Social determinants of health (SDOH) are closely intertwined with multiple social and economic factors. Reflection is critical to learning SDH. However, only a few reports analyze SDH programs; most are cross-sectional studies. We sought to conduct a longitudinal evaluation of the SDH program in a community health education (CBME) course launched in 2018 based on the level and content of student-reported reflection on SDH.
Research design: A general inductive approach to qualitative data analysis. Educational Program: A compulsory 4-week internship in general medicine and primary care at the University of Tsukuba School of Medicine, Japan, is offered to all fifth- and sixth-year medical students. The students spent three weeks on duty at community clinics and hospitals in suburban and rural areas of Ibaraki Prefecture. After the first day of SDH lectures, students were asked to prepare structured case reports based on situations encountered during the course. On the last day, students shared their experiences in group meetings and presented a paper on SDH. The program continues to improve and provide teacher development. Study participants: students who completed the program between October 2018 and June 2021. Analytical: The level of reflection is classified as reflective, analytical or descriptive. Content is analyzed using the Solid Facts platform.
We analyzed 118 reports for 2018-19, 101 reports for 2019-20 and 142 reports for 2020-21. There were 2 (1.7%), 6 (5.9%) and 7 (4.8%) reports of reflection, 9 (7.6%), 24 (23.8%) and 52 (35.9% ) analysis reports, 36 (30.5%) respectively, 48 (47.5%) and 79 (54.5%) descriptive reports. I won’t comment on the rest. The number of Solid Facts projects in the report is 2.0 ± 1.2, 2.6 ± 1.3, and 3.3 ± 1.4, respectively.
As SDH projects in CBME courses are refined, students’ understanding of SDH continues to deepen. Perhaps this was facilitated by the development of the faculty. A reflective understanding of SDH may require further faculty development and integrated education in the social sciences and medicine.
Social determinants of health (SDH) are non-medical factors that influence health status, including the environment in which people are born, grow, work, live and age [1]. SDH has a significant impact on people’s health, and medical intervention alone cannot alter the health effects of SDH [1,2,3]. Health care providers must be aware of SDH [4, 5] and contribute to society as health advocates [6] to mitigate the negative consequences of SDH [4,5,6].
The importance of teaching SDH in undergraduate medical education is widely recognized [4,5,7], but there are also many challenges associated with SDH education. For medical students, the critical importance of linking SDH to biological disease pathways [8] may be more familiar, but the connection between SDH education and clinical training may still be limited. According to the American Medical Association Alliance for Accelerating Change in Medical Education, more SDH education is provided in the first and second years of undergraduate medical education than in the third or fourth years [7]. Not all medical schools in the United States teach SDH at the clinical level [9], course lengths vary [10], and courses are often electives [5, 10]. Due to the lack of consensus on SDH competencies, assessment strategies for students and programs vary [9]. To promote SDH education within undergraduate medical education, it is necessary to implement SDH projects in the final years of undergraduate medical education and conduct appropriate evaluation of the projects [7, 8]. Japan has also recognized the importance of SDH education in medical education. In 2017, SDH education was included in the core curriculum of demonstration medical education, clarifying the goals to be achieved upon graduation from medical school [11]. This is further emphasized in the 2022 revision [12]. However, methods for teaching and assessing SDH have not yet been established in Japan.
In our previous study, we assessed the level of reflection in senior medical students’ reports as well as their processes by assessing the evaluation of the SDH project in a community-based medical education (CBME) course [13] at a Japanese university. Understanding SDH [14]. Understanding SDH requires transformative learning [10]. Research, including ours, has focused on students’ reflections on evaluating SDH projects [10, 13]. In the initial courses we offered, students seemed to understand some elements of SDH better than others, and their level of thinking about SDH was relatively low [13]. Students deepened their understanding of SDH through community experiences and transformed their views of the medical model into a life model [14]. These results are valuable when curriculum standards for SDH education and their assessment and assessment are not yet fully established [7]. However, longitudinal evaluations of undergraduate SDH programs are rarely reported. If we can consistently demonstrate a process for improving and evaluating SDH programs, it will serve as a model for better design and evaluation of SDH programs, which will help develop standards and opportunities for undergraduate SDH.
The purpose of this study was to demonstrate the process of continuous improvement of the SDH educational program for medical students and to conduct a longitudinal evaluation of the SDH educational program in a CBME course by assessing the level of reflection in student reports.
The study used a general inductive approach and conducted qualitative analysis of project data annually for three years. It evaluates SDH reports of medical students enrolled in SDH programs within CBME curricula. General induction is a systematic procedure for analyzing qualitative data in which the analysis can be guided by specific evaluative goals. The goal is to allow research findings to emerge from frequent, dominant, or important themes inherent in the raw data rather than predefined by a structured approach [15].
Study participants were fifth- and sixth-year medical students at the University of Tsukuba School of Medicine who completed a mandatory 4-week clinical internship in the CBME course between September 2018 and May 2019 (2018–19). March 2020 (2019-20) or October 2020 and July 2021 (2020-21).
The structure of the 4-week CBME course was comparable to our previous studies [13, 14]. Students take CBME in their fifth or sixth year as part of the Introduction to Medicine course, which is designed to teach foundational knowledge to health care professionals, including health promotion, professionalism, and interprofessional collaboration. The goals of the CBME curriculum are to expose students to the experiences of family physicians who provide appropriate care in a variety of clinical settings; report health concerns to citizens, patients, and families in the local health care system; and develop clinical reasoning skills. . Every 4 weeks, 15-17 students take the course. Rotations include 1 week in a community setting, 1-2 weeks in a community clinic or small hospital, up to 1 week in a community hospital, and 1 week in a family medicine department at a university hospital. On the first and last days, students gather at the university to attend lectures and group discussions. On the first day, the teachers explained the course objectives to the students. Students must submit a final report related to the course objectives. Three core faculty (AT, SO, and JH) plan most of the CBME courses and SDH projects. The program is delivered by core faculty and 10-12 adjunct faculty who are either involved in undergraduate teaching at the university while delivering CBME programs as practicing family physicians or non-physician medical faculty familiar with CBME.
The structure of the SDH project in the CBME course follows the structure of our previous studies [13, 14] and is constantly modified (Fig. 1). On the first day, students attended a hands-on SDH lecture and completed SDH assignments during a 4-week rotation. Students were asked to select a person or family they met during their internship and gather information to consider possible factors that could affect their health. The World Health Organization provides Solid Facts Second Edition [15], SDH worksheets, and sample completed worksheets as reference materials. On the last day, students presented their SDH cases in small groups, each group consisting of 4-5 students and 1 teacher. Following the presentation, students were tasked with submitting a final report for the CBME course. They were asked to describe and relate it to their experience during the 4-week rotation; they were asked to explain 1) the importance of healthcare professionals understanding SDH and 2) their role in supporting the public health role that should be played. Students were provided with instructions for writing the report and detailed information on how to evaluate the report (supplementary material). For student assessments, approximately 15 faculty members (including core faculty members) assessed the reports against the assessment criteria.
An overview of the SDH program in the CBME curriculum of the University of Tsukuba Faculty of Medicine in the 2018-19 academic year, and the process of SDH program improvement and faculty development in the 2019-20 and 2020-21 academic years. 2018-19 refers to the plan from October 2018 to May 2019, 2019-20 refers to the plan from October 2019 to March 2020, and 2020-21 refers to the plan from October 2020 to June 2021. SDH: Social Determinants of Health, COVID-19: Coronavirus Disease 2019
Since its launch in 2018, we have continually modified the SDH program and provided faculty development. When the project began in 2018, the core teachers who developed it gave teacher development lectures to other teachers who would participate in the SDH project. The first faculty development lecture focused on SDH and sociological perspectives in clinical settings.
Following the completion of the project in the 2018-19 school year, we held a teacher development meeting to discuss and confirm the project’s goals and modify the project accordingly. For the 2019-20 school year program, which ran from September 2019 to March 2020, we provided Facilitator Guides, Evaluation Forms, and Criteria for Faculty Coordinators to conduct SDH Topic Group Presentations on the final day. After each group presentation, we held group interviews with the teacher coordinator to reflect on the program.
During the third year of the program, from September 2020 to June 2021, we held faculty development meetings to discuss the goals of the SDH educational program using the final report. We made minor changes to the final report assignment and evaluation criteria (supplementary material). We have also changed the format and deadlines for filing applications by hand and filing before the last day to electronic filing and filing within 3 days of the case.
To identify important and common themes across the report, we assessed the extent to which SDH descriptions were reflected and extracted the robust factual factors mentioned. Because previous reviews [10] have considered reflection as a form of educational and program evaluation, we determined that the specified level of reflection in evaluation could be used to evaluate SDH programs. Given that reflection is defined differently in different contexts, we adopt the definition of reflection in the context of medical education as “the process of analyzing, questioning and reconstructing experiences with a view to evaluating them for learning purposes.” /or improve practice,” as described by Aronson, based on Mezirow’s definition of critical reflection [16]. As in our previous study [13], 4-year period in 2018–19, 2019–20 and 2020–21. in the final report, Zhou was classified as descriptive, analytical, or reflective. This classification is based on the academic writing style described by the University of Reading [17]. Since some educational studies have assessed the level of reflection in a similar way [18], we determined that it is appropriate to use this classification to assess the level of reflection in this research report. A narrative report is a report that uses the SDH framework to explain a case, but in which there is no integration of factors.An analytical report is a report that integrates SDH factors. Reflection Sexual reports are reports in which the authors further reflect on their thoughts about SDH. Reports that did not fall into one of these categories were classified as not evaluable. We used content analysis based on the Solid Facts system, version 2, to assess the SDH factors described in the reports [19]. The contents of the final report are consistent with the program objectives. Students were asked to reflect on their experiences to explain the importance of healthcare professionals understanding SDH and their own role. in society. SO analyzed the reflectance level described in the report. After considering the SDH factors, SO, JH, and AT discussed and confirmed the category criteria. SO repeated the analysis. SO, JH, and AT further discussed the analysis of reports that required changes in classification. They reached final consensus on the analysis of all reports.
A total of 118, 101 and 142 students participated in the SDH program in the 2018-19, 2019-20 and 2020-21 academic years. There were 35 (29.7%), 34 (33.7%) and 55 (37.9%) female students, respectively.
Figure 2 shows the distribution of reflection levels by year compared to our previous study, which analyzed the levels of reflection in reports written by students in 2018-19 [13]. In 2018-2019, 36 (30.5%) reports were classified as narrative, in 2019-2020 – 48 (47.5%) reports, in 2020-2021 – 79 (54.5%) reports. There were 9 (7.6%) analytical reports in 2018-19, 24 (23.8%) analytical reports in 2019-20 and 52 (35.9%) in 2020-21. There were 2 (1.7%) reflection reports in 2018-19, 6 (5.9%) in 2019-20 and 7 (4.8%) in 2020-21. 71 (60.2%) reports were categorized as non-evaluable in 2018-2019, 23 (22.8%) reports in 2019-2020. and 7 (4.8%) reports in 2020–2021. Classified as not assessable. Table 1 provides example reports for each reflection level.
Level of reflection in student reports of SDH projects offered in the 2018-19, 2019-20 and 2020-21 academic years. 2018-19 refers to the plan from October 2018 to May 2019, 2019-20 refers to the plan from October 2019 to March 2020, and 2020-21 refers to the plan from October 2020 to June 2021. SDH: Social Determinants of Health
The percentage of SDH factors described in the report is shown in Figure 3. The average number of factors described in the reports was 2.0 ± 1.2 in 2018-19, 2.6 ± 1.3 in 2019-20. and 3.3 ± 1.4 in 2020-21.
Percentage of students who reported mentioning each factor in the Solid Facts Framework (2nd Edition) in the 2018-19, 2019-20, and 2020-21 reports. The period 2018-19 refers to October 2018 to May 2019, 2019-20 refers to October 2019 to March 2020 and 2020-21 refers to October 2020 to June 2021, these are the scheme dates. In the 2018/19 academic year there were 118 students, in the 2019/20 academic year – 101 students, in the 2020/21 academic year – 142 students.
We introduced an SDH education program into a required CBME course for undergraduate medical students and presented the results of a three-year evaluation of the program assessing the level of SDH reflection in student reports. After 3 years of implementing the project and continuously improving it, most students were able to describe SDH and explain some of the factors of SDH in a report. On the other hand, only a few students were able to write reflective reports on the SDH.
Compared to the 2018-19 school year, the 2019-20 and 2020-21 school years saw a gradual increase in the proportion of analytical and descriptive reports, while the proportion of non-assessed reports decreased significantly, which may be due to improvements in program and teacher development. Teacher development is critical to SDH educational programs [4, 9]. We provide ongoing professional development for teachers participating in the program. When the program was launched in 2018, the Japan Primary Care Association, one of Japan’s academic family medicine and public health associations, had just published a statement on SDH for Japanese primary care physicians. Most educators are unfamiliar with the term SDH. By participating in projects and interacting with students through case presentations, teachers gradually deepened their understanding of SDH. In addition, clarifying the goals of SDH programs through ongoing teacher professional development may help improve teacher qualifications. One possible hypothesis is that the program has improved over time. Such planned improvements may require considerable time and effort. Regarding the 2020–2021 plan, the impact of the COVID-19 pandemic on students’ lives and education [20, 21, 22, 23] may cause students to view SDH as an issue affecting their own lives and help them think about SDH.
Although the number of SDH factors mentioned in the report has increased, the incidence of different factors varies, which may be related to characteristics of the practice environment. High rates of social support are not surprising given the frequent contact with patients already receiving medical care. Transportation was also mentioned frequently, which may be due to the fact that CBME sites are located in suburban or rural areas where students actually experience inconvenient transportation conditions and have the opportunity to interact with people in such environments. Also mentioned were stress, social isolation, work and food, which more students are likely to experience in practice. On the other hand, the impact of social inequality and unemployment on health may be difficult to understand during this short period of study. The SDH factors that students encounter in practice may also depend on the characteristics of the practice area.
Our study is valuable because we are continually evaluating the SDH program within the CBME program we offer to undergraduate medical students by assessing the level of reflection in student reports. Senior medical students who have studied clinical medicine for many years have a medical perspective. Thus, they have the potential to learn by relating the social sciences required for SDH programs to their own medical views [14]. Therefore, it is very important to provide SDH programs to these students. In this study, we were able to conduct ongoing evaluation of the program by assessing the level of reflection in student reports. Campbell et al. According to the report, US medical schools and physician assistant programs evaluate SDH programs through surveys, focus groups, or mid-group evaluation data. The most commonly used measurement criteria in project evaluation are student response and satisfaction, student knowledge, and student behavior [9], but a standardized and effective method for evaluating SDH educational projects has not yet been established. This study highlights longitudinal changes in program evaluation and continuous program improvement and will contribute to the development and evaluation of SDH programs at other educational institutions.
Although students’ overall level of reflection increased significantly throughout the study period, the proportion of students writing reflective reports remained low. Additional sociological approaches may need to be developed for further improvement. Assignments in the SDH program require students to integrate sociological and medical perspectives, which differ in complexity compared to the medical model [14]. As we mentioned above, it is important to provide SDH courses to high school students, but organizing and improving educational programs starting early in medical education, developing sociological and medical perspectives, and integrating them can be effective in furthering students’ advancement. ‘develop. Understanding SDH. Further expansion of teachers’ sociological perspectives may also help to increase student reflection.
This training has several limitations. First, the study setting was limited to one medical school in Japan, and the CBME setting was limited to one area in suburban or rural Japan, as in our previous studies [13, 14]. We have explained the background of this study and previous studies in detail. Even with these limitations, it is worth noting that we have demonstrated results from SDH projects in CBME projects over the years. Second, based on this study alone, it is difficult to determine the feasibility of implementing reflective learning outside of SDH programs. Further research is needed to promote reflective learning of SDH in undergraduate medical education. Third, the question of whether faculty development contributes to program improvement is beyond the scope of the hypotheses of this study. The effectiveness of teacher team building needs further study and testing.
We conducted a longitudinal evaluation of the SDH educational program for senior medical students within the CBME curriculum. We show that students’ understanding of SDH continues to deepen as the program matures. Improving SDH programs may require time and effort, but teacher development aimed at increasing teachers’ understanding of SDH can be effective. To further improve students’ understanding of SDH, courses that are more integrated into the social sciences and medicine may need to be developed.
All data analyzed during the current study are available from the corresponding author on reasonable request.
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Post time: Oct-28-2023