In an era of pronounced human migration, changing demographics, and growing financial gaps between rich and poor, foundational education programs for health professionals need to equip their graduates with at least a fundamental understanding of how the conditions and circumstances in which individuals and populations exist affect mental and physical
health. Professionals who specialize in health care, often as providers, will likely have an individual-, disease-, and treatment-focused orientation to health systems, while those who specialize in public health will focus predominantly on prevention and wellness efforts aimed at communities and populations. Yet regardless of their role, responsibilities, and health system orientation, all health professionals are part of a holistic system in an interconnected world in which they increasingly must rely on others within and outside of the health professions. Thus, they must have an understanding of outside forces that influence decisions affecting patients and populations. Such outside forces include predetermined circumstances based on an individual’s or community’s access to money, power, and resources, as well as local, national, and global policies. Health professional students who are exposed to these concepts in ways that inspire further learning are better positioned to educate future generations of health professionals, having experienced this education firsthand. However, even the most experienced educator cannot alone provide students with all facets of education necessary for a complete understanding of what the World Health Organization (WHO) terms the “social determinants of health” as “the conditions in which people are born, grow, live, work, and age, including the health system” (2016a).
Educators need to partner with others to provide this sort of education. By partnering with other professionals, professions, sectors, and communities, educators can model the sorts of activities that health professionals wish to pursue in their respective roles as providers or population health specialists, or in other selected career paths. Because the time health professionals spend in foundational education and training is small compared with career-based education, it is also the job of educators to instill a desire in their students for greater learning about the social determinants of health. With continued formal and informal learning, health professionals are best positioned to work with others in taking action on the social determinants of health to improve the health and well-being of individuals, communities, and populations.
It is in this context that the individual sponsors of the Global Forum on Innovation in Health Professional Education of the Institute of Medicine (IOM) of the National Academies of Sciences, Engineering, and Medicine (see Appendix C) requested that the IOM convene a committee to develop a high-level framework for educating health professionals to address the social determinants of health.
The study committee comprised 10 experts from diverse backgrounds, professions, and expertise who convened for 4 days to review the literature
and hear public testimony on how health professionals are currently being educated to address the social determinants of health, and to develop a framework for better educating health professionals in this critical arena. As defined in its statement of task (see Box 1-1), the committee was to focus on experiential learning opportunities in and with communities in developing this framework. The framework would draw on a variety of outlined perspectives spanning the continuum of health professional learning, from foundational to graduate education to continuing professional development. The global and diverse makeup of the individual sponsors and members of the Global Forum is reflected in the committee’s composition. As requested by the sponsors, the framework would be general in nature to suit multiple contexts around the world but adaptable for local applications that might differ by setting and circumstances.
The committee’s approach to carrying out its statement of task encompassed
- a balanced committee of experts vetted for biases and conflicts of interest;
- a commissioned paper examining existing programs and curricula designed to educate health professionals to address the social determinants of health (see Appendix A);
- 1 day of open testimony from outside experts, which supplemented the knowledge of the committee members (see Appendix B for the agenda for this session and Appendix D for speaker biographies);
- 3 days of closed-door deliberations during which the committee agreed on a framework, a conceptual model, and recommendations; and
- virtual meetings during which the recommendations presented in this report were finalized.
The conditions encompassed by WHO’s definition of the social determinants of health are typically predetermined based on an individual’s or community’s access to money, power, and resources—which are also influenced by policy choices—from local to global contexts. They are most responsible for the “unfair and avoidable differences in health status seen within and between countries” (WHO, 2016a). A girl born in Sierra Leone who survives to the age of 5 is halfway through her predicted life span by the time she reaches age 17, whereas a girl born on the same day in Japan can expect to live into her 80s and will likely not die before she turns 5. This is the case because, unlike her counterpart in Sierra Leone who faces an under-5 mortality rate of 316 per 1,000 live births, the girl in Japan has only a 5 in 1,000 probability of dying before she reaches her fifth birthday (Marmot, 2005). These are the sobering messages of Sir Michael Marmot, who describes the “gross inequalities in health” (p. 1) that exist among countries but are also evident within even the wealthiest of nations. Marmot and others have shed light on how compiled morbidity and mortality data at the national level can obscure intergroup disparities within a country (Braveman and Tarimo, 2002; The Economist, 2012; Marmot, 2005).
In the United Kingdom, population differences often are referred to as “inequalities” among groups based on socioeconomic conditions (Marmot and Allen, 2014). In the United States, for example, the term “disparities” is often interpreted as racial and ethnic differences in health care (HHS, 2016a). “Health equity” is a third term that, according to Wirth and colleagues (2006) in their guide to monitoring the Millennium Development Goals, is based on simple notions of fairness and distributive justice. The authors further delineate nuances between disparities and inequities, saying, “when disparities are strongly and systematically associated with certain social group characteristics such as level of wealth or education, whether one lives in a city or rural area, they are termed inequities” (Wirth et al., 2006). All of these contextual nuances of gross inequalities in health have similar origins in the social determinants of health.
A landmark study by McGinnis and Foege (1993) identifies and quantifies causes of death in the year 1990. What is revealing about their research is that half of the deaths could be attributed to nongenetic factors such as tobacco, diet/activity patterns, alcohol, and firearms. Since that time, others have categorized these factors into major domains that include (1) individual behaviors, (2) social environment or characteristics, (3) environmental conditions, and (4) health services and health care (CDC, 2014; HHS, 2016b; McGinnis et al., 2002). Link and Phelan (1995) draw connections between social conditions and risk factors similar to those identified by McGinnis and Foege—what these authors refer to as the “risks of the risks.” They argue that to focus on individual treatment strategies would be to miss the opportunity for broad-based societal interventions.
Given the ways in which race and socioeconomic status combine to affect health and disease rates (Williams, 1999), many researchers and public health advocates now identify racism as a determinant of health (Jones et al., 2009; Markwick et al., 2014; Reading and Wien, 2009). A meta-analysis of the literature examining the impacts of racism on mental and physical health outcomes uncovered 293 studies published between 1983 and 2013 (Paradies et al., 2015). The analysis revealed that racism is associated with poorer mental and physical health after controlling for age, sex, birthplace, and education. While the vast majority of the articles in this review focus on the United States, WHO also is aware of the interactions among ethnicity, race, and health (WHO, 2014). A study cited in its Review of Social Determinants and the Health Divide in the WHO European Region shows that Roma children in the former Yugoslav Republic of Macedonia, Montenegro, and Serbia have the highest rates of stunting, which exceed 17 percent in each of those countries (Falkingham et al., 2012).
There is growing awareness of the value of diversity in health professional education that goes beyond scholarships offered to underrepresented groups, and of the fact that such diversity could directly (e.g., through university–community partnerships) and indirectly (e.g., through faculty hiring and retention policies) impact the social determinants of health. Approaches for increasing diversity and enhancing the mix of backgrounds that make up the health and education workforce vary (Dogra et al., 2009; Price et al., 2009). Dogra and colleagues (2009) offer suggestions for developing cultural diversity in education by integrating institutional policies, curriculum content, faculty development, and assessment. While valuable, the need for culturally similar health professionals that reflect the changing demographics would add greater credibility to these efforts
(Cohen et al., 2002; Gijón-Sánchez et al., 2010; Grumbach and Mendoza, 2008; Phillips and Malone, 2014). In this regard, Price and colleagues (2009) suggest that attention to the structural barriers, such as retention efforts and mentorship, could improve the psychological climate and structural diversity of the institution. Structural changes can increase the number of students from diverse backgrounds; however, some argue that increasing diversity does not go far enough. They contend that increasing the diversity of educational organizations and schools does not necessarily create an environment of inclusivity where all students, faculty, staff, and others feel safe interacting and working within their respective environments (Elliot et al., 2013; Haney, 2015; Mulé et al., 2009). With greater attention to equity, the ideals for diversity found in mission statements, visions, and policies can more likely be realized for individuals particularly those from marginalized communities.
The WHO Commission on Social Determinants of Health—comprising policy makers, researchers, and representatives of civil society from around the globe—analyzed the evidence for concluding that the poor health of certain individuals and groups is due to inequities caused by unequal distribution of power, income, goods, and services (WHO, 2008). Based on this analysis, the Commission’s report calls on WHO and its member states to “lead global action on the social determinants of health with the aim of achieving health equity.” Such unfairness, the report contends, dramatically impacts the ability of individuals and communities to access health-promoting resources such as health care, schools, education, safe working environments, and healthy living conditions (WHO, 2008). The report offers three overarching recommendations for moving the world toward achieving health equity within a generation:
- Improve daily living conditions.
- Tackle the inequitable distribution of power, money, and resources.
- Measure and understand the problem and assess the impact of action.
The first of these recommendations specifically calls for policies to achieve goals that would improve the well-being of girls and women as reflected in the Millennium Development Goals. It also emphasizes the importance of early child development and education and the creation of conditions that would have positive impacts throughout an individual’s life span. The second recommendation acknowledges the need to address
inequities, such as those between men and women, through good governance, adequate financing, and a strong public sector. The third recommendation is focused on establishment of a system of accountability both within countries and globally.
Complementing the work of the WHO Commission, the Lancet convened global academic thought leaders to articulate a new vision for health professional education (Frenk et al., 2010). The Lancet commissioners, too, note glaring gaps and inequities in health both within and among countries. They further express concern that health professionals are not graduating with the sorts of competencies needed to understand how to combat such disparities. To address this and other concerns, the commissioners recommend instructional and institutional strategies for reforming health professional education that, if adopted, would lead to transformative learning and interdependence in education, respectively. The Lancet commissioners posit that the purpose of transformative learning is to “produce enlightened change agents” (Frenk et al., 2010, p. 1924) and to create leaders. Interdependence would involve the alignment of education and health systems; stronger and more stable networks, alliances, and partnerships; and a broader perspective on learning that would encompass models, content, and innovations from all countries and communities. These instructional and institutional strategies would involve competency-based approaches to instructional design that are global and collaborative and would place particular emphasis on faculty development. The envisioned health workforce that would result from implementation of these strategies would be better prepared to advocate with and for others, to partner with community leaders to make positive change in their community, and to work toward achieving equity in health and well-being for all populations.
Taking action on the social determinants of health as a core function of health professionals’ work holds promise for improving individual and population health outcomes, leading in turn to significant financial benefits. Congruent with these economic gains, however, Sir Michael Marmot stresses that taking action to reduce health inequalities is a “matter of social justice” (Allen et al., 2013; Marmot, 2005; Moscrop, 2012). Additionally, WHO has made addressing the social determinants of health one of its six priority areas (WHO, 2014), and recognizes that educating the health workforce to promote health equity by addressing and taking action on the social deter-
minants of health is a fundamental requirement of the health and education systems (WHO, 2008, 2013a). Achieving this goal, however, is not just a matter of health workforce curriculum development. The 2006 WHO World Health report (WHO, 2006) and other influential reports highlight two connected and interdependent issues for health workforce education: (1) the critical shortages, maldistribution, and skill gaps of the current health workforce; and (2) the challenges entailed in educating and training the health workforce in many countries, including insufficient financial means, facilities, and numbers of educators to train an adequate, competent cadre of health workers (COGME, 1998; Ko et al., 2007; WHO, 2013b).
The adoption of the 2030 Agenda for Sustainable Development (UN, 2015) has provided the impetus and architecture for the movement of WHO (the United Nations agency responsible for health) and the United Nations Educational, Scientific and Cultural Organization (UNESCO, the United Nations agency responsible for education) into an era of closer collaboration. Emerging global and national strategies for developing human resources for health stress that education of the health workforce in the social determinants of health must be framed within a country’s individual sociopolitical context and embedded in cross-sectoral efforts to promote heath equity (WHO, 2015a). The alignment of health, education, and development toward sustainable development goals has reinforced the need for such a cross-sectoral approach.
United Nations agencies recognize that standardized measurement and accountability will be required (MA4Health, 2015). The development of national health workforce accounts, including one for education, is integral to the WHO Global Strategy on Human Resources for Health (OECD et al., 2015; WHO, 2009, 2015b).
Many agencies and organizations, as well as individual educators, practitioners, and researchers, acknowledge that the complex nature of the social determinants of health is best addressed interprofessionally (Art et al., 2007; Bainbridge et al., 2014; Mihalynuk et al., 2007; Solar and Irwin, 2010). Such collaborations need to include not only an appropriate mix of health professionals and health sector workers, but also professionals and workers from other sectors (Allen et al., 2013; Art et al., 2007; Bainbridge et al., 2014; Lomazzi et al., 2016; Solar and Irwin, 2010). The effective application of interprofessional and cross-sectoral education has potential significant downstream consequences, not only in improving health outcomes, but also in reducing health inequalities and promoting health equity (Bollela et al., 2015). However, given the lack of racial and ethnic diversity in health professional education, a number of the health professions, and thus health professional teams, a key opportunity is missed to use workforce diversity as a way to eliminate health disparities (Cohen et al., 2002; Dapremont, 2012; Grumbach and Mendoza, 2008; HRSA, 2006; Price
et al., 2005). The disparity between the diversity of teams and the diversity of the communities they serve undermines the effectiveness of the care and services provided.
On October 21, 2011, member states and stakeholders came together for the World Conference on the Social Determinants of Health. At that historic event, participants shared a global platform for dialogue on experiences related to policies and strategies aimed at reducing health inequities. It was here that the Rio Political Declaration on Social Determinants of Health1 was adopted by the 120 member states, and discussion focused on how the recommendations of the WHO Commission on Social Determinants of Health (WHO, 2008), which laid the foundation for the Rio Political Declaration, could be taken forward. A goal of this effort was to create energy for country-driven efforts leading to national action plans and strategies (WHO, 2011).
Numerous governments and their ministries have responded to this call to action (Government of Canada, 2015; WHO, 2016b). In addition, a wide array of educational, health professional, and community associations and organizations from around the world have similarly called for action and have begun taking steps toward building a workforce competent to address the social determinants of health (Australian Medical Association, 2007; CMA, 2013; CORDIS, 2015; HHS, 2010c; IFMSA, 2014; Solar and Irwin, 2010; UNDP, 2013; WHO, 2014; WHPA, 2010). Foundations have been another powerful force in efforts addressing the social determinants of health (RWJF, 2008; WKKF, 2016).
A review of the literature (see Appendix A) reveals that educators are responding to the need to address the social determinants of health, but that many of these efforts are conducted uniprofessionally or with a small number of interacting professions, and the education is heavily weighted toward classroom activities. Additionally, experiential learning opportunities tend to be short-term, volunteer, and in the form of community service learning activities, and rural clinical settings are at times described as community-based education with no outreach into the community. While
1 The Rio Political Declaration on Social Determinants of Health (WHO, 2011) is the formal statement of 120 heads of government, ministers, and government representatives that affirms their “determination to achieve social and health equity through action on social determinants of health and well-being by a comprehensive intersectoral approach” (Marmot et al., 2013; WHO, 2011, p. 1). It expresses their understanding that “health equity is a shared responsibility and requires the engagement of all sectors of government, of all segments of society, and of all members of the international community, in an ‘all for equity’ and ‘health for all’ global action” (p. 1).
each effort to address the social determinants of health is laudable and can add educational value if done well, a single isolated activity does not rise to the vision of the WHO or Lancet global health thought leaders. These commissions suggest a more comprehensive approach to educating health professionals that would draw on best practices of
- interprofessional education,
- community-engaged learning,
- experiential education, and
- health outcomes research.
Obstacles to incorporating any one of these approaches into health professional education have been fully explored. However, many health professional and educational organizations have found ways of facilitating each approach. These methods could be evaluated to determine the appropriateness of adapting them to health professional education addressing the social determinants of health, provided that faculty are appropriately trained and the community is prepared to partner.
In contrast to the theoretical discussion of the social determinants of health and health professional education presented in this chapter, Chapter 2 examines how educators and educational organizations and institutions are addressing the social determinants of health through different curricula and programs. The information in this chapter was informed by the background paper commissioned for this study (see Appendix A), whose authors reviewed the published literature specifically on education addressing the social determinants of health conducted in and with communities. Terms of reference for this paper, and accordingly the authors’ literature search, were quite narrowly defined to reflect the scope of the committee’s task.
Chapter 3 shifts from individual examples of education, networks, and partnerships to the broader concept of frameworks within which curricula and programs can be tailored to meet situational requirements. The committee reviewed numerous frameworks for this study. Chapter 3 describes ten of the most relevant structures, drawn from such areas as education, public health, community engagement, and social accountability. These structures capture various aspects of the committee’s charge that informed its development of the framework and the recommendations supporting its implementation presented in this report. The committee’s framework and recommendations, along with a conceptual model for strengthening health
professional education in the social determinants of health, appear in the fourth and final chapter of this report.
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