Implementation of Educational Opportunities for Social Determinants of Health in Health Professions Education: A Scoping Review

• Graduate health professions education programs are currently teaching students about the social determinants of health in a variety of ways. Delivery methods include small- and large-group discussions, community-based learning, individual and group assignments, didactic lectures and activities, service-learning opportunities, interprofessional education opportunities, simulations, and clinical education activities.

• Assessment of students’ knowledge of social determinants of health is primarily conducted through student reflections and participation in group discussions; techniques for obtaining objective measures of student knowledge on this topic are limited.

• There is limited information regarding the delivery of educational opportunities related to social determinants of health specific to athletic training programs. This scoping review serves as a call to athletic training educators to disseminate information about the educational opportunities used within their professional programs.

The social determinants of health (SDH) are factors and conditions that impact the health and well-being of patients and communities more than the health care provided. The World Health Organization defines 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,” and Healthy People 2030 summarized the 5 key areas of SDH as (1) health care access and quality, (2) education access and quality, (3) social and community context, (4) economic stability, and (5) neighborhood and built environment.^1,2  These nonmedical factors influence health and well-being, are experienced at all levels of society (global, national, and local), and typically arise because of disparities of wealth or resources.³  Therefore, many organizations have created an internal task force to address the negative influence of SDH on individuals and communities.^4–6  Medical, dental, nursing, and other health science professional education programs also require SDH-related instruction to prepare students to address these factors in their future practice.^7–11 

Recently, efforts have increased to educate health care professionals about SDH. Some programs and institutions have used a single lecture or a guest speaker to deliver SDH content to learners. Some have curated clinical education and service-learning projects over time to improve student knowledge and application of SDH.^9–11  Programs implementing SDH educational opportunities as part of their didactic and clinical experiences have reported that student perceptions about SDH changed and their knowledge improved.^10,12  However, few studies highlight the need to incorporate SDH content throughout programs or suggest that this content should not be delivered in a single effort.^12,13  Although curricular content standards have evolved to include SDH, in some fields, such as athletic training, the standards are new, and little guidance is provided for incorporating this important topic into educational programming.

In 2020, the Commission on Accreditation of Athletic Training Education added a curricular content standard that mandates that professional athletic training programs ensure students can “identify health care delivery strategies that account for health literacy and a variety of SDH.”¹⁴  This patient-centered care approach is promising, and, although others have suggested how to incorporate it into their health care programs, little has been published regarding the implementation of SDH material in athletic training programs. Understanding how other health care professions are implementing SDH into their curricula could serve as a guide for athletic training educators. Therefore, in the current scoping review, we aimed to map the literature that explores the implementation of educational opportunities focused on SDH in health professions education programs.

The current scoping review was conducted according to the JBI Manual for Evidence Synthesis and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews for reporting results.^15,16  The review was also conducted using an a priori protocol.¹⁷ 

Our study question for the scoping review was centered on the educational opportunities related to SDH that are being implemented in health professions education programs, including the details of their implementation process.

To be included in our scoping review, articles had to have been published in the last 5 years and describe how material related to SDH was implemented in a graduate health professions education program in the United States. Our review focused on studies published in the last 5 years because a previously published study performed a similar review using articles from 10 years ago.¹⁸  As such, we wanted our review to represent only new published studies. Only original research and educational technique articles were included. Further, only studies published in English were included because the research team lacked knowledge of other languages.

Articles were excluded if the SDH educational opportunities were implemented in a nongraduate health professions program (ie, undergraduate or associate level) in the United States. With the shift to all entry-level master’s degree programs in athletic training, we wanted to ensure that the findings of this scoping review were at the appropriate education level. Additionally, articles that described entire courses or curricula were excluded.

Because our study’s purpose was to provide ideas and guidance to educators for incorporating SDH into athletic training education programs, we developed a defined protocol before extracting data. However, during our search, some articles included entire courses or curricula on SDH, which deviated from our protocol, so we excluded those articles because their scope was beyond our intended study purpose.

To identify relevant articles, we searched the PubMed, CINAHL, and Health Policy Reference Center databases. Two education databases, ERIC and Education Source, were also searched. After our initial search strategy was developed and refined, a trained medical librarian (CJG) performed all searches. At first, several iterative pilot searches were conducted, primarily in PubMed, to guide the development of the search strategy and identify relevant and irrelevant search terms. The search strategy was tested by ensuring that all exemplar articles were placed in the search results of at least 1 database. A combination of controlled vocabulary and free-text keywords were used, tailored to each database, to ensure all relevant literature was identified. Controlled vocabulary terms were exploded in PubMed and CINAHL but not in the other databases. Given the scope of the other databases, we had to be more selective with controlled vocabulary terms to avoid irrelevant results. In accordance with Peer Review of Electronic Search Strategies (PRESS) guidelines, the entire search strategy for each database was peer reviewed by another medical librarian. Results of that peer review are available in Supplemental Appendix 1.

Identified articles from our search had to include 1 keyword in each of the following concepts: SDH, health sciences education, and education implementation. The SDH were searched at a broad level, and the 5 key areas of the SDH were intentionally excluded based on a lack of relevant articles during our pilot searches. The 3 main concepts were searched using the AND Boolean operator, and synonyms and related concepts were added using the OR Boolean operator. During the search, we excluded articles with the terms scoping review or systematic review in the title because our strategy excluded studies related to methods of evidence synthesis. When searching in the CINAHL database, we excluded continuing education units because we considered them inappropriate for inclusion in our scoping review. Searches in all databases were limited to literature published from January 1, 2017, to the search date of September 19, 2022. An updated search was also conducted on March 3, 2023, and included studies published from September 20, 2022, to the new search date. Details on how many results were retrieved from each database, as well as when and why articles were excluded from this study, are available in the PRISMA flow diagram in Supplemental Appendix 2.

Our search strategy also included content from the gray literature, such as dissertations and magazine articles. These sources were included in our search results and screened for inclusion when possible. The websites of various professional and educational organizations in the health sciences were also hand searched by the librarian and included during the screening process. Websites were searched using a combination of built-in search engines and browsing the websites through their navigation menus.

Covidence software (https://www.covidence.org/) was used for deduplication; title, abstract, and full-text screening; and data extraction. Our full search strategy, including the free-text keywords used, controlled vocabulary terms used for each database, complete search strings, and list of the websites searched for gray literature, is available in Supplemental Appendix 3.

The titles and abstracts of identified articles were independently reviewed by 2 research team members (KJP, BCJ), and a third research team member was used for tiebreakers (ZKW). Two authors also conducted the full-text review of articles (KJP, BCJ), and a third author was used for tiebreakers (ZKW). Data extraction was completed by 2 authors (KJP and ZKW). Key information extracted from each included article was the study design, type of graduate education, aims of the studies, description of technique, timing of implementation, type of curricular delivery, and outcomes.

To provide a comprehensive report of recent educational opportunities related to the implementation of SDH in health professions programs, extracted data from each reviewed article are summarized in the Table by curricular topic, type of curricular delivery, curricular assessment, and description of the technique. Specifically, we categorized the type of curricular delivery by the following: didactic, clinical education, community-based learning, individual assignment, interprofessional education, service-learning experience, simulation, small-group discussion, or reflection. Timing of the implementation in the program and assessment after SDH implementation were extracted and reported when available. We used the Miller assessment pyramid for the classification of assessments.¹⁹  These data were collected to assess student progress toward competency with the SDH content to further guide the successful implementation of this material into professional athletic training curricula. When applicable, frequency and percentage were used to summarize outcomes.

Our initial searches yielded 2006 articles for review, and an additional 3 articles were identified through our gray literature search (Figure). After removal of duplicates, 1508 articles were screened by title and abstract. After exclusion of 1389 articles that fit the exclusion criteria as determined from title/abstract screening, 119 studies underwent full-text screening to assess their eligibility for inclusion. Of those, 83 were considered ineligible, and 36 studies were included in our scoping review.^{7,8,11,20–52} 

Details about the studies included in our scoping review are presented in the Table. Of the 36 studies, most (23, 63.9%) used an observational design that included medical students or residents (31, 86.1%). The number of participants in reviewed studies ranged from 5 to 319 participants.

In the stated aims of the reviewed studies, the educational learning objectives were often identified using the verbs develop, implement, and evaluate. Commonly shared aims of the studies included creating and describing a learning activity, module, course, or curriculum that introduced SDH as a whole concept or as a specific portion of it, such as a social context. Instructional activities were described as methods to discuss and explore with the learners, and the studies often addressed the implementation of the instructional technique using such terms as feasibility, effectiveness, and acceptability. Described evaluation strategies included examining the knowledge, skills, and attitudes of the participants to investigate how well the learners could identify, observe, and document SDH. The perceptions, confidence, and reflective impact of the learners after the instructional technique were also examined.

The reviewed studies covered a range of curricular topics (Table). Although many covered SDH broadly, others focused on more specific topics, such as health equity, health disparities and inequities, and cultural competency. Some emphasized the importance of SDH screening and documentation. In the studies that highlighted specific SDH, the determinants most often covered were poverty, neighborhood/built environments, adverse childhood experiences, food access or insecurity, and lesbian, gay, bisexual, transgender, and queer/questioning health.^*

The educational techniques and opportunities of the reviewed studies varied greatly, from interprofessional patient case scenarios to lectures with guest panels to neighborhood tours (Table). Twenty-seven studies used 2 or more types of curricular delivery. Didactic (19, 52.8%) and small-group discussion (14, 38.9%) methods were used most often, but simulation (10, 27.8%) and community-based learning (10, 27.8%) were also common. Didactic sessions ranged from 1 to 3 hours in duration, and the covered topics were varied. Most often, didactic sessions were paired with small-group discussions, clinical education, or a service-learning project.

When SDH opportunities were incorporated into clinical education, they were in the form of SDH documentation or assessment.^{7,11,33,44,50}  Students were provided with methods of SDH collection or assessment and then instructed to document their findings. Examples of the methods used by these studies included observation cards; the Income, Housing, Education, Legal Status, Language/Immigration, Personal Safety tool; and the Health Leads Social Needs Screening Toolkit.^11,33,44 

Simulations involving patient cases or standardized patients were implemented in many of the reviewed studies to provide students with an opportunity to practice their skills. After didactic lectures or community panels, standardized patients, transgender patient cases, budgeting case scenarios, poverty simulations, and virtual simulations were used most often.^†

Six studies used community-based learning techniques that included a neighborhood/city tour of 1 to 4 hours’ duration to educate students about SDH.^{20,25,27,36,38,40}  The tours often consisted of stops (eg, grocery stores, clinics, housing units) in low-socioeconomic-status neighborhoods to explore how SDH contribute to health disparities. All tours, including a virtual neighborhood tour, had a reflection or debrief with faculty at the end of the learning activity.³⁸  Other types of community-based learning activities included providing a community cooking demonstration, teaching geographic information system mapping, watching the film Resilience, and creating a wellness fair for elementary schools.^21,32,46 

Overall, the majority of the 36 reviewed studies (34, 94.4%) used formative assessment rather than summative assessment (2, 5.6%) to evaluate student learning at the end of the instructional opportunity. Most studies (34, 94.4%) described identity-based assessment methods, such as reflections, personal and professional identity, attitude assessments, and ethical value assessments. Twenty-two (61.1%) studies used only identity-based assessment. The other 12 used identity-based assessment with another form of assessment, such as knowledge (5, 13.9%), action (2, 5.6%), performance (4, 11.1%), or knowledge and performance (1, 2.8%). The 2 studies that did not use identity-based assessment used performance-based (1, 2.8%) or action-based (1, 2.8%) assessment only.

Outcomes varied widely among the reviewed studies because of different assessment methods. Of the 3 primary types of outcomes measured in the 36 reviewed studies, over half (23, 63.9%) involved student self-reported increases in confidence, knowledge, or skills related to SDH. Fifteen studies (41.7%) included an outcome assessing student satisfaction of the learning experience or some aspect of curricular quality improvement.

The reviewed studies used a variety of methods to objectively examine outcomes related to knowledge, confidence, or skills. Self-reported outcomes in the 36 reviewed studies included perceptions of knowledge or awareness of SDH (14, 38.9%) and confidence (2, 5.6%), comfort (2, 5.6%), and familiarity (1, 2.8%) with SDH. Five studies used student documentation of patient encounters to identify increases in the frequency of documentation or mention of SDH.^{7,11,19,38,44}  Two studies reported an increase in student scores on assessments that used factual, knowledge-based questions, which suggested increased knowledge.^39,41  Several studies used student-reported outcomes related to clinical skills or abilities; some skills were related to communicating or knowing each individual’s role within an interprofessional care team (2, 5.6%), recognizing when SDH were influencing a patient’s health (4, 11.1%), addressing a patient’s needs in relation to SDH (4, 11.1%), or referring a patient to another professional when appropriate (2, 5.6%).^{11,23,26,29,36,44} 

Students were largely satisfied with the SDH learning experience. In the 15 studies that evaluated student satisfaction, all interventions were regarded positively by students, and they reported that experiences met the learning objectives, increased their awareness or knowledge of the subject, and motivated them to engage in better clinical practices. In one study, students specifically recommended that the learning intervention be provided to future cohorts.³¹  In another, they indicated that they wished they had received this instruction earlier in their program.²⁶ 

In the current scoping review, we explored the implementation of educational opportunities focused on SDH in health professions education programs. With the Commission on Accreditation of Athletic Training Education adding SDH to the 2020 standards, it is important to assist athletic training educators with how to implement this complex concept into their programs. Yet there is limited research in this area in athletic training, directing us to search for similar health care professions literature. Thirty-six studies were included in our review, and results indicated that various SDH opportunities currently exist in these programs. Overall, the educational opportunities reported in the reviewed studies successfully increased students’ perceived knowledge or awareness of the potential impact of SDH on patients. Students also self-reported satisfaction with the activities. By reviewing the current literature regarding the implementation of SDH educational opportunities in graduate health professions education programs, the results of our scoping review may provide athletic training educators with guidance for incorporating SDH into their programs. Ideally, we hope that the diverse methods of SDH integration presented in these studies will encourage and aid the integration of SDH into athletic training education.

The 36 identified and reviewed articles included in the current scoping review highlighted how SDH can be integrated into graduate-level health professions education. Our results, including the large number of articles reviewed, are similar to those of Doobay-Persaud et al.¹⁸  In that 2019 scoping review, the authors investigated teaching of SDH in undergraduate medical education.¹⁸  They reported that community engagement or clinical-based learning was used most often to teach SDH, and, as in the current study, assessment of student outcomes lacked objective measures.¹⁸  In our scoping review, we included studies from a larger number of health care professions, and the majority of studies used more than one form of curricular delivery for SDH opportunities. We found that didactic and small-group discussions were used most often. These findings support previous suggestions that SDH should be incorporated into the curriculum through multiple methods.^10,53  In one study, Martinez et al outlined tips for incorporating SDH into undergraduate medical programs, including defining key terms, guiding students in self-reflection, using application exercises, and offering service-learning opportunities.⁵³  Many of the studies included in our review used these methods; however, most of the educational opportunities were limited to a single opportunity during a single course, which may be inadequate to prepare health care providers to address SDH in practice.

When designing educational opportunities for teaching SDH, several strategies should be considered for successful integration, such as adequate preparation, timing of the educational opportunities, and required resources.^54,55  A strategy for avoiding negative consequences, such as unwanted bias, should also be developed before implementing these educational opportunities.⁵⁶  For instance, several studies in our review emphasized socioeconomic status in their SDH activity even though it is just one of many determinants that can affect a patient’s health and care plan.^{25,29,35,38,41}  By focusing on a single determinant, those authors may have introduced bias to their study. Ideally, SDH content should be taught in a way that increases student awareness of nonphysical factors that affect patient care without creating implicit bias.⁵⁷  Similarly, educators should use caution when developing teaching content for SDH to avoid adding their biases into presented materials or activities.⁵⁸  For example, using neighborhood tours or placing students at underserved clinical sites to illustrate low socioeconomic status or unsafe neighborhoods may be detrimental to students who live in or near these specific areas or identify with the demographics, as it could reduce people to their identities by using the instructional design to highlight negative SDH experiences to others. Further, low socioeconomic status should not be the sole SDH that educators teach. Instead, students should be taught the complexity and interconnectedness of all SDH. Therefore, we recommend educators be mindful of the tax that could be placed on others or a community when asked to share their story of negative SDH experiences for educational purposes.

In the current scoping review, assessment of student learning was rarely included as an outcome in the reviewed studies. Although our results suggested students had positive perceptions of their learning experiences and increased their knowledge of SDH, reported assessments were most often self-reflective and not objective or performance based. Similar gaps have been noted in other studies.^18,59  Until better assessment strategies are implemented, it is difficult to evaluate students’ actual knowledge of SDH. However, Mangold et al suggested guidelines for determining what SDH content should be assessed, how to evaluate it, and who should assess it.⁵⁹  Although that study focused on improving physician and physician assistant knowledge of SDH, their experts ranked standardized patient encounters as the top method for assessing student knowledge of SDH.⁵⁹  To assess student skills related to SDH, they ranked standardized patient encounters, direct observation during clinical experiences, and skill-based assessments as the top methods to be used.⁵⁹  Although additional studies are needed, these rankings may serve as a starting point to assist athletic training educators with formulating SDH assessments that are appropriate for the profession.

Several limitations should be considered when interpreting our results. The current scoping review included only articles written in English and published within the past 5 years. Our results were also limited by the information and level of detail reported in the 36 reviewed studies. Therefore, the limitations of those studies should also be considered. For example, most studies did not provide demographic data about the participating students, so results cannot be generalized to every graduate health profession student and program. Further, the time to develop the SDH educational opportunities, allocation of faculty, and costs associated with each educational opportunity were not provided in the majority of studies, which limited our ability to report these finer details in our review. Similarly, information about the assessment of the educational opportunities in the reviewed studies lacked detail and, ultimately, limited our ability to assess student knowledge. Therefore, the extent to which these educational opportunities improved student knowledge of SDH remains unknown. Future research should investigate how to evaluate student outcomes objectively.

Social determinants of health content and activities should be strategically planned and interwoven into professional athletic training curricula. This scoping review details the breadth of educational opportunities that have been implemented successfully in various graduate health professions programs. Before implementation, educators should consider several aspects of curricular delivery related to SDH, including reducing bias, implementation logistics, and objective assessment of student knowledge. To further the research conducted in this topic area for the athletic training profession, educators should consider disseminating SDH educational opportunities that they currently use in their programs.

Social determinants of health educational opportunities are provided to graduate health profession students in a variety of ways and, in many instances, throughout their programs. Athletic training educators should consider implementing some of the successful opportunities presented in this review and develop objective assessment measures to capture changes in students’ knowledge.

Despite the increased need to educate future health care providers about SDH, there are no concrete guidelines on how to do so for many health professions, especially athletic training. The results of our scoping review identified the most recent educational opportunities for implementing SDH into graduate health education programs and highlighted gaps in the literature related to the assessment and measured outcomes of these opportunities. Therefore, all health professions educators should continue efforts to share and disseminate educational opportunities related to SDH to improve student outcomes and the care of future patients. Additional studies should also be conducted to investigate the best methods for assessing student learning and knowledge of SDH.

We would like to recognize A.T. Still University’s scientific writer, Deborah Goggin, for her edits to this manuscript. Thank you for your assistance.