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

Introduction: 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. Methods: 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. Results: 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. Conclusion: Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.