Background:
The World Health Organization defines the social determinants of health (SDH) as "the non-medical factors that influence health outcomes" [1]. Understanding SDH is vital for addressing health inequities, and the teaching of SDH is a critical component of our medical schools’ social accountability mandates to meet the priority health needs of our communities [2-6].
Pregnancy is both a transient and vulnerable period in the life of both the mother and her baby. Literature indicates that mothers living in poverty are more likely to encounter stressful challenges, such as food and housing insecurity, and engage in unhealthy behaviours, such as smoking, and are at higher risk of experiencing pregnancy complications, such as preterm birth, with fewer resources and supports. Babies born in lower economic positions are at higher risk of delayed cognitive development and school performance. Adolescent pregnancies are associated with higher rates of sexually transmitted infections, violence and substance abuse. Indigenous women are at higher risk of adverse outcomes, such as gestational diabetes and postpartum depression. Research has described patterns of health inequities for multiple maternal and pediatric health outcomes [7].
The impacts of SDH are especially relevant when viewing the health of women and their children through a life course lens, which describes the temporal aspect of social inequity, the social gradient in health, as being established prior to birth and that the effects of inequity accrue over time.
Knowledge gap:
Having an overview of current SDH teaching is a necessary first step to augment and improve the teaching of SDH in undergraduate medical education (UGME) curricular content and educational experiences. Existing reviews have synthesized evidence on SDH teaching in undergraduate and postgraduate medical education, drawing on examples of implementation and evaluation across various educational settings [8-10].
However, no study has conducted a comprehensive nationwide analysis of the teaching of SDH within curricula related to obstetrics and gynecology (O&G), women’s health, and sexual and reproductive health in UGME in Canada, despite its critical role in addressing reproductive health inequities.
Proposed study:
We propose to fill this gap by conducting primary research to evaluate the state of SDH teaching in O&G education across Canadian medical schools. By analyzing curriculum documents, we hope to identify national trends, gaps, and opportunities to improve SDH education and advance socially accountability in UGME teaching and training. Our study is one step towards improving UGME curricular content and educational experiences so that graduating physicians will have a better understanding of the importance of SDH on the health of their patients and communities, and consequently, will be able to work collaboratively to provide more responsive and patient-centred care.
Overall Design:
This study will use a qualitative content analysis to systematically assess how SDH are integrated into medical school curricula across Canada. Focusing on the teaching of O&G, women’s health, and sexual and reproductive health, the research will analyze curricula documents from all 17 Canadian medical schools to provide a comprehensive overview of the current state of SDH education.
Data Collection:
Curricular documents will be requested from administrative staff at all 17 Canadian medical schools. A standardized protocol will ensure uniformity in the scope of collected materials. Where gaps exist, follow-up clarification will be requested to ensure completeness.
Sample:
The sample will include curricula documents such as:
- Learning objectives and syllabi for Pre-Clerkship course content relating to Obstetrics and Gynecology, Women’s Health, and Reproductive and Sexual Medicine
- Core objectives for Clerkship OB/GYN rotations.
- Organized Pre-Clerkship and Clerkship elective experiences in Obstetrics and Gynecology, Women’s Health, and Reproductive and Sexual Medicine
Data Analysis:
A qualitative content analysis will be conducted to assess:
- The presence or absence and extent (measured in learning hours) of SDH-related content.
- Themes such as health inequities, cultural competence, and systemic barriers.
- Educational methods, including didactic teaching, case-based learning, and experiential activities.
Documents will be coded for recurring themes and categorized to highlight patterns and gaps by both the Principal Investigator and student Co-Investigator. Differences of opinion will be navigated through discussion and participation of a third investigator, who has significant medical education research experience.
Timeline and Plan for Dissemination of Results:
The study will take place over three months in the summer of 2025. Document collection will occur in June, followed by qualitative analysis in July. Results will be synthesized and will be presented to the UGME Curriculum Committee, Faculty of Medicine, University of Ottawa, and the results will be shared with the networks of the Association of Faculties of Medicine of Canada.
An abstract and poster will also be prepared in August 2025 to be submitted to medical education conferences, including the International Congress on Academic Medicine (ICAM), the International Association for Health Professions Education (AMEE) Conference, and the Society of Obstetricians and Gynaecologists of Canada (SOGC) Annual Clinical and Scientific Conference (ACSC).
A manuscript is planned for submission to a peer-reviewed medical education journal by the end of 2025.
References
- World Health Organization. Social determinants of health [Internet]. Geneva: World Health Organization; [cited 2024 Dec 17]. Available from: https://www.who.int/health-topics/social-determinants-of-health
- Boelen C, Woollard R. Social accountability and accreditation: A new frontier for educational institutions. Med Educ. 2009;43(9):887-94. doi:10.1111/j.1365-2923.2009.03413.x
- Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-9.
- Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923-58. doi:10.1016/S0140-6736(10)61854-5
- Sherbino J, Bonnycastle D, Côté B, Flynn L, Hunter A, Ince- Cushman D, Konkin J, Oandasan I, Regehr G, Richardson D, Zigby J. Health Advocate. In: Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available from: file:///Users/ellamiklaucic/Downloads/canmeds-full-framework-e%20(1).pdf
- Association of Faculties of Medicine of Canada. Vision for Canadian Medical Schools. Ottawa: AFMC; [date unknown]. Available from: https://www.afmc.ca/wp-content/uploads/2022/10/sa_vision_canadian_medical_schools_en.pdf
- Daoud N, O’Campo P, Minh A, et al. Patterns of social inequalities across pregnancy and birth outcomes: a comparison of individual and neighborhood socioeconomic measures. BMC Pregnancy Childbirth. 2014; 14, 393. Available from: https://doi.org/10.1186/s12884-014-0393-z
- Evans J, Mazmanian PE, Cohen J, et al. Teaching the social determinants of health in undergraduate medical education: a scoping review. J Gen Intern Med. 2020;35(2):482-9. Available from: https://doi.org/10.1007/s11606-019-05453-w
- Nguyen P, Smith C, Thompson K, et al. Integrating the social determinants of health into graduate medical education training: a scoping review. BMC Med Educ. 2024;24: [forthcoming]. Available from: https://doi.org/10.1186/s12909-024-04867-0
- Jones T, Greenberg S, Jones R, et al. A scoping review of social determinants of health curricula in post-graduate medical education. PubMed Central; 2019. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC