Curriculum design in health should be based on the essential competencies required for contemporary professional health practice. The knowledge, skills, and attributes of health practitioners, regardless of discipline, are critical for a person's health outcomes; however, the health of community members is also strongly influenced by factors such as wealth, living environment, and education. There are strong and consistent associations between these factors and health outcomes (Wilkinson & Marmot, 2003). Understanding the impact of the determinants of health is critical for health professionals who are committed to improving health (Frenk et al., 2010). The literature describes the inclusion of social medicine content in some health professional programs (Kasper, Greene, Farmer, & Jones, 2016). However, it has been reported that students in the health disciplines frequently complete their programs of study having paid little attention to the determinants of health (Harpin et al., 2016; Waite & Brooks, 2014). Few studies report curriculum strategies regarding either innovative teaching approaches or students' interpretations of determinants of health. One recent study has examined differences and similarities in students' mental models about determinants of health at the start of an interprofessional educational experience, reporting that students from different health profession backgrounds emphasized some shared and some different opinions about determinants of health (Russell, Davidson, Rhoads, & Petrusa, 2017).This article presents the findings of a research project that sought to explore how students in the early stages of two health professional degrees (nursing and pharmacy) depicted the determinants of health and identifies areas for future curriculum development for students in these programs.
Description of the Course and the Photograph Essay Assessment
The course Essentials of Health Care Practice is a required course in the first year of university studies in the Bachelor of Nursing and the Bachelor of Pharmacy departments at one Australian university as of 2017. Nursing students make up approximately 80% of the class cohort. Students in the course include individuals who come into university directly from high school and individuals who have completed all or part of another university or vocational degree, and individuals who may have been engaged in full-time employment for several years. This course provides an overview of the organization of the Australian health care system, professionalism, ethical reasoning, and the social, cultural, and environmental determinants of health. In the assessment task, which is the focus of this study, students were required to take a photograph in their local environment that demonstrated social, cultural, or environmental determinants of health. In an accompanying essay style report, students were also required to outline how the photograph demonstrated the determinant of health and to describe how this determinant would influence health status. Students were also asked to describe approaches that could be used to improve equity regarding that determinant.
Each assessment was read and reviewed and the subject of each essay was categorized. The text within the assignments was analyzed using content analysis techniques (Graneheim & Lundman, 2004). The process involved reading the essays, identifying meaning units, condensing and grouping the meaning units, and then attaching a theme to each group of meaning units. The themes were checked against the essay texts to ensure they were grounded in the data.
The project was explained to all students attending class in one of the early weeks of the semester; written information and consent forms were provided to the students by an academic staff member not teaching in the course. Assessment pieces, only from individual students who gave written permission for the analysis to be undertaken, were analyzed only after all students had received final results for the course. Only student numbers, not student names, were used in record keeping. The written materials provided to students included information that advised students of no penalty for nonparticipation, as required by the ethics committee. The research was approved by the RMIT College of Science, Engineering and Health Ethics Committee.
Of the 389 students who studied the course in 2017, 129 students gave permission for analysis of their assessments. After submission, a total of 110 assessments were available for analysis. Students were required to take a photograph in their local environment and link this to a determinant of health. A large proportion (34%) of students focused on social factors such as a living wage and homelessness. Students depicted the living wage in their photographs in several different ways—for example, through focusing on costs of essential utilities and an empty purse, a high-visibility vest associated with being employed at an Australian supermarket chain, and bins of vegetable and fruit food waste. Individual lifestyle factors were addressed by 26% of students who presented fast food and obesity, smoking and illicit drug use, and alcohol consumption. Subject matter for these photographs (e.g., fast food or smoking) was presented in a consistent manner—fast food, packets of cigarettes, or alcohol bottles. In the category of individual lifestyle, factors lack of exercise was depicted by only one student. Physical determinants were presented by almost one quarter (24%) of students in a consistent manner—overflowing rubbish bins and filthy toilets. Determinants related to the availability of health services (addressed by 11% of students) and policy making (addressed by 4% of students) were depicted infrequently. Photographs of rural road signage signifying the journey to the nearest city hospital most frequently depicted restricted access to health services faced by individuals living in rural and remote areas. Determinants of health associated with policy were depicted through syringe disposal boxes and vaccination signage. The content analysis of the essays revealed two predominant themes with respect to the approaches that could be used to improve health status equity, with regards to the determinant depicted by the student's photograph. The first of these was education and the second was the role of the government.
Theme 1: Education
Education was frequently described by students as a potential approach to improving health status equity with respect to many of the determinants that were identified through the students' photographs. Education was perceived as being provided by schools, consequently influencing adult health-related behaviors, and overcoming poverty. Examples of participants' statements reflecting the role of education include the following:
- Education improves health related behaviors by furnishing the decision-making skills of individuals. (Student 3)
- Public school funding should be improved in order to improve the level of education received and thus tackle the inequality issue(s). (Student 8)
- Health and equality can be improved in regards to financial hardship [sic] is to make education more affordable and accessible for all. (Student 98)
Education was also seen as being provided through unnamed initiatives to address individual behaviors. Participants' statements reflecting this theme included the following:
- Good education can make a person change his lifestyle to a better one, removing unhealthy junk food and replacing it with better more nutritious food. He might also start going to the gym and exercise regularly, and by that he has already prevented a variety of illnesses such as diabetes and high blood pressure. (Student 27)
- One approach that could be used to improve health status…is to educate individuals about healthy foods. Many individuals who eat fast food and foods that contribute poorly to their diet are not aware of the risks that are associated with eating those foods…. When individuals are educated, they can make the correct decisions when it comes to nutritious foods. (Student 40)
Theme 2: The Role of the Government
A second theme was around the role of the government. The government was seen as having a role across a broad range of determinants. Examples of participants' statements reflecting the role of education included the following:
- Having a limited amount of money could mean that only essential products are bought and basic sanitary products are left out, which could lead to skin infections. This could be solved by the government providing hygiene packs that contain basic sanitary products at no cost every month to each Aboriginal household to ensure hygienic [sic] related diseases are eliminated. (Student 4)
- The Australian government should provide stable accommodation for the homeless individual…. The Australia [sic] police should not allow any homeless staying in the street. They should be able to send them to emergency accommodation…. The government should organize social and emergency housing for all homeless individuals or people in need who currently do not have a fixed address. (Student 35)
- The government needs to support organizations and assist specialists and their families to settle into a new lifestyle in rural communities. (Student 70)
- The government can also financially aid food banks to increase their capacity and distribution network to further expand their activities. (Student 94)
- The subsidizing of fresh fruit, vegetables, fish and lean meats would an effective and positive outcome…also easy to implement. (Student 102)
- However, the government as well as other stakeholders can encourage young people to exercise as a way of reducing the risk of obesity. (Student 122)
Students were required to take a photograph in their local environment and link this to a determinant of health. As described, students chose a broad range of subjects to photograph so it is likely that these represent their perceptions of the determinants of health within their local community. Students were required to present potential solutions to addressing the determinant depicted by the photograph. The content analysis of the essays revealed two predominant themes—the first of these was education, both in terms of accessible quality schooling across the community and targeted health behavior educational initiatives. The second theme was the role of the government. Although we know that this is not the case (Dossey & Keegan, 2012), many students in this first-year course expected that providing general information through targeted education initiatives about healthy lifestyles would improve individual behaviors, often without an insight into the social factors (such as poverty), which may additionally inhibit the uptake of healthier behaviors. There is currently variable inclusion of health psychology concepts, including the stages of change and the motivation and facilitation of change in nursing and pharmacy programs (Burns et al., 2012; Howard, 2018; O'May et al., 2016; Um, Krass, Armour, Gill, & Chaar, 2016). The findings from this study will prompt further curriculum development in both the nursing and the pharmacy programs at this university to address the need for students to understand the concepts associated with facilitating behavior change strategies (Battise, DeValve, Marlowe, Beasley, & Miller, 2014) and better prepare graduates for contemporary professional health practice. All policy, including health policy, evolves as an outcome of political ideologies, the power of interest groups and public opinion (Hunter, 2015). Nurses are recognized to be in the position to reshape the policy environment to enable equitable care of individuals within the health systems, and, as such, nurses and nursing students should understand the process of policy influence (Staebler et al., 2017). In pharmacy, the activities of many pharmacists are directed to improving the drug-use process and include services that contribute to the rational and economic use of medicine. It has been suggested that the curriculum should include the internal and external factors that drive change in practice, such as the policy and political environments, in which health services operate (Nunes-da-Cunha & Fernandez-Llimos, 2017). Within the student cohort, there was a significant misunderstanding about the role of government, including the role of the government in providing access to quality schooling and the consequential need for policy development. A knowledge deficit relating to policy development with respect to health care services has been noted by others working in Australian nursing programs (Mackey et al., 2018) and may in part reflect the lack of a compulsory civics curriculum in Australian high schools (Forster, Beale, & Richardson, 2018).
In this project, we sought to explore first-year students' understanding of the determinants of health, as observed by them in their environment as part of an innovative photograph essay assessment.
Through the analysis of the assessment artifacts, we have identified that further curriculum development is required in both the nursing and the pharmacy programs at this university to assist students to understand the processes of influencing policy and policy development.
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