2

Educating Health Professionals to Address the Social Determinants of Health in and with Communities

HISTORICAL PERSPECTIVE

Many of the concepts behind community-engaged learning, problem-based learning, and community-oriented education grew out of the work of Sidney and Emily Kark (Gofin, 2006). As early as 1940, the Karks began blending community engagement with public health practice and primary care in an impoverished, rural province of South Africa in what they called “community-oriented primary care” (Mullan and Epstein, 2002). According to Geiger (2002), the Karks understood that “social, economic, and environmental circumstances are the most powerful determinants of population health status” (p. 1713). Their ideas and theories spread around the globe, influencing health care delivery in such places as Jerusalem, the Republic of South Africa, the United Kingdom, and the United States (Geiger, 1993, 2002; Mullan and Epstein, 2002). They also led to numerous education and training programs in Chile, Cuba, Egypt, Europe, India, Israel, the Philippines, South Africa, Sudan, and the United States (Risley et al., 1989; THEnet, 2015a,b). While those educational initiatives did not explicitly reference the social determinants of health, because they predated the origin of that construct, they did involve education in communities that was focused on the social and environmental causes of ill health (Magzoub et al., 1992; Risley et al., 1989).

The lack of explicit recognition of the term “social determinants of health” is not uncommon. For example, mission statements, strategic documents, and curricula from the field of social work typically emphasize “social justice” despite having a strong focus on interventions addressing the social determinants of health (CASW, n.d.; Craig et al., 2013). Of course, the opposite is also true. Some programs that tout learning activities addressing the social determinants of health in reality provide only segments of a curriculum—for example, teaching statistics about health disparities in isolation, offering community service projects with no contextual framing or opportunities for reflection, providing only classroom education with no experiential component, and offering educational opportunities for learning about health disparities only in clinical (not community) settings (Cené et al., 2010; Chokshi, 2010). While potentially valuable, no one such activity performed in isolation provides learners a full understanding of how the different components of a health system are integrated and thus how the learner’s role fits with others in the wider health system. Without such an orientation, understanding and acting on the social determinants of health in partnership with others will prove difficult if not impossible.

Networks and Partnerships

In 1979, leaders of mainly small pilot medical models of community-oriented education gathered for the first time in Kingston, Jamaica, to share their work, ideas, and aspirations (The Network, 2004, 2014a). At this meeting, participants agreed to form a group of interconnected health science innovation educators in what came to be known as The Network (Kantrowitz et al., 1987). Years later, The Network joined with another World Health Organization (WHO) initiative called Towards Unity for Health (TUFH) to create what is now known as The Network: Towards Unity for Health (also known as The Network). This nongovernmental organization advocates for community-engaged health professional education through local and international actions, partnerships, and sharing of ideas and expertise (The Network, 2014b).

Other groups have since undertaken similar efforts to make health professional education more responsive and relevant to societal needs (Richards, 2001). One such entity is the Training for Health Equity Network (THEnet), a “growing global movement committed to achieving health equity through health professions education, research and service that is responsive to the priority needs of communities” (THEnet, 2015c). Community engagement is an important component of all the work done by THEnet and its member schools, and partnerships with communities are part of THEnet’s development, implementation, and evaluation efforts (THEnet, 2015c). Its member schools are from Australia, Belgium, Canada, Cuba, Nepal, the Philippines, South Africa, Sudan, and the United States (THEnet, 2015b).

The nonprofit membership organization Community-Campus Partnerships for Health (CCPH) is another effort to address the social determinants of health (CCPH, n.d.). Established in 1997, its focus is on promoting health equity and social justice. CCPH connects communities and campuses in the United States and in Canada to improve the health of communities through service learning, community-based participatory research, broad-based coalitions, and other partnership strategies (CCPH, 2007).

The U.S. government is currently developing Healthy People 2020. The Healthy People 2020 and related websites highlight the importance of addressing the social determinants of health and including prevention and population health content in health professionals’ education (APTR, 2016; HHS, 2016a,b,c). This effort has led to numerous online educational resources for students and health professionals to learn how to reach national health goals (HHS, 2016d). Another U.S.-based initiative is working through the Association of Academic Health Centers to raise awareness and build partnerships for a more coordinated response to addressing the social determinants of health (AAHC, 2015; Wartman, 2010; Wartman and Steinberg, 2011).

Lessons Learned

Between 1998 and 2000, The Network identified nine health professional education programs deemed exemplary (Richards, 2001). Criteria for inclusion were based on demonstration of the following educational components:

• commitment to multidisciplinary and community-based education,
• longitudinal community placements,
• formal linkages with government entities, and
• a structured approach to community participation.

Each of the nine schools (in Chile, Cuba, Egypt, India, the Philippines, South Africa, Sudan, Sweden, and the United States) was visited by one of The Network’s researchers. In his overall review of the programs, Richards (2001) identifies common features and shared dilemmas among programs:

• All of the exemplars provided a variety of community-based learning experiences, and most used a problem-based learning approach.
• While the different schools required similar competencies and knowledge for graduation, the local context drove the individual student activities.
• Learning to work collaboratively with other professionals and professions was deemed essential.
• All of the programs emphasized the relationship between individual and population health, which typically included a local socioeconomic perspective.
• Interventions and strategies are meaningless unless they match local needs and conditions.
• Learning to advocate for patients and the community is an important aspect of career development, particularly as it relates to public policy.
• Institutionalization of innovative reforms is slow and sometimes never realized, despite 5-10 years of sustained involvement by deans and distinguished faculty members.

Fourteen years later, Strasser and colleagues (2015) drew lessons from rural, community-engaged medical schools in Australia, Canada, and the Philippines. They concluded that community engagement must be sensitive to local variations; community leaders need to be pursuaded of the value of engaging with universities through open and honest dialogue; and stronger partnerships will develop if differences between partners are viewed as complementary assets rather than challenges (Strasser et al., 2015). The sus-

tainability of such a program will depend heavily on the success of the local partnership, although success also will depend on the national and sub-national context in which a program functions (Coffman and Henderson, 2001; Loh et al., 2013; Supe and Burdick, 2006).

Additional lessons can be learned from countries with national health systems that align education with health service delivery. In Brazil, for example, health professional education and the health workforce are shared responsibilities of the Ministry of Education and the Brazilian Unified Health System (Sistema Único de Saúde [SUS]), which guarantees universal and free health care coverage for all. These two bodies work together through the Interministerial Committee for Education and Health Labour Management, which was established in 2007 (WHO, 2013a). Much of their work is based on the integration of teaching and service through multidisciplinary teams and has led to innovations in community-based education and explicit use of community health agents to establish linkages with care and wellness efforts (Bollela et al., 2015; Macinko and Harris, 2015). One education example, known as the Education Program for Health Work (PET Health), is the Ministry of Health strategy for promoting teaching-service-community integration by creating working groups of teachers, undergraduate students, and health professionals for interprofessional education and practice (Bollela et al., 2015). Faculty supervise undergraduate students working in primary health care in Family Health Units. These units are part of Brazil’s Family Health Strategy (previously called the Family Health Program), which is aimed at providing a range of health care services to families in their homes, at clinics, and in hospitals (WHO, 2008). Rapid expansion of the Family Health Strategy led to shortages of health professionals. This gap was filled through the recruitment of almost 15,000 physicians, primarily from Cuba. Studies on the strategy’s expansion have shown improved children’s health and reduced infant mortality, as well as associations with diminished mortality from cardio- and cerebrovascular events, reductions in hospital admissions, and fewer rates of complications from diabetes (Macinko and Harris, 2015; Paim et al., 2011; Rasella et al., 2014; Rocha and Soares, 2010).

Not without difficulties, Brazil has been pursuing this path for several decades. Substantial investments have been made to change the curricula of medical, dental, and nursing schools, leading them to integrate students into the public Unified Health System and making them more responsive to the needs of the communities they serve, rather than just individual patients (Bollela et al., 2015; Ferreira et al., 2007). National guidelines have been revamped and principles adopted that are conducive to greater emphasis on the social determinants of health and health inequalities.

Cuba is another country with a strong national health system that relies heavily on primary care providers who are trained in rural settings

with community service as a requirement (Morales Idel et al., 2008). To align education with health and workforce needs, the Cuban Ministries of Education, Higher Education, and Public Health all take responsibility for training health professionals. The academic requirements are set by the Ministries of Health and Education, while the Ministry of Public Health sets up and maintains the actual training for the university-level health science professions (Morales Idel et al., 2008). This public health orientation has led to curriculum reform as the Ministry of Public Health has sought to balance Cuba’s changing population health profile with needed human resources for health to meet the health system’s staffing needs. These efforts have included identifying and enrolling in medical schools qualified students from underserved populations who are expected to return to their community following graduation (Keck and Reed, 2012).

Despite these two examples, alignment between the education and health sectors and between the health system and the needs of communities remains weak in most countries (Frenk et al., 2010). Greater alignment would support and empower communities, the health workforce, and educators to work together in an equal partnership to address the social determinants of health, recognizing that context and circumstances will determine the shape, form, and nature of these partnerships (Chiang et al., 2015; WHO, 2013b).

ANALYZING THE EVIDENCE BASE

Searching the literature for impact studies of experiential, community-based, or community-engaged learning activities that specifically identify the social determinants of health as an impact measure presents numerous difficulties. Publication biases exist toward developed, English-speaking countries, and terminology differs among countries and programs. If the term “social determinants of health” is not used in an article, for example, the search will not identify that article. Articles that will be missed include those addressing programs established before the term “social determinants of health” was coined. As a result, some published programs and activities may have been missed during the literature review conducted for the present study. However, because the statement of task for this study (see Box 1-1 in Chapter 1) refers specifically to the social determinants of health, the search conducted for the background paper commissioned by the committee was narrowed accordingly, and 33 relevant papers were identified (see Appendix A for more detail). What is remarkable about the findings of this review is how varied these programs were and how few of their evaluations looked beyond learning outcomes. In addition, the vast majority of the programs relied on self-reported information from the learners themselves. While interesting, these reported findings do not help determine whether

the educational intervention or activity impacted the social determinants of health, improved the health or well-being of the community, or should be considered for diffusion or scale-up.

The lack of analysis of outcomes with respect to improving the health and well-being of communities and their members is due to a multitude of research and resource issues (Art et al., 2007). Identifying linkages between education and health outcomes is time-consuming and requires specific expertise to produce accurate findings. Also, confounding factors related to community movement and migration as well as project funding can alter the results in ways that make accurate data analysis impossible (Art et al., 2007). Despite these challenges, efforts have been made to determine the impacts of service-learning and community-based educational interventions. Most of the published work in this area either is descriptive or emphasizes learning outcomes of uniprofessional education (Dongre et al., 2010; Essa-Hadad et al., 2015; Klein and Vaughn, 2010; O’Brien et al., 2014; Rebholz et al., 2013; Whelan and Black, 2007), although there are some examples describing interprofessional community-based education and learning outcomes (Art et al., 2007; Bainbridge et al., 2014; Mihalynuk et al., 2007). One such example, described in Box 2-1, is an interprofessional, longitudinal, community-engaged curriculum recently established at Florida International University’s Herbert Wertheim College of Medicine. The purpose of the curriculum is to educate students in and with communities on the social determinants of health. After 1 year of home visits provided in the context of medical and health education interventions, analyses indicate favorable short-term and intermediate impacts on health, cost savings, and efficacy (Rock et al., 2014).

Other examples drawn from medicine, nursing, dentistry, and public health education have been implemented with the intent of impacting health systems, as well as the chronic disease profiles of communities and their members (Ferreira et al., 2007; Lipman et al., 2011; Ross et al., 2014; Sabo et al., 2015). Examples from social work education include efforts to build community partnerships (Mokuau et al., 2008; Wertheimer et al., 2004). In particular, Mokuau and colleagues (2008) and others show how the application of principles of community-based participatory research that align with cultural values can impact health inequities through social change (Braun et al., 2006; Kaholokula et al., 2013; Mokuau et al., 2008). In dental education, a study on the financial implications of placing students in community clinics found that dental students make a significant contribution to clinic productivity and finances (Le et al., 2011).

Some university programs have sought to emulate the success of agriculture extension programs in reaching local communities. The University of Kentucky’s Health Education through Extension Leadership program is a partnership between the College of Public Health and the College of

Agriculture and its Cooperative Extension Service. The program focuses on reducing Kentucky’s chronic disease rates through dissemination of health and wellness information on preventable risk factors (Riley, 2008). At the University of New Mexico Health Sciences Center (UNMHSC), honest and at times disheartening conversations with rural community leaders led to the establishment of a statewide Health Extension Rural Office (HERO) program (Kaufman et al., 2010, 2015). The program focuses on community-derived health priorities within the university’s mission areas of education, clinical service, and research. It is run through the university’s Office of the Vice President for Community Health, which collaborates with the New Mexico Department of Health to develop county health report cards. The report cards provide data on leading causes of morbidity and mortality, as well as information on the health workforce, community planning priorities, and the center’s programs. HERO agents use the report cards to track the responsiveness and effectiveness of UNMHSC programs in addressing community health needs. One diabetes education program

led to a significant drop in HbA_1C levels of Hispanic patients with diabetes (Kaufman et al., 2010).

Numerous publications have identified a need for public health schools and institutes to educate learners more actively in policy and advocacy, given the important role of policy change in population health (Caira et al., 2003; Fleming et al., 2009; Hearne, 2008; Hines and Jernigan, 2012; Mirzoev et al., 2014; Pandey et al., 2012). However, information on courses designed to educate health professional learners about translating public health science into policy action is incomplete and limited (Pandey et al., 2012). Longest and Huber (2010, p. 50) describe key steps that public health schools can take to enhance the capabilities of faculty with respect to influencing policy making: “(1) building infrastructures to support and facilitate this role, (2) teaching faculty members how to be more influential in the policy arena, and (3) aligning incentives and rewards for faculty who contribute to improved public health by influencing the formation and implementation of public health policy.”

BUILDING A DIVERSE AND INCLUSIVE HEALTH WORKFORCE

One approach to building the diversity of the health workforce is through greater mixing of university and community representatives, potentially through work on pipeline initiatives (Nivet and Berlin, 2014; Snyder et al., 2015). In fact, numerous programs funded by the U.S. Department of Health and Human Services are aimed at broadening and enhancing pipeline programs designed to enable racial and ethnic minority and disadvantaged students to enter careers in the health professions and health sciences (HHS, 2009). While these programs hold great promise, enhanced information sharing across agencies and programs could improve coordination and sharing of lessons learned among agencies and programs (HHS, 2009).

In some ways, diversity is about collaboration—collaborating with different professions, institutions and programs, communities, populations, and sectors and with individuals from different backgrounds and cultures. It is the particular situation that dictates who will be engaged, and the players themselves will determine how best to manage the collaboration. For example, the Nursing Workforce Diversity Program of the Health Equity Academy at Duke University, described in Box 2-2, includes a partnership between program administrators and social workers. Involving social workers in its nursing program is one way the Academy helps to ensure the success of its students, who themselves may have experienced social and cultural challenges similar to those of the communities and patients they will be expected to interact with throughout their training and career.

Dogra and colleagues (2009) studied the potential for developing and delivering education in cultural diversity in medical schools across Canada, the United Kingdom, and the United States. They offer 12 suggestions for overcoming resistance through a multifaceted approach that entails integrating the subject into institutional policies, curriculum content, faculty development, and assessment. The first of the 12 suggestions is to “design a diversity and human rights education institutional policy” (p. 2) And while doing so would demonstrate leadership’s interest in diversity, a gap will remain between diversity concepts and practice absent an environment of inclusivity of all students, faculty, and staff (Elliot et al., 2013; Haney, 2015).

Finally, engaging students in reviewing university policies on diversity and inclusivity exposes them to the concept of ineffective versus effective policy making. Similarly, students pursing clinical careers could be “trained to ask specific questions on rounds that frame individual patient encounters as windows into broader community health and policy issues” (Jacobsohn et al., 2008, abstract).

CONTINUING PROFESSIONAL DEVELOPMENT

Health professional education at the foundational education and training level is a small percentage of the overall learning that takes place throughout the career of a health professional. Therefore, continuing professional development represents an opportunity to build and maintain competencies in areas that, because of time and other constraints, could not be fully addressed during foundational education and training. These areas may include interprofessional education and community-engaged research.

One research-driven initiative began through the INDEPTH Network, based in Ghana. INDEPTH is an international network of demographic research institutions whose mission is to “harness the collective potential of the world’s community-based longitudinal demographic surveillance initiatives in low and middle income countries to provide a better understanding of health and social issues and to encourage the application of this understanding to alleviate major health and social problems” (INDEPTH Network, n.d.). To this end, the network established INDEPTH Training and Research Centres of Excellence (INTRECs). These centers provide training related to the social determinants of health to INDEPTH researchers and enable information sharing with decision makers (INTREC, n.d.-a). INTREC training is divided into five blocks that are taught by faculty and specialists from Germany, Ghana, Indonesia, the Netherlands, South Africa, Sweden, and the United States:

Block 1: SDH [Social Determinants of Health] Framework, taught through an online course

Block 2: Methods to Study SDH, taught through mixed-methods workshops

Block 3: Data Analyses Workshop, taught through a workshop

Block 4: Communication Strategies, taught through an online seminar

Block 5: Sharing Results of the Training, done through an online forum (INTREC, n.d.-b)

Analysis of the baseline situation in each of the INTREC focus countries (Bangladesh, Ghana, India, Indonesia, South Africa, Tanzania, and Vietnam) is available through individually developed country reports (Addei et al., 2012; Kalage et al., 2012; Kekan et al., 2012; Maredza et al., 2012; Nahar et al., 2012; Phuong et al., 2012; Susilo et al., 2012). Each report follows a similar structure, which starts with a country analysis and ends with a series of actionable recommendations directed at government, nongovernmental organizations, and the INTREC itself. The analysis includes the following three primary areas:

1. Collect information on training related to the social determinants of health currently taking place in the country.
2. Identify core issues related to the social determinants of health of concern for the country.
3. Gather and review relevant government policies and ongoing work of nongovernmental organizations in the country.

Another example is the Society for Public Health Education’s State Health Policy Institute (SHPI) curriculum, designed to educate U.S. state legislators and other professionals in the latest policies and research in chronic disease prevention and control (SOPHE, n.d.). Between 2009 and 2011, SHPI organized three courses and trained an elite corps of 40 health promotion policy experts on policy issues such as health education, nutri-

tion, childhood obesity, eliminating health disparities, and tobacco prevention and education (SOPHE, n.d., preface).

Other programs and initiatives involve postdoctoral education and continuing professional development to promote professionals’ learning in and with communities. Compared with data-driven projects, these activities often take a broader, more systems-based approach to learning and implementation (Beyond Flexner, n.d.; FAIMER, 2015; Kellogg Health Scholars, 2016; MEDICC, 2016). One example is the U.S. Robert Wood Johnson Foundation’s Health & Society Scholars program, which targets individuals at the postdoctoral level at any stage in their career. Scholars receive 2 years of support to “investigate the connections among biological, behavioral, environmental, economic, and social determinants of health and develop, evaluate, and disseminate knowledge and interventions based upon these determinants” (De Milto, 2014). The program emphasizes collaboration and exchange across disciplines and sectors to address the determinants of population health and contribute to policy change. Another example is Medical Education Cooperation with Cuba’s Community Partnerships for Health Equity. This program provides learning opporutnities for health profesionals to experience Cuba’s community-engaged health and education system, and then adapt aspects of that model to improve health and health equity in communities in the United States (MEDICC, 2016). Communities in four underserved U.S. neighborhoods—South Los Angeles and Oakland, California; Albuquerque, New Mexico; and the Bronx, New York—have all benefited from a health profesional’s initiative to learn about and take action on addressing the social determinants of health in and with their local communities.

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