The present study investigated the understanding of social determinants of health (SDH) among final-year medical students from three Italian universities (Florence, Milan, and Naples). Data were derived from interviews, integrating quantitative findings with qualitative thematic insights.

General understanding of SDH

Most students demonstrated a basic awareness of SDH, although definitions often required prompting. A small minority articulated a comprehensive understanding, while the majority recognized the existence of both proximal and distal determinants influencing health outcomes.

Across universities, comprehension levels were similar. In Florence and Naples, students were equally divided between those needing prompting and those showing general understanding. In Milan, a greater proportion required assistance, though a few demonstrated more advanced conceptual knowledge.

Social determinants recalled by participants

Students identified a broad range of determinants, grouped into macro-categories:

Economic conditions (income inequality, employment, economic status)—22 mentions

Physical environment (housing quality, air and water safety, exposure to hazards)—22 mentions

Education—14 mentions

Lifestyle and behaviors (physical activity, smoking, alcohol consumption)—13 mentions

Biological/genetic factors—13 mentions

Nutrition—9 mentions

Social environment (community support, family role, discrimination)—8 mentions

Access to healthcare—7 mentions

Some students also mentioned non-traditional factors, including age (6), sex (4), chronic health conditions (2), and life expectancy (2). Although not typically classified as SDH, these factors were perceived as indirectly influencing health through social, economic, and environmental interactions.

Perceived impact of SDH on health

Students highlighted the influence of low socioeconomic and social status on health, associating it with poorer living conditions and higher exposure to disease risk. Common examples included respiratory infections related to pollution, unsafe housing, and smoking, as well as benefits of balanced diet and physical activity.

Regional variations were observed

University of Florence: emphasis on poverty and environmental health risks

Humanitas University: focus on hygiene and smoking behaviors

Naples: broader understanding of SDH as multifactorial contributors to health inequality

Most important determinant

Overall, 27% of respondents identified socioeconomic status as the primary determinant, 24% cited education or diet, 13% housing, and 7% access to potable water or quality healthcare services.

Regional trends showed:

University of Florence: 40% education, 40% socioeconomic status, 20% diet

Humanitas University: 30% socioeconomic status, 30% housing, 20% access to healthcare, 20% education

University of Naples Federico II: 50% diet, 20% access to potable water, 10% each for education, socioeconomic status, and housing

Students associating health with socioeconomic status emphasized unequal access to medical services and its influence on other determinants. Those prioritizing education noted its role in symptom recognition, preventive behavior, and informed decision-making. Diet was valued for chronic disease prevention and management, while housing and clean water were recognized for infection prevention.

Policy awareness and investment in SDH

Overall, students demonstrated limited awareness of national investments in SDH. Fifty-three percent believed investments were insufficient, 36.7% responded affirmatively but expressed skepticism about fund utilization, and 10% were unsure.

By region:

University of Florence: 20% affirmative, 50% negative, 30% unsure

Humanitas University: 20% affirmative (all skeptical of effectiveness), 80% negative

University of Naples Federico II: 70% affirmative (43% skeptical), 30% negative

Half of the respondents were aware of at least one national campaign addressing SDH, commonly anti-smoking or cancer screening initiatives. A minority mentioned vaccination campaigns or activities linked to the National Recovery and Resilience Plan (PNRR).

Regarding healthcare funding, 43% believed hospitals received preferential investment, 37% disagreed, and 20% were uncertain. Milan students most frequently perceived hospital funding as dominant, while Florence students were evenly divided.

Education and awareness of SDH in medical curricula

Sixty-seven percent reported insufficient SDH coverage in medical education. Affirmative responses (30%) were mainly from Florence, and 3% were unsure.

Eighty percent attended at least one lecture addressing SDH, often indirectly via public health or occupational medicine courses:

University of Florence—90%

Humanitas University—70%

University of Naples Federico II—80%

Over 93% considered medical doctors responsible for advocating SDH, recognizing their authority and influence, though institutional support was deemed necessary for effective communication.

Knowledge of international health frameworks

Awareness of the WHO Ottawa Charter (1986) was low: 70% had never heard of it, and only 12.5% of those familiar could recall its key elements. Florence students showed slightly higher awareness, while Milan and Naples had minimal exposure.

Similarly, 83% could not identify international goals, agreements, or treaties addressing SDH. Among the 17% who could, most cited environmental health campaigns, reflecting partial understanding of global health promotion efforts.