Integration of knowledge and competencies regarding sex, gender and further diversity aspects into the curricula of health professions education in Germany – barriers and supporting factors

Integration of knowledge and competencies regarding sex, gender and further diversity aspects into the curricula of health professions education in Germany – barriers and supporting factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integration of knowledge and competencies regarding sex, gender and further diversity aspects into the curricula of health professions education in Germany – barriers and supporting factors Sabine Ludwig, Susanne Dettmer, Raphael Kohl, Kristin Kühn, Gabriele Kaczmarczyk, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2996367/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Knowledge of sex, gender and further diversity categories is important to achieve equitable and individualized healthcare. An official statement of the German government stipulates the mandatory integration of sex and gender aspects into the curricula of health professions. Here we aim at evaluating the extent of curricular integration as well as barriers and factors supporting the integration. Methods The study was conducted online between January and March 2020. Three semi-standardized questionnaires were developed and sent to the deans of all medical faculties and a random sample of 197 (36.7%) heads of nursing schools (NS) and 97 (33.9%) heads of physiotherapy schools (PS). They were asked about the extent of curricular integration of diversity aspects as well as barriers and aspects facilitating the integration. Results The response rate was 75.6% (n=31; MS), 52.5% (n=94; NS) and 54.6% (n=53; PS). The highest level of curricular integration was achieved by 3.7% (MS), 4.8% (NS) and 6.4% (PS). Teachers were indicated to be mainly responsible for the integration (MS: 36%; NS: 73%; PS: 65%). Sociocultural aspects were integrated to a lesser extent in MS curricula compared to NS and PS. Qualitative analysis showed lack of gender theory in curricula. Conclusions Sex and gender aspects are integrated into around 30% of medical, nursing and physiotherapy curricula. Main supporting factors were the integration into the German National Learning Catalogue of Medicine and framework curricula. Case discussions were considered to be the most suitable teaching format. Future directions are the integration of gender theories. sex gender health professions medical education physiotherapy nursing Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Worldwide, inequalities are seen across the different levels of healthcare due to different social determinants, such as, e.g., sex/gender, socio-economic status or color of skin (Shannon et al., 2019 ; Gross et al., 2020 ). The Covid-19 Pandemic has intensified them and data show sex/gender differences in the access to testing, risk of infections, outcome, incidence, prevalence, morbidity and mortality of the disease (Seeland et al., 2020 ; UN, 2022). Sex- and gender-based research has also shown differences in the incidence, prevalence, development, diagnosis and treatment of diseases with, e.g., a higher prevalence of depression in women and higher suicide rates for men. Women and men with a lower educational level show a higher prevalence (RKI, 2020a). Rheumatoid arthritis and osteoporosis are more frequent in women, with osteoporosis being underdiagnosed in men (RKI, 2020b). There are also differences in the access to emergency care with severely injured men being more likely to be directed to trauma centres than women (Gomez et al., 2012 ). In physiotherapy, there are differences in rehabilitation, pain management, and fear of falling (Pohl et al., 2015 ; Stenberg et al., 2022 ). Beside the knowledge of medical facts, nurses are trained to also consider socio-cultural aspects in order to ensure adequate care after hospital stay. However, the working environment of nurses is still based on traditional gender roles with the female nurse being expected to serve. This can be a barrier for the development of critical thinking and gender aware teaching and learning in nursing education and thus sex and gender aware nursing care Although knowledge of sex and gender differences is discussed more frequently in nursing training than in medical school, this is left to chance and not systematically implemented (Andrew et al., 2023 ). Already in 2006, the World Health Organization stated the importance of integrating gender into the curricula for health professionals (WHO, 2006). This strongly contributes to achieving the sustainable development goals “ Ensure healthy lives and promote well-being for all at all ages “ (SDG) 3, „ Achieve gender equality and empower all women and girls “ (SDG 5) and “ Reduce inequality within and among countries “ (SDG 10) as outlined by the United Nations in its agenda 2030 (UN, 2015). The process of integration has also been supported by a position paper of the Standing Committee of European Doctors (CPME, 2016). In 2021, an official statement of the German government stipulated the mandatory integration of sex/gender sensitive aspects into the curricula of health professions (SPD, Bündnis 90/Die Grünen, & FDP, 2021). In this study, the definition of diversity according to the German General Equal Treatment Act (AGG) comprising six categories is used: age, sex/gender, ethnicity, physical impairment, sexual identity/orientation and religion (BMJ, 2006). However, many other categories such as, e.g., socioeconomic status, education, hair color or body shape also play a role. Here, “sex“ is defined as the biological dimension (e.g., sex chromosomes, sex hormones) and “gender” as the sociocultural dimension such as gender roles, lifestyle, behavior and social expectations (Regitz-Zagrosek, 2012 ). In Germany, in other European countries and worldwide, efforts are being made to integrate sex, gender and further diversity categories into health professions education, with the focus so far on the integration into medical curricula (Verdonk et al., 2005 ; Ludwig et al. 2015 ; Miller et al., 2016 ; Nachtschatt et al., 2018 ; Khamisy-Farah & Bragazzi, 2022 ). However, a survey of the German Medical Women's Association has shown that gender-sensitive aspects are not yet systematically integrated into the curricula of medical faculties in Germany (Ludwig et al., 2016 ; Dettmer et al., 2021 ). Besides the integration into the medical profession, there are no studies on the extent of a systematic integration into nursing and physiotherapy education, although nurses account for more than 50% of the national health workforce in many countries with the majority being female (WHO, 2023) and physiotherapists are the third largest occupational group in the health professions after nurses and doctors (German Federal Statistical Office, 2021). Nurses and physiotherapists have a key role in healthcare, prevention and health promotion (Başar & Demirci, 2018 ; Yang, 2020 ). Knowledge of and competencies regarding sex/gender differences and further diversity categories in the prevention, development and therapy of diseases, on gender-sensitive communication with patients as well as on psychosocial factors are therefore of great importance (Hammarström et al., 2016 ; Ion et al., 2021 ; Stenberg et. al., 2022 ; Ludwig, 2022 ). Diversity- and sex/gender aware nurses and physiotherapists can thus improve care processes and patient outcomes by an improved patient- centeredness of care (Tzeng et al., 2011 ; Bisconti et al., 2020 ; Ludwig 2020a; Stenberg et al., 2022 ; Ludwig, 2022 ). Here the aim was to evaluate the extent of curricular integration of sex, gender and further diversity categories into medical, nursing and physiotherapy education, and the integration into pathology, theoretical and practical courses. Also, we aimed to assess the relevance of sex/gender and diversity competencies for the professional work of doctors, nurses and physiotherapists, the structures responsible for the integration and for sustainability, the integration into the assessment, into student and graduate evaluations as well as barriers for the integration, factors supporting it and measures necessary. Methods Three semi-standardized questionnaires were developed and programmed in the evaluation system UNIPARK of Questback. The online surveys were conducted from January 2020 until March 2020 and sent to n = 41 deans of medical schools. For the vocational training schools for nursing a random sample weighted by the federal states of n = 197 (36.7%) out of 537 nursing schools and a random sample of n = 97 (33.9%) out of 286 vocational training schools for physiotherapy received the questionnaire. The questionnaires were addressed to the heads of vocational training schools for nursing and physiotherapy excluding higher education institutions. Questionnaire development In an interdisciplinary, iterative process, three semi-standardized questionnaires were developed with experts in sex- and gender-sensitive medicine, diversity in health professions education, medical sociology, quality assurance in health professions education, public health, physiotherapists, medical doctors and experts with a background in nursing. The questionnaire was based on the experiences from a survey on the extent of integration of sex/gender aspects into medical curricula in Germany (Ludwig et al., 2016 ) and adapted to education in nursing and physiotherapy. Questions for the nursing and physiotherapy schools’ curricula were derived from the national regulations and framework curricula for both professions (BMJV, 1994; 2017). At the beginning of the questionnaire, the terms sex (“biological dimension”) and gender (“sociocultural dimension”) were explained in order to avoid misinterpretation. The surveys contain questions on the relevance of the integration of sex and gender aspects as well as diversity aspects (scale: very relevant/relevant/not relevant/not relevant at all/ no answer), the level of the curricular integration (level 1: Integration into several courses, level 2: Integration into multiple courses, level 3: Longitudinal integration, level 4: Longitudinal integration and integration into the assessment), the extent of the curricular integration into pathology courses (scale: yes, sociocultural aspects/yes, biological aspects/yes, both/no/not applicable), theoretical courses and practical course in nursing and physiotherapy (nursing: yes, sociocultural aspects/yes, biological aspects/yes, both/no/not applicable; physiotherapy: yes/no/no answer; multiple choice), the integration into teaching formats and teaching materials (multiple choice questions), structures for the curricular integration and the sustainability of integrated aspects (multiple choice question), the integration of new research results (fully agree/agree/do not agree/do not agree at all/no answer) as well as the integration into assessment items and evaluations (scale: yes/no/no answer). Furthermore, the participants were asked about the barriers for the integration, factors supporting it and measures necessary (open questions). The level of the curricular integration was evaluated based on standard evaluation criteria developed by Verdonk et al. ( 2005 ) and Ludwig et al. ( 2015 ). Questionnaire administration An electronic version of the questionnaire was programmed in the evaluation system UNIPARK of Questback. In December 2019, a pretest was conducted for all three professions and further modifications were made based on the feedback. The survey was anonymous. The participants were informed of the study and were formally asked for their written consent to publish aggregated data. They were reminded weekly to participate in order to increase the response rate. The study was approved by IRB committee of Charité – Universitätsmedizin Berlin, Germany. All methods were performed in accordance with the relevant guidelines and regulations of Charité – Universitätsmedizin Berlin, Germany. Statistics Statistical data analysis was performed using SPSS® Statistics 25.0 (IBM, Böblingen, Germany). Descriptive statistical data analysis includes percentages and item scores. Results The response rate was 75.6% (n = 31) for medical schools, 52.5% (n = 94) for nursing schools and 54.6% (n = 53) for physiotherapy schools. Ratings of the Relevance The majority of the deans of MS (93%), the heads of NS (95%) and PS (92%) consider knowledge of sex and gender aspects as very relevant or relevant for the work of the health professionals (Fig. 1A). Diversity aspects are rated to be very relevant or relevant by 96% of the deans of MS, by 98% of the heads of NS and by all (100%) of the heads of PS (Fig. 1B). [Figure 1 here] Level of curricular integration Sex and gender aspects have been integrated into several courses (level 1) with a proportion of 70.4% (MS), 56% (NS) and 66% (PS) respectively. An integration into multiple courses (level 2) was achieved by 22.2% (MS), 30% (NS) and 15% (PS). A longitudinal integration into different teaching formats, learning objectives and courses all over the curriculum (level 3) has been achieved by a proportion of 7.4% (MS), 14% (NS) and 19% (PS). The highest level of integration (level 4) - longitudinal integration with assessment - has been achieved by 3.7% (MS), 4.8% (NS) and 6.4% (PS) (Fig. 2). [Figure 2 here] Established Structures for the integration and sustainability of integrated aspects Faculty teachers were mainly indicated to be responsible for the integration in NS (73%) and PS (65%). In MS, it is more diverse with a proportion of 43% for a gender equality officer, 36% for teachers and a commission for curriculum development. A gender and diversity change agent was stated to be mainly responsible for the integration with proportions of 14% (MS), 4% (NS) and 2% (PS). In MS, teaching coordinators (50%) and the gender equality officers (50%) were stated to be mainly responsible for the sustainability of the integrated aspects as well as an expert group on gender mainstreaming (25%). Eight MS answered this question. In PS the teachers (65%) and the heads of schools (46%) were mentioned to be mainly responsible for the integration, but also the curriculum commission (13%), the gender equality officer (4%) and a change agent (2%). Some of the schools also stated that they do not have resources for this (22%), 46 PS answered the question. Multiple answers were possible. A total of 14 deans of MS, 93 heads of NS and 52 heads of PS responded to this question. Biological (“sex”) and sociocultural (“gender”) content in theoretical and practical courses Medicine Besides biological aspects (“sex”), 32% of the medical schools indicated that they also integrate the sociocultural dimension (“gender”) such as lifestyle, gender roles, behavior and social expectations into the different teaching subjects, 68% do not integrate them. Nursing and Physiotherapy NS indicated that both the biological and sociocultural dimension are integrated with a share of 81% in care interventions, 70% in care anamnesis, and 51% in documentation of care, whereas the focus was on the sociocultural aspects. The extent of the integration amounts to 31% in classes of internal medicine, 32% in surgery and 23% in classes on pharmacology. In classes on care of patients with mental diseases the share was 73%, in classes on communication 63%, and mobility and self-care 61% (Table 1). In PS both the biological and sociocultural dimensions were mainly integrated into subjects such as geriatric medicine (73%), psychiatry and psychotherapy (68%), psychosomatic medicine (63%), and pediatrics (56%). They were also integrated into the thematic fields and classes on occupational health, endocrinology, neurology (each 51%), internal medicine (50%) and cardiology (50%) (Table 2). In the practical courses on physiotherapy assessment and anamnesis (87%) massage therapy (85%), examination and treatment methods (83%), and communication (72%) sex/gender aspects are integrated. Sex/gender aspects are also integrated into theoretical courses and into the competence area documentation and language. A proportion of 93% of heads of PS indicate that students are prepared for and informed about sexual harassment at the workplace (Table 2). [Table 1 here] [Table 2 here] Diversity aspects In NS and PS diversity categories are integrated to a large extent into courses on prevention and health promotion (Fig. 3). Sex/Gender aspects are integrated by a proportion of 90% of NS and 86% of PS and cultural background by 96% of NS and 79% of PS. Sexual orientation is integrated by 26% of PS, almost half of the NS do not integrate this category. [Figure 3 here] PS indicated to integrate diversity categories such as age (79%), sex/gender (72%), disabilities (70%), cultural background (67%), Religion (27%) and sexual identity (20%) into courses on scientific work. Integration of new research results A proportion of 34% of NS and 33% of PS integrated new research results into the teaching and learning, two thirds (NS: 66%; PS: 67%) do not integrate them. Teaching formats In NS case discussions (62%) were the most frequently used teaching format to convey sex/gender knowledge and competencies followed by practical courses in the school (47%) and bedside teaching (47%). Practice and consolidation courses accounted for 43%, lectures and seminars for 37%, self-directed learning for 27% and eLearning formats for 5%. In PS practical courses (67%) and case discussions were the most frequently used teaching format to convey sex/gender knowledge and competencies followed by bedside teaching (52%), lectures (40%), practice and consolidation courses (33%) and seminars (29%). Self-directed learning accounted for 10%. None of the schools used eLearning formats to teach sex/gender knowledge and competencies. Multiple answers were possible (Fig. 4). A proportion of 39% of MS offer an elective on sex/gender aspects as a teaching format with a higher prevalence in schools with reformed curricula than traditional curricula. [Figure 4 here] Assessment of gender knowledge and competencies A share of 11% of MS, 29% of NS and 18% of PS integrate sex and gender knowledge and competencies into exams, most of them (MS: 89%; NS: 71%; PS: 82%) do not integrate them into the assessment items. Integration into quality assurance instruments In MS sex and gender competencies are only evaluated in 3% of student evaluations and 24% of graduate surveys, in NS 4% and in PS they are not evaluated at all. Barriers for the integration, facilitating factors and measures supporting the integration The deans of MS and the heads of NS and PS were also asked about the barriers for the integration, the factors supporting it as well as regarding the measures they consider necessary for the integration. As barriers for the integration, lack of resources, lack of interest and awareness in civil society, lack of adequate teaching material, an already condensed curriculum and no person responsible for the integration were mentioned (Supplementary Table 1). A diversity and gender change agent, a dean for gender and diversity issues and expert groups and committees on diversity and gender aspects were stated as factors having supported the integration. The development of new curricula such as the introduction of new modular medical curricula and the systematic integration of sex and gender learning objectives during module planning session facilitated the integration. Furthermore, the recruitment of professorships with a gender/diversity focus and the consideration of gender aspects in faculty development plans as well as in the funding of research projects are stated. The integration of sex, gender and further diversity aspects into national framework curricula, study and training regulations, into the guidelines of the Federal Institute for Vocational Education and Training and into national learning objectives catalogues such as the German National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) were rated as facilitating factors and measures necessary for the integration as well as the integration into assessment items. The provision of comprehensive teaching materials for example by the development of databases and eLearning platforms, the inclusion of gender aspects in all textbooks as well as education and training courses for lecturers and research funding opportunities on sex/gender aspects in the fields of medicine, nursing and physiotherapy. Finally, a more sensitive handling of the topic in public and a general social discussion on the appreciation of gender-sensitive medicine, nursing and physiotherapy were mentioned (Supplementary Table 1). Discussion The survey showed that deans of MS and heads of NS and PS rated sex/gender knowledge and competencies as well as further diversity categories as relevant for the professional work as a medical doctor, nurse or physiotherapist. This is in line with the results of a study by Jenkins et al. ( 2016 ) and Ludwig et al. ( 2020b ) showing that medical students rate gender and diversity competencies as relevant for their future work as physicians. Moreover, female medical students and female health professionals rate these aspects as more relevant than their male counterparts (Dielissen et al., 2009 ; Clever et al., 2020 ). Medical schools with reformed curricula consider them as more important than schools with traditional curricula (Dettmer et al., 2021 ). Virologists and immunologists however consider the integration as less important, but still integrate them into few courses (Schluchter et al., 2023 ). Bisconti et al. ( 2020 ) showed that physiotherapists also consider knowledge on sex/gender aspects as relevant, but more than half (55%) of the study participants rate their knowledge as low-to-moderate. A study in Taiwan also found that medical and nursing teachers consider gender awareness, knowledge on sexism and sexual harassment as relevant for their students (Yang, 2020 ). Only few schools have achieved a longitudinal integration of sex, gender and further diversity categories including the assessment and thus the highest level of education. However, around a third of the nursing schools and around one fifth of the medical and physiotherapy schools integrate them into multiple courses and have therefore achieved level two of the integration. We see efforts in several countries, but a systematic and consistent integration is still not achieved internationally (Khamisy-Farah & Bragazzi, 2022 ). The different diversity categories such as sex/gender and cultural background are considered in courses on prevention and health promotion from a considerable proportion of schools, but sexual identity/orientation is only mentioned by around one fourth, the majority does not integrate this category. This is also shown in a study by Muntinga et al. ( 2016 ) from the Netherlands. Only a small number of schools consider sexual identity. This is in line with a study from Ross et al. (2019) showing that people identifying as LGBTIQ + report discriminatory experiences, discomfort, and lack of knowledge when attending physiotherapy. Ion et al. ( 2021 ) also state that gender identity has to be part of the nursing curricula. NS and PS integrate more sociocultural “gender” aspects than MS. Our results only give an indication of the extent of integration of sex and gender aspects into the different subjects, but do not allow any conclusions about the depth of knowledge and thus the acquired competencies. A study in the UK with physiotherapy students showed that gender was rarely explicitly discussed and found a profound gender orthodoxy in physiotherapy education (Hammond, 2013 ). Furthermore, a study in Australia showed that nursing students with less traditional gender beliefs are more autonomous and reflect more on care interventions. Integration of gender theory is therefore considered necessary to empower female nursing students, make them aware of sociocultural gender roles and how to overcome them and thus improve their professional competence (Andrew et al., 2023 ). Verdonk et al. (2018) developed the Nijmegen Gender Awareness Scale that was used in several countries for medical students, e.g., in Portugal (Morais et al., 2020 ), Sweden (Andersson et al., 2012 ), Switzerland (Rrustemi et al., 2020 ) as well as in Italy (Bert et al., 2022 ) and was also applied for nursing science (Aliri et al., 2022 ). The studies showed that gender awareness increases during medical studies and that male students have more stereotypes (Rrustemi et al., 2020 ). Teachers are particularly responsible for integrating sex, gender and further diversity categories into teaching and learning. However, if faculty teachers are mainly responsible, the integration depends on their affinity, interest in this topic as well as on their gender competence and knowledge. Also due to lecturers’ mobility this might not be a systematic and sustainable approach. Besides the faculty teachers, gender equality officers are mentioned to be responsible for the integration. Considering the current tasks of gender equality officers, it must be assumed that they are not able to fulfil the task comprehensively also in terms of time. In addition, it is also not part of their official tasks (Clever et al., 2020 ). The survey by the German Medical Women’s Association showed that there are indications that the use of a gender and diversity change agent is an effective approach to integrating gender aspects and could thus achieve the highest level of integration (Ludwig et al., 2015 , 2016 ). In NS and PS case discussions, practical training in the schools and bedside teaching are mainly used to convey diversity, especially sex and gender aspects. At the time of the study the extent of integration into e-learning teaching formats was small, but it is assumed that due to the COVID-19 pandemic, the need for e-learning material has increased, so that concepts for online teaching materials will be part of the teachers' tasks in the future and will provide opportunities for further integration of diversity aspects. As far as teaching materials are concerned, sex and gender aspects are integrated in about two thirds of the cases. They are not integrated in more than half of the PowerPoint presentations and in about two thirds of the scripts and handouts. This is in line with a study from the Netherlands on the integration of diversity aspects in a medical curriculum: Despite supportive framework conditions, the teaching material is not yet sufficiently gender- and diversity-sensitive (Muntinga et al. 2016 ). The toolbox of the Free University of Berlin, among others, can be used to support diversity-sensitive teaching (Freie Universität Berlin, 2018). Barriers and supporting factors The main supporting factors mentioned by MS, NS and PS are the integration into national regulations and framework curricula, accreditation guidelines, introduction of new curricula or curricular revisions, the integration into the assessment and evaluations, professorships for diversity and sex/gender aspects and adequate research funding. Main barriers are lack of interest in civil society and thus of lecturers and students, knowledge and competencies of teachers and lecturers, training programs, little space foreseen in the curriculum as well as inadequate research funding. Those findings are in line with a study by van der Meulen et al. ( 2017 ) who conducted qualitative interviews with teaching coordinators of the medical faculty at Radboud University in the Netherlands. The integration into quality assessment instruments such as accreditation guidelines and into national framework curricula and regulations (top-down approach) and the involvement of students (bottom-up approach) were found to be supporting factors for the integration and contributing to the sustainability and are similar to results from studies by Tannenbaum & Moineau ( 2016 ) and Ludwig et al. ( 2018 ). Our results show that sex and gender aspects are not yet integrated into the assessment items of the schools. A study of Schluchter et al. ( 2020 ) has also shown that only few sex/gender aspects are integrated into medical state examinations in the United States and Germany. A qualitative study by Clever et al. ( 2020 ) who conducted qualitative interviews with sex/gender experts in medical eduction in German speaking countries also found that the lack of knowlegde of teachers, adequate teaching material, limited financial resources and lack of interest in civil society are main barriers for the integration. Celik et al. ( 2009 ) who interviewed nine pairs of General Practicioners in the Netherlands found similar results and Bert et al. ( 2022 ) showed that female and gender-sensitive lecturers correlated with less stereotypes among students. Several learning tools have already been developed in order to improve gender awareness and the knowlegde and competencies of teachers and students, such as the online learning and knowledge-sharing platforms on sex and gender aspects in medicine “eGender” (Seeland et al., 2016 ) and “GenderMed-Wiki” (Schreitmüller et al., 2018 ). Furthermore, tools for the gendered assessment of pain rehabilitation were developed (Hammarström et. al., 2016 ) as well as the Canadian “Gender Lens Tool” (AMWA, 2023) being translated into German and piloted in a course on Gender Medicine (Weyers et al., 2017 ). To our knowledge, specific online learning or exchange platforms for nursing and physiotherapy education do not exist yet. The inclusion into textbooks is also considered as supporting the integration, however, it is shown that only few textbooks, e.g., in medicine integrate them (Dijkstra et al., 2008 ). Limitations For nursing and physiotherapy education only vocational training schools were included in the survey, but no higher education institutions for both professions. The deans of faculty and the head of schools might not have been aware of the sex and gender aspects that are taught by their teachers. Although explanation of the terms “sex” and “gender” were given, there might still have been misinterpretations. Further health professions such as occupational or speech therapy were not included in the study. Conclusion Although sex, gender and further diversity categories are considered to be relevant for the professional work as health professionals, they are not yet systematically integrated into medical, nursing and physiotherapy curricula. Medical faculties have established structures for the integration, but the extent of integration is not larger than that of the other professions. For a systematic integration, sex, gender and further diversity categories need to be integrated as mandatory teaching and learning content into the national regulations of the health professions, into national learning objectives catalogues such as the German National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) and in quality assurance instruments, e.g., graduate surveys, student evaluations and accreditation criteria. Faculty teachers need to be trained and taught gender competencies and theories. For this, online courses should be specifically developed for the health professions and support provided to the schools and medical faculties for developing gender/sex-sensitive curricula. The establishment of a central assessment center for counselling and support for the integration and implementation of sex and gender-sensitive learning objectives in school curricula could be an effective measure. An incentive system could additionally increase motivation by, e.g., awarding a certificate for "gender-sensitive teaching" as a visible quality feature of the training institution. Finally, more bachelor, master and doctoral theses on sex/gender aspects in health should be carried out and promoted and new findings in gender research should be transferred into teaching and made accessible to all health professionals. Further studies should examine how students and trainees of nursing and physiotherapy evaluate the relevance of sex, gender and further diversity categories for their work and their competencies. Integration of sex and gender aspects should be mandatory for all health professions including pharmacology curricula. Besides the lecturers, the deans and head of schools are important drivers of change regarding more diversity sensitive education in the health professions. The results of this study can support them with the curricular integration of sex, gender and further diversity categories in their own institutions. Declarations Ethics approval and consent to participate The participants gave their written informed consent. The study was approved by IRB committee of Charité – Universitätsmedizin Berlin, Germany. All methods were performed in accordance with the relevant guidelines and regulations of Charité – Universitätsmedizin Berlin, Germany. Consent for publication The survey was anonymous. The participants were informed of the study and were formally asked for their written consent to publish aggregated data. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to anonymous request of the survey and deliberate participation but are available from the corresponding author on reasonable request. Competing interests The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The study was funded by the German Federal Ministry of Health (GE 2018 04 38). Authors' contributions S.L., U.S., S.D., G.K., R.K. designed, conducted and administered the study. S.L., U.S., S.D., G.K., R.K., K.K. analyzed and discussed the data. S.L. and R.K. prepared the figures and tables, S.L. drafted the first version of the manuscript and conducted literature research. U.S., S.D., G.K., R.K., K.K. reviewed the manuscript for important intellectual content. All authors have read and approved the revised manuscript. Acknowledgement We would like to thank the German Federal Ministry of Health for financing the study. Furthermore, we would like to thank the deans of the medical schools and the heads of the vocational training schools for nursing and physiotherapy for participating in the study. We would also like to thank Christina Hoffmann and Tamara Schneider for the sex and gender-based analysis of the physiotherapy framework curricula, the critical review of the physiotherapy questionnaire as well as literature research and personal reminders of the heads of schools to participate in the survey. References Aliri, J., Prego-Jimenez, S., Goñi-Balentziaga, O., Pereda-Pereda, E., Perez-Tejada, J., & Labaka Etxeberria, A. (2022). Gender awareness is also nurses’business: Measuring sensitivity and role ideology towardspatients. 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What should se taught and what is taught: Integrating Gender into Medical and Health Professions Education for Medical and Nursing Students. Int J Environ Res Public Health , 17(18):6555. doi: 10.3390/ijerph17186555. PMID: 32916861; PMCID: PMC7558635. Tables Tables 1 to 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1JAHPESexgenderinhealthprofessionseducation.xlsx Supplementary Table 1: Barriers, supporting factors and measures to facilitate the integration *frequency of how often the individual subcategories were stated Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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22:28:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24252,"visible":true,"origin":"","legend":"\u003cp\u003eTeaching formats to convey sex and gender knowledge and competencies\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-2996367/v1/ce7a7d0beef87ab20c3ef44b.png"},{"id":38355145,"identity":"b2b06a1e-9be5-48a4-bb96-afbf23ac07ea","added_by":"auto","created_at":"2023-06-11 14:44:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":466925,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2996367/v1/0db79e21-6bc3-496b-b26b-8e618639f80e.pdf"},{"id":37799100,"identity":"60ec17a7-93c4-49ac-8a7f-5808e2b9a796","added_by":"auto","created_at":"2023-05-31 22:12:19","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20159,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 1: Barriers, supporting factors and measures to facilitate the integration\u003c/p\u003e\n\u003cp\u003e*frequency of how often the individual subcategories were stated\u003c/p\u003e","description":"","filename":"SupplementaryTable1JAHPESexgenderinhealthprofessionseducation.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-2996367/v1/77377f45e54360f99d7a6663.xlsx"},{"id":37799623,"identity":"c6ce2205-265e-40ff-b630-2200a6ec559f","added_by":"auto","created_at":"2023-05-31 22:20:19","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":208208,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-2996367/v1/117801c41b0ad3949824926a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Integration of knowledge and competencies regarding sex, gender and further diversity aspects into the curricula of health professions education in Germany – barriers and supporting factors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorldwide, inequalities are seen across the different levels of healthcare due to different social determinants, such as, e.g., sex/gender, socio-economic status or color of skin (Shannon et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Gross et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The Covid-19 Pandemic has intensified them and data show sex/gender differences in the access to testing, risk of infections, outcome, incidence, prevalence, morbidity and mortality of the disease (Seeland et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; UN, 2022).\u003c/p\u003e \u003cp\u003eSex- and gender-based research has also shown differences in the incidence, prevalence, development, diagnosis and treatment of diseases with, e.g., a higher prevalence of depression in women and higher suicide rates for men. Women and men with a lower educational level show a higher prevalence (RKI, 2020a). Rheumatoid arthritis and osteoporosis are more frequent in women, with osteoporosis being underdiagnosed in men (RKI, 2020b). There are also differences in the access to emergency care with severely injured men being more likely to be directed to trauma centres than women (Gomez et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In physiotherapy, there are differences in rehabilitation, pain management, and fear of falling (Pohl et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Stenberg et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Beside the knowledge of medical facts, nurses are trained to also consider socio-cultural aspects in order to ensure adequate care after hospital stay. However, the working environment of nurses is still based on traditional gender roles with the female nurse being expected to serve. This can be a barrier for the development of critical thinking and gender aware teaching and learning in nursing education and thus sex and gender aware nursing care Although knowledge of sex and gender differences is discussed more frequently in nursing training than in medical school, this is left to chance and not systematically implemented (Andrew et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlready in 2006, the World Health Organization stated the importance of integrating gender into the curricula for health professionals (WHO, 2006). This strongly contributes to achieving the sustainable development goals \u0026ldquo;\u003cem\u003eEnsure healthy lives and promote well-being for all at all ages\u003c/em\u003e\u0026ldquo; (SDG) 3, \u0026bdquo;\u003cem\u003eAchieve gender equality and empower all women and girls\u003c/em\u003e\u0026ldquo; (SDG 5) and \u0026ldquo;\u003cem\u003eReduce inequality within and among countries\u003c/em\u003e\u0026ldquo; (SDG 10) as outlined by the United Nations in its agenda 2030 (UN, 2015).\u003c/p\u003e \u003cp\u003e The process of integration has also been supported by a position paper of the Standing Committee of European Doctors (CPME, 2016). In 2021, an official statement of the German government stipulated the mandatory integration of sex/gender sensitive aspects into the curricula of health professions (SPD, B\u0026uuml;ndnis 90/Die Gr\u0026uuml;nen, \u0026amp; FDP, 2021).\u003c/p\u003e \u003cp\u003eIn this study, the definition of diversity according to the German General Equal Treatment Act (AGG) comprising six categories is used: age, sex/gender, ethnicity, physical impairment, sexual identity/orientation and religion (BMJ, 2006). However, many other categories such as, e.g., socioeconomic status, education, hair color or body shape also play a role. Here, \u0026ldquo;sex\u0026ldquo; is defined as the biological dimension (e.g., sex chromosomes, sex hormones) and \u0026ldquo;gender\u0026rdquo; as the sociocultural dimension such as gender roles, lifestyle, behavior and social expectations (Regitz-Zagrosek, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Germany, in other European countries and worldwide, efforts are being made to integrate sex, gender and further diversity categories into health professions education, with the focus so far on the integration into medical curricula (Verdonk et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Ludwig et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Miller et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Nachtschatt et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Khamisy-Farah \u0026amp; Bragazzi, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, a survey of the \u003cem\u003eGerman Medical Women's Association\u003c/em\u003e has shown that gender-sensitive aspects are not yet systematically integrated into the curricula of medical faculties in Germany (Ludwig et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Dettmer et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBesides the integration into the medical profession, there are no studies on the extent of a systematic integration into nursing and physiotherapy education, although nurses account for more than 50% of the national health workforce in many countries with the majority being female (WHO, 2023) and physiotherapists are the third largest occupational group in the health professions after nurses and doctors (German Federal Statistical Office, 2021).\u003c/p\u003e \u003cp\u003eNurses and physiotherapists have a key role in healthcare, prevention and health promotion (Başar \u0026amp; Demirci, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Yang, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Knowledge of and competencies regarding sex/gender differences and further diversity categories in the prevention, development and therapy of diseases, on gender-sensitive communication with patients as well as on psychosocial factors are therefore of great importance (Hammarstr\u0026ouml;m et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ion et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stenberg et. al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ludwig, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Diversity- and sex/gender aware nurses and physiotherapists can thus improve care processes and patient outcomes by an improved patient- centeredness of care (Tzeng et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Bisconti et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Ludwig 2020a; Stenberg et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ludwig, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHere the aim was to evaluate the extent of curricular integration of sex, gender and further diversity categories into medical, nursing and physiotherapy education, and the integration into pathology, theoretical and practical courses. Also, we aimed to assess the relevance of sex/gender and diversity competencies for the professional work of doctors, nurses and physiotherapists, the structures responsible for the integration and for sustainability, the integration into the assessment, into student and graduate evaluations as well as barriers for the integration, factors supporting it and measures necessary.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThree semi-standardized questionnaires were developed and programmed in the evaluation system UNIPARK of Questback. The online surveys were conducted from January 2020 until March 2020 and sent to n\u0026thinsp;=\u0026thinsp;41 deans of medical schools. For the vocational training schools for nursing a random sample weighted by the federal states of n\u0026thinsp;=\u0026thinsp;197 (36.7%) out of 537 nursing schools and a random sample of n\u0026thinsp;=\u0026thinsp;97 (33.9%) out of 286 vocational training schools for physiotherapy received the questionnaire. The questionnaires were addressed to the heads of vocational training schools for nursing and physiotherapy excluding higher education institutions.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire development\u003c/h2\u003e \u003cp\u003eIn an interdisciplinary, iterative process, three semi-standardized questionnaires were developed with experts in sex- and gender-sensitive medicine, diversity in health professions education, medical sociology, quality assurance in health professions education, public health, physiotherapists, medical doctors and experts with a background in nursing. The questionnaire was based on the experiences from a survey on the extent of integration of sex/gender aspects into medical curricula in Germany (Ludwig et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and adapted to education in nursing and physiotherapy. Questions for the nursing and physiotherapy schools\u0026rsquo; curricula were derived from the national regulations and framework curricula for both professions (BMJV, 1994; 2017).\u003c/p\u003e \u003cp\u003eAt the beginning of the questionnaire, the terms sex (\u0026ldquo;biological dimension\u0026rdquo;) and gender (\u0026ldquo;sociocultural dimension\u0026rdquo;) were explained in order to avoid misinterpretation.\u003c/p\u003e \u003cp\u003eThe surveys contain questions on the relevance of the integration of sex and gender aspects as well as diversity aspects (scale: very relevant/relevant/not relevant/not relevant at all/ no answer), the level of the curricular integration (level 1: Integration into several courses, level 2: Integration into multiple courses, level 3: Longitudinal integration, level 4: Longitudinal integration and integration into the assessment), the extent of the curricular integration into pathology courses (scale: yes, sociocultural aspects/yes, biological aspects/yes, both/no/not applicable), theoretical courses and practical course in nursing and physiotherapy (nursing: yes, sociocultural aspects/yes, biological aspects/yes, both/no/not applicable; physiotherapy: yes/no/no answer; multiple choice), the integration into teaching formats and teaching materials (multiple choice questions), structures for the curricular integration and the sustainability of integrated aspects (multiple choice question), the integration of new research results (fully agree/agree/do not agree/do not agree at all/no answer) as well as the integration into assessment items and evaluations (scale: yes/no/no answer). Furthermore, the participants were asked about the barriers for the integration, factors supporting it and measures necessary (open questions). The level of the curricular integration was evaluated based on standard evaluation criteria developed by Verdonk et al. (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) and Ludwig et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire administration\u003c/h2\u003e \u003cp\u003eAn electronic version of the questionnaire was programmed in the evaluation system UNIPARK of Questback. In December 2019, a pretest was conducted for all three professions and further modifications were made based on the feedback.\u003c/p\u003e \u003cp\u003eThe survey was anonymous. The participants were informed of the study and were formally asked for their written consent to publish aggregated data. They were reminded weekly to participate in order to increase the response rate. The study was approved by IRB committee of Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin, Germany. All methods were performed in accordance with the relevant guidelines and regulations of Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin, Germany.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eStatistical data analysis was performed using SPSS\u0026reg; Statistics 25.0 (IBM, B\u0026ouml;blingen, Germany). Descriptive statistical data analysis includes percentages and item scores.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe response rate was 75.6% (n = 31) for medical schools, 52.5% (n = 94) for nursing schools and 54.6% (n = 53) for physiotherapy schools.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRatings of the Relevance\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of the deans of MS (93%), the heads of NS (95%) and PS (92%) consider knowledge of sex and gender aspects as very relevant or relevant for the work of the health professionals (Fig. 1A). Diversity aspects are rated to be very relevant or relevant by 96% of the deans of MS, by 98% of the heads of NS and by all (100%) of the heads of PS (Fig. 1B).\u003c/p\u003e\n\u003cp\u003e[Figure 1 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel of curricular integration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSex and gender aspects have been integrated into several courses (level 1) with a proportion of 70.4% (MS), 56% (NS) and 66% (PS) respectively. An integration into multiple courses (level 2) was achieved by 22.2% (MS), 30% (NS) and 15% (PS). A longitudinal integration into different teaching formats, learning objectives and courses all over the curriculum (level 3) has been achieved by a proportion of 7.4% (MS), 14% (NS) and 19% (PS). The highest level of integration (level 4) - longitudinal integration with assessment - has been achieved by 3.7% (MS), 4.8% (NS) and 6.4% (PS) (Fig. 2).\u003c/p\u003e\n\u003cp\u003e[Figure 2 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEstablished Structures for the integration and sustainability of integrated aspects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFaculty teachers were mainly indicated to be responsible for the integration in NS (73%) and PS (65%). In MS, it is more diverse with a proportion of 43% for a gender equality officer, 36% for teachers and a commission for curriculum development. A gender and diversity change agent was stated to be mainly responsible for the integration with proportions of 14% (MS), 4% (NS) and 2% (PS). In MS, teaching coordinators (50%) and the gender equality officers (50%) were stated to be mainly responsible for the sustainability of the integrated aspects as well as an expert group on gender mainstreaming (25%). Eight MS answered this question. In PS the teachers (65%) and the heads of schools (46%) were mentioned to be mainly responsible for the integration, but also the curriculum commission (13%), the gender equality officer (4%) and a change agent (2%). Some of the schools also stated that they do not have resources for this (22%), 46 PS answered the question. Multiple answers were possible. A total of 14 deans of MS, 93 heads of NS and 52 heads of PS responded to this question.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBiological (“sex”) and sociocultural (“gender”) content in theoretical and practical courses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMedicine\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBesides biological aspects (“sex”), 32% of the medical schools indicated that they also integrate the sociocultural dimension (“gender”) such as lifestyle, gender roles, behavior and social expectations into the different teaching subjects, 68% do not integrate them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eNursing and Physiotherapy\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNS indicated that both the biological and sociocultural dimension are integrated with a share of 81% in care interventions, 70% in care anamnesis, and 51% in documentation of care, whereas the focus was on the sociocultural aspects. The extent of the integration amounts to 31% in classes of internal medicine, 32% in surgery and 23% in classes on pharmacology. In classes on care of patients with mental diseases the share was 73%, in classes on communication 63%, and mobility and self-care 61% (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn PS both the biological and sociocultural dimensions were mainly integrated into subjects such as geriatric medicine (73%), psychiatry and psychotherapy (68%), psychosomatic medicine (63%), and pediatrics (56%). They were also integrated into the thematic fields and classes on occupational health, endocrinology, neurology (each 51%), internal medicine (50%) and cardiology (50%) (Table 2).\u003c/p\u003e\n\u003cp\u003eIn the practical courses on physiotherapy assessment and anamnesis (87%) massage therapy (85%), examination and treatment methods (83%), and communication (72%) sex/gender aspects are integrated. Sex/gender aspects are also integrated into theoretical courses and into the competence area documentation and language. A proportion of 93% of heads of PS indicate that students are prepared for and informed about sexual harassment at the workplace (Table 2).\u003c/p\u003e\n\u003cp\u003e[Table 1 here]\u003c/p\u003e\n\u003cp\u003e[Table 2 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDiversity aspects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn NS and PS diversity categories are integrated to a large extent into courses on prevention and health promotion (Fig. 3). Sex/Gender aspects are integrated by a proportion of 90% of NS and 86% of PS and cultural background by 96% of NS and 79% of PS. Sexual orientation is integrated by 26% of PS, almost half of the NS do not integrate this category.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Figure 3 here]\u003c/p\u003e\n\u003cp\u003ePS indicated to integrate diversity categories such as\u0026nbsp;age (79%), sex/gender (72%), disabilities (70%), cultural background (67%), Religion (27%) and sexual identity (20%)\u0026nbsp;into courses on scientific work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntegration of new research results\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA proportion of 34% of NS and 33% of PS integrated new research results into the teaching and learning, two thirds (NS: 66%; PS: 67%) do not integrate them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTeaching formats\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn NS case discussions (62%) were the most frequently used teaching format to convey sex/gender knowledge and competencies followed by practical courses in the school (47%) and bedside teaching (47%).\u0026nbsp;Practice and consolidation courses accounted for 43%, lectures and seminars for 37%, self-directed learning for 27% and eLearning formats for 5%.\u003c/p\u003e\n\u003cp\u003eIn PS\u0026nbsp;practical courses\u0026nbsp;(67%) and case discussions were the most frequently used teaching format to convey\u0026nbsp;sex/gender knowledge and competencies\u0026nbsp;followed by bedside teaching (52%), lectures (40%), practice and consolidation courses (33%) and seminars (29%). Self-directed learning accounted for 10%. None of the schools used eLearning formats to teach sex/gender knowledge and competencies. Multiple answers were possible (Fig. 4).\u003c/p\u003e\n\u003cp\u003eA proportion of 39% of MS offer an elective on sex/gender aspects as a teaching format with a higher prevalence in schools with reformed curricula than traditional curricula.\u003c/p\u003e\n\u003cp\u003e[Figure 4 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssessment of gender knowledge and competencies\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA share of 11% of MS, 29% of NS and 18% of PS integrate sex and gender knowledge and competencies into exams, most of them (MS: 89%; NS: 71%; PS: 82%) do not integrate them into the assessment items.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntegration into quality assurance instruments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn MS sex and gender competencies are only evaluated in 3% of student evaluations and 24% of graduate surveys, in NS 4% and in PS they are not evaluated at all.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBarriers for the integration, facilitating factors and measures supporting the integration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe deans of MS and the heads of NS and PS were also asked about the barriers for the integration, the factors supporting it as well as regarding the measures they consider necessary for the integration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs barriers for the integration, lack of resources, lack of interest and awareness in civil society, lack of adequate teaching material, an already condensed curriculum and no person responsible for the integration were mentioned (Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003eA diversity and gender change agent, a dean for gender and diversity issues and expert groups and committees on diversity and gender aspects were stated as factors having supported the integration. The development of new curricula such as the introduction of new modular medical curricula and the systematic integration of sex and gender learning objectives during module planning session facilitated the integration. Furthermore, the recruitment of professorships with a gender/diversity focus and the consideration of gender aspects in faculty development plans as well as in the funding of research projects are stated.\u003c/p\u003e\n\u003cp\u003eThe integration of sex, gender and further diversity aspects into national framework curricula, study and training regulations, into the guidelines of the Federal Institute for Vocational Education and Training and into national learning objectives catalogues such as the German \u003cem\u003eNational Competence Based Catalogue\u003c/em\u003eof\u0026nbsp;\u003cem\u003eLearning Objectives\u003c/em\u003e for Undergraduate\u0026nbsp;\u003cem\u003eMedical\u003c/em\u003eEducation (NKLM) were rated as facilitating factors and measures necessary for the integration as well as the integration into assessment items.\u003c/p\u003e\n\u003cp\u003eThe provision of comprehensive teaching materials for example by the development of databases and eLearning platforms, the inclusion of gender aspects in all textbooks as well as education and training courses for lecturers and research funding opportunities on sex/gender aspects in the fields of medicine, nursing and physiotherapy. Finally, a more sensitive handling of the topic in public and a general social discussion on the appreciation of gender-sensitive medicine, nursing and physiotherapy were mentioned (Supplementary Table 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe survey showed that deans of MS and heads of NS and PS rated sex/gender knowledge and competencies as well as further diversity categories as relevant for the professional work as a medical doctor, nurse or physiotherapist. This is in line with the results of a study by Jenkins et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Ludwig et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020b\u003c/span\u003e) showing that medical students rate gender and diversity competencies as relevant for their future work as physicians. Moreover, female medical students and female health professionals rate these aspects as more relevant than their male counterparts (Dielissen et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Clever et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Medical schools with reformed curricula consider them as more important than schools with traditional curricula (Dettmer et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Virologists and immunologists however consider the integration as less important, but still integrate them into few courses (Schluchter et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Bisconti et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) showed that physiotherapists also consider knowledge on sex/gender aspects as relevant, but more than half (55%) of the study participants rate their knowledge as low-to-moderate. A study in Taiwan also found that medical and nursing teachers consider gender awareness, knowledge on sexism and sexual harassment as relevant for their students (Yang, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnly few schools have achieved a longitudinal integration of sex, gender and further diversity categories including the assessment and thus the highest level of education. However, around a third of the nursing schools and around one fifth of the medical and physiotherapy schools integrate them into multiple courses and have therefore achieved level two of the integration. We see efforts in several countries, but a systematic and consistent integration is still not achieved internationally (Khamisy-Farah \u0026amp; Bragazzi, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe different diversity categories such as sex/gender and cultural background are considered in courses on prevention and health promotion from a considerable proportion of schools, but sexual identity/orientation is only mentioned by around one fourth, the majority does not integrate this category. This is also shown in a study by Muntinga et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) from the Netherlands. Only a small number of schools consider sexual identity. This is in line with a study from Ross et al. (2019) showing that people identifying as LGBTIQ\u0026thinsp;+\u0026thinsp;report discriminatory experiences, discomfort, and lack of knowledge when attending physiotherapy. Ion et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) also state that gender identity has to be part of the nursing curricula.\u003c/p\u003e \u003cp\u003eNS and PS integrate more sociocultural \u0026ldquo;gender\u0026rdquo; aspects than MS. Our results only give an indication of the extent of integration of sex and gender aspects into the different subjects, but do not allow any conclusions about the depth of knowledge and thus the acquired competencies. A study in the UK with physiotherapy students showed that gender was rarely explicitly discussed and found a profound gender orthodoxy in physiotherapy education (Hammond, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Furthermore, a study in Australia showed that nursing students with less traditional gender beliefs are more autonomous and reflect more on care interventions. Integration of gender theory is therefore considered necessary to empower female nursing students, make them aware of sociocultural gender roles and how to overcome them and thus improve their professional competence (Andrew et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVerdonk et al. (2018) developed the Nijmegen Gender Awareness Scale that was used in several countries for medical students, e.g., in Portugal (Morais et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), Sweden (Andersson et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), Switzerland (Rrustemi et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) as well as in Italy (Bert et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and was also applied for nursing science (Aliri et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The studies showed that gender awareness increases during medical studies and that male students have more stereotypes (Rrustemi et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTeachers are particularly responsible for integrating sex, gender and further diversity categories into teaching and learning. However, if faculty teachers are mainly responsible, the integration depends on their affinity, interest in this topic as well as on their gender competence and knowledge. Also due to lecturers\u0026rsquo; mobility this might not be a systematic and sustainable approach. Besides the faculty teachers, gender equality officers are mentioned to be responsible for the integration. Considering the current tasks of gender equality officers, it must be assumed that they are not able to fulfil the task comprehensively also in terms of time. In addition, it is also not part of their official tasks (Clever et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe survey by the German Medical Women\u0026rsquo;s Association showed that there are indications that the use of a gender and diversity change agent is an effective approach to integrating gender aspects and could thus achieve the highest level of integration (Ludwig et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn NS and PS case discussions, practical training in the schools and bedside teaching are mainly used to convey diversity, especially sex and gender aspects. At the time of the study the extent of integration into e-learning teaching formats was small, but it is assumed that due to the COVID-19 pandemic, the need for e-learning material has increased, so that concepts for online teaching materials will be part of the teachers' tasks in the future and will provide opportunities for further integration of diversity aspects.\u003c/p\u003e \u003cp\u003eAs far as teaching materials are concerned, sex and gender aspects are integrated in about two thirds of the cases. They are not integrated in more than half of the PowerPoint presentations and in about two thirds of the scripts and handouts. This is in line with a study from the Netherlands on the integration of diversity aspects in a medical curriculum: Despite supportive framework conditions, the teaching material is not yet sufficiently gender- and diversity-sensitive (Muntinga et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The toolbox of the Free University of Berlin, among others, can be used to support diversity-sensitive teaching (Freie Universit\u0026auml;t Berlin, 2018).\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and supporting factors\u003c/h2\u003e \u003cp\u003e The main supporting factors mentioned by MS, NS and PS are the integration into national regulations and framework curricula, accreditation guidelines, introduction of new curricula or curricular revisions, the integration into the assessment and evaluations, professorships for diversity and sex/gender aspects and adequate research funding. Main barriers are lack of interest in civil society and thus of lecturers and students, knowledge and competencies of teachers and lecturers, training programs, little space foreseen in the curriculum as well as inadequate research funding.\u003c/p\u003e \u003cp\u003eThose findings are in line with a study by van der Meulen et al. (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) who conducted qualitative interviews with teaching coordinators of the medical faculty at Radboud University in the Netherlands. The integration into quality assessment instruments such as accreditation guidelines and into national framework curricula and regulations (top-down approach) and the involvement of students (bottom-up approach) were found to be supporting factors for the integration and contributing to the sustainability and are similar to results from studies by Tannenbaum \u0026amp; Moineau (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Ludwig et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur results show that sex and gender aspects are not yet integrated into the assessment items of the schools. A study of Schluchter et al. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) has also shown that only few sex/gender aspects are integrated into medical state examinations in the United States and Germany.\u003c/p\u003e \u003cp\u003eA qualitative study by Clever et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) who conducted qualitative interviews with sex/gender experts in medical eduction in German speaking countries also found that the lack of knowlegde of teachers, adequate teaching material, limited financial resources and lack of interest in civil society are main barriers for the integration. Celik et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) who interviewed nine pairs of General Practicioners in the Netherlands found similar results and Bert et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) showed that female and gender-sensitive lecturers correlated with less stereotypes among students.\u003c/p\u003e \u003cp\u003eSeveral learning tools have already been developed in order to improve gender awareness and the knowlegde and competencies of teachers and students, such as the online learning and knowledge-sharing platforms on sex and gender aspects in medicine \u0026ldquo;eGender\u0026rdquo; (Seeland et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and \u0026ldquo;GenderMed-Wiki\u0026rdquo; (Schreitm\u0026uuml;ller et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, tools for the gendered assessment of pain rehabilitation were developed (Hammarstr\u0026ouml;m et. al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) as well as the Canadian \u0026ldquo;Gender Lens Tool\u0026rdquo; (AMWA, 2023) being translated into German and piloted in a course on Gender Medicine (Weyers et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, specific online learning or exchange platforms for nursing and physiotherapy education do not exist yet. The inclusion into textbooks is also considered as supporting the integration, however, it is shown that only few textbooks, e.g., in medicine integrate them (Dijkstra et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eFor nursing and physiotherapy education only vocational training schools were included in the survey, but no higher education institutions for both professions. The deans of faculty and the head of schools might not have been aware of the sex and gender aspects that are taught by their teachers. Although explanation of the terms \u0026ldquo;sex\u0026rdquo; and \u0026ldquo;gender\u0026rdquo; were given, there might still have been misinterpretations. Further health professions such as occupational or speech therapy were not included in the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough sex, gender and further diversity categories are considered to be relevant for the professional work as health professionals, they are not yet systematically integrated into medical, nursing and physiotherapy curricula. Medical faculties have established structures for the integration, but the extent of integration is not larger than that of the other professions. For a systematic integration, sex, gender and further diversity categories need to be integrated as mandatory teaching and learning content into the national regulations of the health professions, into national learning objectives catalogues such as the German National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) and in quality assurance instruments, e.g., graduate surveys, student evaluations and accreditation criteria.\u003c/p\u003e \u003cp\u003eFaculty teachers need to be trained and taught gender competencies and theories. For this, online courses should be specifically developed for the health professions and support provided to the schools and medical faculties for developing gender/sex-sensitive curricula. The establishment of a central assessment center for counselling and support for the integration and implementation of sex and gender-sensitive learning objectives in school curricula could be an effective measure. An incentive system could additionally increase motivation by, e.g., awarding a certificate for \"gender-sensitive teaching\" as a visible quality feature of the training institution. Finally, more bachelor, master and doctoral theses on sex/gender aspects in health should be carried out and promoted and new findings in gender research should be transferred into teaching and made accessible to all health professionals.\u003c/p\u003e \u003cp\u003eFurther studies should examine how students and trainees of nursing and physiotherapy evaluate the relevance of sex, gender and further diversity categories for their work and their competencies. Integration of sex and gender aspects should be mandatory for all health professions including pharmacology curricula. Besides the lecturers, the deans and head of schools are important drivers of change regarding more diversity sensitive education in the health professions. The results of this study can support them with the curricular integration of sex, gender and further diversity categories in their own institutions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants gave their written informed consent. The study was approved by IRB committee of\u0026nbsp;Charité – Universitätsmedizin Berlin, Germany. All methods were performed in accordance with the relevant guidelines and regulations of Charité – Universitätsmedizin Berlin, Germany.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey was anonymous.\u0026nbsp;The participants were informed of the study and were formally\u0026nbsp;\u003c/p\u003e\n\u003cp\u003easked for their written consent to publish aggregated data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to anonymous request of the survey and deliberate participation but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the German Federal Ministry of Health (GE 2018 04 38).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.L., U.S., S.D., G.K., R.K. designed, conducted and administered the study.\u0026nbsp;S.L., U.S., S.D., G.K., R.K., K.K. analyzed and discussed the data. S.L. and R.K. prepared the figures and tables, S.L. drafted the first version of the manuscript and conducted literature research. U.S., S.D., G.K., R.K., K.K. reviewed the manuscript for important intellectual content.\u0026nbsp;All authors have read and approved the revised manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the German Federal Ministry of Health for financing the study. Furthermore, we would like to thank the deans of the medical schools and the heads of the vocational training schools for nursing and physiotherapy for participating in the study.\u0026nbsp;We would also like to thank Christina Hoffmann and Tamara Schneider for the sex and gender-based analysis of the physiotherapy framework curricula, the critical review of the physiotherapy questionnaire as well as literature research and personal reminders of the heads of schools to participate in the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAliri, J., Prego-Jimenez, S., Go\u0026ntilde;i-Balentziaga, O., Pereda-Pereda, E., Perez-Tejada, J., \u0026amp; Labaka Etxeberria, A. (2022). 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PMID: 32916861; PMCID: PMC7558635.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sex, gender, health professions, medical education, physiotherapy, nursing ","lastPublishedDoi":"10.21203/rs.3.rs-2996367/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2996367/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge of sex, gender and further diversity categories is important to achieve equitable and individualized healthcare. An official statement of the German government stipulates the mandatory integration of sex and gender aspects into the curricula of health professions. Here we aim at evaluating the extent of curricular integration as well as barriers and factors supporting the integration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted online between January and March 2020. Three semi-standardized questionnaires were developed and sent to the deans of all medical faculties and a random sample of 197 (36.7%) heads of nursing schools (NS) and 97 (33.9%) heads of physiotherapy schools (PS). They were asked about the extent of curricular integration of diversity aspects as well as barriers and aspects facilitating the integration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe response rate was 75.6% (n=31; MS), 52.5% (n=94; NS) and 54.6% (n=53; PS). The highest level of curricular integration was achieved by 3.7% (MS), 4.8% (NS) and 6.4% (PS). Teachers were indicated to be mainly responsible for the integration (MS: 36%; NS: 73%; PS: 65%). Sociocultural aspects were integrated to a lesser extent in MS curricula compared to NS and PS. Qualitative analysis showed lack of gender theory in curricula.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSex and gender aspects are integrated into around 30% of medical, nursing and physiotherapy curricula. Main supporting factors were the integration into the German National Learning Catalogue of Medicine and framework curricula. Case discussions were considered to be the most suitable teaching format. Future directions are the integration of gender theories.\u003c/p\u003e","manuscriptTitle":"Integration of knowledge and competencies regarding sex, gender and further diversity aspects into the curricula of health professions education in Germany – barriers and supporting factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-31 22:12:14","doi":"10.21203/rs.3.rs-2996367/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a407720-4545-45c8-88c7-1468774566a5","owner":[],"postedDate":"May 31st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-06-11T14:44:19+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-31 22:12:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2996367","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2996367","identity":"rs-2996367","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}