Medical students’ experiences of health inequalities and inclusion health education

Inclusion health groups experience a significantly larger burden of morbidity and mortality than the general public. Despite this, undergraduate medical education is often limited in its approach to inclusion health curricula, leaving students disengaged and lacking understanding.

substance misuse and sex work, have markedly higher morbidity and mortality than the general population. 3 Previous literature has emphasised the importance of including health inequalities teaching in undergraduate medical curricula. 4 However, despite calls for improvements in health inequalities education, an abundance of literature suggests that exposure to inclusion health groups in medical curricula is either limited, optional or student driven.
The teaching of health inequalities varies across UK medical schools, 4 though lectures are a popular choice in the delivery of this content. 5 Whilst lectures are time-and resource-efficient in delivering large amounts of content to large cohorts, research suggests that students are disenchanted with this method based on passive acquisition of knowledge. 6 Students have reported they feel less engaged with lectures and lack understanding of the relevance of health inequalities lectures. 7 If medical students are to provide equitable and compassionate care to future patients from inclusion health groups, it is critical to develop engaging inclusion health education that can improve rapport, patient care and patient outcomes.
It is critical to develop engaging inclusion health education that can improve rapport, patient care and patient outcomes. 2. What has influenced medical students' attitudes towards inclusion health groups?

BOX 1 Inclusion health definition
Inclusion health is a term used to describe people who are socially excluded and typically experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma). 3 This can include people who experience homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery but can also include other socially excluded groups. This population frequently experience stigma and discrimination and have poorer predicted health outcomes and a shorter life expectancy than the average population. 3 Year of study (number of participants) 3rd

TA B L E 1 Details of the two studies included in this paper
Year (6) 1st Year (1) 3rd Year (1)  5th Year (2) DIXON et al.

| ME THODS
Both student researchers applied a constructivist approach to explore the richness of participants' learning experiences 8  This paper brings together findings from both studies to emphasise how the type of exposure to inclusion health groups may influence medical students' attitudes and behaviours (Table 1).

| Feelings of unpreparedness
Participants in both studies expressed concern about their lack of experience and skills working with inclusion health patients, with one student feeling completely useless (P1, fifth year) and another

| Preference for interactive teaching and learning
Our participants reported experiential opportunities were more engaging than traditional lecture-based teaching, recalling positive experiences of campus teaching involving people from inclusion health groups: Our participants reported experiential opportunities were more engaging than traditional lecture-based teaching. Experiential learning in community settings has been somewhat restricted due to the pandemic, but we have incorporated pre-recorded narratives from patients with lived experience of exclusion as part of our online offering to all students (currently these resources are from open access sources rather than created by the university, see box 2).

BOX 2 Current health inequalities and inclusion health content at our institution
These topics are mainly taught in year two of the medical curriculum in a population health module. The teaching methods are hour long lectures to the whole year and some facilitated small group discussions. Topics include the wider determinants of health, understanding health inequalities, care for the disempowered, the role of health policy in sustainable and equitable health care and key issues in global health. A two week student selected component (SSC) on 'Tackling health inequalities' was developed as an optional choice for second and third year students in 2019. This covered healthcare for inclusion health groups including people experiencing homeless, refugees and asylum seekers, people with addiction problems and those involved in prostitution. The SSC included discussions with people with lived experience, films, documentaries, debate and a clinical placement in inclusion health.
DIXON et al.

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Exposure to the real-life impacts of health inequalities on individuals appears to enable students to challenge their own preconceptions. 7 Our participants reported that they had even developed the confidence to challenge behaviour that they perceived to be prejudicial or discriminatory. This is an important finding in light of the potential for negative role models to perpetuate stigma and poor attitudes towards patients. 10 When medical students question the actions of those they work with, there is potential for transformative learning for both students and professionals alike.

Exposure to the real-life impacts of health inequalities on individuals appears to enable students to challenge their own preconceptions.
When medical students question the actions of those they work with, there is potential for transformative learning.

| Limitations
Participants Teachers of core medical curricula should apply methods that have been well-received in studentselected components.
It is not possible to draw conclusions from our studies about how widespread negative placement experiences might be, but it is important for clinical educators to be aware of the risks of perpetuating stigma and discrimination. This is an important area for further future research.

E TH I C A L A PPROVA L
This study was granted ethical approval upon review by the

University of Leeds School of Medicine Ethics Committee (SoMREC)
Applied Heath Sub-committee. Permission to recruit participants was given by the appropriate gatekeeper. There was no potential harm to participants; anonymity of participants was guaranteed and informed consent of participants was obtained for data collection and publication.

BOX 3 Changes to the health inequalities and inclusion health content at our institution as a result of the studies
We have reduced both the number and duration of lectures on this content and have instead utilised technology and a flipped learning approach to engage students with directed online learning in preparation for small group work discussions and self-reflective practice. This blended approach includes case studies from health care professionals working in inclusion health, as well as narratives from people with lived experience of social exclusion, such as patient stories from Fairhealth (https://fairh ealth.org.uk/stori es/) and the use of virtual consultations from Virtual Primary Care (https://vpc.medic alsch oolsc ouncil.org.uk/).