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ORIGINALRESEARCH
Medicalstudents’experiencesofhealthinequalitiesand
inclusionhealtheducation
Hannah Dixon |Anna Povall |Alison Ledger |Gemma Ashwell
FacultyofMedicineandHealth,Schoolof
MedicineandHealth,UniversityofLeeds,Abstract
Leeds,UKBackground:Inclusionhealthgroupsexperienceasignificantlylargerburdenofmor-
,undergraduatemedicaledu-
GemmaAshwell,FacultyofMedicineandcationisoftenlimitedinitsapproachtoinclusionhealthcurricula,leavingstudents
Health,SchoolofMedicineandHealth,
UniversityofLeeds,WorsleyBuilding,disengagedandlackingunderstanding.
Leeds,:Weconductedtworesearchstudiestoexploremedicalstudents’experi-
Email:.******@
compulsoryandelectiveinclusionhealtheducationviasemi-­structuredinterviews.
Interviewresponseswereaudio-­recorded,transcribedandanalysedthematically.
Findings:Weidentifiedseveralkeyfindingsacrossthetwostudies.
Firstly,medicalstudentsfeltunpreparedtoworkwithinclusionhealthgroups.
Furthertothis,medicalstudentshaveapreferenceforinteractiveteachingandlearn-
ingininclusionhealtheducation.
Finally,encounteringinclusionhealthgroupsbychance(onplacement)orchoice(op-
tionalinitiatives)presentdifferentopportunities.
DiscussionandConclusion:Ourresearchsuggeststhatsimplybeingexposedtoin-
clusionhealthgroupsthroughlecturesandonplacementisnotconsideredsufficient
bymedicalstudents,andinfactcanleadtotheperpetuationofmisinformationand
stigma.
Participantsperceivedthatoptionalinitiativesor‘choiceencounters’hadprofoundly
positiveimpactsonattitudesandinterest,particularlywhentherewereopportunities
aflippedclassroomapproachtoinclusionhealtheducationalongwithintegratedex-
perientiallearningwouldprovidemedicalstudentswithcomprehensiveandpatient-­
focusedlearningopportunities.
1 | INTRODUCTIONUnitedKingdom(UK)healthinequalitieshavewidenedoverall,and
lifeexpectancyforthepoorest10%
HealthinequalitiesaretheunfairandpreventabledifferencesinAttheverysharpendofhealthinequalities,inclusionhealthgroups
(seebox 1)suchasthoseexperiencinghomelessness,imprisonment,
ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium,
providedtheoriginalworkisproperlycited.
©&SonsLtd.
| ;00:1–6.
2 | DIXONetal.
substancemisuseandsexwork,havemarkedlyhighermorbidityandThedisparitybetweeneducationalrecommendationsandreal-
PreviousliteraturehasemphasisedtheimportanceofincludingattheUniversityofLeedsasintercalatedmedicaleducationresearch
.(Theintercalateddegreeisanadditionalyearofstudywhich
However,despitecallsforimprovementsinhealthinequalitiesed-allowsmedicalstudentstostudyasubjectrelatedtomedicineinfur-
ucation,anabundanceofliteraturesuggeststhatexposuretoinclu-therdetailandnormallyincludesaresearchproject.)Weconducted
sionhealthgroupsinmedicalcurriculaiseitherlimited,optionalortwolinkedstudiesexploringmedicalstudents’experiencesofhealth
-
schools,4thoughlecturesareapopularchoiceinthedeliveryofstudents’experiencesofrelevantstudentselectedcomponents(SSCs),
 Whilstlecturesaretime-­andresource-­efficientinaddressingthefollowingresearchquestions:
deliveringlargeamountsofcontenttolargecohorts,researchsug-
-­yearmedicalstudentsto
(SSCs)whichaddress
feellessengagedwithlecturesandlackunderstandingoftherel-thethemeofhealthinequalities?
-
provideequitableandcompassionatecaretofuturepatientsfromityrelatedSSCsandtowhatextentaretheirexpectations
inclusionhealthgroups,itiscriticaltodevelopengaginginclusionrealised?
healtheducationthatcanimproverapport,patientcareandpa-,ifany,dohealthinequalityrelatedSSCshaveon
’attitudesandbehaviourstowardspatientsfrominclu-
sionhealthgroupswhilstonsubsequentclinicalplacements?
Itiscriticaltodevelop
ResearcherHDexploredsourcesofinfluenceonstudents’at-
engaginginclusionhealthtitudestowardsinclusionhealthgroups,addressingthefollowing
educationthatcanimproveresearchquestions:
’attitudestowardsinclusionhealth
rapport,patientcareandgroups?
’attitudestowardsinclu-
sionhealthgroups?
BOX1 Inclusionhealthdefinition
Inclusionhealthisatermusedtodescribepeoplewhoaresociallyexcludedandtypicallyexperiencemultipleoverlappingriskfactorsfor
poorhealth(suchaspoverty,violenceandcomplextrauma).3 Thiscanincludepeoplewhoexperiencehomelessness,drugandalcohol
dependence,vulnerablemigrants,GypsyandTravellercommunities,sexworkers,peopleincontactwiththejusticesystemandvictims
ofmodernslaverybutcanalsoincludeothersociallyexcludedgroups.
Thispopulationfrequentlyexperiencestigmaanddiscriminationandhavepoorerpredictedhealthoutcomesandashorterlifeexpectancy
TABLE1 Detailsofthetwostudiesincludedinthispaper
Study1Study2
MethodsRecruitmentviaemailcirculatedbyadministrativestaff;Semi-­structuredinterviews;Thematicanalysis
withinconstructivistparadigm
InclusioncriteriaUniversityofLeedsmedicalstudentswhohadUniversityofLeedsmedicalstudentsfromany
completedoneofsixSSCspertainingtohealthyear
inequalitiesintheirsecondorthirdyearofstudy
Totalnumberofparticipants6(5inperson,1online)4(2inperson,2online)
Yearofstudy(numberofparticipants)3rdYear(6)1stYear(1)
3rdYear(1)
5thYear(2)
DIXONetal. | 3
2 | METHODSChanceencounterswereoftendescribedasnegativeinnature:
Bothstudentresearchersappliedaconstructivistapproachto[Discussingapatientwhowasinpolicecustodyon
exploretherichnessofparticipants’learningexperiences8andstandardplacement]Ididnoticeadifferencebe-
recruitedeligiblestudentsviaemailcirculationlistsforinterviewtweenhow[thedoctor]treatedhimandhowshe
-­structuredin-treatedpeopleonthewards…Ijustthoughtshewasa
terviewstoallowunanticipatedinsightstobeexploredandde-lotharsher.(P2,firstyear)
velopedinterviewguidesafterreviewingrelevantliteratureand
,thestudentre-
searchersinterviewed10 medicalstudentsatdifferentstagesIncomparison,the‘choice’encountersweredescribedasmorepivotal
ofthefiveyearsofundergraduatemedicaltraininginLeeds(P1tostudents’
toP10).Theinterviewsfromeachstudywereaudio-­recorded,reflectedontheimpactofchoiceencountersontheirknowledgeand
transcribedandthematicallyanalysed,9independentoftheotherattitudes:
LeedsSchoolofMedicineResearchEthicsCommittee(Applied[Reflectingonanextra-­curricularencounterwitha
Healthsub-­committee).patientinpolicecustody].
Thispaperbringstogetherfindingsfrombothstudiestoempha-
sisehowthetypeofexposuretoinclusionhealthgroupsmayinflu-Thedoctortoldusthattheonlytimewediscriminate
encemedicalstudents’attitudesandbehaviours(Table1).'thadthatpositiveexperi-
ence,Iwouldhavethoughtthattheother[negative]
experiencewasnormal…ImagineifIneverques-
3 | FINDINGStionedthat?Youwouldprobablygoontopractice
withthatmindset.(P2,firstyear)
| Feelingsofunpreparedness
IthinktheSSCreallychangedmyperspective[onthe
Participantsinbothstudiesexpressedconcernabouttheirlackofimpactofhealthinequalities].Beforethen,Iwasnaïve
experienceandskillsworkingwithinclusionhealthpatients,withtotheseissues…I’msogratefulthatIhadthatoppor-
onestudentfeelingcompletelyuseless(P1,fifthyear)andanothertunity,butit’sashamethatsomanydidn’thavethat
feelinghelplessbecauseI’dhavenoideawhattosuggestorwhattoopportunitybecausetheydidn’tseekitout.(P1,fifth
do…(P2,firstyear).Studentsanticipatedthatspecialistskillswereyear)
neededtocommunicateandmeettheneedsofinclusionhealthpa-
tients,withoneparticipantexpressing:IjustfeelthatIdon'thavethe
particularskillset…(P3,thirdyear).Participantswentontoexplainhowsuchpositiveexperiencesled
themtoseekoutfurtherinclusionhealthexperiencesbychoice:
StudentsanticipatedthatIthinkthoseexperiencesthemselveshavemademe
keentoseekoutmoreexperiences…thedominoef-
specialistskillswereneededfect!(P3,thirdyear)
tocommunicateandmeet
Idon’tthinkI'dhavetakenanactiveinterestinseek-
theneedsofinclusionhealthingoutlearningaboutthat[healthinequalities]ifI
’thadthatSSP!(P1,fifthyear)
andhowtheygainedasenseofconfidenceandanabilitytoquestion
| Bychanceorbychoice?others:
ParticipantsdescribedtheirencounterswithinclusionhealthgroupsIfeelmorethatIwouldchallengebehaviourthatI
asencounters‘bychance’(onplacement)or‘bychoice’(anencoun-didn’tthinkwasappropriateandmaybemoreinthe
teroccurringthroughanoptionalinitiative,suchasanSSC,extra-­wayofencouragingpeopletothinkofthebiggerpic-
curricularactivityorelective).ture.(P4,thirdyear)
4 | DIXONetal.
BOX2 Currenthealthinequalitiesandinclusionhealthcontentatourinstitution
,understanding
healthinequalities,careforthedisempowered,theroleofhealthpolicyinsustainableandequitablehealthcareandkeyissuesinglobal
health.
Atwoweekstudentselectedcomponent(SSC)on‘Tacklinghealthinequalities’wasdevelopedasanoptionalchoiceforsecondandthird
,refugeesand
asylumseekers,
experience,films,documentaries,debateandaclinicalplacementininclusionhealth.
| PreferenceforinteractiveteachingandlearningItimpactsyouinawaythatwouldprobablymake
youamuchbetterdoctor,lessjudgemental,less
Ourparticipantsreportedexperientialopportunitiesweremoreen-discriminatoryaswellasjustmoreempathetic.(P7,
gagingthantraditionallecture-­basedteaching,recallingpositiveex-thirdyear)
periencesofcampusteachinginvolvingpeoplefrominclusionhealth
groups:
4 | DISCUSSION
Ourparticipantsreported
Weidentifiedthatlecture-­basedhealthinequalitiesteachingmay
experientialopportunitiescontributetofeelingsofunpreparednessincaringforinclusion
weremoreengagingthanhealthgroups.
traditionallecture-based­Lecture-­basedhealth
contributetofeelingsof
It’sadifferentwayoflearningandweallhadtheop-
portunitytoaskthepeoplethatcameinquestions…unpreparednessincaringfor
itmadethewholesessionmoreinteractiveandweinclusionhealthgroups.
learntalotmorefromit.(P5,thirdyear)
Student-­selectedinclusionhealthcomponents(‘choiceencoun-
It’sreallyeasytojustsitthroughalectureandnotters’)seemedtohavemorepowerfulimpactsonattitudesandin-
reallyengagebutwhenthereissomeonestandingatterest,particularlywhentherewereopportunitiestolearndirectly
thefronttellingyouwhattheyhavebeenthrough,-
youwillrememberthat.(P6,thirdyear)dicatedthatcoreme