Addressing complex societal challenges in health education – A physiotherapy-led initiative embedding inclusion health in an undergraduate curriculum

Disclaimer

The views expressed in this article are those of the authors. Publication in HRB Open Research does not imply endorsement by the Health Research Board of Ireland.

Introduction

Inclusion health is an approach that aims to address the extreme health inequalities experienced by socially excluded people (Luchenski et al., 2018). Social exclusion such as that experienced by the homeless, Travellers and Aboriginal people, people with substance disorders, sex workers and prisoners, are associated with extreme levels of morbidity and mortality. Socially excluded people frequently have experienced multiple adverse events in childhood and adulthood (Fitzpatrick et al., 2012). Socially excluded populations have a mortality rate eight times higher than the average for men, and nearly 12 times higher for women (Aldridge et al., 2018).

In Ireland, a shortage of public housing has led to homelessness becoming a national crisis. Homelessness has predominantly affected people who have already experienced social exclusion and adversity since childhood, and compounds the effect of social exclusion on health. Since 2013, the number of homeless adults in Dublin has doubled (Focus Ireland). Homeless individuals are particularly vulnerable to dramatically poor mental and physical health, including younger onset of chronic disease, multi-morbidity and a reduced life expectancy (Fazel et al., 2014). Median age at death for homeless people in Dublin is devastatingly low at 44 years for males and 36 years for females (Ivers et al., 2019).

Unsurprisingly, given high rates of physical and mental ill-health, homelessness is associated with increased usage of unscheduled health care. A recent study in a homeless population (Bowen et al., 2019) showed an emergency department visit rate 60 times that compared to the general population. Centrally located Dublin hospitals of St. James’s Hospital Dublin and the Mater Hospital have seen a proliferation of homeless patients admitted and readmitted frequently. Despite representing just 0.4% of the catchment population of St James’s, homeless people account for almost 10% of emergency department attendances and inpatient stays (Ní Cheallaigh et al., 2017). In other areas country wide with high levels of deprivation, health care professionals will see homeless patients presenting across multiple services.

Homeless and other socially excluded people represent a distinct and significant population (Stovall et al., 2016), and require cultural and structural competency to address their healthcare needs (Beach et al., 2005; Metzl & Hansen, 2014). In order to address the complex health needs of homeless individuals, health care providers need an understanding of the forces that determine health outcomes at individual and societal levels. For example, clinician awareness of low levels of functional literacy in homeless adults and of the physical challenges presented by mandatory periods outside hostels during the daytime may result in an improved ability to provide information which can be implemented by a homeless patient.

The curricula of higher education instituted need to reflect these changing requirements for healthcare delivery (Dean et al., 2009; McMahon et al., 2016). Exposure of undergraduate students to patients from socially excluded groups is necessary so that graduates can become empathetic advocates and effective and innovative clinicians to help drive better health outcomes for vulnerable groups. Formal integration of the topic of inclusion health in medical and allied health undergraduate curricula is often lacking and/or unmeasured (Stovall et al., 2016). We suggest a formal approach should be taken and this letter will describe the development of an inclusion health placement and a step wise method of introducing this topic into the undergraduate curriculum which we have initiated in our setting.

Inclusion health clinical placement

St James’s Hospital has developed an integrated, interdisciplinary inclusion health team, with an initial focus on homeless adults. The team had reported a high incidence of frailty in homeless adults in the catchment area (de Paul, 2017), and had noted a high rate of need for physiotherapy in homeless inpatients referred to the service. Ongoing collaboration with the clinical and academic physiotherapy department led to the development of an inclusion health placement for undergraduate physiotherapy students.

We report the design and roll out of a dedicated four-week inclusion health placement delivered to 3^rd year undergraduate physiotherapy students of Trinity College Dublin in Jun-July 2019 on a pilot basis. The clinical placement was based in St. James’s Hospital and linked to community-based health and social care services for homeless adults.

Students were supervised by two clinical tutors who were senior clinicians with a dedicated role in clinical education. The main client group were homeless in-patients of St. James’s Hospital who were referred due to diverse physical and mobility limitations. Students assessed and treated this group, facilitated by the clinical tutor. Another facet of the placement was the design, set-up and delivery, of a student led exercise class in a residential hostel for homeless adults in the local area. Students also attended GP-led clinics for refugees in direct provision and a dedicated clinic for Roma people in an observational capacity.

We found there were additional considerations to setting up a clinical experience within the inclusion health area, which are applicable to future placements/clinical exposures. These are shown in Table 1. The ‘student voice’ - physiotherapy student post-placement reflections and guidance specifically for future students embarking on an inclusion health placement are presented in Table 2.

This inclusion health placement demonstrated bi-directional positivity – of the students towards this placement and client group and of homeless clients towards meaningful engagement and cooperation with student physiotherapists. Students reported this was a valuable learning opportunity. We are planning to run this placement again in the next academic year 2019–2010 with an increased focus on other socially excluded groups such as refugees and travellers.

Curricular changes

Inclusion health is a complex topic which overlaps with mental and physical disease, as well as substance abuse and structural factors underlying the effect of social exclusion on health. An additional challenge to introducing it into the formal undergraduate curriculum is the lack of best practice guidelines (Department of Health and Social Care, 2016) or set of competencies. As demonstrated in Figure. 1, our approach is to introduce this topic in a step-wise fashion.

Figure 1. Step-wise approach of developing suite of inclusion health learning activities from Year 1 (Academic year 2018–2019) projected to Year 2 (Academic Year 2019–2020) and Year 3 (2020–2021) into formal undergraduate curriculum.

In the academic year 2018–2019, we commenced with group-based student led presentations on the topic of inclusion health, entitled ‘’Inclusion health and physiotherapy in the homeless community’’ and ‘’Role of physiotherapy in people who are asylum seekers/refugees, including special considerations post torture’’. Students were given the topic as well and signposted to key resource materials and subtopics to consider for inclusion in their presentations. In 2019–2020, the topic of inclusion health will be formally integrated into a pre-existing learning module (a specialist rehabilitation module, delivered in 3^rd year) and to the curriculum document. Evaluation of inclusion health learning outcomes will take place in formal summative assessments. In addition to the student-led presentation, there will be scheduled lectures on inclusion health, including homeless, traveller and refugee/asylum seeker health. In 2020–2021 an inter-professional learning activity, which is under development, will include 2–3 diverse allied health professional students and will complement the suite of learning activities.

Conclusion

Clinical practicum and curricula should be realigned to meet the needs of the 21^st century of which the health of socially excluded groups is a pressing need. This letter describes a unique initiative to incorporating the topic of inclusion health in an undergraduate physiotherapy programme via development of a 4-week elective clinical placement and integration into the formal undergraduate curriculum.

Delivery of a universal basic level of knowledge and formal integration of inclusion health into the undergraduate curriculum as described in this letter would ensure all students are exposed to this topic with the aim to equip all future graduates with the skills and knowledge base to work with this vulnerable and complex group to optimise health outcomes.

For deeper understanding a dedicated clinical practicum or clinical placement would be recommended. Due to the nature of the area it would not be feasible to offer this opportunity to all students. Notwithstanding this, a dedicated inclusion health placement is likely to engage students as agents of change in the health care delivery system who can be communication catalysts and agents of change for the future. Sharing this experiential learning with other students, professionals, educators and health care institutes may enhance future engagement with these marginalised groups.

We suggest the approach of a dedicated clinical exposure and formal integration into the curriculum could be rolled out to other health care students and applied pragmatically to other settings based on local needs and expertise.

Data availability