How do medical students learn about SDH in the community? A qualitative study with a realist approach

Abstract

Introduction

The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities.

Methods

A 4-week clinical practice program was conducted for 5^th- and 6^th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives.

Results

First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students’ confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings.

Conclusion

Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.

Keywords:

• Community health education; program evaluation; outcome and process assessment; social context; behavior mechanisms

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Acknowledgments

The authors would like to thank all the students who participated in this study. We also thank all our department faculty members who contributed to student education and data collection.

Ethics approval statement

This study was approved by the Ethics Committee of the University of Tsukuba (approval number: 2676).

Glossary

Social determinants of health (SDH): Are the non-medical factors that influence health outcomes. Social determinants are the conditions under which people are born, grow, work, live, and age, and the broader forces and systems that shape the conditions of everyday life. These forces and systems include economic policies and systems, development issues, social norms, social policies, and political systems.

Community-based medical education (CBME): Refers to medical education that is based on clinical training in the community; CBME provides exposure to patients who are managing their illnesses in their homes, societies, and communities. Primary care clinicians and other health care providers accept learners in their own practices, professional communities, and local communities.

The realist approach: Is designed to answer questions such as “what works, for whom and under what circumstances?” based on a paradigm of realism between positivism and social constructivism.

Disclosure statement

The authors declare that they have no conflict of interest.

Author Contributions

All authors were involved in the conception and design of this study. Data analysis was conducted by JH, AT and SO, and was further refined by all authors. JH mainly wrote the paper. The other authors then revised it critically for intellectual content, and all of them approved the paper.

Additional information

Funding

This work was supported by JSPS KAKENHI Grant Number JP19K10527.

Notes on contributors

Junji Haruta

Junji Haruta, MD, PhD, is Associate Professor, Medical Education Center, School of Medicine, Keio University, Tokyo, Japan and Visiting Associate Professor, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Ayumi Takayashiki

Ayumi Takayashiki, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Sachiko Ozone

Sachiko Ozone, MD, PhD, Department of Family Medicine, General Practice and Community Health, Faculty of Medicine, University of Tsukuba, Japan.

Takami Maeno

Takami Maeno, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.

Tetsuhiro Maeno

Tetsuhiro Maeno, MD, PhD, Department of Primary Care and Medical Education, Faculty of Medicine, University of Tsukuba, Japan.