Using comics to integrate the social determinants of health in dental education

In November 2023, the World Health Organization (WHO) produced a report1 entitled "Integrating the social determinants of health into health workforce education and training." It urged academic institutions and educators to reform curricula and make "action on the social determinants of health a key part of the role and responsibilities" of all health workers. This idea had already surfaced in dentistry with an innovative biopsychosocial approach, the Montreal–Toulouse Model (MTM).2 The MTM aims at guiding oral health professionals to provide person-centered care and address the social determinants of health (Figure 1). It presents "three types of tasks (understanding, decision-making, and intervening) that dentists should take in each of three overlapping levels (individual, community, and society)."2 Traditional educational methods, however, with learners considered as passive recipients of knowledge, are insufficient to help them adopt biopsychosocial approaches,3 which for many constitute a paradigmatic change. For this, academia needs to adopt or develop educational methodologies and tools more adapted to these important challenges.1, 3 McGill Faculty of Dental Medicine and Oral Health Sciences developed a two-credit graduate course (26 hours in class) to support oral health professionals' adoption of the MTM model. More specifically, our objective was to foster their ability to provide person-centered care and address the social determinants of health. To overcome the limitations of traditional educational methods, we adopted a transformative learning methodology, in which students engage in a process of reflection, questioning, and perspective shifting.4 To support this process, which emphasizes on critical thinking and students' active participation, we used an original tool: comics. Stories with text and pictures, comics constitute a powerful medium to convey emotions and describe complex phenomena such as the interplay between health and people's conditions of life. Green5 considers that "comics provide students the freedom to reflect honestly (and safely) about the forces that shape their emerging professional identities." We asked students to read and critically reflect on a selection of comic books addressing, directly or indirectly, various aspects of the MTM (Table 1), before discussing them in the class. In parallel, we invited them to write weekly reflections in which they described their personal development process. Students also received training on how to create comics, before producing a short comic related to the themes of the MTM in lieu of a final essay. The assessment of students' learning was thus formative. Welcome to the Graphic Medicine Manifesto, in MK Czerwiec et al. Graphic Medicine Manifesto. Penn State University Press; 2015. The Graphic Medicine Manifesto explains how comics can be used in health education. Bedos C, Vergnes JN, Apelian N. Towards a biopsychosocial approach in dentistry: the Montreal–Toulouse Model. Br Dent J. 2020;228(6):465–468. This scientific article presents the Montreal–Toulouse Model, which will be soon freely available in a comic book format. Cunningham D. Psychiatric Tales. Bloomsbury USA; 2011 Cunningham presents several stories based on his personal experience working as a mental health nurse on a psychiatric ward. Small D. Stiches: A Memoir. W. W. Norton 2009. Small describes his experience of cancer during childhood and his long journey toward recovery. Bagge P. Woman Rebel. The Margaret Sanger Story. Drawn 2013. Bagge presents the long and controversial life of Margaret Sanger, a nurse and activist who fought to legalize birth control in the United States. Satrapi M. (The complete) Persepolis. Pantheon; 2007. Satrapi depicts the course of her life following the Iranian Islamic revolution in 1979. Leavitt S. Tangles. Alzheimer's, My Mother, and Me. Skyhorse Publishing; 2012. Leavitt describes the last years of her mother's life, a Nova Scotia (Canada) teacher diagnosed with Alzheimer at age 55. Chast R. Can't We Talk About Something More Pleasant? Bloomsbury USA; 2014. Chast tells the story of her aging parents, describing their growing difficulties to live alone before moving into an assisted-living home. Bell C. El Deafo. Amulet Books; 2014. Bell chronicles her hearing loss at a young age after being affected by a meningitis, sharing her experiences of being deaf. Optional: McCloud S. Making Comics: Storytelling Secrets of Comics, Manga, and Graphic Novels. HarperCollins Publishers; 2006. Scott McCloud wrote this comic book to comprehensively explain how to analyze and make comics. Robertson DA, illustrated by Henderson SB. 7 Generations: A Plains Cree Saga. Highwater Press; 2015. 7 Generations: A Plains Cree Saga follows an Aboriginal family over seven generations, from the early 19th century to the present day. Jimmy Beaulieu, Luc Bossé, Pascal Girard, Michel Hellman, Iris, and Louis Rémillard, in partnership with Christophe Bedos, Alissa Levine, Sophie Dupéré, and the Collectif pour un Quebec sans pauvreté. Défavorisés: des Histoires d'Aide Sociale. Five Quebec artists, in partnership with a team of researchers and antipoverty activists, tell short stories about poverty, exclusion, and health. Lewis J, Aydin A, art by Powell N. March (Trilogy). Top Shelf Productions; 2016. This biography of John Lewis, a leader of the Civil Rights movement, depicts the struggle against segregation in the 1950s and 1960s. Students explained that comics, with their vivid storytelling and imagery, made the concepts described in the course tangible and engaging. It opened new perspectives for them, extending beyond theory to practical application. Compared to more conventional approaches, comics illuminated the various aspects of the MTM, allowing students to relate it to their own experiences in a meaningful way. They also discovered that creating comics, although challenging, was an enriching process that allowed them, especially when their comic included autobiographic elements, to better understand themselves and the social determinants of health through lived personal experiences. Figure 2 illustrates how Newsha Toreihi, former student and coauthor of this article, reflected on her own experience when discovering that her 8-year-old patient was selling flowers in the streets instead of attending school. Overall, the students experienced some degree of transformation in their professional identity and considered biopsychosocial approaches and upstream actions positively. Even though they still need to be rigorously evaluated, transformative methodologies using comics constitute promising ways to train oral health professionals about biopsychosocial approaches. Future work is intended to connect the ideas presented in this paper with specific learning outcomes, including students' ability to address patients' social determinants of health, and engage in upstream activities at the community and societal levels. The authors would like to thank the Canadian institutes of health research, the Fonds de recherche du Québec - santé (FRQS), the Réseau Québécois de recherche intersectorielle en santé buccodentaire et osseuse durable (RiSBOd). They also express their gratitude to Dr. Daniel Ha, a talented artist and dental care provider.