Graduate and Undergraduate Medical Curricula That Address the Needs of People Who Experience Homelessness: A Scoping Review Protocol

Matthew Linvill; Logan Verlaque; Caitríona O’Sullivan; Felicia Manocchio; Matthew King; Connor Mabbott; Aisling Walsh; Gráinne Cousins

doi:10.12688/hrbopenres.13902.1

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Study Protocol

Graduate and Undergraduate Medical Curricula That Address the Needs of People Who Experience Homelessness: A Scoping Review Protocol

[version 1; peer review: 2 approved with reservations]

Matthew Linvill ¹, Logan Verlaque¹^*, Caitríona O’Sullivan¹^*, [...] Felicia Manocchio¹^*, Matthew King¹^*, Connor Mabbott¹^*, Aisling Walsh², Gráinne Cousins³

Matthew Linvill ¹, Logan Verlaque¹^*, [...] Caitríona O’Sullivan¹^*, Felicia Manocchio¹^*, Matthew King¹^*, Connor Mabbott¹^*, Aisling Walsh², Gráinne Cousins³

^* Equal contributors

PUBLISHED 03 Jul 2024

Author details Author details

¹ School of Medicine, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland
² School of Population Health, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland
³ School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Irel, Dublin, Leinster, D02 YN77, Ireland

Matthew Linvill
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Logan Verlaque
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Caitríona O’Sullivan
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Felicia Manocchio
Roles: Data Curation, Formal Analysis, Investigation, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Matthew King
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Connor Mabbott
Roles: Data Curation, Formal Analysis, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Aisling Walsh
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – Review & Editing

Gráinne Cousins
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

The impact that increased homelessness has on the healthcare system should be of great concern to medical providers and the institutions that train them. While the demand for medical providers who understand the healthcare needs of homeless individuals is high, traditional medical curricula do not adequately address this.

Objectives

This scoping review aims to examine published undergraduate and graduate medical curricula that address the healthcare needs of homeless individuals to support the development and evaluation of homeless healthcare curricula globally.

Methods

This paper will utilise Arksey & O’Malley’s framework for scoping reviews to ensure a systematic scoping review. Research will be conducted in accordance with the Joanna Briggs Institute's (JBI) Updated Methodological Guidance for the Conduct of Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Review (PRISMA-ScR). Due to financial and time constraints, only articles published after 2000 and written in English will be reviewed. A comprehensive search strategy will be developed that includes searches in PubMed, Scopus, Embase and CINAHL with additional hand-searching of key articles. Each article will be screened independently by two reviewers. A third reviewer will resolve any disagreements. Data extraction will begin with a pre-defined extraction form (Extended Data File 3) and will be subsequently analysed with JBI’s current guidelines on inductive approaches to qualitative content analysis.

Conclusion

Research findings will be distributed to individuals who oversee the university’s medical curricula at the Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences. Discussions will be held to assess opportunities for the implementation/integration of homeless healthcare curricula. Furthermore, these findings will be disseminated globally to healthcare providers and administrators at conferences, hospitals and clinics.

Keywords

homeless, graduate, undergraduate, curricula, education, medical, student, review

Corresponding author: Matthew Linvill

Competing interests: No competing interests were disclosed.

Grant information: Health Research Board Ireland [APA-2022-014]. This work was also supported by The Royal College of Surgeons in Ireland (RCSI) Student Engagement and Partnership (StEP) Program.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Linvill M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Linvill M, Verlaque L, O’Sullivan C et al. Graduate and Undergraduate Medical Curricula That Address the Needs of People Who Experience Homelessness: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations]. HRB Open Res 2024, 7:43 (https://doi.org/10.12688/hrbopenres.13902.1) First published: 03 Jul 2024, 7:43 (https://doi.org/10.12688/hrbopenres.13902.1) Latest published: 03 Jul 2024, 7:43 (https://doi.org/10.12688/hrbopenres.13902.1)

Introduction

We are living in what the World Bank has called the “deepest global recession since World War II”¹. According to a 2020 report by the European Federation of National Organisations Working with the Homeless (FEANTSA) and the Foundation Abbé Pierre, the European Union has witnessed a 70% increase in the number of people experiencing homelessness or living in emergency/temporary accommodation in the last decade². North American data show similarities, with a recent report by the Canadian Observatory on Homelessness reporting that more than 500,000 Americans and 250,000 Canadians experience homelessness each year³.

The impact that homelessness has on the healthcare system should be of great concern to medical providers and warrants further attention by the institutions that train them⁴. In 2022, an umbrella review by Fornaro et al. analysed eight meta-analyses and two systematic reviews finding that people without housing have a higher risk of hospitalisation, HIV, anxiety and depression⁵. While the demand for healthcare among people experiencing homelessness is high, according to Julian Tudor Hart’s ‘Inverse Care Law,’ healthcare supply varies inversely with healthcare demand⁶. Therefore, providing adequate healthcare to homeless individuals is a challenge for all countries as they strive to meet the UN’s sustainable development goals and promote well-being for all⁷.

While the demand for healthcare within homeless communities is high, there is a lack of published evidence-based curricula that address how medical students can provide effective healthcare to homeless populations⁴. Fortunately, recent initiatives in homeless healthcare curricula have improved students’ attitudes towards people experiencing homelessness and strengthened their abilities to care for these populations^8–15. For example, Liu et al. described a novel student-run Patient Navigator Program (PNP), which significantly improved medical students’ self-assessed attitudes towards individuals experiencing homelessness¹⁰. This program also improved students’ self-perceived knowledge, efficacy in working with and skills in caring for underserved groups. In addition, homeless healthcare curricula also support the United Nations’ efforts to reduce poverty and inequality. This addresses the UN’s Sustainable Development Goals (SDGs) 3 and 10 which promote “good health and well-being” and “reduced inequalities'' for all⁷.

Study rationale and objectives

Scoping reviews are useful tools for systematically mapping a body of literature that has not been comprehensively reviewed¹⁶. They are also useful for identifying knowledge gaps, clarifying concepts and reviewing current literature¹⁷. This scoping review aims to assess published undergraduate and graduate medical curricula that address homeless healthcare. The purpose of this study is to support the development and evaluation of homeless healthcare curricula globally. This research builds on the work of Hashmi et al., which conducted a mixed methods study to develop an evidence-based Homeless Health Curriculum Framework. In contrast to Hashmi et al., who focused on “undergraduate medical education or practitioners and/or public health or preventative medicine”⁴, we will examine undergraduate and graduate medical curricula. Furthermore, while Hashmi et al. focused on the development of a Homeless Health Curriculum Framework, we seek to answer what existing medical curricula work to improve medical students' knowledge of homeless healthcare and medical students’ skills in working with homeless populations.

Methods

Study design

All published research that examines medical curricula built to improve undergraduate and graduate medical students' knowledge of homeless patients' healthcare needs and medical student´s skills in working with homeless patients will be reviewed. To ensure a systematic and complete scoping review, this paper will be guided by Arksey & O’Malley’s framework for scoping reviews¹⁸. Furthermore, research will be conducted in accordance with the Joanna Briggs Institute's (JBI) Updated Methodological Guidance for the Conduct of Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review [PRISMA-ScR]^19,20. To ensure research is current and translatable, only articles published after 2000 and written in English will be reviewed.

Protocol and registration

This protocol is registered with The Open Science Framework (OSF), https://doi.org/10.17605/OSF.IO/N3PJ5. The scoping review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review [PRISMA-ScR]²⁰. The completed PRISMA-ScR checklist is in Extended Data File 4.

Stage 1: Identifying the research question

To identify a research question, an initial literature search was conducted. During this search, the following terms were used; “homeless”, “medical student” and “education”. Following discussions with the research team, the study's rationale and objectives were determined. Research rationale and objectives were updated iteratively. This review is a component of a larger project which aims to inform a homeless healthcare curriculum for medical students globally.

This scoping review seeks to answer the question, what medical curricula exist that aim to improve medical students' knowledge of the healthcare needs of homeless populations and medical students´ skills in working with homeless populations? Review objectives include:

1. To summarise homeless healthcare initiatives in undergraduate and graduate medical curricula.
2. To assess the implementation of different delivery methods of homeless healthcare curricula.
3. To ascertain key priorities for the development of different homeless healthcare curricula.

Stage 2: Identifying relevant articles

Search strategy. Our search strategy was finalised in August 2023. Per JBI guidelines, a three-step search strategy was followed²¹. Step one included an initial search for papers published in CINAHL and PubMed. Key search terms included “homeless”, “medical student” and “education”. Following an initial search, an information specialist was consulted for the formulation of a prototype search strategy with MeSH terms (Extended Data File 1). This search string was piloted with a literature search of 10 preliminary articles. Following the pilot, the search strategy was iterated to refine results. This search string was entered into the databases PubMed, Scopus, Embase and Cinahl. Finally, a scan of relevant review articles’ references was conducted for additional papers that meet inclusion criteria. All articles were published after 2000 and recorded in English.

Inclusion and exclusion criteria. During this scoping review, the Population, Concept and Context (PCC) framework was used to establish inclusion criteria [Table 1]¹⁹. Qualitative, quantitative and mixed-method studies will be included to broadly assess different characteristics of the literature. Furthermore, observational and experimental quantitative study designs will be examined. Qualitative studies will include action research, ethnography, phenomenology, grounded theory and qualitative descriptive design. In addition, all references from empirical research review articles will be screened for inclusion. Before full implementation of inclusion and exclusion criteria, criteria will be tested on 20 initial articles to assess the criteria’s quality.

Table 1. The Population, Concept and Context (PCC) framework for establishing inclusion criteria and guiding the review¹⁹.

PCC Component	Component Details
Population	Undergraduate and Graduate Medical Students
Concepts	Homeless Healthcare Medical Curricula, Programmes, Courses, Modules, Series, Lectures, Classes or Trainings.
Context	Research published in English. No country or geographic region will be excluded.

Inclusion criteria

Research that:

i) describes or evaluates homeless healthcare curricula.
ii) involves formal or informal curricula targeted towards medical students.
iii) involves undergraduate and/or graduate medical students.
iv) may include interprofessional education.
v) quantitative, qualitative or mixed methods research.

Exclusion criteria

Research that:

i) does not examine medical curricula.
ii) does not examine curricula that work to improve students’ knowledge of homeless patients’ healthcare needs or improve students’ skills to care specifically for homeless patients.
iii) involves curricula targeted towards the public and not medical students.
iv) involves curricula targeted towards all hospital staff and not solely medical students.
v) is not published in English.
vi) grey literature, opinion pieces, conference abstracts or theses.

Homeless healthcare curricula will be defined as curricula that aim to strengthen medical students’ ability to work with homeless patients and improve their understanding of homeless patients’ healthcare needs. Homeless patients will be defined using the European Typology of Homelessness and Housing Exclusion (ETHOS). This framework was redesigned in 2017 by FEANTSA to create a common language for measuring and understanding the different types of homelessness in Europe²². ETHOS categorises homelessness into 4 categories: roofless, houseless, insecure and inadequate²². For this review, homeless patients will be defined as people living rough (people who live on the streets or public places without shelter that can be defined as living quarters), people living in emergency accommodation and people who reside in accommodation for the homeless.

Stage 3: Study selection

Screening of relevant research articles will consist of two phases: i) an initial screening of the articles’ titles and abstracts; ii) a full-text review. During phase one, all relevant articles will be transferred into EndNote 20. After the removal of duplicates, the remaining articles will be transferred into Covidence for the removal of additional duplicates not identified by EndNote. Furthermore, Covidence will be used to screen the articles’ titles and abstracts. One researcher (ML) will screen 100% of the titles/abstracts and four researchers (LV, FM, MK, and CM) will ensure each article is screened twice. A third reviewer (CO) not involved in the initial screening, will resolve any disagreements. During phase two full-text articles will be independently reviewed by two reviewers (LV, FM, MK, CM, and CO). A third-party reviewer (ML) will help the group reach a consensus if there is a conflict.

Stage 4: Extracting the data

Using the JBI framework, six reviewers will extract relevant information from the included articles¹⁹. A pilot data extraction form will be developed using JBI guidelines on inductive approaches to qualitative content analysis [Extended Data File 3]²³. This form will be independently piloted on ten articles by four reviewers (FM, LV, CO and ML). The data extraction form will be revised as necessary after this pilot phase. Following the extraction of research data, corresponding data will be logged into Google Sheets for coding.

Stage 5: Collating, summarising and reporting results

Codes will be developed as the analysis is completed in Google Sheets. Codes will be drafted by two researchers and agreed on by the team. The quality of research evidence will not be assessed, as this is normal for scoping reviews¹⁸. After organising the results, stakeholders such as practitioners who care for homeless patients, educators, medical students and medical training programs will be consulted. Research recommendations will build on the gaps identified. These components of the study will involve significant cooperation with stakeholders during Stage 6 (see below).

Stage 6: Consulting with stakeholders

Following the collection and organisation of our results, recommendations will be disseminated to stakeholders involved in the delivery of medical curricula. Discussions will be held that assess opportunities for implementing/integrating focused teachings on homeless healthcare curricula. Furthermore, these findings will be disseminated to experienced healthcare stakeholders at conferences, hospitals and clinics globally. This research will advocate for medical curricula that improve medical students’, residents’ and trainees' understanding of and skills in addressing the healthcare needs of people experiencing homelessness.

The primary objective of this research is to inform decision-makers of the relevance of homeless healthcare medical curriculum. We aim to foster inclusivity and awareness among medical professionals regarding the unique healthcare challenges faced by this demographic. Through engaging with key stakeholders in various disciplines, we aim to strengthen medical professionals' comprehension of inclusion medicine and dedication to promoting homeless patients’ needs in healthcare.

Research checklist

This review was conducted using the PRISMA-SCR extension checklist [Extended Data File 4]²⁰.

Limitations

Our scoping review has several limitations. First, due to limited time and resources only articles published after 2000 and in English will be reviewed, however, we believe that the research we analyse will examine research before 2000. Second, scoping reviews are limited because they do not formally appraise research quality and they do not assess the balance of evidence in favour of the effectiveness of an intervention¹⁸. While these limitations could be addressed with a systematic review, quantitative data on homeless healthcare curricula is limited.

Dissemination

Results will be submitted to a peer-reviewed journal as well as national and international conferences. This research has the potential to inform the development of homeless healthcare curricula globally.

Study status

This study is in the process of extracting data from articles. We anticipate the review will be completed by August 2024.

Conclusion

This is the first scoping review to be published that examines undergraduate and graduate medical curricula that address homeless healthcare. This review aims to support the development and evaluation of an internationally applicable homeless healthcare curriculum. All published research that examines medical curricula built to improve undergraduate and graduate medical students' knowledge of homeless patients' healthcare needs and medical student´s skills in working with homeless patients will be reviewed. The findings of this review will be shared with stakeholders involved in the development of medical curricula. This research aims to advocate for medical curricula that improve medical students’, residents’ and trainees' understanding of and skills in addressing the healthcare needs of people experiencing homelessness.

Ethics and consent

Ethical approval and consent were not required for this scoping review.

Data availability

Underlying data

No data is associated with this article.

Extended data

Open Science Framework: Graduate and Undergraduate Medical Curricula That Address the Needs of People Who Experience Homelessness: A Scoping Review Protocol. https://doi.org/10.17605/OSF.IO/N3PJ5²⁴.

Extended data are available in “files” and include:

- Search Strategy
- PRISMA flow diagram²⁰
- Data extraction form prototype
- PRISMA-SCR extension checklist²⁰

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Acknowledgements

Thank you very much to Chiara Cecchinelli, an incredible librarian from the Royal College of Surgeons Ireland, who greatly assisted in the development of our search strategy.

Faculty Opinions recommended

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