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Dissertation/Thesis Abstract

Examining A Current Practice Culture Using The Social Determinants of Health as A Baseline to Develop A Transformative Education Curriculum for A Primary Care Health Workforce in India
by Cobb, Nadia Miniclier, Ph.D., Trident University International, 2019, 221; 27540190
Abstract (Summary)


In 2015 India’s Ministry of Health & Family Welfare had developed the National Initiative on Allied Health Professionals to strategically plan and help develop a health workforce to increase access to care, in an effort to meet their goal of Universal Health Care by 2020. At that time the physician assistant profession in India was under consideration to expand its role to include primary care, with a focus on rural and marginalized populations. The current 20+ year old physician assistant profession in India had exclusively been developed for sub-specialty surgical care in tertiary health centers.

Globally, the convergence of dire health workforce shortages; the evidence that 80% of a person’s health status is determined by the social determinants of health (SDOH), with medicine impacting 20%; the shift in community based primary care from tertiary health care; the recognition that ‘health is an investment’ leading to economic growth; have all fueled health professional educational shifts. These emphasize transformative education, with focus on the SDOH, community engagement and skills mix teams.

Developing the new ‘specialty’ of community based primary care physician assistants for India, requires developing curriculum that prepares them to be ‘fit-for-purpose’ with the appropriate skills mix to meet population needs. They must understand and be able to address the multi-dimensional complexities including vast geographic, cultural, socioeconomic, community as well as historical differences. Such a workforce could significantly impact 70% of India’s 1.2 billion people, as they live in rural areas.

This, first of a kind, study was developed to shed light on the current practice milieu of physician assistants in India, to not only reflect their training, clinical practice culture, but also appreciate strengths and areas that would be beneficial to focus upon in developing a primary care physician assistant curriculum/cadre. Previous studies have focused on the educational outcomes of learners, rather than the practice baseline that they will access as learners and graduates. This study created a tool to assess the currently practicing physician assistants’ perceived importance and application of the SDOH in the care of patients.


This mixed methods cross-sectional study took place at the India Association of Physician Assistants Conference in October 2015. There were 600 attendees (297 practicing physician assistants) from all over India. Participants completed an anonymous survey ranking their perceived importance of SDOH categorical questions in the care of patients, and if they had ‘asked them in patient history’ and ‘factored them into the patient’s discharge plan’ for the last 10 patients they cared for. They were also asked to reflect on what keep patients from improving, despite an adequate discharge plan.


The two SDOH categories that have associations with ‘ranking of importance’ at the categorical level, and ‘asked in patient history’ and ‘factored into discharge plan’ are Community Context (p < 0.001, p < 0.02) and Health Behavioral (p < 0.001, p < 0.036). The top 5 ranked questions are from the Health Behavior (2 out of the 4 questions in this category), Biological (4/4), and Socioeconomic (1/11) categories. Of the highly ranked questions only the following were statistically significantly in their association with ‘asked in history’ and ‘considered in the development of the discharge plan’: Socioeconomic ‘if the patient has children, how many?’ (ranked #7; ‘asked’ p = 0.001; ‘discharge’ p = 0.01); Structural ‘how far has the patient traveled for your care?’ (ranked #8; ‘asked’ p = 0.001; ‘discharge’ p = 0.001); Health Behavior ‘does the patient engage in risky sexual behavior?’ (ranked #10; did not ‘ask’ p = 0.001, did not ‘discharge’ p = 0.001). The top 4 ranked questions were not statistically significantly associated with ‘asked in history’ and ‘considered in discharge planning’.


The results of this study demonstrate the need for health professional education that includes more depth in the SDOH. The ranking of importance of the SDOH categorical questions overall, as well as individually, show significant gaps in understanding of Community Context, Socioeconomic and Structural impacts on health. The application results in ‘asked in history’ and/or ‘considered in discharge planning’ are further evidence that despite ranking levels, the operationalization of them in patient care is sporadic at best. This baseline sheds light on current practice where new physician assistants will train, opportunities for new curriculum to transform the new health workforce, and also where continuing professional development can be implemented to meet the new global health workforce focus.

Indexing (document details)
Advisor: Gomez, Frank
Commitee: Gieseker, Karen, Ryans, Brandon, Wilson, Angela
School: Trident University International
Department: College of Health Sciences
School Location: United States -- California
Source: DAI-A 81/4(E), Dissertation Abstracts International
Subjects: Educational evaluation, Health education, Medicine
Keywords: Clinical practice, India, Physician assistant, Primary care, Social determinants of health, Transformative education
Publication Number: 27540190
ISBN: 9781088389287
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