Addressing the social determinants of health (SDH) is a primary strategy to attaining health equity.1 The World Health Organization defines the SDH 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. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”2 The SDH affect an individual’s ability to live healthy and be healthy.3 Therefore, SDH education is an important component of an undergraduate medical curriculum. In recognition of the importance of SDH, the Liaison Committee on Medical Education requires this topic to be included in medical school curricula.4 However, inclusion of SDH does not ensure that students will graduate with the ability to apply these concepts in a manner that will help their patients attain improved health outcomes or health equity.
Medical students should understand and have the ability to address the SDH to provide optimal care. To achieve this end, the medical education community has been called on to incorporate SDH into curricula5 but has limited guidance regarding what and how to teach and how to evaluate students in this domain. Our goal was to use a modified Delphi technique6 that was focused on understanding the best approaches to teach medical students about SDH to develop an SDH curricular guide through consensus expert opinion.
While efforts to teach SDH are increasing, to date there has been little published literature, to our knowledge, describing ways in which educators have decided how to structure their SDH curricula. By gathering information from medical educators, community providers, and students, we conducted this study to begin to address this gap in the literature. Our findings can serve as a basis for the development of a consensus guide for the design and implementation of a robust SDH curriculum for medical students.
We developed a comprehensive list of topics that might be included in an SDH curriculum by conducting a scoping review as preparation for the Delphi process. The review question was developed by the research team using the framework proposed by Arksey and O’Malley.7 We worked in partnership with a PhD-level librarian and focused on gathering information from previously published work on SDH education studies and program descriptions. Our general research question was, “What has been published on the topic of teaching medical students about SDH?” We searched five databases: PubMed, Embase, Educational Resources Information Center (ERIC), Web of Science, and Cochrane Database of Controlled Trials in November 2016 using the following search terms: social determinants of health (and variations), healthcare disparities (and variations), health status disparities (and variations), health disparity (and variations), healthcare inequities (and variations), health inequity (and variations), health equity (and variations), medical education/curricula, educational model, problem-based learning, medical school, service learning, experiential learning, interprofessional education, community-based education, and community-based learning. Multiple reviewers (including K.M.S., T.R.B., A.A.D.P., and M.D.A.) identified articles for inclusion in three rounds. Initially, reviewers scanned titles and abstracts (3,571 articles), and in the final round they reviewed the full-text articles and limited included articles to those published in the English language and from U.S. and Canadian medical schools from 2010 to 2015 (171 articles). In total, we included 22 articles in the final analysis for item extraction. The final scoping review methodology and results are available.8
We identified potential participants for the Delphi expert panel through the scoping review, as well as from key informants, including community members and medical students. We invited a total of 57 panelists to participate via e-mail. Panelists were offered small monetary remuneration for completion of the surveys that composed the first round of the Delphi process. As stipulated by recommended Delphi guidelines, we planned to conduct survey rounds until consensus was reached, although we did not define consensus a priori, as we hoped to create a list of topics ranked by importance rather than a definitive guide of exact topics to include in an SDH curriculum.
Delphi survey development
To develop the survey and increase study rigor, we:
- reviewed curricula and assessment tools identified by the scoping review and selected curricular components,
- contacted authors of key manuscripts to seek further detail,
- interviewed individuals involved in robust SDH curricula, and
- reviewed a local public health report, Healthy Chicago 2.0,9 the Chicago Department of Public Health’s four-year community health improvement plan to improve health equity for additional topics.
On completion, we compiled all identified items into a master list, collapsed similar items, and edited for grammatical consistency. At the end of this process, we had selected 136 items to include in the first survey round. The list was split into three topic areas: knowledge, skills and attitudes, and logistics. Because of the large number of items, we distributed the survey in three separate parts, each focused on the topics listed above: knowledge, with sections on the social environment, built environment, access to care, and forces and systems; skills and attitudes; and logistics, with sections regarding the timing, delivery, value, level of assessment, assessment methods, and barriers.
In the knowledge as well as skills and attitudes sections, we asked panelists to rate the importance of topics that could be included in an SDH curriculum. In the logistics section, panelists gave input on how best to teach and assess SDH by rating educational strategies related to assessment approaches and the integration of SDH content into an existing curriculum. After each survey section, we offered panelists feedback about previous responses.
After the initial Delphi round was complete, we surveyed our panel again, providing data from the first round responses. We did not use a predefined rating cutoff, as the items were all highly rated in the first round. All items were therefore included for review in the knowledge and skills and attitudes sections. However, for the logistics section, we included only the top responses for panelists’ review and re-ranking during the second round. The top four to seven responses for each question were listed, and panelists were asked to change the rank order of the items if they wished. We provided panelists with the previous round’s ranking range as a reference. The number of items listed were chosen using natural cut points in the original ranking. We also asked panelists to offer further comment on any of the topics and content included in the Delphi surveys. At the end of the second round, the panelists had made only minimal changes to the rankings and ratings from the first round, and we decided that we had reached group consensus at that time.
This study was deemed to be exempt by our local institutional review boards.
Twenty-two panelists completed at least one survey and 16 panelists completed all three surveys from Delphi round 1. This group included community advocates, medical students, public health researchers, and academic faculty members that represented a broad U.S. geographic distribution. At least 13 of the panelists have published on SDH or SDH education. See Table 1 for further details about the panel’s composition. A total of 12 participants completed the second, final round.
Overall, the highest-ranked knowledge topics that panelists felt should be included in SDH curricula were “racism,” “discrimination and stigma,” “poverty,” “health care system and policy,” “factors affecting availability of primary care,” “role of social influences such as segregation or racism or homophobia,” and “structural inequality.” List 1 provides all of the topic rankings.
Panelists’ Ranking of the Importance of Knowledge Topics, From a Study of Inclusion of Social Determinants of Health Content in Undergraduate Medical Education, 2017a
- Racism (4.7)
- Discrimination and stigma (4.7)
- Health care system and policy (4.6)
- Poverty rate (4.6)
- Community violence (4.5)
- Segregation (4.5)
- Literacy rate (4.4)
- Mass incarceration (4.4)
- Social cohesion (4.3)
- Education attainment (4.3)
- Culture (4.2)
- Quality of schools (4.2)
- Early childhood education availability (4.1)
- Unemployment rate (4.0)
- Community agencies (4.0)
- Proximity to employment (4.0)
- After-school programs (4.0)
- Exercise and wellness classes (3.5)
- Availability of grocery stores (4.4)
- Affordable housing availability (4.2)
- Open spaces, parks, and playgrounds (4.2)
- Proximity to health care facilities (4.1)
- Proximity to mental health facilities (4.1)
- Lead burden in housing (4.0)
- Neighborhood walkability (4.0)
- Public housing accessibility (4.0)
- Public transportation accessibility (4.0)
- Foreclosures (4.0)
- Lighting (3.8)
- Housing vacancy rates (3.7)
- Climate change (3.7)
- Pedestrian plans to promote active transportation (3.3)
- Sidewalk maintenance (3.1)
- Mixed land use (3.1)
- Shared use agreements (3.1)
- Bike network plans to promote active transportation (3.1)
Access to Care
- Factors affecting availability of primary care (4.6)
- Role of social influences such as segregation or racism or homophobia (4.6)
- Factors affecting availability of mental health services (4.5)
- Factors related to insurance coverage (4.4)
- Factors affecting availability of dental services (4.4)
- Provider cultural humility (4.4)
- Factors relating to language proficiency by provider or patient (4.4)
- Factors affecting availability of health care for undocumented residents (4.2)
- Role of safety net hospitals (4.1)
- Patient out-of-pocket cost (4.1)
- Role of Federally Qualified Health Centers (4.0)
- Factors affecting availability of early intervention (3.9)
- Factors affecting availability of ancillary care (i.e., vision, hearing) (3.9)
- Factors affecting availability of WIC (3.9)
- Factors related to accessing and using transportation (3.8)
- Role of provider payment rates (3.8)
- Factors related to providing and accessing charity care (3.8)
- Factors related to accessing and using transportation (3.8)
- School-based health centers (3.7)
Forces and Systems
- Structural inequality (4.6)
- Social justice (i.e., school discipline policies, criminal justice reform) (4.5)
- Political landscape (4.3)
- Community health needs assessment and implementation (4.2)
- Nutrition related (e.g., soda tax, health vending) (3.9)
- Tobacco related (3.8)
- Injury prevention related (e.g., seat belt laws) (3.5)
Abbreviation: WIC indicates Women, Infants, and Children program.
aOrganized by topic and mean ranking.
One participant commented,
It is not easy to say that one [topic] is less important than the other.
Skills and attitudes
The panelists ranked “work effectively with community providers such as community health workers,” “how to work effectively as a member of a multidisciplinary team,” and “how to screen patients for assets and needs” as the most important skills to teach. Regarding key attitudes that students should hold, those that received the highest ranking were “appreciation that the SDH are some of the root causes of health outcomes and health inequities,” “that care occurring inside the health system is only a small component of what impacts a patient’s overall health status,” and “patient health and well-being in the context of family, culture, community and society.” List 2 provides a list of the full ranking of the skills and attitudes topics.
Panelists’ Ranking of the Importance of Skills and Attitudes Topics, From a Study of Inclusion of Social Determinants of Health Content in Undergraduate Medical Education, 2017a
- Work effectively with community providers such as community health workers (4.8)
- Work effectively as a member of a multidisciplinary team (4.7)
- Screen patients for assets and needs (4.6)
- Develop patient care strategies based on SDH (4.5)
- Access community resources (4.4)
- Leverage partnerships to improve health (4.3)
- Identify multisector community resources (4.2)
- Use data effectively for planning (4.2)
- Implement community engagement strategies (4.2)
- Recognize potential data sources (3.9)
- Apply policy, system, and environmental change strategies to improve health (3.8)
- Participate in policy efforts (3.7)
- Incorporate scientific information into written documents or testimony (3.6)
- Appreciation that the SDH are some of the root causes of health outcomes and health inequities (4.9)
- That care occurring inside the health system is only a small component of what impacts a patient’s overall health status (4.8)
- Patient health and well-being in the context of family, culture, community and society (4.7)
- Recognition of their social capital as physicians or health care providers in their interaction with patients, communities, media and policy makers to improve health (4.5)
- Appreciation of the interaction between individual and population health (4.4)
- Appreciation of the impact of collective advocacy by professional organizations to improve health (4.1)
Abbreviation: SDH indicates social determinants of health.
aOrganized by topic and mean ranking.
One panelist commented,
Students should complete this curriculum with an improved awareness about the magnitude of the impact of the SDH on individual and population health and recognition that health care addresses/impacts only a small piece of health, but at the same time feeling empowered that they can make a difference and be part of the solution.
Panelists were asked about when SDH should be included in a medical school curriculum. Most panelists felt that the SDH curriculum should be taught continuously over the entire training period and integrated into the overall curriculum. They also ranked highly a hybrid approach of integration and independence. Teaching SDH only in the preclinical classes or clinical rotations or as an isolated topic was not rated highly by the expert panel. One panelist commented:
Teaching SDH as an integrated piece of the curriculum would help to counteract the long-standing and commonly held view that SDH are not really “health problems.” One of the issues with medicine today is that things such as SDH and mental/behavioral health issues are compartmentalized separately from physical health. We need to move toward an integrated definition of health and, by extension, an integrated way of practicing health. We do both ourselves and our patients/their families a disservice if we do otherwise.
The highest-ranked methods for delivering teaching about SDH in the curricula were “longitudinal integration,” “service learning,” “clinical setting,” and “case-based learning.” Lecture was the least favored method.
Panelists were asked to rank different reasons that teaching about SDH is valuable. The highest-rated responses were “assists in future patient care,” “assists in patient care now,” “assists in improving the health of communities in the future,” and “assists in improving the health of communities now.”
Panelists ranked items related to what levels of assessment should be used to support the development of the SDH curricula as well as what methods should be used to assess learners. The highest-ranked approaches to support SDH curriculum development were at the community and patient levels. The top-ranked learner assessment methods included “patient feedback,” “measures of improved community health,” “community health worker feedback,” and “community service provider feedback.” The assessment methods found to be less important were “group projects such as papers,” “oral examinations,” and “multiple-choice test questions.” A panelist commented:
I don’t think it will be hard to assess, measure, etc., once the ball is rolling. I do think the biggest obstacle is getting support to start moving the ball. We need buy-in, funding, and willingness to change curriculum. These are huge limitations. This is why I think one important strategy will be to get the larger board certifying bodies to recognize SDH as something worth testing … they will then eventually put pressure on our schools to begin to think creatively and address the teaching.
We asked panelists about possible barriers to teaching about SDH. The highest-ranked barriers were “faculty recognition of its importance or relevance,” “finding time in the curriculum,” and “identifying the most effective strategies to teach about SDH.” As one panelist noted:
Key for buy-in of any of this, however, is to advocate for SDH to be present within the standardized tests.
Overall allocation of curriculum
Panelists were asked how much of the total medical school curriculum should be dedicated to SDH and, of that amount, how it should be allocated between preclinical and clinical years. In the first round, panelists responded with a wide range (5%–80%; mean 30%) of curricular time that should be dedicated to SDH content. Panelists were able to see the responses of the other experts in the second round, and thus amend their own response taking these into account. The range narrowed in the second round (20%–35%; mean 29%), showing “consensus,” as demonstrated by the narrower range (Figure 1). Of this overall amount, respondents recommended allocating 13% (range 10%–18%) for the preclinical years and 15% (range 10%–20%) for the clinical years. A full listing of the logistics responses is provided as Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A629.
We developed and conducted a modified Delphi study of educators, researchers, students, and community advocates in an effort to develop an SDH curricular guide. Through this process, we learned what experts endorsed as essential knowledge, skills, and attitudes that medical students should acquire during their training, as well as feedback related to teaching methods and evaluation components. Delphi panelists reported that it is important that students develop a broad sense that access to health care is a modest determinant of health at the population level. Panelists reported that defining any specific topic area as most important is somewhat arbitrary. The panelists also reflected on logistical challenges in implementing SDH content and assessment, but reported that once buy-in by medical school administration occurs, these challenges can be resolved. The major challenge to fully integrating SDH teaching into the medical school curriculum is that it currently is not assessed on national standardized tests nor meaningfully required, not just recommended, by accreditation bodies. Until this state of affairs changes, medical schools will prioritize teaching topics that are tested and required.
These findings can help to inform best practices for SDH curricular development.
To date, most of the articles in the medical education literature that describe SDH teaching interventions (which were the focus of our scoping review) focus on a sample of students, usually a self-selected group. The evaluation components that are reported in these papers usually consist of satisfaction and attitude change surveys and occasionally self-reported knowledge acquisition. Very few of the publications reported the use of objective assessment strategies.
The recent National Academy of Medicine (NAM) report, A Framework for Educating Health Professionals to Address the Social Determinants of Health, recommends using a framework that includes three domains to educate health professionals about SDH: education, community collaboration, and institutional alignment.3 Our findings are consistent with the NAM’s recommendations and provide additional detail about content to include when developing an SDH curriculum. Not only can these findings help to guide educators in shaping the content and the structure of their curriculum, but they also challenge the field to develop improved assessment strategies to evaluate the impact that teaching medical students about SDH has on patient-level and community-level outcomes, as well as encouraging students to work to improve health equity.10
Limitations of our modified Delphi study include that the expert panel may not have been representative of medical schools and community advocates nationally. Items were identified for inclusion through the scoping review, and as such, if certain topics were not major themes, they were not included in the Delphi process. For example, there was a paucity of data on workplace-based assessments and direct observations, though these are likely valuable assessment methods to be explored in the future. In addition, immigration and cultural humility were not specifically defined as curricular topics within our review because we believe that these constructs require their own intentional instructional approach and, therefore, were not included in the Delphi study. Each of these topics should be considered in more detail in future efforts to integrate SDH into curricular content for medical students. It was difficult to limit topics because most of the panelists felt that all the listed topics were important to include in a medical school’s SDH curriculum. In addition, a key component for determining how a program should structure their SDH curricula should be based on local community needs and must include local community input.
Whereas the NAM report provides a critically needed framework for teaching medical students about SDH, the findings from this study offer important quantitative and qualitative data to help answer the essential questions that educators have about what to teach and how to teach and assess it. Ultimately, the intention of this study is to help move the field of medical education forward in outlining content and structure as we move from teaching some students to teaching all students about SDH, and toward developing an evidence-based best practice for doing so.
Our findings extend the current discussion and provide a guide to assist educators in teaching medical students about SDH, so that they can both understand and act to affect the forces and systems that in turn shape the policies and systems that influence their patients’ ability to live healthy and be healthy.
The authors wish to thank all of the Delphi panelists for their time and thoughtful responses.
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