Effectiveness of alternative approaches to integrating SDOH into medical education: a scoping review | BMC Medical Education

An initial search was performed through the six databases. The full keyword search yielded an initial 933 articles imported into the Endnote X9 reference manager. These articles were from the following sources: PubMed (n = 55), Education Source (n = 87), ERIC (n = 94), APA PsycInfo (n = 99), Ovid MEDLINE (n = 369), and Scopus (n = 229). After removing duplicates based on EndNote’s find duplicate function and a hand search for duplicates (n = 279), 654 articles remained. Figure 1 depicts the PRISMA flow diagram for study inclusion.

In the first screening step, were a total of 588 articles excluded. Exclusion criteria were; not relevant (n = 329), did not cover medical curricula (n = 118), covered SDOH as applied to global health but not in the country of study (n = 41), were based on service-learning and not didactic content (n = 30), did not focus on SDOH (n = 12), not a study (n = 11), not in English (n = 5). Lastly, pilot courses were excluded (n = 3), and articles that did not provide sufficient information to evaluate the SDOH curricula (n = 39) were removed, leaving 66 articles for eligibility.

In this step, 66 full articles were examined and included employing the WHO definition of SDOH. A total of 58 articles were excluded because they were concerned with work-based learning in the community and not a structured curriculum (n = 4), insufficient curriculum details (n = 31), addressed non-medical students (n = 9), and studies related to public health curricula focusing on the prevention of infectious and chronic diseases rather than tackling the barriers of healthcare services (n = 10). Additionally, studies deemed irrelevant (n = 2) were identified and excluded. Studies that evaluated pilot courses (n = 3) were excluded as this study aimed to examine the formal curricula integrated into medical schools.

None of the records searched through the grey literature search were eligible for inclusion. The last search from the six included databases and the citation search of the reference lists yielded eight articles for inclusion in the scoping review. An additional manual search through the reference lists of these included articles yielded one further article which met eligibility criteria. The last search from the six included databases and the citation search of the reference lists yielded eight articles for inclusion in the scoping review.

Overview of SDOH curricula

Table 2 provides an overview of each SDOH curriculum, and its primary feature. Of the eight curricula included in the review, six were from medical schools in the United States [11,12,13,14,15,16], one from the United Kingdom (U.K.) [17], and one from Israel [18]. Seven programs were aimed at medical students [11, 12, 14,15,16,17,18], and only one curriculum was an inter-professional program covering medical students and other health professionals, including medical, nursing, pharmacy school, public health students, and social work students [13].

A three-step review process was undertaken covering the structure of each curriculum (such as whether it was mandatory or not, the duration of the program), its content (the conceptual framework employed, which didactic methods were included, and the primary learning competencies focused on) and lastly whether the program was evaluated.

Structure and content of SDOH curricula

Five medical schools included the SDOH curricula as a mandatory module [11, 12, 16,17,18], whereas three had it as an elective course [13,14,15]. The included programs varied in duration and timing during medical school training. Five were integrated over an entire academic year [11, 14, 16,17,18]; one of the five programs lasted 18 months (with a six-month preparation phase), and the remaining three varied between three and four months [12, 13, 15]. Regarding timing, four SDOH curricula were for third and fourth-year medical students at the beginning of the clinical clerkship [12, 16,17,18]. The final three programs focused on the first- and second-year medical students [11, 14, 15]. The remaining inter-professional program was integrated at different levels according to each school module design, so the timing of the course was variable [13].

All programs were structured based on a cited public health framework. The U.S. medical curricula [13, 14] were based on the United States public health department’s Healthy People 2020 objectives, the overarching 10-year strategic plan for eliminating health disparities [19, 20]. The main objectives of the U.S. initiative are eliminating health disparities related to socioeconomic conditions, gender, age, race, disability, sexual preference, or environmental status. These objectives can be achieved by improving the health status on a national level, promoting health equities for all age groups, increasing the awareness of the public sector regarding SDOH, working on intersectoral levels to enhance practices, and providing measurable indicators for health level improvement. Healthy people 2020 captures 12 SDOH related topics, including health access, education, preventive Medicine, environmental condition, violence, sexual health, nutrition and physical health, maternal health, mental health, oral health, drug abuse, and smoking.

Two programmes drew upon two different WHO frameworks [17, 18]; the U.K. medical school SDOH curriculum [17] adopted the WHO Life Course model [21] which identifies the physical and social risk factors during various stages of life from prenatal to middle age, impacting health outcomes in later life. This model educates health professionals regarding the relationship between socioeconomic conditions and health inequalities. The Etgar course [18] from Israel adopted Michael Marmot’s The Social Determinants of Health guidance [22], explaining ten solid points that link the social structure to the patient’s health outcome. This guidance was an initiation of the WHO urban health centre to work as guidance for the public and policymakers.

The Health equity curriculum [16] at the Wake Forest School of Medicine is based on the National Academic of Science, Engineering, and Medicine’s Framework For educating Health Professionals to Address the Social Determinants of health which recommends incorporating SDOH teaching over three domains; education, community, and organisations collaboration. The education domain comprises four areas, collaborative learning, experiential learning, integrated curriculum, and continuing professional [5]

The Interprofessional course at the University of South Carolina [13] integrated multiple frameworks. Specifically, it incorporated the Society of General Internal Medicine’s Disparities Task Force guidelines for health disparities education, which covers the racial health disparities and the required knowledge to understand, assess, and recognise the barriers to health inequities. The American Academy of Paediatrics; and The Midwest Academy Manual for Activists frameworks were used to guide the organisational social work implemented in the curricula [23, 24].

The student-run clinic program at the Mayo Clinic Alix School of Medicine [11] and the emergency clerkship course from the New Jersey Medical School [12] stated that both curricula’ accreditation using the Liaison Committee on Medical Education guidance. However, the framework designing for the SDOH curricula was not listed [25].

The method of delivering the SDOH courses also varied. Most of the curricula were delivered via group tutorials, sessions or group discussions within a classroom or clinical rotations. Three courses [13, 14, 18] used a combination of two teaching modalities: experiential learning and didactic. Another three courses [12, 16] used the same approach adding the student’s reflection as a writing assay or oral presentation third modality. On the other hand, the student-run clinic course used the experiential learning method through the weekly student-run clinic [11]. Lastly, the U.K. SDOH curricula applied the innovative flipped classroom method, which includes pre-class learning resources and classroom discussion to enhance that knowledge [17].

The eight medical school curricula had diverse educational objectives. These varied considerably but tended to have a standard set of competencies: the ability to assess and recognise SDOH related health barriers according to each defined framework, interprofessional skills, representing the core competency of collaborative learning and communication. The programmes also sought to cultivate reflective skills, leadership and teamwork expertise. Teaching the students the ability to identify, analyse and evaluate the related issue or so-called” Critical thinking” was guided only by two programs [14, 22]. The eight medical programs learning competencies are detailed in Table 2.

Evaluation and outcomes of the SDOH curricula

All the included curricula were evaluated for the knowledge, the gained competencies, and students’ confidence to work with underserved populations. Yet, none of the studies assessed the impact of the student’s knowledge on the patient’s health outcomes. The evaluations were all performed with online surveys taken pre-and post-curriculum. Two of the eight programs also performed semi-structured interviews to evaluate the course [11, 17].

The eight programs improved the student’s knowledge of SDOH concepts and implications on health outcomes; three programs [11, 15, 16] boosted the student’s confidence level in dealing with social factors. One program [12] improved the ability to recognise the SDOH elements. Another program [13] conveyed interprofessional collaboration outcomes on students learning process.

Looking across programs, the highest-rated modalities according to students’ self-assessment across the eight programs were the group discussions and the community engagement, which featured realistic patient-centred care experiences.

The analysis of each curriculum showed the following. The Wake Forest School of Medicine curricula [16] was evaluated based on three cohorts of 314 students. These cohorts included: the students who received the entire course (nine modules), the shorter course (three modules) and those who did not receive any teaching. The evaluation found significant improvements in the student’s confidence and knowledge regarding SDOH through engagement within the emergency department. Knowledge was found to be retained for one year after the exposure to the longitudinal curricula. The results showed no difference between curricula of three to nine modules. The assessment represented the importance of incorporating the curriculum into the clinical clerkship years. The students will be confident to engage with patients and the thriving community partnership to identify the areas of need.

Similarly, the Tulane University elective Curriculum evaluation [14] was carried out three times, pre-and post-curricula and for the students who didn’t receive the elective curricula. The evaluation, which involved 58 students, represented the increase of the students’ awareness regarding SDOH through the community-based service and their wellness to work with the underserved population in the future. however, it showed the need for implementing early seminars for pre-clinical engagement to improve the acquired knowledge.

The Student-run clinic curriculum at the Mayo Clinic Alix School of Medicine [11] evaluation showed students’ confidence to work with an underdeveloped population increased. The evaluation (N = 90 students) demonstrated the disparate outcomes related to the stigma reinforcement of the disadvantaged patients, the tension from dealing with patients in the early clinical years, and the various degrees of commitment to the self-directed learning aspect of the curricula.

The Etgar course curriculum [18] at Azrieli Faculty of Medicine at Bar-Ilan University evaluated the post-home visit surveys of 177 students. The analysis showed that home visits helped increase the student’s awareness of the broader social context of the health inequities of their patients. The curricula enabled the students to explore the complexity of SDOH related factors in a realistic environment; however, the students reported that organising the visits and household language barriers were significant challenges.

The SDOH curriculum [12] at the New Jersey Medical School evaluated 56 students. After the course, online reflection showed increased recognition of the students’ SDOH related factors and the ability to apply this knowledge in their practice. However, the evaluation reported that increasing the engagement with an experienced facilitator and more interactive learning activities will significantly impact the students’ learning process.

The SDOH curricula [17] at University College London were evaluated using the ‘flipped classroom method’ through an online survey and semi-structured interviews. The evaluation involved 289 students and revealed an increase in students’ perspectives regarding the social factors and their implication on their practice. Yet, the student’s feedback favoured the discussion session over the taught part of teaching.

The evaluation of the Inter-Professional curriculum [13] at the University of South Carolina via pre and post-program survey showed enhancement of the students’ knowledge regarding interprofessional collaboration between various disciplines. The evaluation, which involved 500 students, revealed that creating more interactive learning modalities will improve the learning impact.

A pre and post-program survey used to evaluate the Health disparities elective curricula [15]. The evaluation indicated that their knowledge and confidence regarding SDOH improved significantly, and it is now being proposed as a mandatory course.