How do medical students learn about SDH in the community? A qualitative study with a realist approach

The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities. A 4-week clinical practice program was conducted for 5^th- and 6^th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives. First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students’ confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings. Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.

在日益分化的社会中，学习健康社会决定因素（social determinants of health, SDH）的必要性日益提升，但相关教育干预举措复杂多变，且其学习机制尚不明确。为此，本研究采用实在论研究方法，识别社区场景下的健康社会决定因素学习模式，即情境（context, C）、机制（mechanism, M）与结果（outcomes, O）。
本研究为日本5年制与6年制医学生开设了为期4周的临床实践项目，该项目包含健康社会决定因素专题讲座，以及围绕社区内与健康社会决定因素相关的案例开展的小组研讨活动。本研究基于CMO框架视角，采用主题分析法对医学生撰写的健康社会决定因素学习结构性反思报告进行了分析。
首先，医学生先期已对健康社会决定因素的概念有所认知，并参与到以社会模式为核心的社区场景中；随后他们通过观察学习与榜样讲解，转变了自身的认知视角。其次，医学生直面医学模式中的内在矛盾，这一过程促使他们能够对确凿事实形成整合性的解读。第三，通过对比不同地区的具体实践经历并加以言语化梳理，医学生对健康社会决定因素的概念理解得以深化。第四，相较于临床诊疗场景中的身份定位，医学生以非权威的身份参与实践，由此培育起对普通民众的共情之心。
医学生可通过四类健康社会决定因素学习模式，理解社会与医学之间的内在关联。