuity clinics, residents learned to use a substance abuse screening tool as part of the adult patient intake process. Residents also received feedback regarding their psychiatric care of patients through a community psychiatric clinic. Hospital case workers collaborated with residents to discuss patients as part of case and disease management teams. Finally, residents and nurse practitioner students performed house visits together to learn skills in health promotion for patients with low incomes. As described, this curriculum was developed in partnership with the community health centers and emphasizes experiential learning for residents. One goal was for residents to attain knowledge, attitudes, and skills needed to care for vulnerable and underserved urban patients; however, the curriculum was not evaluated regarding these outcomes.

Catalanotti and colleagues (2013)60 described their elective two-week community health curriculum for internal medicine residents. The course included several curriculum delivery methods including lecturers and clinical experience. Guest lecturers spoke on foundational knowledge (e.g., health disparities), physician career development, or the health needs of vulnerable populations. In addition to lectures, residents worked at local community health centers six afternoons during the two weeks (while maintaining their regular continuity clinic one afternoon each week). The preceptors at the community health centers received the course objectives but were not required to participate in any further training. At the end of the curriculum, residents gave presentations at their home institutions on the services offered by their clinical sites and discussed ways to improve care for patients. The purpose of the curriculum was to increase residents’ awareness of community resources and to improve their comfort in discharging patients to community follow-up visits. After the program, residents reported that learning about community health was important to their training. Compared with their precurriculum scores, residents’ postcurriculum scores demonstrated higher perceived competence at discharging inpatients to community follow-up appointments, but the scores indicated no changes in residents’ perceived likelihood to practice primary care or to practice in an underserved community.

Curriculum evaluation

Of the 43 articles, 27 (63%) reported outcomes of training: 7 (16%) evaluated postintervention outcomes only52–54,58,64,70,72; 12 (28%) used a single-arm pre/post study design50,55,59–62,65–68,74,75; 6 (14%) used nonrandomized designs with control groups51,56,57,63,69,71; and 2 (5%) used randomized, controlled designs.49,73 As anticipated, the outcomes evaluated were heterogenous. Most studies that assessed outcomes measured learner attitudes such as resident satisfaction (n = 11; 26%) and/or self-reported knowledge and attitudes about SDH (n = 18; 42%). The following programs used several methods to measure specific objectives of their curricula and scored the highest on the MERSQI tool.

Green and colleagues (2014)68 developed a health literacy curriculum that incorporated didactic sessions and standardized patient (SP) encounters. The purpose of the curriculum was to train residents to use plain language, to confirm patients’ understanding by using “teach-back” methods, and to ask open-ended questions during encounters. Following the didactic sessions, residents practiced clear health communication techniques in small groups with SPs. To evaluate the program effectiveness, the authors used a pre/post study design with no control group. In addition, residents videotaped at least two random patient encounters. These were later reviewed by the authors using a standardized checklist. The authors measured changes in residents’ knowledge and attitudes about health literacy using a questionnaire they (the authors) had developed. Overall, resident attitudes improved after training, and their knowledge about health literacy significantly improved. In the videotaped encounters, residents demonstrated significant improvement post curriculum in their use of plain language, teach-back methods, and open-ended questions.

Klein and colleagues (2014)69 developed a curriculum that combined didactic and experiential learning to teach pediatric residents about SDH. The curriculum included two 90-minute conferences during which faculty presented clinical vignettes depicting residents screening for SDH in either an inappropriate or appropriate manner. In the inappropriate scenarios, residents completed social histories without screening for SDH, despite verbal cues from the patients. In appropriate scenarios, residents successfully recognized the cues and engaged in SDH screening. In addition to the videos, the curriculum included didactic sessions on SDH topics. The authors evaluated the effect of the curriculum on resident SDH screening competency, the number of referrals to available medical–legal partnerships (MLPs), the number of cans of formula distributed, and parents’ perceptions of the residents. To measure SDH screening competency, residents completed pre- and postintervention surveys measuring their competence engaging in conversations about SDH-related issues and their knowledge of available resources to address SDH. The authors audited electronic health record documentation to measure the number of MLP referrals and cans of formula distributed. Finally, the authors surveyed three families per resident after well-child visits. Compared with the control group, the intervention group reported significantly higher competence in screening for SDH. MLP referral rates and formula distribution increased post curriculum for the intervention group compared with control group. Parent trust was high for both groups, with no significant differences.

Supplemental Digital Appendix 4, available at, summarizes the outcomes and results measured for studies that included program evaluation according to Moore and colleagues’ seven outcome measurement levels.


Although residents must demonstrate competence in a variety of clinical skills prior to graduation, SDH skills are not explicitly required16; trainees may achieve clinical competence using skills minimally related to addressing SDH. Moreover, best educational practices to teach SDH are not well understood. The findings of our scoping review of the literature indicate that existing SDH curricula are heterogeneous in their content; implementation or delivery; and evaluation methods. Educational content includes general concepts related to SDH, as well as specific content regarding care of vulnerable patient groups, such as those with low health literacy. Methods of implementing the curricula range from didactic sessions to longitudinal experiential learning. Evaluation methods also vary widely. Many programs do not assess learners, some assess only learner attitudes, and only a few assess clinical behaviors. Although the observed heterogeneity of content, delivery, and assessments makes comparing the curricula difficult, we believe the six studies we highlighted (in Results, above) provide some guidance to other residency programs seeking to implement or enhance their SDH training.

According to our findings, educational topics related to SDH are numerous and varied. While covering all SDH-related content may not be practical for all residency programs, a few programs47,52,70,74 cited frameworks that encompass multiple domains of SDH76,77 and provide a clear rationale for selecting specific content. For example, as mentioned, MacNamara and colleagues (2014)70 responded to the need for improved health care for recently resettled populations in their community by designing a curriculum using frameworks in cultural humility and transnational competence.76,77 These frameworks, and others we encountered in our broader literature search,78,79 such as one proposed by the WHO that describes structural and intermediary SDH,79 are valuable for educators to consider because they provide a comprehensive view of all SDH content and can prevent unintentional omissions of key content. Specific skills in one content area may not automatically confer skill in another. For example, a program that helps residents learn to identify and address intimate partner violence may not help them address patients with low health literacy. Knowledge of comprehensive SDH frameworks can help educators deliberately select content areas appropriate for their residents and patient populations.

Curricular implementation was similarly varied. Some programs delivered content in brief didactic sessions, such as through video vignettes,69 and others developed longitudinal programs based on tenets of experiential learning.39 At one end of the continuum,69 all content was delivered in two 90-minute sessions, whereas at the other,39 residents participated in an “urban health track” that was implemented longitudinally over four years. While one may expect a longitudinal or intensive curriculum to result in increased changes in behaviors, our findings did not clearly demonstrate this result. We believe, therefore, that training programs seeking to implement SDH training can select a curriculum that best fits within the culture and constraints of their individual programs.

Perhaps most important, many studies evaluated outcomes related to the delivered curriculum. Most studies reported positive effects of their programs, though most studies measured only satisfaction and/or change in resident knowledge. A few studies in our review received high MERSQI scores (indicating high quality) and reported positive effects on residents’ behavior or skills; interestingly, these studies included programs with both limited, didactic training71 and more resource-intensive training with experiential learning.39 Comparisons of curricular effectiveness based on specific features of a curriculum (e.g., duration, experiential vs. didactic) were not possible given the heterogeneity of assessment types. These outcome studies provide valuable information for program directors seeking to implement SDH curricula, as leaders can assess learner attitudes, knowledge, or behaviors and select curricula that best address their areas of need.

Our review is unique given its focus on SDH education during residency. Prior reviews have primarily focused on curricular efforts in undergraduate medical education. Training during residency differs substantially from that which occurs during medical school, and relies heavily on learning through clinical experience. Without an explicit emphasis on teaching SDH, this apprenticeship learning environment may convey a hidden curriculum about the value of SDH and risks worsening SDH-related attitudes and behaviors. For example, if residents perceive faculty as showing disrespect to patients by equating the need to consider SDH with being “difficult” or “noncompliant,” resident cynicism may increase.80 Residency training also serves as the final formal learning environment for primary care providers before they begin practicing in internal medicine, family practice, and pediatrics. Thus, identifying generalizable, effective SDH curricula for residents that emphasize transferable skills (i.e., skills that can be applied in a variety of practice settings) is particularly important. In addition, other programs have focused exclusively on cultural competency81 or health disparities.82 SDH encompasses both of these topic areas but also covers broader socioeconomic and political structures that affect equity and health outcomes, such as education, housing, income, social values, and policies. By broadening our search to include SDH, we hoped to identify curricular approaches that improve clinical behaviors, such as identifying barriers to care in urban, rural, immigrant, and other underserved populations, that may have otherwise been omitted from prior reviews.

Our study should be considered in the context of its limitations. First, we limited our time frame to publications within the past 10 years, and could have omitted important curricula published outside that time window. Second, we may have missed innovative and effective curricula that did not result in publication, or we may have found only results that give an overly positive impression of learner outcomes due to publication bias. Furthermore, as in all reviews, despite our use of standard search strategies, such as key word searches, we may have missed relevant articles, especially from sources such as MedEdPORTAL and iCollaborative.83 We found that articles in these databases may not be consistently indexed by all relevant characteristics. Completing a full search of these databases would have required a manual review of all catalogued articles, which was beyond the scope of this review. Additionally, our study focused only on residency curricula for primary care physicians. Other SDH curricula targeting other health care professionals may be relevant for physicians; however, we chose to limit our search to medical training because medical residents may have unique learning needs and environments. As mentioned, we were unable to conduct formal comparisons among curricula to determine which were “best.” Instead, we met and collectively determined which studies warranted highlighting, based on their content’s adherence to best practices in medical curriculum design. Lastly, each reference was initially screened by only one reviewer because of limitations in time and resources. To mitigate this limitation, we required all screeners to complete training in determining eligibility and demonstrated interrater reliability.

Reviewing the body of literature allowed us to identify gaps in knowledge and, in turn, provide lessons learned and some best practices to guide future medical education efforts. First, competencies related to SDH-related skills are limited and may be fulfilled using other, unrelated skills. Others have advocated for specific competencies in identifying and mitigating SDH.19 We believe that providing specific competencies would decrease heterogeneity in SDH-related content and their associated assessments. Second, integrating and studying these curricula within a variety of residency programs is important for evaluating the generalizability of their effectiveness. Third, information regarding faculty development would help programs where faculty currently lack experience in teaching about SDH. The studies included in this review lacked detailed information regarding professional development, although the curricula may have incorporated programs designed to develop effective teachers. Lastly, we do not know the effects of teaching SDH on the patients or communities that residents care for. Future studies should examine whether patients’ health outcomes or experiences of care change when residents receive training to identify and mitigate SDH.

Teaching SDH is critical for mitigating health disparities; however, the content and the delivery of SDH curricula vary considerably in primary care residency programs. Similarly, the approaches to evaluating curricula are also heterogeneous, making comparisons challenging. We propose that accreditation and certification boards more explicitly require skills training in SDH. Additionally, increasing grant funding to support research on resident and patient outcomes is critical for improving the quality of relevant medical education. We also encourage specialty and educational societies, particularly those representing primary care fields, to develop standardized practices for content, delivery (implementation), and evaluation of SDH curricula, by using Kern’s six-step approach.28 Once educators select content and delivery, optimally they would then select desired outcomes from standard assessment mapping to Moore and colleagues’ taxonomy of outcomes.29 By following these processes, curricula would provide ongoing information that would lead to a deeper understanding of what aspects of a curriculum most strongly shape learner behaviors, and what is required to replicate them in other settings.


The authors wish to thank Dr. Mobola Campbell-Yesufu for her feedback ensuring that results were relevant to educators. The authors also wish to thank Nicola Lancki for her assistance with calculating interrater reliability.


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