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Representation of social determinants of health in German medical education: protocol of a content analysis study

Introduction Action on the social determinants of health has been key for improving health and prolonging life in the past, and remains so today. Against this background, WHO’s Commission on Social Determinants of Health has called for increased efforts to create health workforces trained in recognising, understanding and acting on the social determinants of health. However, little is known about the extent to which current medical education systems prepare graduates for this challenge. We, therefore, aim to analyse the extent to which the medical curriculum in Germany incorporates content on the social determinants of health. Methods and analysis We will conduct a qualitative and quantitative content analysis of four key document groups which influence medical education in Germany: the national medical catalogue of learning objectives; examination content outlines provided by the German Institute for Medical and Pharmaceutical Examination Questions; the online textbook most widely used for final examination preparation and the full set of questions from two national medical licensing examinations. We will analyse these documents based on a coding system, which we derived deductively from the report of WHO’s Commission on Social Determinants of Health as well as other key publications of WHO. We will report quantitative indicators, such as the percentage of text related to social determinants of health for each document type. Moreover, we will conduct a semiqualitative analysis of relevant content. Ethics and dissemination This study is based on the analysis of existing documents which do not contain personal or otherwise sensitive information. Results from the study will be published in a scientific peer-reviewed journal.

The IMPP-GK2 consists of a foreword, an excerpt of the medical licensure act (Approbationsordnung für Ärzte) as well as a summarized enumeration regarding the contents of the final written exam. Afterwards follows a systematically and alphabetically ordered list of health disorders (part 1) as well as a list of clinical pictures (part 2), which are in many cases specified by examples. Those contents are not presented in a running text but as a list.
Every exam consists of 320 multiplechoice questions. Each question consists of introductory clauses which give a case description and the actual question, followed by 5 multiplechoice options. While 260 questions are not interconnected, 60 questions are part of 4 case studies. In most cases, these case studies are a longer text of 1-2 pages, which describe the case of one patient indepth and are followed by 15 questions, which focus on different aspects of the pathology, diagnostics, or therapy mentioned in the case study.
The 100-day learning plan of the online-textbook AMBOSS contains about 800 chapters (Lernkarten) (at the time we obtained permission and the complete file of chapters was provided to us as in pdf format). The contents of the chapters are oriented towards the contents of the exams. The majority of chapters relates to major clinical subjects. To a smaller quantity subjects like epidemiology, social medicine or alternative medicine are displayed. The plan intends to be studied within 100 days of preparation (85 days for studying the chapters and 15 days for repeating the studied contents and rehearsing the final exam by completing former original versions of the exams.) Since its launch in 2012 the contents of the 100-day learning plan as well as the other contents of the online-textbook have been continuously extended and adapted, for example new features like interactive videos, quiz and highlighting functions were added.

. SDH in general
The SDH are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. 1 • Societal conditions in which people are born, grow, live, work and age [1][2][3] • Reducing social and health inequities through action on SDH 2 3 • Raising awareness on SDH and health equity among health professionals 4 • Integration of equity into health systems, policies, and programs 1-3 5-7 • Visibility, monitoring and research on health inequities or SDH 1-3 6 • Addiction 8

Early childhood development and education
Early childhood development and education includes development in the physical, social-emotional, linguistic/cognitive domains in the period from prenatal development to eight years of age. It refers to the environmental conditions (socioeconomic, socio-cultural as well as physical) to which children are exposed in the earliest years that sculpt the developing of the brain and are determinants of health, well-being, and learning skills across the life course. It includes factors and institutions (e.g. the health care system) that affect child health and survival, but goes beyond these to consider how the early years can be used to foster basic learning, school success, economic participation and health to create thriving global citizens. 1 The second aspect of early childhood development and education includes the important issue of education, specifically primary and secondary education. Here, we will expand this criterion to adolescence as well.
• Education especially in critical period of early childhood development (incl. universal availability, accessibility, quality, equity in outcomes and access) 1-3 6 7 9 • Supporting, nurturing, caring, and responsive living environments for children 1 9 • Health care from pre-pregnancy, through pregnancy and childbirth, to the early years of life 1 • Aspects of physical, social/emotional and language/cognitive development of children 1

Living conditions
Living conditions include the physical built or natural environment to which people are exposed to and in which they conduct decisions on health-related behaviour. They include shaping factors, economic and social policy responses as well as regulatory control, which influence these environments. 1 • Housing including availability, cost, safety and quality of adequate housing 1-3 10 • Waste management & disposal 10 • Sustainable, reliable and affordable energy supply 10 11 • Transportation (infrastructure, incl. safety, accessibility, sustainability) 1 7 10 12 13 • Water and Sanitation 1 9 10 • Food environments 1 7 9 10 • Physical activity environments 1 10 • Availability and accessibility of parks, open spaces and recreational facilities 1 9 10 • Climate change and health 1 10 13 • House-hold and ambient air-pollution 1 10 • Liveable and secure communities and livelihoods (incl. violence, crime and accidents) 1 13

Employment and work
Employment and work focuses on employment (unemployment, precarious work, informal work, child labour, job insecurity) and working conditions (exposure to health hazards, stress and risk of injury) and their effects on individual and public health. It includes shaping factors, economic and social policy responses, regulatory control on national and supranational level as well as economic and social development strategies, which may impact employment and working conditions. 1 • Employment status and health (incl. unemployment, precarious work, informal work, temporary work, child labour, and slavery/bonded labour) 1-3 7 • Working conditions (incl. work related accidents, exposures, stress) 1-3 • Further education (beyond secondary education) 2 7 9

Social protection
Social protection is part of a country's or communities' broader social policy framework, which encompasses all policies, institutions and interventions to help people to effectively participate in society provided by public and private providers. It is aimed at reducing and eliminating economic and social vulnerabilities to poverty and deprivation, helping people escape poverty and to protect vulnerable populations from events beyond their control. 1 14 • Social protection schemes or institutions to prevent poverty and low living standards 1 7 14 • Protection in working life (incl. in case of illness induced absenteeism, disability and work related accidents, rehabilitation and retraining schemes) 1 • Social and legislative protection for vulnerable populations (e.g. single mothers) 1 6 7 14 • Social support 14

Universal health coverage
Universal health coverage refers to the availability, accessibility and acceptability of the promotive, preventive, curative, rehabilitative and palliative health services by everyone who needs them. Universal health coverage also encompasses that these health services need to be of sufficient medical and scientific quality to be effective, do not expose the user to financial hardship and are not blocked due to discriminatory regulation or institutions. 1 5 • Availability, accessibility, acceptability of health services (incl. health education, early detection, treatment, rehabilitation and palliative services) 1 3 5 6 • Sufficient medical and scientific quality of health services 1 6 7. Health in all policies "Health in All Policies" is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being." 1 15 • Intersectoral action for health and health equity 1-3 6 16 17 • Health in all policies as essential approach for enhancing fairness, justice and inclusiveness in societies 17 18 • Influences on health determinants outside the health sector 1 17-19

Health financing
Health financing is broaching the issue of different finance mechanisms funding public services and health as a common good, explaining the connections between poverty and health, the relation between economic development and health and discussing public and private finance mechanisms for health services. It includes aspects of affordability, individual and household expenditure for health and the budget impact of disease on individuals and societies.
• Affordability, out-of-pocket spending and protection against financial-risk including health insurance schemes 1-3 5 6 14

Role of markets
Broaching the issue of the responsibility of markets influencing public health on a grand scale, discussing pros and cons of market influences and possible global governance mechanisms to regulate markets in terms of unhealthy goods. 1 • Health conditions related to (international) trade rules 1 • Health benefits due to health technologies, goods and services 1 • Commercialization of health care 1

Nondiscrimination
The code non-discrimination refers to "any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status, sexual orientation and civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health." 5 • Vulnerable groups and non-discrimination 1-3 • Attention to gender-related inequities and discrimination 1-3 6 • Social disadvantage 20

Political empowerment
Political empowerment aims to promote and enhance inclusive and transparent decision-making, implementation and accountability for health and health governance at all levels, including through enhancing access to information, access to justice and public participation. Political empowerment focuses on the empowerment of the role of communities and the strengthening of civil society. Aspects of empowerment and the promotion of inclusive and transparent governance approaches includes the safeguarding against conflict of interests. 1 2 • Transparency of, participation of civil society in, and participation of vulnerable groups in policy making and public health decision making on determinants of health 1-3 6

Global governance
Global governance encompasses the role of international and supranational protagonists (such as WHO), institutions and regulations in the action on global health, social determinants of health and health inequities. 1 2 • Action by the WHO and the international community to protect population health from harmful products, environments as well as trade and lending agreements 1-3 6 • Funding for action on SDH provided by the WHO and the international community 2 3 • Action to improve participation of developing countries in global decision-making 6 • Foster North-South and South-South cooperation for integrated action on health inequities 14

Explicit
To be used for passages which mention SDH explicitly (e.g. by discussing the intention of a social protection policy to prevent poverty) opposed to an implicit mentioning of an SDH (e.g. by mentioning or discussing the existing of health insurance in Germany)

Socioeconomic status and health
To be used for passages in which socioeconomic status or related descriptors (income, occupation or education status) are discussed or mentioned in the context of health status or health outcome (e.g. low socioeconomic status as a risk factor for disease). This category is also aimed to capture passages, in which health inequities (avoidable inequalities in heath rooted in social or economic circumstances) are discussed (e.g. heterogeneity in health status across the society).
• Social gradient attributable to inequities regarding financial resources 1 21  Which part of the text should be coded?

General Coding Guidelines
In running text, any phrase, which contains a reference to SDH, should be coded as a whole, even if not all aspects of the sentence are exclusively focused on SDH. Clauses separated by semicolon from the main phrase are considered separate sentences, and can be coded separately from the main phrase. In enumerations, only those bullet points, which refer to SDH, should be coded. In this specific case, coding of separate words is acceptable.

Frequent occurrences
Description A passage does only refer to SDH if the context is taken into account.
Passages should be interpreted in their broader context, if a context is presented. If the context of a specific passage, or a reference to another part of the text contained in this passage, makes it likely and plausible that the passage refers to SDH it should be coded as such, even if the passage considered in isolation might not refer explicitly and unequivocally to SDH. The wording or context allows for various interpretations, some of them pertaining to SDH and others do not.
If the interpretation pertaining to SDH seems reasonably plausible, this should be coded. E.g. there is no distinction in German language between the English expressions "sex" and "gender". The German word "Geschlecht" can therefore be interpreted as mainly related to biological issues (which would not be coded) or social issues (which would be coded). The wording or context allows for various interpretations, some of them pertaining one SDH category and others another SDH category.
If the interpretations pertaining to SDH categories seems reasonably plausible, both categories should be applied (see Table 5: Specific rules for double coding).
A passage mentions conditions which are influenced by SDH, but which do not mention or discuss this influence implicitly or explicitly.
The mere fact that a condition is, based on the knowledge of the study authors, influenced by SDH, does not alone suffice to justify coding. To justify coding, the fact that it is influenced by SDH must be mentioned or discussed at least implicitly in the text. A passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH category.
These passages should be double-coded: With the specific code at first (to underline this code as priority) and with "SDH in general" in addition (For exception to this rule see Table 5: Specific rules for double coding).
Passages mention individual lifestyles and health behaviours, which are related to SDH.
While lifestyles and health behaviours are almost always -at least partly -influenced by social factors, respective passages should only be coded if the social influence on the individual health behaviour or lifestyle factor in question is mentioned in the text. General guideline for double coding (see Table 9 for code-specific guidelines on double coding) A passage refers to several specific SDH (e.g. working conditions and gender equity or health-in-all-policies and living conditions).
In this case, the passages should be double-coded.

General coding guidelines
Specific coding guidelines for the document type NKLM Which part of the text should be coded? In running text, any phrase which contains a reference to SDH should be coded as a whole, even if not all aspects of the sentence are exclusively focused on SDH.
In the NKLM split sentences that span different levels (X.1 competencies, X.1.1 sub-competencies, and X.1.1.1 learning objectives) should be treated as separate sentences. If only one level contains information, only this part of the sentence should be coded. In this specific case, coding of incomplete sentences is acceptable.
Clauses separated by semicolon from the main phrase are considered separate sentences, and can be coded separately from the main phrase. In enumerations, only those bullet points, which refer to SDH, should be coded. In this specific case, coding of separate words is acceptable.

Frequent occurrences Description A passage does only refer to SDH if the context is taken into account
Passages should be interpreted in their broader context. If the context of a specific passage, or a reference to another part of the text contained in this passage, makes it likely and plausible that the passage refers to SDH it should be coded as such, even if the passage considered in isolation might not refer explicitly and unequivocally to SDH.
Examples should be used to interpret the respective learning goal or competency. If at least one of the examples is pertaining to SDH, both this example and the respective learning goal or competency should be coded (even if the learning goal or competency considered in isolation does not refer explicitly to SDH).
This rule does not apply in cases in which an example seems obviously unrelated to the respective learning goal or competency. In this case, only the example should be coded. The wording or context allows for various interpretations, some of them pertaining to SDH and others do not.
If the interpretation pertaining to SDH seems reasonably plausible, this should be coded. E.g. there is no distinction in German language between the English expressions "sex" and "gender". The German word "Geschlecht" can therefore be interpreted as mainly related to biological issues (which would not be coded) or social issues (which would be coded). The wording or context allows for various interpretations, some of them pertaining one SDH category and others another SDH category.
If the interpretations pertaining to SDH categories seems reasonably plausible, both categories should be applied.

Frequent occurrences
Description Text mention conditions which are influenced by SDH, but which do not mention or discuss this influence implicitly or explicitly.
The mere fact that a condition is, based on the knowledge of the study authors, influenced by SDH, does not alone suffice to justify coding. To justify coding, the fact that it is influenced by SDH must be mentioned or discussed at least implicitly in the text.
A passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH category.
These passages should be double-coded: With the specific code at first (to underline this code as priority) and with "1. SDH in general" in addition. (Exception to the rule: No double coding with code "1. SDH in general") Passages mention individual lifestyles and health behaviours, which are related to SDH.
While lifestyles and health behaviours are almost always -at least partly -influenced by social factors, respective passages should only be coded if the social influence on the individual health behaviour or lifestyle factor in question is mentioned in the text. General guideline for double coding (see Table 9 for code-specific guidelines on double coding) A passage refers to several specific SDH (e.g. working conditions and gender equity or health-in-all-policies and living conditions).
In this case, the passage should be double-coded.
In the case that the examples refer to several distinct SDH, they should be coded with their specific code, while the respective learning goal or competency should be coded with the code "1. SDH in general" (unless the learning goal is sufficiently specific to allow for a specific SDH code). General coding guidelines Specific coding guidelines for the document type IMPP-GK2 Which part of the text should be coded? In running text, any phrase which contains a reference to SDH should be coded as a whole, even if not all aspects of the sentence are exclusively focused on SDH.
The IMPP-GK2 consists of foreword, an excerpt of the medical licensure act (Approbationsordnung für Ärzte) as well as a summarized enumeration regarding the contents of the final written exam. Afterwards follows a systematically and alphabetically ordered list of health disorders (part 1) as well as a list of clinical pictures (part 2), which are in many cases specified by examples. Those contents are not presented in a running text but in a list of terms of diseases, sometimes added by examples but with no further explanation or context.
Clauses separated by semicolon from the main phrase are considered separate sentences, and can be coded separately from the main phrase. In enumerations, only those bullet points which refer to SDH should be coded. In this specific case, coding of separate words is acceptable.

Frequent occurrences
Description A passage does only refer to SDH if the context is taken into account.
Passages should be interpreted in their broader context. If the context of a specific passage, or a reference to another part of the text contained in this passage, makes it likely and plausible that the passage refers to SDH it should be coded as such, even if the passage considered in isolation might not refer explicitly and unequivocally to SDH.
As the IMPP-GK2 is, excluded the running text and enumeration before part 1 and 2, a list of single terms, sometimes specified with examples, but not presented with explanation, it is not possible to interpret those in a broader context.
The wording or context allows for various interpretations, some of them pertaining to SDH and others do not.
If the interpretation pertaining to SDH seems reasonably plausible, this should be coded. E.g. there is no distinction in German language between the English expressions "sex" and "gender". The German word "Geschlecht" can therefore be interpreted as mainly related to biological issues (which would not be coded) or social issues (which would be coded). The wording or context allows for various interpretations, some of them pertaining one SDH category and others another SDH category.
If the interpretations pertaining to SDH categories seems reasonably plausible, both categories should be applied.

Frequent occurrences
Description Text mention conditions which are influenced by SDH, but which do not mention or discuss this influence implicitly or explicitly.
The mere fact that a condition is, based on the knowledge of the study authors, influenced by SDH, does not alone suffice to justify coding. To justify coding, the fact that it is influenced by SDH must be mentioned or discussed at least implicitly in the text.
As there is no discussion of the health disorders and clinical pictures presented a relation to SDH can not be expressed by discussion but either has to belong to the item of the list itself or has to refer to it explicitly or implicitly.
A passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH category.
These passages should be double-coded: With the specific code at first (to underline this code as priority) and with "1. SDH in general" in addition. (Exception to the rule: No double coding with code "1. SDH in general".) Passages mention individual lifestyles and health behaviours, which are related to SDH.
While lifestyles and health behaviours are almost always -at least partly -influenced by social factors, respective passages should only be coded if the social influence on the individual health behaviour or lifestyle factor in question is mentioned in the text. General guideline for double coding (see Table 9 for code-specific guidelines on double coding) A passage refers to several specific SDH (e.g. working conditions and gender equity or health-in-allpolicies and living conditions).
In this case, the passage should be double-coded. In running text, any phrase which contains a reference to SDH should be coded as a whole, even if not all aspects of the sentence are exclusively focused on SDH.
Only those sentences of the introductory clauses should be coded, which are implicitly or explicitly related to SDH. The question and its multiple-choice options should be treated as one entity and thus its contents should be taken into account mutually.
Clauses separated by semicolon from the main phrase are considered separate sentences, and can be coded separately from the main phrase. In enumerations, only those bullet points, which refer to SDH, should be coded. In this specific case, coding of separate words is acceptable.

Frequent occurrences Description A passage does only refer to SDH if the context is taken into account
Passages should be interpreted in their broader context. If the context of a specific passage, or a reference to another part of the text contained in this passage, makes it likely and plausible that the passage refers to SDH it should be coded as such, even if the passage considered in isolation might not refer explicitly and unequivocally to SDH.
The broader context of the multiple-choice questions is its introductory clause or the running text of the case studies, presenting a context and background information in which the multiple-choice questions should be answered.
The wording or context allows for various interpretations, some of them pertaining to SDH and others do not.
If the interpretation pertaining to SDH seems reasonably plausible, this should be coded. E.g. there is no distinction in German language between the English expressions "sex" and "gender". The German word "Geschlecht" can therefore be interpreted as mainly related to biological issues (which would not be coded) or social issues (which would be coded). The wording or context allows for various interpretations, some of them pertaining one SDH category and others another SDH category.
If the interpretations pertaining to SDH categories seems reasonably plausible, both categories should be applied.

Frequent occurrences
Description Text mention conditions which are influenced by SDH, but which do not mention or discuss this influence implicitly or explicitly.
The mere fact that a condition is, based on the knowledge of the study authors, influenced by SDH, does not alone suffice to justify coding. To justify coding, the fact that it is influenced by SDH must be mentioned or discussed at least implicitly in the text. A passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH category.
These passages should be double-coded: With the specific code at first (to underline this code as priority) and with "1. SDH in general" in addition. (Exception to the rule: No double coding with code "1. SDH in general) Passages mention individual lifestyles and health behaviours, which are related to SDH.
While lifestyles and health behaviours are almost alwaysat least partly -influenced by social factors, respective passages should only be coded if the social influence on the individual health behaviour or lifestyle factor in question is mentioned in the text. General guideline for double coding (see Table 9 for code-specific guidelines on double coding) A passage refers to several specific SDH (e.g. working conditions and gender equity or health-in-allpolicies and living conditions).
In this case, the passage should be double-coded.

General coding guidelines
Specific coding guidelines for the document type AMBOSS Which part of the text should be coded? In running text, any phrase which contains a reference to SDH should be coded as a whole, even if not all aspects of the sentence are exclusively focused on SDH.
The chapters consist of a headline, an abstract as well as a running text and enumeration of bullet points, all presented in a certain sequence (e.g. epidemiology, aetiology, classification…). All of those parts should be coded if it contains a reference to SDH. Links, videos or other added features will not be taken into account, as they are not part of the actual presented text.
Clauses separated by semicolon from the main phrase are considered separate sentences, and can be coded separately from the main phrase. In enumerations, only those bullet points which refer to SDH should be coded. In this specific case, coding of separate words is acceptable.

Frequent occurrences
Description A passage does only refer to SDH if the context is taken into account.
Passages should be interpreted in their broader context. If the context of a specific passage, or a reference to another part of the text contained in this passage, makes it likely and plausible that the passage refers to SDH it should be coded as such, even if the passage considered in isolation might not refer explicitly and unequivocally to SDH.
Listed terms and bullet points will only be coded if the presented context, such as the headline or further presented information.
The wording or context allows for various interpretations, some of them pertaining to SDH and others do not.
If the interpretation pertaining to SDH seems reasonably plausible, this should be coded. E.g. there is no distinction in German language between the English expressions "sex" and "gender". The German word "Geschlecht" can therefore be interpreted as mainly related to biological issues (which would not be coded) or social issues (which would be coded). The wording or context allows for various interpretations, some of them pertaining one SDH category and others another SDH category.
If the interpretations pertaining to SDH categories seems reasonably plausible, both categories should be applied.

Frequent occurrences
Description Text mention conditions which are influenced by SDH, but which do not mention or discuss this influence implicitly or explicitly.
The mere fact that a condition is, based on the knowledge of the study authors, influenced by SDH, does not alone suffice to justify coding. To justify coding, the fact that it is influenced by SDH must be mentioned or discussed at least implicitly in the text. A passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH category.
These passages should be double-coded: With the specific code at first (to underline this code as priority) and with "1. SDH in general" in addition. (Exception to the rule: No double coding with code "1. SDH in general). Passages mention individual lifestyles and health behaviours, which are related to SDH.
While lifestyles and health behaviours are almost always -at least partly -influenced by social factors, respective passages should only be coded if the social influence on the individual health behaviour or lifestyle factor in question is mentioned in the text. General guideline for double coding (see Table 9 for code-specific guidelines on double coding) A passage refers to several specific SDH (e.g. working conditions and gender equity or health-in-allpolicies and living conditions).
In this case, the passage should be double-coded.

. SDH in general
Any passage, which mentions SDH in general terms but which cannot be linked to any of the specific categories as described below.
Code 1 should only be used if none of the more specific SDH is pertinent, i.e. it should not be double-coded in conjunction with any of the specific SDH codes. Exception: If a passage pertains to a specific SDH but its content is broader and not covered to full extent by the specific SDH it should be double-coded: With the specific code at first (to underline this code as priority) and with "1. SDH in general" in addition. The authors expect this case to be especially relevant for the analysis of the NKLM and its listed examples. For instance of the case "vaccinations" -according to this rule -the doublecoding "2. Early childhood development and education" (as first priority because most vaccinations are especially relevant in early childhood and adolescence) and "1. SDH in general" (because the relevance and use of vaccinations is not limited to the period of childhood) would be most plausible.
• Discussions of individual lifestyles and health behaviours without reference to social or otherwise SDH-relevant contextual factors, which influence these individual lifestyles, and behaviours.
• Any passage, which relates to any of the specific SDH codes (see Table 5: Specific rules for double coding).

Code Inclusion criteria Double coding Exclusion criteria 2. Early childhood development and education
• Any exogenic (or contextual) influences on early childhood development and education (ECD), which include physical, social and cognitive domains and their effect on future health. • This may include individual lifestyles and behaviours of the parents, or any other person other than the child itself, affecting the child's development, as well as any contextual condition existing in the child's environment (e.g. smoking). • This includes institutions and social services, which impact ECD (e.g. child support benefits, availability of day-care facilities for children, regulations regarding sick leave). • Access to medical services (e.g. preventive examinations. • Primary prevention of partly or primarily biomedical factors influencing the child's development (e.g. vaccinations).
• Screening for diseases, genetic or otherwise primarily biomedical factors influencing the child's development (secondary prevention; e.g. phenylketonuria diagnostics).
• Rehabilitation procedures of a child (e.g. assisting devices, special schooling) (tertiary prevention). • Passages mention the effect of a disease or condition on ECD (e.g. mumps can trigger deafness). • Passage mention the effect of a disease or condition and/or its treatment on social or economic outcomes in the far future (e.g. effects on occupational opportunities). • Passages mention behaviour of parents, caregivers or social community that may affect the ECD. • Passages mention institutions or social services aimed at improving ECD. • Passages mention social or physical environments, which may (positively or negatively) affect ECD (e.g. availability of playgrounds).
Double coding should be used, if the passage refers both to ECD as well as to a broader context of SDH. For instance in the case of "vaccinations" the double-coding "2. Early childhood development and education" (as first priority because most vaccinations are especially relevant in early childhood and adolescence) and "1. SDH in general" (because the relevance and use of vaccinations is not limited to the period of childhood) would be most plausible.
• Genetic or otherwise primarily biomedical factors influencing the child's development, without referring to a context of SDH, prevention measures, access to treatment or rehabilitation efforts. • Passages addressing the best treatment/intervention of a given disease. • Passages addressing a disease/condition, which might affect ECD (e.g. polio), but this effect is not mentioned in the text.

Code
Inclusion criteria Double coding Exclusion criteria 3. Living conditions • Any passages which directly or indirectly address the impact of physical living environments, its infrastructure (e.g. clean water and sanitation, electricity) or design on health.
• Any passage referring to housing and shelter, clean water and sanitation or electricity in regards to environmental routine, effects of urbanisation (e.g. air quality), mobility, harmful influences of the environment (e.g. noise, pollutants) (except occupational risks), environmental aspects in relation to accidents (e.g. traffic lights, road blocks, safety measures), food environments, physical activity.
• Environmental health aspects relating to the environment.
Any passage discussing how living conditions influence health outcomes, but which refer not to a "space" somehow but focus on the origin of these living conditions by mentioning market interests (code 9) or the need for or existence of public regulations of these conditions (code 7) or which are part of the occupation and workplace (code 4) should be coded elsewhere.

Employment and work
• Passages on work-related health conditions should only be coded if influences of the work and employment conditions on health are at least implicitly mentioned.
• Any passage discussing working conditions in the context of health outcomes.
• Any passage discussing employment conditions in the context of health outcomes.
• Sections discussing the occupational context of a disease (e.g. risk of losing the job; occupational reintegration).
• Risks and hazards associated with specific working or employment conditions (incl. unemployment).
• Beneficial effects of specific working or employment conditions. • Any passage discussing occupational health and safety issues.
• Any passage discussing international or national institutions (formal/informal) in regards to working or employment conditions in the context of health.
• Passages treating exclusively biomedical aspects of health conditions, which may, or may not be work-related.
• Welfare schemes, occupational insurance are to be coded with code 5, unless the code explicitly refers to the interplay of occupation and health (e.g. unemployment insurance paying for occupational reintegration after disease).

Code Inclusion criteria Double coding Exclusion criteria 5. Social protection
• Any passage which refers to a social protection system, which may affect health outcomes directly (e.g. work accident insurances).
• Any passage which mentions a social protection system, which may affect health outcomes indirectly through the prevention of poverty, financial hardship or exploitative conditions on the labour market (e.g. pension schemes, maternity leave).
• Passages discussing Maternity leave and/or child support benefits should be double-coded with code "5. Social protection" as well "2. Childhood development and education". • The codes "5: Social protection" and "6. Universal health coverage" should only be used for doublecoding if a passage pertains both to health coverage and some other form of social protection (e.g. both health coverage and unemployment benefits). Passages pertaining exclusively to health coverage (and not any other form of social protection) should only be coded with code 6.
• Passages treating exclusively health care issues should be coded only with code "6.Univeral health coverage". They should only be double-coded with code 5 if they discuss both health and non-health social services.
• Passages treating exclusively the financing of social protection structures should be coded only with code "8.Health financing".

Code
Inclusion criteria Double coding Exclusion criteria 6. Universal health coverage • Any passage that mentions Universal health coverage (UHC), explaining the different axes of the UHC dimensions and displaying the importance of UHC as part of the global 2030-agenda. 22 • Any passage that explicitly mentions the availability (or the lacking availability) of specific promotive, preventive, curative, rehabilitative and palliative health services. • Any passage that explicitly mentions the availability (or the lacking availability) of treatment options. • Any passage discussing issues of accessibility (physical, financial, informational) of health services. • Passages discussing the safety of medications or medical equipment as well as adverse events in the context of mentioning the availability (or lacking availability) of alternatives (use of high risk medications (e.g. in sleeping sickness treatment) because safer medication is not available).
• Passages discussing the safety of medications or medical equipment as well as adverse events in the context of social, cultural, economic or political institutions or conditions as a source of the safety issues or adverse events (e.g. use of insufficiently sterile equipment due to budget). • Any passage that explicitly refers to evidence-based medicine in the context of universal health coverage. • Any passage mentioning the acceptability (or nonacceptability) of health services e.g. due to socio-cultural reasons (e.g. demand to be treated by female gynaecologist). • Any passage mentioning stigma and discrimination in the context of the usage of services in the health care system. • Any passage referring to conditions or populations with a lower usage of health care. • Any passage referring to health services research. • Any passage that refers to inequality in regards to usage, access or availability of health services (e.g. due to income level, social status, or residency). • Any passage referring to inequal treatment due to differences in socio-economic status.
•Any passage that refers to inequality in the access of health services throughout differences in private and public insurance systems. • Any passage that mentions aspects of empowerment to use The codes "6. Universal health coverage" and "8. Health financing" should only be used for doublecoding if a passage discusses both financial and non-financial aspects of health coverage (e.g. passages referring to out-of-pocket spending of health services of sufficient medical and scientific quality). Passages pertaining exclusively to financial aspects of health coverage should only be coded with code 8. We are aware of the fact, that the definition of Universal health coverage is inevitably related to financial aspects. However, to ensure a clearer distinction between institutional and organizational aspects of health coverage and the financial part, we defined that all non-financial issues of health coverage will be coded with code 6, while all financial issues of health coverage will be coded with code 8.
• Passages treating exclusively the financing of health care should only be coded with code "8.Health financing". • Medical-guidelines should not be coded it they are not mentioned in a broader context related to the health system and/or evidence-based-medicine. • Passages, which only implicitly mention the availability of health, services (e.g. a passage mentioning that a person is treated in the hospital (and thereby implying that hospitals exist).
• Passages discussing the safety of medications of medical equipment as well as adverse events without mentioning the availability or lacking availability of alternatives OR social, cultural, economic or political institutions or conditions as a source of the safety issues or adverse events. • Any passage referring to out-of-pocket spending of health services which are not of sufficient evidence-based medical and scientific quality.

Code
Inclusion criteria Double coding Exclusion criteria 7. Health in all policies • In order to reduce overlap, code "7. Health in all Policies" (HiaP) will focus on intersectoral interventions not covered in any other SDH code, namely outside of health financing, employment and work and safety regulation, social protection institutions or systems. Intersectoral means that two different sectors have to be included as a minimum, e.g. the health sector, financial sector, sector of foreign affairs etc. • Any passage discussing public regulations, which require an intersectoral approach (e.g. the regulation of markets by state institutions) and which influence health outcomes (both harmful and beneficial outcomes).
• Any passage mentioning policies which are not part of the health care system but which affect health outcomes (e.g. taxation to lower smoking rates; urban planning to improve health; travel bans to spread infectious diseases). • Interventions/Legislation to reduce violence and crime.
• Passages discussing cooperation between different parts of the health system, without reference to factors located outside the health system. • Passages discussing primarily health care financing (should be coded with code 8).
• Passages discussing social protection institutions and systems (should be coded with code 5).
• Passages discussing policies regarding occupational health (should be coded with code 4).

Financing of social services
• Any passage discussing financing of social services, including health, such as health insurance fees, the financial coverage of medical treatments, the percentage of out-of-pocket payments etc.
The codes "8. Health financing" and "6. Universal health coverage" should only be used for doublecoding if a passage discusses both financial and non-financial aspects of health coverage. Passages pertaining exclusively to financial aspects of health coverage should only be coded with code 8. We are aware of the fact, that the definition of Universal health coverage is inevitably related to financial aspects. However, to ensure a clearer distinction between institutional and organizational aspects of health coverage and the financial part, we defined that all non-financial issues of health coverage will be coded with code 6, while all financial issues of health coverage will be coded with code 8.

Code
Inclusion criteria Double coding Exclusion criteria 9. Role of markets • Any passage discussing regulations of markets, which influence health outcomes on a grand scale (e.g. markets promoting the consumption of tobacco, alcohol and processed foods) and which mention the role and interests of those markets in terms of their economic and commercial interests.
• Any passage discussing health outcomes of markets settled on a macro level.
• Any passage which discusses interventions of stakeholders outside the health system to influence health outcomes (e.g. church-based food banks, Public-Private-Partnerships to develop new drugs; pledges of private-sector companies to reduce sugar content in soft drinks).
• Any passage, which refers only to Individuals as part of the economic market system in general without mentioning the health outcomes of markets on a macro level.
• Any passage discussing regulations of markets, but which do not refer explicitly or implicitly to any health outcome.
•Any passage discussing regulations of markets without mentioning explicitly or implicitly the role of markets in terms of their commercial interests (should be coded with code 7, if meeting the related definition).

Non-Discrimination
• Any passage discussing all kinds of inequity due to race, gender, national origin, religion, physical or mental disability, medical condition, pregnancy, marital status or sexual orientation religion in accordance to the right to health.
• Any passage mentioning equity or inequity due to race, gender, national origin, religion, physical or mental disability, medical condition, pregnancy, marital status or sexual orientation religion without referring to a resulting health impact.

Political empowerment
• Any passage discussing the health outcomes of political empowerment. This includes first of all political forms of empowerment, such as issues related to inclusion, personal rights and freedom, participation possibilities etc.
• Any passage discussing mainly other non-political-forms of empowerment should be coded -if reasonable -with another specific code. E.g., material forms of empowerment might be coded with code 8.

Global governance
• Passages discussing structures and mechanisms of a global governance system, which influence health outcomes.

Auxiliary codes
• Passages mentioning SDH explicitly (e.g. by discussing the intention of a social protection policy to prevent poverty) opposed to an implicit mentioning of an SDH (e.g. by mentioning or discussing the existing of health insurance in Germany).
The rules for double-coding do not apply to the auxiliary code "Explicit", which can be double-coded with any other code.

Socioeconomic status and health
• Passages discussing or mentioning socioeconomic status or related descriptors (income, occupation or education status) in the context of health status or health outcome (e.g. low socioeconomic status as a risk factor for disease).
• Passages discussing health inequities (avoidable inequalities in health rooted in social or economic circumstances) are discussed (e.g. heterogeneity in health status across the society).
The rules for double-coding do not apply to the auxiliary code "Socioeconomic status and health", which can be double-coded with any other code. research experience using qualitative methods as part of bachelor thesis in geography and dissertation in medicine.

Reflection of the analysts on their perceptions and expectations about the research topic
FH, JMS, KG and PP formulated the expectation that both the National Competency-Based Catalogue of Learning Objectives for Medicine (Nationaler Kompetenzbasierter Lernzielkatalog Medizin) (=NKLM) and the Content Catalogue for the Second Part of the Examination of Doctors, provided by the German Institute for Medical and Pharmaceutical Examination Questions (IMPP Gegenstandskatalog für den zweiten Abschnitt der ärztlichen Prüfung) (=IMPP-GK2) may contain substantial content directly or indirectly related to social determinants of health (SDH). Even when SDH are not mentioned explicitly and under specific terms, all authors suggest a certain range of contents, which can be interpreted as related to the relevant passages in the NKLM. Because of our expectation that SDH might more often be mentioned implicitly than explicitly, the auxiliary code "explicit" was created in order to highlight those passages from the main part. However, such content is expected to be virtually absent from the actual exams, and from the textbooks most commonly used by students to prepare for them. Thus, the named authors expect a crucial gap between the -at least possible interpretation of SDH mentioned in NKLM at first place -and the existence of SDH contents in the final exams and its preparation materials.
Moreover, the named authors expect a difference between SDH mentioned related to broader social structures and those merely focused on an individual lifestyle level. Only mentioning SDH isolated in the latter does not match the authors' as well as the common understanding of the term SDH, which is the one used in this study.
Furthermore, FH expects a difference between SDH mentioned mostly on a national level but rarely on a broader international and global level. However, to meet the need of a deep and comprehensive understanding of SDH global relations and structural interactions cannot be neglected -even in a national medical curriculum. JMS and SD expressed the expectation that content related to SDH is generally insufficiently represented in medical education, including all the documents used as primary sources in our research.
SD raised the possibility that conducting the study while the NKLM is being revised and reforms of the national exams are the subject of ongoing political discussions might influence the authors in drawing their conclusions based on the results of data analysis.
Moreover, all authors felt that the NKLM should meet higher standards than the actual exams and the textbooks, as it seems likely that the NKLM will be implemented only partially anyhow, e.g., that content mentioned in the NKLM will be lost during translation into practice.

Literature review
To inform our overall research design, as well as the background and discussion section we conducted a focused literature review. We used the following PubMed search syntax for the literature search: