Medical doctors play a critical role in disease prevention and health promotion, and as well as in the development of public health policy at a national or health service administration level [1]. The undergraduate level or junior years in medical education provides an important opportunity to expose future doctors to relevant public health learning [1]. Whilst the significance of incorporating public health into the medical curricula is well acknowledged, medical educators face a number of challenges [1] due to the broad scope of public health [2] and an already overcrowded medical curriculum dominated by clinical and biomedical worldviews [3,4] making it almost impossible to add public health content [3,5]. A recent systematic review on the barriers and enablers of teaching public health in undergraduate medical schools found that increasing the integration of public health into other subjects was a more viable solution to improving public health as opposed to trying to add more public health subjects [6].

The ability to conceptualize public health as part of the medical curricula is key to improving how much it is incorporated in the medical curriculum, and how well this is done [1,3]. A failure to do this well can lead to doctors who are inadequately prepared for work after graduation and can limit their preparedness for emerging public health issues such as novel communicable diseases and the changing landscape of public health in local and global settings [1]. For example, the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic required medical schools to rapidly develop students’ understanding of how control and mitigation efforts are influenced by broader health administration and societal factors, including hospital staffing constraints and capacity, vaccine hesitancy, increasing incidence of mental health issues, and the role of the social determinants of health [1,7].

In Indonesia, the government is involved in many areas of medical education, including setting the competency standards [8,9]. The medical curricula were developed based on the 2012 Indonesian Standard for Doctor Competency (Standar Kompetensi Dokter Indonesia [SKDI 2012]) [8]. Whilst some schools also refer to the Standar Nasional Pendidikan Profesi Dokter Indonesia 2019 (SNPPDI 2029), it has not yet been approved by the government. The SKDI 2012 lists 38 public health topic areas (for example maternal and child health), that can be included in teaching content [8]; however, how many and which of the 38 to include are at the discretion of each medical school, resulting in significant variation and inconsistency across the country [10]. Furthermore, the SKDI 2012 did not set any level of competency which should be achieved with the included public health topics, nor is there room to public health examination to the Objective-Structured Clinical Examination, which leads to further inconsistency across the country. Added to this, the Indonesian Medical Educator Association for Public Health, Preventive Medicine and Community Medicine (Badan Kerja Sama Bagian Ilmu Kesehatan Masyarakat - Ilmu Kedokteran Pencegahan - Ilmu Kedokteran Komunitas Fakultas Kedokteran se-Indonesia [BKS IKM IKP IKK FKI]) was not involved in the development of the SKDI 2012 or SNPPDI 2019.

Medical schools in Indonesia are either publicly or privately funded. Every 5 years, a national accreditation assesses medical schools’ performance in several areas including governance, infrastructure, academic content and research [9]. Public health teaching or its inclusion in the curriculum is not evaluated [11]. The national medical competency exam cannot serve as a tool for assessing the quality of public health teaching, as the public health component is minor, and the multiple-choice style questions are insufficient to assess public health competency [11]. As such, no adequate mechanisms are in place to ensure the content or scope within schools and across the country.

What medical educators believe about the significance of teaching a subject determines whether or not they teach it and how well [6]. However, there is very limited research in this area and previous research has focused on innovations in public health education or has medical students as participants [12,13]. The Theory of Planned Behavior (TPB) posits that human behavior is guided by three domains: attitudes, subjective norms, and perceived control [14]. The more favorable one’s attitude and subjective norms, and the greater their perceived control, the stronger their intention to perform the behavior. TPB has been frequently used to understand clinicians’ behaviors [15], and also to examine medical educators’ behaviors, including incorporating non-biomedical focused subjects into medical curricula [16,17], including qualitatively to understand teaching in higher education [18]. Therefore, the aim of this study is to explore medical educators’ perceptions about what factors contribute to their intention to teach public health in Indonesian undergraduate medical schools.

In the quantitative component of the larger study where the sample for this qualitative study is drawn from, it is unknown how many medical schools actually sent out the expression of interest to their medical educators and how many medical educators they had. However, a total of 144 medical educators provided their details to be interviewed. Data saturation was reached after 11 interviews, but seven more interviews were undertaken to ensure participants were captured across different characteristics, including subject taught (public health, clinical, biomedical), degree in public health or medical education, representation from the BKS IKM IKP IKK FKI, regions, and accreditation grades. Interviews ranged from 22 to 60 minutes.

Tables 1 and 2 show participant characteristics. The majority were female (n=14), from the western region (n=12), and aged 31–40 years (n=8) (Table 1), nearly all were medical doctors (n=17), and the majority taught non-public health subjects (n=14) (Table 2).

Five central subthemes emerged under the TPB domains: Attitudes: (1) defining public health; Subjective norms: (2) room in the medical curriculum, and (3) teaching and assessment; Perceived behavioral control: (4) confidence or capabilities of medical educators; and (5) institutional support. These are discussed below.

Under the three TPB domains, we found five major sub-themes regarding Indonesian medical educators’ views on teaching public health to undergraduate medical students. Due to the broad nature of public health, medical educators found it difficult to define public health and its scope; most did not understand public health and believed it was restricted to health promotion and prevention. This finding is similar to a study in India, another developing country [2]. In contrast, in Germany medical educators defined public health in narrow terms closely related to their discipline [21]. How medical educators define public health is important as it can influence the quantity and scope of public health in the curriculum [2], and can make it easier to standardize public health teaching within countries and globally.

Medical educators in this study believed there was enough public health in the curriculum because it was taught in both the bachelor and clinical stages. This finding is similar to a UK study involving 24 medical schools, where participants felt that the amount of time allocated for public health in their curriculum was “about right” [22]. However, other studies have highlighted that simply having discrete subjects of sufficient credit size did not mean that educators felt that students learnt enough public health [23], and medical educators in this study felt that the quality and relevance of the content was equally as important. This has also been found in studies in China and the United Kingdom [23,24]. Developing learning objectives at a nation-wide level may help to ensure that the curriculum is relevant [23,24]. However, although Indonesia has developed national guidelines for the medical curricula, it requires refining to ensure some standardization at the school level and also nationally.

In an already overcrowded medical curriculum, improving public health teaching does not necessarily mean more space needs to be allocated [1]. Some participants in this study felt that public health was already sufficiently integrated into the curriculum. This is supported by a UK study which recommended both integrated and discrete subjects [23]. A study in a South African medical school and another of 24 UK medical schools (which constituted 75% of all their medical schools), proposed that offering public health as an elective subject could be the solution [3,22]. However, a study in Indonesia suggested that offering elective subjects should be done cautiously, and consideration should be given to human resources availability, as well as whether medical educators were sufficiently motivated to teach the public health elective subjects [25].

There is no gold standard on how best to integrate public health into other subjects. In this study, to integrate public health into other subjects, participants allocated a time slot (usually 1–2 hour-lecture) for public health within a teaching block of non-public health subjects. A medical educator (usually from the public health department) delivered the public health content in that block. Public health topics could be epidemiology, risk factors and prevention of the diseases, as well as government programs to tackle the diseases. In the United Kingdom, integration to clinical subjects was achieved not only through lectures, but also through student case analysis projects for example, which required students to include the associated epidemiological and public health issues in their discussion [22].

Choosing the best way to assess student public health competency is challenging not only in Indonesia but also in other countries [22]. While a relatively straightforward assessment works best for more “traditional abilities” such as clinical competence [26], assessing public health was more difficult. Public health education is unique and requires innovative assessment [1]. Medical educators in this study felt that the usual multiple-choice question-style assessment used for mid and final exams could not sufficiently assess students’ public health competency. Multiple choice questions were also widely used in the previously mentioned UK medical schools study; however, these were combined with other forms of assessments such as essay, presentation, project work and an Objective Structured Clinical Examination [26]. A more structured approach to assess students’ public health competency has been used in a US medical school [26]. Students began by learning to recognize and reflect on their own cultural values, as well as on the diverse background values of patients and health professionals whom they encountered [26]. They were then required to design a “hypothetical community intervention project” or participating in a service-learning project [26].

Similar to other countries, Indonesian medical educators, including those in this study, are mostly clinicians first, and lacked training both in terms of public health content and in teaching skills [27]. For this, substantial institutional support in terms of providing proper training, infrastructure, and policy, is key [1]. A study involving medical educators from 12 European countries about teaching cultural competence, found that medical schools did not provide them with training to teach it [28]. Similarly, a study in 14 Australian and New Zealand universities found that medical educators required more support to teach nutrition effectively [5]. Training provided by medical schools focused more on acquiring general skills for teaching [28], while, for public health teaching, training would need to address specific aspects such as educators’ knowledge of government public health policies and initiatives, community health development, as well as the ability to recognize relevant topics, and to transfer content in a way that medical students find relevant to their future work [29].

Medical education, or the lack thereof, is believed to have contributed to the exacerbation of health inequalities [1]. To address this, the ability and willingness of medical educators to refocus and reorient medical education to be more relevant to society’s health need is central [28]. Strong institutional support is essential to develop supportive environments for building interdisciplinary collaboration that enables faculties and medical educators to work together to create change [30]. The provision of training to equip medical educators with the necessary capacity to develop ongoing teaching evaluation and improvement cycles is critical, along with good reward systems to recognize the efforts that have been made by medical educators [30].