Privilege as a Social Determinant of Health in Medical Education: A Single Class Session Can Change Privilege Perspective

Abstract

Accredited medical schools are required to prepare students to recognize the social determinants of health, such as privilege, yet privilege education has been overlooked in medical school curricula. The purpose of this study is to determine whether a single class session on privilege, within a social justice elective offered to first and second year medical students, is sufficient to change the perspective of medical students concerning their own personal privilege. A pre-class survey, followed by a class session on privilege, and post-class survey were conducted. Thirteen of the 18 students enrolled in the elective completed the pre-class survey. Ten students completed the post-class survey, although only 9 completed both the pre- and post-class surveys. The demographic profile of the participants was 93% Asian and 7% White ethnicity, with 57% identifying as being culturally American. There was no significant difference between average male and female or between age groups' self-assessed privilege amounts. For all characteristics tested, except hair color, participants had an increased self-assessed privilege perspective following the class. Three participants had an overall positive difference in privilege perspective, three participants had an overall negative difference in privilege perspective, and three participants had only a minimal change in privilege perspective. The absolute total difference in privilege perspective was 25 units of change. The single class session on privilege was sufficient to change significantly the perspective of medical students on their own personal privilege; however, future studies with larger groups of medical students are needed to elucidate other findings suggested by this study.

Introduction

Within the realm of social determinants of health in medical education, such as education, culture, socioeconomic status, housing and employment, the topic of privilege is often overlooked. Privilege, as defined in this paper, is “when one group has something of value that is denied to others simply because of the groups they belong to, rather than because of anything they've done or failed to do. Access to privilege doesn't determine one's outcomes, but it is definitely an asset that makes it more likely that whatever talent, ability, and aspirations a person with privilege has will result in something positive for them.”¹

Accredited United States medical schools are required to prepare students to “recognize […] determinants of health, […] and to recognize the potential health-related impact on patients of behavioral and socioeconomic factors.”² However, there is a current lack of research regarding medical school curricula including the topic of privilege, despite it being considered a social determinant of health. The importance of understanding one's own privilege as a future healthcare professional is critical to the delivery of equitable health care to all patients, as demonstrated by the World Health Organization's (WHO) 1996 report entitled Equity in Health and Health Care. Equity in health and health care, as explained in this report, “means that people's needs, rather than their social privileges, guide the distribution of opportunities for well-being […] (and) pursuing equity in health and health care means trying to reduce avoidable gaps in health status and health services between groups with different levels of social privilege.”³ Since current data from the Association of American Medical Colleges (AAMC) shows that “for the past two decades, over 60 percent of medical students are from families with incomes in the top quintile of all American families,”⁴ there is serious need for medical schools to educate future physicians about their own privilege within the larger social determinants of health to provide better care for future patients. Based on the Liaison Committee on Medical Education's requirements, medical schools should already be teaching medical students about such topics as privilege; however, a search of the PubMed database for the terms “medical student privilege” results in 43 related articles, none of which pertain to medical student education.

The purpose of this study is to determine whether a single class session on privilege within an elective on social justice in medicine offered to first and second year medical students is sufficient to change the perspective of medical students on their own personal privileges; it is hoped that better understanding of personal privilege will enable these future physicians to deliver equitable health care to their future patients.

Methods

The Elective

The University of Hawai‘i at Manoa (UHM) John A. Burns School of Medicine (JABSOM) offers an elective in “Social Justice in Health” to first year (MS1) and second year (MS2) medical students. The elective is offered through the JABSOM Department of Native Hawaiian Health. Students receive one credit hour for the class, which meets for one and a half hours weekly for nine weeks. The elective was first offered to the class of 2015, when a four year elective program leading to the “Dean's Certificate of Distinction in Social Justice” was established.⁵ The elective is now taught by medical students who took the course the prior year, under the mentorship of two faculty advisors. Due to the student-run nature of the elective, topics covered vary year by year. Topics of the 2015 elective included physician advocacy, gender roles and stereotypes, privilege, sexual orientation and identification, Hansen's disease in Hawai‘i, and international medical aid. The 2015 elective was taught by three MS2s, with each class session led by a single teacher or two co-teachers. Eighteen medical students enrolled in the 2015 elective, of whom five were MS2s.

The Class

A class session in January 2015 focused on privilege, defined as “when one group has something of value that is denied to others simply because of the groups they belong to, rather than because of anything they've done or failed to do.”¹ One week prior to the class, an online survey (approved by the University of Hawai‘i's Institutional Review Board, CHS #22769, which declared this study “exempt”) was made available to the 18 students enrolled in the elective. The survey reproduces Paul Kivel's popular walk exercise.⁶ A UHM system email was required to access the survey, however, all survey results were submitted anonymously via the Google poll. Prior to the class session, students were also asked to write their definition of privilege and three of their own personal privileges on a note card before class and to read Dowsett's article “What My Bike has Taught Me about White Privilege.”⁷ The class session on privilege included the following activities: (1) establishment of ground rules; (2) collection of the pre-class notecard assignment; (3) redistribution (to ensure anonymity) and discussion of the notecard definitions of privilege and listed privileges; (4) reading of Allan Johnson's definition of privilege;¹ (5) watching Tiffany Jana's TEDXRVA Women talk on “The Power of Privilege;⁸ (6) a think-pair-share exercise on race, gender, sexual orientation, and disability status; and (7) Paul Kivel's walk exercise.⁶ Following the class session, another survey (also IRB approved), with both identical and new questions as compared to the pre-class survey, was made available to the students. A UHM system email was once again required to access the survey and the survey results were submitted anonymously via the Google poll. Only the identical questions used on both the pre- and post-class surveys were analyzed in this paper, as new post-class survey questions providing feedback on the various educational materials used during the course itself were not relevant to our study. The resulting pre- and post-class survey data was linked to those who participated by matching age, gender, ethnicity, and cultural identity. The resulting data was then analyzed using Microsoft Excel, including the use of a two-sample t-test and analysis of variance.

Paul Kivel's Revised Walk Exercise⁶

To assess the self-privilege of the medical students, the lead author adapted Paul Kivel's original walk exercise questions. The survey consists of 41 questions. The first four questions of the survey instrument, as seen in Appendix 1, were included in order to allow pre- and post-class survey results for participants to be linked for analysis. Question 5 was added to assess a change in personal privilege perspective and is addressed in the following paragraph. Individual responses to Questions 6–41 remained unchanged between the pre- and post-class surveys, and thus, were not analyzed in this study; one question was excluded due to a lack of white participants. To facilitate analysis, the walk exercise questions were re-worded to require a yes or no response. To compare results, questions where an answer favored more privilege were given a “Unit of Change” (UC) value of plus 1 (+1), while those that favored less privilege were given a UC value of minus 1 (−1). An example of one of the questions from the survey is “Are any members of your immediate family doctors, lawyers, or other professionals?” where a yes response would receive a +1 UC and a no response would receive a -1 UC. (See Appendix 1 for the survey instrument.) The resulting scores were added for all questions with the total for each participant, termed “Privilege Amount,” seen in Table 1.

Table 1.

Pre-Class Assessment of Self-Privilege

Participants	Privilege Amounta
Average Female	13.7
Average Male	18.5

^aThe “Privilege Amount” was determined by adding the resulting scores for all analyzed survey questions, as detailed in Appendix 1, where a response to a question in favor of privilege resulted in a 1, and a response to a question in favor of less privilege was given a −1.

1. Difference between the privilege amount average between the female and male participants using a two-sample t-test, t= 1.00, 11 d.f., P < .05.
2. Comparison between the various age groups using analysis of variance at the P < .05 level (F(6,6) = 1.02, P = .489).
3. Mean Privilege Amount is 16.

Pre- and Post-Class Privilege Perspective

Responses to Question 5 in the pre- and post-class survey were used to assess a change in personal privilege perspective due to the class session. Question 5 asked students to rate on a scale of 1 to 10 how certain personal characteristics have given them a privilege over others, as seen in Appendix 1. This resulting data was analyzed separately from the walk exercise questions. The difference between pre- and post-class surveys was found by subtracting the pre-class survey rating from the post-class survey rating for each characteristic listed. A resulting positive value corresponds to an increase in privilege perspective on the post-class survey while a resulting negative value corresponds to a decrease in privilege perspective on the post-class survey. The mean difference between pre- and post-class surveys for each characteristic was then calculated to determine whether the change was significant.

Results

Class Demographics

A total of 13 students completed the pre-class survey (72% response rate), with a participant age range from 21 to 30 years. Participants self-identified their gender, ethnicity, and cultural identity on both the pre- and post-class surveys, as seen in Table 2. No data was collected regarding student socioeconomic background. Roughly two thirds of the participants were female (64%), with most participants being of Asian ethnicity (36% Chinese, 36% Japanese, and 14% Korean) and of an American cultural identity (57%). Ten students completed the post-class survey (56% response rate), with one new participant and 9 participants who completed both the pre- and post-class surveys (50% response rate). There was no significant difference between the Privilege Amount average between female and male participants (two-sample t-test, t= 1.00, 11 d.f., P < .05) or between the various age groups at the P < .05 level (analysis of variance, (F(6,6) = 1.02, P = .489), as seen in Table 1.

Table 2.

Self-Reported Demographic Information from Pre- and Post-Class Surveys

Gender	Number of Participants	% of Participants (N=14)
Male	5	36%
Female	9	64%
Ethnicity
Caucasian	1	7%
Chinese	5	36%
Filipino	1	7%
Japanese	5	36%
Korean	2	14%
Cultural Identity
American	8	57%
Other	6	43%

Note - Students self-identified their gender, ethnicity, and cultural identity with which they predominantly identify on both pre- and post-class surveys in order for their responses on both surveys to be linked and analyzed. The option of “Other” was given for both the ethnicity and cultural identity questions on both surveys. No definition of what constituted American cultural identity was given to participants.

Pre- and Post-Class Privilege Perspective

The difference between pre- and post-class surveys on how various characteristics give individual privilege were averaged, with each characteristic, except hair color, having a positive change in perspective, as seen in Table 3. The largest changes in privilege perspective were observed for home location, 1.9, disability status, 1.8, and high school attended, 1.1. The smallest changes in privilege perspective were observed for college attended 0.2 and cultural identity, 0.4. The sum of differences between pre- and post-class surveys for the various character istics for each study participant resulted in a positive change in perspective in six participants (66% of participants) and a negative change in perspective in the remaining three participants, as seen in Table 4. There was an absolute total difference in privilege perspective for all of the participants of 25 UC.

Table 3.

Mean Difference Between Pre- and Post-Class Surveys on How Various Characteristics Give Individual Privilege

Characteristic	Mean Difference (N=9)
Skin Color	0.6
Hair Color	0
Cultural Identity	0.4
Sexual Orientation	0.9
Gender	0.6
Disability Status	1.8
Mother's Profession	0.7
Father's Profession	0.9
Home Location	1.9
High School Attended	1.1
College Attended	0.2

Table 4.

Sum of the Differences between Pre- and Post-Class Surveys for Survey Instrument Question 7

Participants (Gender, Ethnicity, Culture)	Summative Difference for All Characteristics (N=9)
F, Korean, American	21
F, Japanese, Japanese	6
F, Chinese, American	4
F, Japanese, American	−19
F, Korean, American	56
F, Chinese, Chinese	−8
F, Chinese, American	10
M, Caucasian, American	58
M, Japanese, American	−47
Absolute Total Difference of all Characteristics	25

Discussion

This study on privilege serves to demonstrate that having a single class session on privilege can change significantly the perspective of medical students on their own personal privileges. Of course, the demographic makeup of the sample, which reflects the student population of JABSOM, differs from other medical school settings in that participants were primarily of Asian ethnicity (93%). Despite the ethnic skewing toward Asian ethnicity, the self-identified cultural identity of the sample was still 57% American, indicating that more than half of the participants identify culturally as American despite having Asian ancestry. Of note, a definition of American culture was not given to participants and thus it was left up to individual participants to define this term prior to making their selection. These demographic findings may be unique to Hawai‘i, where the general population census data for one race identifiers is 25% White and 38.3% Asian, and certain findings discussed later may be due to this increased diversity.⁹

Pre-Class Assessment of Self-Privilege

Non-medical literature abounds with references to white male privilege,^10–13 which is consistent with our observation that male medical students have an increased self-assessed privilege compared to their female peers, although not statistically significant in this study. Of note, due to the lack of white participants in our study, no conclusion can be drawn regarding white male medical student privilege compared to others at this time. A power calculation suggests that approximately one half of a JABSOM class, 33 students, would be suitable for results that would potentially be statistically significant for this exercise. If the finding is that both male and female medical students are really not significantly different in regard to privilege, this would go against the non-medical student literature regarding gender privilege and could open up an entirely new area of study.

Pre- and Post-Class Privilege Perspective

We assessed whether the class was successful in changing the perspective of medical students on their own personal privileges. The anticipated learning point was that medical students would begin the class with a lower self-assessed privilege and after attending the class, would leave the class with a higher self-assessed privilege. There was an increase in privilege perspective on the post-class survey for all of the characteristics listed except for hair color. A possible explanation for this particular lack of change in privilege perspective is that since the majority of the participants are of Asian ancestry, having brown or black natural hair color, there was no change in perspective due to an already low assessed privilege due to their hair color. The purpose of this particular question was to ascertain whether light haired people felt that they had a privilege over others, as seems to be the case in non-medical literature that details white privilege. The lack of change may be the result of the diverse demographics of Hawai‘i and the medical school community, or because this particular trait was not covered in sufficient detail during the class session.¹² To determine whether this lack of privilege perspective change is due to the curriculum used or to the demographics of the participants a larger class and survey size would need to be used.

We ascertained the overall change in privilege for each participant. Only three of the participants showed a greater than 15UC positive difference in privilege perspective due to the class, the single Caucasian participant and the only two Korean participants. Due to the lack of educational material regarding non-white privilege, such as Japanese, Korean, and Chinese privilege, a novel culturally validated privilege curriculum needs to be established to make the material more relevant to students from various ethnic and cultural backgrounds. Once established, this curriculum would ideally result in a greater change in privilege perspective between the pre- and post-class surveys, as the material would more broadly relate to students from various backgrounds.

Three of the medical students had a negative difference in privilege perspective following the class, with two of these participants having a greater than -15UC difference. A possible explanation for this finding is that these three participants came into the class with a higher self-assessed privilege value than those of the other participants. The class session, rather than making the participants more aware of their self-privileges, seems to have made them aware that those characteristics they had thought gave them more privilege than others, in fact, do not. This may be due to students who enrolled in the Social Justice in Health elective having prior knowledge of their own self-privileges. To determine whether this is a finding unique to the elective students the surveys and a class on privilege need to be offered to all medical students as part of the normal curriculum.

In order to determine whether the single class session results in a long-term change in privilege perspective for the medical students a future survey of the participants in this initial study will need to be conducted. The goal of the authors is to create a survey instrument that can assess whether the current participants retain their changed perspective at the time of graduation. Since the current participants were either MS1s or MS2s, the future study would take place two years later for the current MS2s and three years later for the current MS1s. It is the hope of the authors that the future study will find that the single class session on privilege does result in long-term changes in privilege perspective; however, this result will not be known for quite a number of years.

Limitations

The small sample size and the imbalance of male and female participants are the primary limitations of this study. The survey instrument was not specific to the population served, as JABSOM has a more multi-cultural student population than do schools elsewhere in the United States. Paul Kivel's walk exercise was developed to examine class and race in the context of a more homogenous Caucasian population, thus the use of this instrument to determine individual participant's privilege amount is not ideal in this diverse population. To the authors' knowledge no culturally and ethnically diverse and validated survey instrument exists at this time and such an instrument is needed to assess more accurately privilege amount in future studies. As noted, the limited research conducted so far focuses on white male privilege, with no studies to date of privilege in multi-ethnic settings such as Hawai‘i. Likewise, available educational material focuses on white male privilege, and so is less relevant to students in Hawai‘i. Due to the small size of the class, we could match pre- and post-survey results with the same participant; however, in a larger setting, a new means of linking survey results would be needed.

Conclusion

Although it was expected that the class session would improve medical students' perspective on their own privileges, it was found that in certain cases the class session may have decreased their self-assessed privilege. This single class session on privilege was sufficient to change medical students' perspectives on their own personal privilege, in ways that can only be further elucidated through the establishment of a more culturally validated privilege curriculum, surveying a greater number of medical students, and in conducting follow-up surveys later in the students' medical school careers to see if the class affected their perspective in the long term. Future research to correlate medical students' degree of privilege and rates of graduation and practice choices would also complement this study well. By incorporating a single class session on privilege into the general medical school curriculum, medical schools could change the perspective of medical students on their own personal privilege and provide a more thorough understanding of privilege as a social determinant of health. Therefore, the authors recommend that medical schools supplement their required educational curriculum on the social determinants of health with a session on privilege so that their students can develop a better understanding of their own privilege and the privilege of their patients, which may enable them to pursue equitable health care to their future patients.

Appendix I. Survey Instrument

Pre- and post-surveys are the same, except for removal of Paul Kivel's walk exercise questions (6–41) and inclusion of course evaluation questions in the post-class survey (not shown).

1. Age

2. Gender

3. The ethnicity you most identify with?

4. The culture you most identify with?

5. For each of the following characteristics, please rate on a scale of 1 to 10 how they have given you privilege over others:

   1. Skin Color
   2. Hair Color
   3. Cultural Identity
   4. Sexual Orientation
   5. Gender
   6. Disability Status
   7. Mother's Profession
   8. Father's Profession
   9. Home Location
   10. High School Attended
   11. College Attended

6. Were your ancestors forced to come to this country or forced to relocate from where they were living permanently?

7. Were your ancestors restricted from living in certain areas?

8. Would you identify your primary ethnicity to be “American?”

9. Were you ever called names or ridiculed because of your:

   1. Race
   2. Ethnicity
   3. Class Background
   4. Cultural Identity

10. Did you grow up with people of color or working class people who were servants, maids, gardeners, or babysitters in your house?

11. Were you ever embarrassed or ashamed of your clothes, your house, or your family when growing up?

12. Are any members of your immediate family doctors, lawyers, or other professionals?

13. Are pimping and prostitution, drugs, or other illegal activities major occupational alternatives in the community where you were raised?

14. Have you ever tried to change your physical appearance, mannerisms, language, or behavior to avoid being judged or ridiculed?

15. Did you study the history and culture of your ethnic ancestors in elementary and/or secondary school?

16. Did you start school speaking a language other than English?

17. Did your family have more than 50 books in the house when you were growing up?

18. Did you ever skip a meal or go away hungry from a meal because there wasn't enough money to buy food in your family?

19. Were one of your parents ever laid off, unemployed, or underemployed not by choice?

20. Have you ever attended a private school or summer camp?

21. Have you ever received less encouragement in academics or sports from your family or from teachers because of your gender?

22. Did you or your family ever have to move because there wasn't enough money to pay rent?

23. Were you told by your parents that you were beautiful, smart, and capable of achieving your dreams?

24. Were you ever discouraged or prevented from pursuing academic or work goals, or tracked into a lower level because of your race, class, or ethnicity?

25. Did your parents encourage you to go to college?

26. Did you grow up in a single parent household?

27. Did you take a vacation outside of your home state prior to your 18th birthday?

28. Did both of your parents complete high school?

29. Do your parents own their house?

30. Do you commonly see people of your race or ethnicity on television or in the movies in roles that you consider to be degrading?

31. Have you ever got a good paying job or a promotion because of a friend or family member?

32. Have you ever been denied a job/position because of your race or ethnicity?

33. Have you ever been mistrusted or accused of stealing, cheating, or lying because of your race, ethnicity, or class?

34. Have you ever inherited, or are going to inherit, money or property?

35. Do you primarily use public transportation to get where you need to go?

36. Do you generally think of the police as people that you can call for help in times of emergencies?

37. Have you ever felt afraid of violence directed toward you because of your race?

38. In general, are you able to avoid communities or places that you consider dangerous?

39. Have you ever felt uncomfortable or angry about a remark or joke made about your race or ethnicity but didn't feel it was safe to confront it?

40. Have you or close friends or family ever been a victim of violence because of your race or ethnicity?

41. Were your parents raised outside of the United States?

Conflict of Interest Statement

We certify that we have no financial affiliation/interest (eg, employment, stock holdings, consultantships, honoraria) in the subject matter, materials, or products mentioned in this manuscript. Neither of the authors of this article have any conflict of interest to report, nor any interests represented with any products discussed or implied.