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

Figures & data

Table 1. Four patterns of a configuration of CMOs (Context, Mechanisms, and Outcomes).

	Context (students)	Context (local medical institutions)	Mechanisms (interventions)	Mechanisms (reasoning)	Outcomes
1	Experience of clinical practice in a university hospital where it is difficult to feel connected to the community and patients' lives	Encounters with role models who talk about the connection between the community and patient life and illness	Observations of physicians’ behavior and narratives making sense of that behavior in the community	Observational learning from role models and verbal explanation	Transformation to a comprehensive perspective on the person
					Significance of intervening as a group in behavioral practices upstream of disease
2	Thinking accustomed to conforming to the medical model	Exposure to a field where contradiction of facing what is not medically correct.	Cross-checking SDH with narratives of patients and surrounding stakeholders	Connecting SDH concepts with concrete experiences in a contradiction between their beliefs and observation	Awareness of the patient context with socioeconomic background upstream of the disease
3	Clinical practice where disease-labelled patients and communities are the learning objects	Practice that makes it easy for patients, families, lay people and communities to recall solid facts that are focused through prior learning.	Visits to patients and patient homes with difficult family and economic challenges reminiscent of SDH encountered in multiple regions	Chunking their experiences with SDH categories and comparison to concrete multiple regions and patients among peers’ experiences, and verbalization on the meaning of these experiences	Conceptual understanding of the impact of the interaction of socioeconomic factors
4	Probable context of the physician as an authority in the hospital.	Participated in the life situation of patients, families, and lay people in the community where the context is easily visible	Imagination of the continuity of time while linking socioeconomic factors and the living environment which is nurtured by understanding the specifics of patients, families, and lay people.	Fostering empathy through a non-authoritative position	Empathic understanding of contextualized patients

Table 2. Representative data was extracted from CMOs based on the medical students’ final reports.

1	Transformative learning brought about through observational learning and linguistic explanation from role models	Medical Student A “I felt that there is a way (to) watch over things like pachinko and cigarettes that make life worth living, without making them stop. I felt the importance of thinking about how we can support (local people's) way of life and what we should change and what we should not change.” Medical student B “An occupational physician I met told me that many of the patients he saw in the emergency room were suffering from a disordered lifestyle, and he wanted to become an occupational physician so that he could help them.” It seems that there were cases in which the results of health examinations improved and people were grateful for the total ban on smoking in the workplace. I think this can be implemented within the framework of the community. I think it is possible to grasp the characteristics involved in the health of the community in advance and give lectures and advice to them.
2	Consciousness of relationships with integrated solid facts achieved by confronting contradictions of the medical model.	Medical Student C “I found out that (the patients I met in the training) had become heavy smokers in the first place because they did not have literacy about the harmful effects of tobacco and because there were many smokers in their workplace, and as a result, they started smoking somehow, and even though they thought it was unhealthy, they had not been able to quit smoking for economic reasons. Without knowing the reasons for smoking in the first place, I felt I could not help this patient quit.” Medical Student D “There was the problem of losing your job if you were hospitalized, and deeper down there was the social context of the lack of educational development in the area, the fact that many people were employed in manual labor, and the lack of health awareness among the citizens because of smoking and drinking.”
3	Conceptual understanding framed by verbalization that clarified students’ experience associated with SDH	Medical student E “Some people lived in a dump, had mortgages and couldn't pay their electricity bills, while others lived in a beautiful house, with a wife who cleaned their rooms and prepared nutritious meals for them every day. Social disparity, stress, unemployment, food, and childhood all seem to be closely related and interrelated in the flow of being an individual. A poor environment also increases the risk of developing lifestyle and infectious diseases, while poor nutrition can lead to impaired immune function and physical ailments.” Medical Student F “A woman in her 40 s, who was responsible for all the household chores by herself, was suspected of relapsing into depression. Approaching only the current problems, such as lack of sleep and the burden of housework, will not lead to a solution, and the essential approach is to consider what the cause is. Why is the family situation such that she has to do both housework and work? What is the economic situation? Is there a community with society? Looking further upstream is especially important when there is no solution or no prospect of a solution.” Medical Student G “By educating children at an early age about the appropriate foods to eat, they will not only contribute to their growth process, but will also pass on the value of appropriate foods to their families as they grow up. If this nutrition education occurs in the entire community, it will contribute to the health of the entire community.”
4	Empathic understanding of human life within contexts fostered by participation in a local community that differ from the hospital context	Medical student H “We heard about a woman who came from outside the prefecture to live with her son. From a medical point of view, I felt that living together would make it easier for her to care for her son, and be safer and lead to better health. However, she said it was the hardest thing for her to leave her old friends and come to the new place where she didn't know anyone.” Medical Student I “By being aware of the individual, where they live and what kind of work they do, rather than labeling patients by age or gender with some kind of disease, we can think of the doctors who provide medical care as members of the community and colleagues who live in the same community. I felt that this was important.”