From Medical to Health Humanities: A Cross-National Scoping Review of Structural–Ethical Curricular Models in the United States, Japan, and China

From Medical to Health Humanities: A Cross-National Scoping Review of Structural–Ethical Curricular Models in the United States, Japan, and China | 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 From Medical to Health Humanities: A Cross-National Scoping Review of Structural–Ethical Curricular Models in the United States, Japan, and China Mingzhu Yang, Shuang Chai, Jinsong Pan, Angela Chang Chiu, Junxin Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8469352/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background In response to health systems demanding clinician engagement with structural determinants of health, Health Humanities (HH) has emerged as a framework integrating structural ethics and institutional accountability. However, cross-national comparison of HH curricula remains constrained by normative benchmarks and inadequate tools for analyzing institutional embedding. Methods We conducted a scoping review (2016–2024) of HH/Medical Humanities curricula in the United States, Japan, and China. We applied a novel diagnostic framework integrating a three-level embedding model (G1: micro, G2: meso, G3: macro) and a Structural Maturity Scale (0–3, capturing varying depths of institutionalization, without implying hierarchy). Analysis was guided by functional equivalence. Results Of 112 included publications, curricula were prevalent at the micro-level (G1) across settings, but meso- and macro-level embedding varied significantly. U.S. curricula showed high maturity (Level 3) with longitudinal, accreditation-aligned integration. Japan exhibited a bimodal pattern (strong G3/G1, limited G2). China demonstrated strong policy-driven embedding (G3/G2) with Level 2 maturity, indicating evolving assessment. We identified three ethical-institutional configurations (rights-based pluralism, relational collectivism, governance-centered public responsibility) and four cross-cutting structural tensions (e.g., depth vs. measurability). Conclusions HH institutionalization follows context-dependent pathways shaped by governance and ethics. The integrated G1-G3 and Maturity Scale framework provides a non-normative, transferable tool for curriculum audit. The proposed Public-Responsibility HH model for China demonstrates how policy-aligned systems can leverage mandates to strengthen pedagogy and assessment. Health Humanities Medical Humanities Structural Ethics Structural Competence Functional Equivalence Curriculum Institutionalization Cross-National Comparison Medical Education Public Responsibility Figures Figure 1 Figure 2 Figure 3 Introduction As health systems increasingly demand that clinicians navigate complex institutional, social, and policy environments, medical education must prepare learners to recognize and respond to structural determinants of health [ 1 – 3 ]. This imperative extends beyond individual patient encounters, requiring competencies that enable future clinicians to interpret how organizational arrangements, governance, and policy shape practice and professional responsibility. Historically, Medical Humanities (MH) curricula have focused on empathy, narrative competence, and moral reflection within the clinician-patient relationship [ 4 , 5 ]. While foundational, MH has been critiqued for operating primarily within an interpersonal ethical frame, offering limited leverage for analyzing institutional drivers of inequity [ 6 , 7 ]. In response, the field has increasingly adopted the broader framework of Health Humanities (HH), which foregrounds structural ethics, institutional accountability, and the governance dimensions of care [ 8 , 9 ]. MH and HH are not mutually exclusive but represent evolving emphases, with HH explicitly extending humanistic inquiry into domains of structure, power, and policy [ 10 ]. Despite growing interest, HH curricular integration remains uneven and difficult to compare cross-nationally. Two key limitations persist. First, evaluations often rely on implicit normative benchmarks—typically grounded in Euro-American expectations—often rooted in Euro-American normative assumptions, risking deficit-oriented interpretations of difference [ 11 – 14 ]. Second, common curriculum design frameworks prioritize instructional coherence but lack analytical tools to examine how humanistic curricula are institutionally embedded, assessed, and sustained under divergent governance conditions [ 15 ]. Consequently, cross-context variation is often described rather than systematically interpreted, hindering the generation of transferable insights. This study bridges these gaps by introducing and applying a diagnostic analytic framework designed for non-normative, cross-national comparison. This framework integrates: (i) a three-level model of curricular embedding—micro (G1: interpersonal/reflective practices), meso (G2: course/program structures), and macro (G3: system/policy integration); and (ii) a Structural Maturity Scale (0–3) capturing institutionalization depth. Guided by the principle of functional equivalence [ 16 ], this approach compares how curricula across contexts fulfil shared educational functions (e.g., cultivating structural awareness), rather than judging them against a single normative model. Applying this framework, we conducted a scoping review of MH/HH curricula (2016–2024) across three purposively selected settings: the United States, Japan, and China. These cases represent analytically contrasting contexts reflecting distinct ethical-institutional configurations—rights-based pluralism, relational collectivism, and governance-centered public responsibility—rather than hierarchical stages of development. This review addresses three questions: 1. How are MH/HH curricula institutionally embedded across differing governance contexts (G1–G3)? 2. How is the "structural turn" operationalized through distinct ethical-institutional configurations? 3. How can structural maturity and curricular integration be assessed using context-sensitive analytic tools? By foregrounding institutional embedding and function-based comparison, this study offers a practical framework for researchers and educators to examine, compare, and adapt HH curricula across heterogeneous systems without presuming a single maturity trajectory. Methods Study design We conducted a scoping review following Arksey and O’Malley [ 17 ] and subsequent refinements [ 18 ], reporting in accordance with PRISMA-ScR [ 19 ]. This approach was chosen to map conceptual orientations and curricular structures in a heterogeneous, evolving field, rather than to evaluate intervention effectiveness [ 17 , 18 ]. Rationale for Case Selection: Purposive Maximum-Variation Sampling The United States, Japan, and China were selected via purposive maximum-variation sampling [ 20 ] to examine how HH institutionalization manifests under contrasting conditions [ 21 ]. They represent distinct configurations: (1) U.S. rights-based pluralism shaped by accreditation and decentralized governance; (2) Japanese relational collectivism emphasizing harmony and narrative reciprocity; and (3) Chinese governance-centered public responsibility characterized by policy mandates aligning education with national health priorities. These serve as an analytic lens, not as fixed national essences. Search Strategy and Data Sources We searched PubMed, Web of Science Core Collection, ERIC, CINAHL, and CNKI for publications from January 1, 2016, to December 31, 2024. The start date was selected to capture literature following the consolidation of “structural turn” frameworks in health professions education, with structural competency serving as a key conceptual anchor [ 3 ]. Search strategies combined terms for (i) MH/HH, (ii) structural/cultural/ethical constructs, (iii) curriculum/medical education, and (iv) national identifiers. Full strategies are in Supplementary Tables S1–S5. Representative strings are shown below. PubMed (representative): ("students medical"[MeSH] OR "faculty medical"[MeSH] OR "health personnel"[MeSH] OR "physicians"[MeSH] OR "internship and residency" [MeSH] OR "medical student*"[tiab] OR "resident*"[tiab] OR "physician*" [tiab] OR "medical educator*"[tiab]) AND ("cultural competency"[MeSH] OR "health equity"[MeSH] OR "cultural humility"[Title] OR "structural competency"[Title] OR "structural violence"[Title] OR "medical humanities"[Title] OR "cross-cultural"[Title] OR "health humanities"[Title] OR "narrative medicine"[Title]) AND ("education medical"[MeSH] OR "curriculum"[MeSH] OR "teaching" [Title] OR "assessment"[Title] OR "competency-based education"[Title]) AND ("China"[All Fields] OR "Japan"[All Fields] OR "United States"[All Fields] OR "USA"[All Fields]) AND 2016/1/1:2024/12/31[pdat]; English/Japanese/Chinese CNKI (representative): (TI='医学人文' OR AB='医学人文' OR KY='医学人文' OR TI='健康人文'AB='健康人文' OR KY='健康人文' OR TI='叙事医学' OR AB='叙事医学' OR KY='叙事医学' OR TI='医学叙事' OR AB='医学叙事' OR KY='医学叙事' OR TI='叙事反思' OR AB='叙事反思' OR KY='叙事反思' OR TI='文化谦逊' OR AB='文化谦逊' OR KY='文化谦逊' OR TI='文化敏感性' OR AB='文化敏感性' OR KY='文化敏感性' OR TI='跨文化' OR AB='跨文化' OR KY='跨文化' OR TI='文化能力' OR AB='文化能力' OR KY='文化能力' OR TI='结构能力' OR AB='结构能力' OR KY='结构能力' OR TI='结构性暴力' OR AB='结构性暴力' OR KY='结构性暴力' OR TI='健康公平' OR AB='健康公平' OR KY='健康公平') AND (TI='医学生' OR AB='医学生' OR KY='医学生' OR TI='医学教师' OR AB='医学教师' OR KY='医学教师' OR TI='医务人员' OR AB='医务人员' OR KY='医务人员' OR TI='临床医师' OR AB='临床医师' OR KY='临床医师' OR TI='住院医师' OR AB='住院医师' OR KY='住院医师' OR TI='医学教育者' OR AB='医学教育者' OR KY='医学教育者') AND (TI='课程' OR AB='课程' OR KY='课程' OR TI='教学' OR AB='教学' OR KY='教学' OR TI='教育' OR AB='教育' OR KY='教育' OR TI='课程改革' OR AB='课程改革' OR KY='课程改革' OR TI='能力本位教育' OR AB='能力本位教育' OR KY='能力本位教育' OR TI='反思写作' OR AB='反思写作' OR KY='反思写作' OR TI='人文素养' OR AB='人文素养' OR KY='人文素养') AND 20160101–20241231 Targeted policy documents referenced by included curricula were reviewed for G3 contextualization only and were not analyzed as empirical studies. Eligibility Criteria and Study Selection Included studies:(1) described a structured MH/HH curriculum/module/ program; (2) were embedded in undergraduate, graduate, or residency medical education in the U.S., Japan, or China; (3) linked activities to competencies/frameworks addressing structural, cultural, or ethical dimensions of care. We excluded opinion pieces, single workshops without institutional embedding, and instrument-validation studies without curricular implementation. Two reviewers independently screened titles/abstracts and full texts. Discrepancies were resolved through discussion or third-reviewer adjudication. The selection process is summarized in Fig. 1 . Diagram description: Database searches yielded 4,140 records; 14 additional records were identified. After deduplication (n = 3,473 screened), 112 publications were included in the qualitative synthesis. Data Extraction Data were extracted using a standardized matrix capturing: ethical orientation; curricular structure and embedding level (G1–G3); pedagogical modalities; assessment strategies; and referenced structural/ethical frameworks. Two reviewers independently extracted data and assigned structural maturity scores, resolving discrepancies through iterative discussion. The data extraction matrix was pilot-tested on a subset of studies and refined prior to full extraction. Conceptual Definitions and Analytic Framework Structural ethics refers to the institutionalization of ethical commitments through curricular structures and governance. The principle of functional equivalence [ 16 ] guided comparison, focusing on how curricula fulfil shared educational functions rather than comparing surface features. The integrated analytic framework comprised : 1. G1–G3 Embedding Model: Micro (G1), Meso (G2), Macro (G3). 2. Structural Maturity Scale (0–3): capturing varying depths of institutionalization rather than hierarchical stages of development. (1)0 = Isolated activity (2)1 = Described curriculum without formal institutionalization (3)2 = Institutionalized curriculum with weak/inconsistent assessment (4)3 = Fully institutionalized curriculum with formal assessment and explicit alignment to a structural-ethical framework. Maturity scores were assigned based on published evidence through iterative reviewer consensus. Data Synthesis Synthesis occurred in two stages:(1) within-case mapping of G1–G3 distributions, pedagogical/assessment patterns, and maturity scores; (2) cross-case interpretation linking institutionalization patterns to the three ethical-institutional configurations. Results Overview of Included Studies After screening,112 publications met eligibility criteria (U.S.: n = 67; China: n = 32; Japan: n = 13) (Fig. 1 ). Most described formally embedded curricula (e.g., longitudinal threads, required modules) linking objectives to competency frameworks addressing ethical, cultural, or structural dimensions. A subset addressed emerging themes like digital health ethics. Distribution of HH curricula across structural embedding levels (G1–G3) Distinct national patterns emerged in how curricula were distributed across embedding levels (Fig. 2 A). G1 (Micro) Initiatives across all settings emphasized empathy, narrative medicine, and reflective practice. In Japan, G1 studies often involved developing empathy/cross-cultural competence instruments, with variable integration into routine assessment [ 22 , 23 ]. G2 (Meso) Required modules and longitudinal threads were reported more in the U.S. and China than Japan. U.S. studies described equity-oriented longitudinal curricula aligned with accreditation [ 24 , 25 ]. Chinese studies reported reforms integrating "humanized care" into structured curricula, with variable assessment formalization [ 26 , 27 ]. G3(Macro) Integration differed substantially. In Japan, national competency frameworks (e.g., Model Core Curriculum 2022) articulated outcomes, but translation into sustained program structures varied [28,38]. In China, curricula were explicitly linked to national policy and licensure requirements [ 29 , 26 ]. In the U.S., studies reflected accreditation standards and professional expectations within a decentralized model. Structural maturity (0–3) and institutionalization patterns Maturity scores indicated systematic cross-national differences across embedding levels and institutionalization dimensions (Fig. 2 A). United States Curricula frequently met Level 3 criteria at G2/G3, characterized by longitudinal integration, credit-bearing status, and formalized assessment aligned with accreditation and equity goals [ 24 , 25 ]. Japan : A bimodal pattern was observed: strong policy-level articulation (G3) coexisted with concentrated G1 activity, while sustained, mature G2 program architectures were less commonly reported [ 22 , 23 , 28 ]. China Curricula were most often Level 2, reflecting clear policy-driven embedding (G3) and programmatic integration (G2), alongside evolving but inconsistently formalized assessment at G1/G2 [ 30 , 27 ]. Taken together, Fig. 2 A visually captures a central pattern: institutionalization profiles vary in form and emphasis across contexts, aligning with distinct governance–ethical configurations rather than reflecting a linear hierarchy of curricular maturity. Figure 2 A. Comparative structural maturity and institutionalization of HH curricula across the United States, Japan, and China. (Left) Mean structural maturity scores (0–3) across three embedding levels: G1 (micro-level pedagogical practices), G2 (meso-level programmatic integration), and G3 (macro- level institutional/governance alignment). (Right) Radar chart summarizing cross-national institutionalization profiles across three dimensions: curricular integration, formalization of assessment mechanisms, and alignment with external standards. Scores reflect patterns derived from qualitative synthesis and indicate relative institutionalization patterns across contexts rather than a linear or hierarchical ordering of performance. Scores are interpretive summaries of institutionalization patterns reported in the literature. Functional equivalence and ethical–institutional configurations Guided by functional equivalence, analysis identified three configurations fulfilling the shared function of cultivating structural awareness (Fig. 2 B): Rights-Based Pluralism (United States) : Emphasizes social accountability, equity, anti-racism, and structural competency [ 24 , 25 ]. Relational Collectivism (Japan) : Emphasizes emotional attunement, narrative reciprocity, and relational interdependence [ 22 , 23 , 28 ]. Governance-Centered Public Responsibility (China; hereafter , public-responsibility logic ) : Aligns humanistic competencies with national policy priorities, social trust, and collective welfare through state-mediated adaptation of global concepts [ 30 , 27 ]. This figure summarizes three dominant ethical orientations identified in the included curricula: rights-based pluralism (United States), relational collectivism (Japan), and governance-centered public responsibility (China). Each configuration represents a distinct pattern of ethical assumptions, pedagogical emphases, and assessment tendencies. Arrows indicate conceptual dialogue and recurring points of tension among the configurations, illustrating how the “structural turn” is translated across cultural and governance contexts without implying a directional or hierarchical relationship. Cross-cutting implementation patterns and recurrent structural tensions Narrative and reflective pedagogies were widely reported. Community-engaged learning was prominent in U.S. curricula [ 31 ]. Assessment varied: U.S. studies reported mixed-methods and validated tools [ 32 – 34 ]; Japanese studies emphasized qualitative feedback [ 23 , 28 , 35 ]; Chinese curricula reported policy-aligned exams and growing use of competency-based tools [ 26 , 27 , 30 , 36 ]. Four recurrent, structurally produced tensions were identified across contexts (Fig. 2 C): T1: Experiential Depth vs. Measurability T2: Policy Ambition vs. Institutional Capacity T3: Clinical Productivity vs. Reflective Practice T4: Self-Culture vs. Other-Culture Reflexivity Their salience varied: T2 and T3 were dominant in China; T1 was prominent in the U.S.; T4 was often implicit in Japan. When interpreted through the axes of the tension matrix, these tensions operate at different relational loci. T1 (experiential depth versus measurability) and T3 (clinical productivity versus reflective practice) were more closely associated with internal curricular design choices and pedagogical trade-offs. In contrast, T2 (policy ambition versus institutional capacity) and T4 (self-culture versus other-culture reflexivity) were more strongly shaped by external governance, policy environments, and sociocultural contexts. The matrix depicts four recurrent tensions observed across contexts: (T1) experiential depth versus measurability, (T2) policy ambition versus institutional capacity, (T3) clinical productivity versus reflective practice, and (T4) self-culture versus other-culture reflexivity. These tensions represent structurally produced features of embedding reflective and ethical education within biomedical training systems rather than remediable implementation barriers. They may co-occur across embedding levels and national contexts, and the matrix emphasizes their relational nature by situating them along internal–external and pedagogical–systemic dimensions , rather than a linear pathway toward resolution. Synthesized cross-national comparison Table 1 synthesizes findings across the three contexts and functions as a non-normative audit heuristic, enabling educators and curriculum leaders to identify context-specific leverage points and vulnerabilities without implying hierarchical superiority. Table 1 Cross-National Comparison of Health Humanities (HH) Curricular Models Dimension United States Japan China Educational Implications Dominant Ethical Orientation Rights-based pluralism; structural justice Relational collectivism; attunement Public responsibility; collective welfare Tailor pedagogy to local ethics for stronger PIF Primary Ethical Focus Structural inequities; anti-racism Interdependence; relational responsibility Duties to state/institution; social trust Integrate with interprofessional education Structural Embedding (G1–G3) Strong G2–G3; longitudinal/system-level Predominantly G1/G3; limited G2 Strong G2–G3; policy-driven Use G1–G3 to audit local embedding Structural Maturity Pattern High Level 3; accreditation-aligned Bimodal; fragmented G2 Predominantly Level 2; evolving assessment Target maturity gaps for faculty development Typical Pedagogical Modalities Community-engaged; equity threads Narrative; emotion-focused reflection Narrative; professionalism modules Adapt modalities to cultural reflexivity Role of Humanities Critical structural analysis Cultivating empathy/harmony Reinforcing virtue/public duty Link to clinical simulations for transfer Assessment Strategies Mixed-methods; validated tools Qualitative; research instruments Examinations; emerging competencies Develop hybrid tools aligned with accreditation Recurrent Tensions T1, T3 prominent T1 salient T2, T3 dominant Build tension-navigation into reflective portfolios Functional Contribution Advocacy-oriented clinicians Relationally attuned practitioners Governance-aligned clinicians Foster adaptable professionals for global practice Discussion A non-normative, structurally grounded framework for comparing HH curricula This study makes a substantive methodological contribution to comparative health professions education by developing and applying a non-normative, structurally grounded framework for analyzing Health Humanities (HH) curricula. Moving beyond implicit Western benchmarks [ 14 , 31 ] and guided by the principle of functional equivalence [ 16 ], we reconceptualize HH not as a universal curricular model but as a structurally contingent practice—shaped by deeply embedded ethical traditions and governance arrangements. Our findings from the United States, Japan, and China demonstrate that distinct ethical-institutional logics generate functionally comparable, yet institutionally divergent, pathways for cultivating structural awareness. This approach directly counters deficit-oriented comparisons and provides a generative “comparative grammar” for the field. By integrating the Structural Maturity Scale with the G1–G3 embedding model, this study provides a "comparative grammar" linking ethical orientation to observable institutionalization patterns (Fig. 2 A, 2 B, Table 1 ). This framework reframes cross-national variation as alternative moral and institutional settlements concerning professional responsibility and medicine's role in society, rather than ranking curricula by presumed advancement. From ethical orientation to institutional configuration The differences in structural maturity and G1–G3 distributions illustrate how ethical commitments are translated into curricular form under specific governance conditions. In the United States , high maturity was associated with strong cross-level alignment: accreditation and social justice advocacy (G3) supported longitudinal program structures (G2), enabling sustained critical pedagogies (G1) [ 32 , 33 ]. In China , strong G2–G3 coupling with Level 2 maturity suggests top-down policy mandates effectively institutionalize HH at program/system levels, while pedagogical depth and consistent competency-based assessment at G1 remain under active development [ 26 , 27 ]. This pattern reflects known challenges, such as formalized assessment structures and uneven faculty preparation for humanities teaching. Japan’s bimodal pattern—robust G3 frameworks and rich G1 practices but fewer sustained G2 structures—reflects an institutional ecology where ethical cultivation is often embedded implicitly rather than programmatically [ 22 , 23 , 28 ]. This aligns with survey evidence showing rapid compliance with national curriculum revisions but heterogeneous meso-level restructuring across schools [ 37 ]. Collectively, these findings underscore that curricular institutionalization is a sociopolitical process mediated by governance and culturally embedded norms of professionalism, not merely a matter of pedagogical design. Structural competence as a culturally mediated construct These patterns challenge the notion of structural competence as a culturally neutral construct. What counts as "structural," where ethical responsibility is located, and how clinicians should act on systemic determinants vary substantially (Fig. 2 B). U.S. curricula frame it through social justice and critical theory, positioning physicians as advocates [ 24 , 25 ]. Japanese curricula cultivate structural sensitivity indirectly through narrative reciprocity and emotional attunement, emphasizing relational harmony [ 22 , 23 , 28 ]. Chinese curricula situate it within a logic of public responsibility, aligning practice with population health and state governance priorities [ 30 , 27 ]. These differences highlight the risks of superficial curriculum transfer without ethical-pedagogical translation, a concern heightened by emerging debates on digital health and AI [ 11 , 30 ]. Effective education for structural competence thus requires culturally literate faculty development that connects local ethical vocabularies to shared structural challenges. Recurrent structural tensions as features of institutionalization The four recurrent tensions(T1-T4) should be understood as enduring features of embedding a reflective field within efficiency-oriented biomedical training systems, not as remediable barriers. Effective HH curricula institutionalize pedagogical spaces where learners can recognize, analyze, and navigate these tensions. This process itself constitutes a core dimension of structural awareness, fostering a pragmatic, reflexive professional orientation. Operationalizing the framework: toward a Public-Responsibility HH model for China Building on comparative insights, we propose an operational Public-Responsibility HH (PR-HH) model tailored to China (Fig. 3 ). This model illustrates how ethical commitments can be stabilized through coordinated G1-G3 alignment, leveraging governance capacity while addressing identified gaps in assessment and pedagogy. G3 (Macro) National policy, licensure exams, and certification standards provide legitimacy and resources. G2 (Meso) Interdisciplinary core courses and longitudinal threads translate policy into sustained programs, mitigating the policy-capacity tension (T2). G1 (Micro) Pedagogies like narrative reflection on policy-clinic interfaces and scenario-based assessment operationalize public-responsibility ethics, addressing clinical productivity tensions (T3) while strengthening competency development (T1). Crucially, the model conceptualizes faculty development and competency-based assessment as bidirectional infrastructures. Downward policy alignment is complemented by upward evaluative feedback, enabling data from G1/G2 teaching to inform curricular governance and policy refinement at G3. This creates a reflexive institutional ecology relevant to other policy-driven systems. Taken together, these analyses clarify both the methodological and practical implications of the proposed framework. Research Significance This study makes two key contributions: 1. Theoretical/Methodological : It advances comparative HH scholarship by providing a non-normative framework centered on functional equivalence and structural embedding. The counters Western-centric evaluative tendencies and offers a transferable diagnostic tool. 2. Practical : For educators and policymakers, the G1-G3 model and Maturity Scale serve as an audit toolkit to identify misalignments between reflective practices, program design, and institutional support. The PR-HH model offers a concrete example of context-sensitive curriculum development. This figure illustrates a vertically integrated PR-HH framework spanning the macro (G3), meso (G2), and micro (G1) levels, supported by two cross-cutting infrastructures: interdisciplinary faculty development and competency-based assessment. The model depicts how ethical commitments are operationalized through coordinated alignment across governance, curriculum, and pedagogy. At the micro level (G1), illustrative pedagogical and assessment practices may include narrative-based reflective exercises and scenario-informed assessments (e.g., narrative OSCEs), demonstrating how public-responsibility ethics can be translated into observable competencies. Arrow legend: Downward arrows indicate policy-driven curricular alignment, institutional mandate, and resource support flowing from G3 to G2 and G1; upward arrows represent evaluative feedback generated from teaching and assessment practices at G1 and G2, which informs continuous curricular adjustment and policy refinement at the macro level. The framework operationalizes the structural–ethical logic identified in the comparative analysis. Implications for global HH education and research Beyond the cases examined, this review underscores the importance of de-centering Western paradigms in HH. By demonstrating functionally equivalent manifestations of the "structural turn," it affirms the legitimacy of diverse ethical-institutional pathways. For global medical schools, the framework offers a practical diagnostic toolkit. It is extensible to other settings (e.g., welfare-state or resource-constrained systems). The PR-HH model, in particular, illustrates how policy-aligned systems can leverage governance mandates while building assessment capacity and faculty expertise—an urgent task amid digital and AI-driven transformations [ 11 ]. Implementation will require phased, context-sensitive adoption to address challenges related to faculty capacity and variable policy enactment. Limitations Several limitations should be acknowledged. First, restricting the review to literature published between 2016 and 2024 may underrepresent earlier curricular developments. Second, the three national cases were purposively selected using a maximum-variation sampling strategy to support theory building on the relationship between governance–ethics configurations and curricular institutionalization. While this design does not aim for global representativeness, it strengthens internal validity and enhances the transferability of the analytic framework by clarifying the boundary conditions under which different institutionalization pathways emerge. Third, reliance on published literature may introduce publication bias and underrepresent informal or undocumented curricular practices. Finally, despite searches in English- and Chinese-language databases, language bias remains possible, particularly with respect to Japanese publications that may not be indexed in the databases searched. These limitations should be considered when interpreting the findings, which are intended to support analytic comparison and framework development rather than exhaustive global mapping. Future studies could extend this framework to additional governance types, including European welfare-state systems and resource-constrained health systems. Further research is also needed to examine how emerging domains such as digital health ethics and AI-mediated care can be meaningfully integrated into HH curricula across diverse institutional contexts. In addition, future research should empirically test the utility of the G1–G3 embedding model and Structural Maturity Scale as an audit framework in diverse medical schools, assessing how their application informs curriculum planning, faculty development, and cross-level alignment over time. Conclusion This scoping review demonstrates that the transition from MH to HH is not a linear global progression but a context-dependent transformation shaped by national ethical traditions and institutional logics. We identified three coherent ethical-institutional configurations in the U.S., Japan, and China that provide distinct yet functionally valid pathways for cultivating structural awareness. By introducing a non-normative comparative framework integrating curricular embedding(G1–G3) with structural maturity, this study advances methodological tools for HH research and evaluation beyond Western-centric standards. From a practical standpoint, the framework offers a diagnostic tool for auditing curricula and identifying alignment gaps. While subject to the limitations of scoping reviews, these findings establish a foundation for future longitudinal and outcome-oriented research. Ultimately, the sustainability of Health Humanities in global medical education depends on developing context-sensitive, institutionally grounded, and ethically pluralistic curricula capable of preparing clinicians for the complex structural realities of contemporary care. Abbreviations HH, Health Humanities MH, Medical Humanities PR-HH, Public-Responsibility Health Humanities PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Declarations Authors’ contributions The authors made the following contributions using the CRediT (Contributor Roles Taxonomy). Mingzhu Yang: Conceptualization, Methodology, Formal analysis, Writing – original draft, Project administration, Funding acquisition. Shuang Chai: Methodology, Investigation, Data curation. Junxin Li: Conceptualization, Supervision, Writing – review & editing. Angela Chang Chiu: Investigation, Writing – review & editing. Jinsong Pan: Data curation. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ethics approval and consent to participate Ethics approval and informed consent were not required because this scoping review used only published literature and publicly available policy documents and did not involve human participants or identifiable personal data. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Additional information is available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding/Support This study was supported by the Shanghai Jiao Tong University (SJTU) Humanistic Research Program (Grant No. JYSR25213) under the project “Cross-Cultural Medical Humanities Education: A Comparative Study” (2025–present). Acknowledgements The authors thank members of the research team for their contributions to data collection and project coordination. We also thank Stella for assistance with literature searching and development of the search strategy. Conflict of Interest The authors declare no competing interests. Submission Note This manuscript has not been published elsewhere and is not under consideration by another journal. References Ormond, M., & Lunt, N. (2020). Transnational medical travel: patient mobility, shifting health system entitlements and attachments. Journal of Ethnic and Migration Studies, 46(20), 4179–4192. https://doi.org/10.1080/1369183X.2019.1597465 Koehn PH. 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Med Humanit. 2015 Jun;41(1):2-7. doi: 10.1136/medhum-2015-010692. PMID: 26052111; PMCID: PMC4484495. Klugman CM, Bracken RC, Weatherston RI, et al. Developing New Academic Programs in the Medical/Health Humanities: A Toolkit to Support Continued Growth. J Med Humanit. 2021 Dec;42(4):523-534. doi: 10.1007/s10912-021-09710-5. Epub 2021 Sep 16. PMID: 34528169; PMCID: PMC8443396. Crawford P. Introduction: global health humanities and the rise of creative public health. In: Crawford P, ed. The Routledge Companion to Health Humanities. London: Routledge; 2020:1–8. https://doi.org/10.4324/9780429469060-1 Atkinson S, Evans B, Woods A, Kearns R. 'The medical' and 'health' in a critical medical humanities. J Med Humanit. 2015 Mar;36(1):71-81. doi: 10.1007/s10912-014-9314-4. PMID: 25502919; PMCID: PMC4352602. Atkinson, Sarah et al., eds. The Edinburgh Companion to the Critical Medical Humanities. Edinburgh: Edinburgh University Press, 2018. Web. Tumuhimbise W, Theuring S, Atukunda EC, et al. Opportunities and challenges of integrating digital health into medical education curricula: A scoping review. Res Sq [Preprint]. 2025 Mar 25:rs.3.rs-6254999. doi: 10.21203/rs.3.rs-6254999/v1. PMID: 40195979; PMCID: PMC11975014. Bleakley A. Medical humanities and medical education: how the medical humanities can shape better doctors. London: Routledge; 2015. https://doi.org/10.4324/9781315771724 Fitzgerald D, Callard F. Social Science and Neuroscience beyond Interdisciplinarity: Experimental Entanglements. Theory Cult Soc. 2015 Jan;32(1):3-32. doi: 10.1177/0263276414537319. PMID: 25972621; PMCID: PMC4425296. Thome H. Comparative historical social research. Hist Soc Res. 1992;17(1):123–129. Howick J, Zhao L, McKaig B, et al. Do medical schools teach medical humanities? Review of curricula in the United States, Canada and the United Kingdom. J Eval Clin Pract. 2022 Feb;28(1):86-92. doi: 10.1111/jep.13589. Epub 2021 Jun 8. PMID: 34105226. Caves KM, Rageth L, Renold U. Apples inside orange peels: Exploring the use of functional equivalents for comparing curriculum processes across contexts. Res Comp Int Educ. 2024 Jun 12;19(3):261-280. doi: 10.1177/17454999241258928. PMID: 39267916; PMCID: PMC11387131 Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. https://doi.org/10.1080/1364557032000119616 Peters MDJ, Marnie C, Colquhoun H,et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev. 2021 Oct 8;10(1):263. doi: 10.1186/s13643-021-01821-3. PMID: 34625095; PMCID: PMC8499488. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018 Oct 2;169(7):467-473. doi: 10.7326/M18-0850. Epub 2018 Sep 4. PMID: 30178033. Palinkas LA, Horwitz SM, Green CA, et al. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015 Sep;42(5):533-44. doi: 10.1007/s10488-013-0528-y. PMID: 24193818; PMCID: PMC4012002. Patton MQ. Qualitative research and evaluation methods. 4th ed. Thousand Oaks: Sage; 2015. Shirai C, Nonaka D, Kobayashi J. Evaluating the cross-cultural competence instrument for healthcare professionals (CCCHP) among nurses in Okinawa, Japan. BMC Health Serv Res. 2024 Mar 23;24(1):369. doi: 10.1186/s12913-024-10814-6. PMID: 38521940; PMCID: PMC10960992. Lee KW. 150 Years of Medical History Education in Japan: History and Challenges. Uisahak. 2023 Aug;32(2):661-696. English. doi: 10.13081/kjmh.2023.32.661. PMID: 37718565; PMCID: PMC10556414. Balhara KS, Regan L, Chopra E, Irvin N. Bringing abstract concepts to life: A health humanities-based approach to teaching social determinants of health. AEM Educ Train. 2024 Feb 9;8(1):e10934. doi: 10.1002/aet2.10934. PMID: 38510731; PMCID: PMC10950014. Liu EY, Batten JN, Merrell SB, Shafer A. The long-term impact of a comprehensive scholarly concentration program in biomedical ethics and medical humanities. BMC Med Educ. 2018 Aug 28;18(1):204. doi: 10.1186/s12909-018-1311-2. PMID: 30153822; PMCID: PMC6114241. Liang X, Wan C, Chu C. Curriculum development of medical humanities based on the “Five-in-One” model under the Healthy China initiative. Educ Teach Forum. 2024;(51):161–164. [Chinese] Guo Z, Su C, He H. Application of narrative medicine combined with objective structured clinical examination in urology internship teaching. China Health Ind. 2024;12(a):192–195. [Chinese] Medical Education Model Core Curriculum Expert Research Committee. Model core curriculum for medical education in Japan: 2022 revision. Tokyo: Ministry of Education, Culture, Sports, Science and Technology; 2023. Available from: https://www.mext.go.jp/content/20230323-mxt_igaku-000028108_00003.pdf National Health Commission of the People's Republic of China. Action Plan for Enhancing Medical Humanistic Care (2024–2027). Beijing: NHC; 2024. Available from: http://www.gov.cn/zhengce/zhengceku/202410/content_6979036.htm [cited 2025 Dec 27]. Zhai H, Xue J, Wu H, et al. A national perspective: integrating medical humanities to address burnout and stress in Chinese medical education. BMC Med Educ. 2025 Feb 25;25(1):304. doi: 10.1186/s12909-025-06875-8. PMID: 40001154; PMCID: PMC11863532. Carr SE, Noya F, Phillips B, et al. Health Humanities curriculum and evaluation in health professions education: a scoping review. BMC Med Educ. 2021 Nov 10;21(1):568. doi: 10.1186/s12909-021-03002-1. PMID: 34753482; PMCID: PMC8579562. DallaPiazza M, Ayyala MS, Soto-Greene ML. Empowering future physicians to advocate for health equity: A blueprint for a longitudinal thread in undergraduate medical education. Med Teach. 2020 Jul;42(7):806-812. doi: 10.1080/0142159X.2020.1737322. Epub 2020 Mar 17. PMID: 32180494. White-Davis T, Edgoose J, Brown Speights JS, et al. Addressing Racism in Medical Education An Interactive Training Module. Fam Med. 2018 May;50(5):364-368. doi: 10.22454/FamMed.2018.875510. PMID: 29762795. Volpe R, Aprile J, Cooper A, et al. Reforming a Health Humanities curriculum: Incorporating social justice into medical education[J]. Studi di Sociologia, 2023: 65-82. https://doi.org/10.26350/000309_000176 Kagawa Y, Ishikawa H, Son D, et al. Using patient storytelling to improve medical students' empathy in Japan: a pre-post study. BMC Med Educ. 2023 Jan 27;23(1):67. doi: 10.1186/s12909-023-04054-1. PMID: 36707818; PMCID: PMC9881337. Bano S, Xia Q, Dirkx J. Developing Intercultural Competency in a Public Health Study Abroad Program: What Does Cultural Learning Mean for Undergraduate Chinese Students?[J]. Journal of Comparative and International Higher Education, 2022, 14(4): 6-21. Haruta J, Urushibara-Miyachi Y, Ito S, et al. The impact of core curriculum revisions on Japanese medical schools: Navigating curriculum evolution. Med Teach. 2024 Sep;46(sup1):S67-S75. doi: 10.1080/0142159X.2024.2346366. Epub 2024 Nov 15. PMID: 39545501. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8469352","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634288331,"identity":"1b34a67b-7ba5-4e8a-b9a4-95f50085b4e6","order_by":0,"name":"Mingzhu Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYBACxmYog5+Zsf3HBwY2MEeCKC2S7c0NkjMY2CQIaoEDgzPHG6R5oKrxamFu5z384eOO2jyGG4kNxjZ/+OoMDjAfvM3DYJeH22F8aZIzzxwvZpyR2JCc28YmYXCALdmahyG5GLcWHjNm3rZjic0SiQ2HcxtAWnjMgC48kNiAW4vxZ5CWNonExmaLPyAt/N8IaTGQ5m2rSezhOdjMzMAGtoWNkBYzyZltB4ol2BvbGHvb2CRnHmYztpxjkIxTi2H/GeMPH9vq8uwPsz9j+PHnGD/f8eaHN95U2OHWApE4nADlHwOGO4g2wKEeCOQhVB1MSw1upaNgFIyCUTBiAQA80VUjhE2zggAAAABJRU5ErkJggg==","orcid":"","institution":"Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Mingzhu","middleName":"","lastName":"Yang","suffix":""},{"id":634288332,"identity":"35a89fe4-055f-4178-9d0c-644b83a4640b","order_by":1,"name":"Shuang Chai","email":"","orcid":"","institution":"Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Chai","suffix":""},{"id":634288333,"identity":"17de5913-7470-4ded-a0e3-45a07d05e8d5","order_by":2,"name":"Jinsong Pan","email":"","orcid":"","institution":"Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jinsong","middleName":"","lastName":"Pan","suffix":""},{"id":634288334,"identity":"cb742c1a-920e-4eff-b991-e5cfeab9b317","order_by":3,"name":"Angela Chang Chiu","email":"","orcid":"","institution":"Johns Hopkins School of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"Chang","lastName":"Chiu","suffix":""},{"id":634288335,"identity":"47c9798e-caf9-407b-b01c-886fc8d318be","order_by":4,"name":"Junxin Li","email":"","orcid":"","institution":"Johns Hopkins School of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Junxin","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-12-29 05:23:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8469352/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8469352/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108644171,"identity":"5f1b0cdb-be68-4798-9bac-23b945b8a500","added_by":"auto","created_at":"2026-05-06 21:32:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":386153,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSee image above for figure legend\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/9d4249fddc81717a0f8ba8b7.png"},{"id":108644173,"identity":"37aec7ac-035c-4c22-9d3e-97bc42d92438","added_by":"auto","created_at":"2026-05-06 21:32:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3458792,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/40a3a553b9344a3be66ad2ec.png"},{"id":108644176,"identity":"073a1df5-f14c-4e3f-8682-c514306d544c","added_by":"auto","created_at":"2026-05-06 21:32:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":441741,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOperational Framework for a Public-Responsibility Health Humanities (PR-HH) Model in the Chinese Context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis figure illustrates a vertically integrated PR-HH framework spanning the macro (G3), meso (G2), and micro (G1) levels, supported by two cross-cutting infrastructures: interdisciplinary faculty development and competency-based assessment. The model depicts how ethical commitments are operationalized through coordinated alignment across governance, curriculum, and pedagogy. At the micro level (G1), illustrative pedagogical and assessment practices may include narrative-based reflective exercises and scenario-informed assessments (e.g., narrative OSCEs), demonstrating how public-responsibility ethics can be translated into observable competencies.\u003c/p\u003e","description":"","filename":"24.png","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/a583671c90a49b3435094464.png"},{"id":108809419,"identity":"e8cb03f0-4ee4-48e3-be41-40f2f3ff9c20","added_by":"auto","created_at":"2026-05-08 15:52:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4105924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/905e41ec-f6be-4e98-87b6-838d8115d64e.pdf"},{"id":108805128,"identity":"deb580e2-e7ff-4898-8379-997d147b0045","added_by":"auto","created_at":"2026-05-08 15:24:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13750,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/03e31ec04f46c44e52442c9e.docx"},{"id":108805148,"identity":"13d85a78-220a-4e29-8add-7e10ea5c7c91","added_by":"auto","created_at":"2026-05-08 15:24:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26653,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1TableS52025.docx","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/e58ef9c373a35cedf81b1cdd.docx"},{"id":108644175,"identity":"7c039ecb-9772-41f5-86b6-d41d8978d869","added_by":"auto","created_at":"2026-05-06 21:32:04","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":92771,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMAScRChecklist2025.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8469352/v1/45cbb8290fe2e73d950e5827.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Medical to Health Humanities: A Cross-National Scoping Review of Structural–Ethical Curricular Models in the United States, Japan, and China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs health systems increasingly demand that clinicians navigate complex institutional, social, and policy environments, medical education must prepare learners to recognize and respond to structural determinants of health [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This imperative extends beyond individual patient encounters, requiring competencies that enable future clinicians to interpret how organizational arrangements, governance, and policy shape practice and professional responsibility.\u003c/p\u003e \u003cp\u003eHistorically, Medical Humanities (MH) curricula have focused on empathy, narrative competence, and moral reflection within the clinician-patient relationship [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While foundational, MH has been critiqued for operating primarily within an interpersonal ethical frame, offering limited leverage for analyzing institutional drivers of inequity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In response, the field has increasingly adopted the broader framework of Health Humanities (HH), which foregrounds structural ethics, institutional accountability, and the governance dimensions of care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. MH and HH are not mutually exclusive but represent evolving emphases, with HH explicitly extending humanistic inquiry into domains of structure, power, and policy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite growing interest, HH curricular integration remains uneven and difficult to compare cross-nationally. Two key limitations persist. First, evaluations often rely on implicit normative benchmarks\u0026mdash;typically grounded in Euro-American expectations\u0026mdash;often rooted in Euro-American normative assumptions, risking deficit-oriented interpretations of difference [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Second, common curriculum design frameworks prioritize instructional coherence but lack analytical tools to examine how humanistic curricula are institutionally embedded, assessed, and sustained under divergent governance conditions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Consequently, cross-context variation is often described rather than systematically interpreted, hindering the generation of transferable insights.\u003c/p\u003e \u003cp\u003eThis study bridges these gaps by introducing and applying a diagnostic analytic framework designed for non-normative, cross-national comparison. This framework integrates: (i) a three-level model of curricular embedding\u0026mdash;micro (G1: interpersonal/reflective practices), meso (G2: course/program structures), and macro (G3: system/policy integration); and (ii) a Structural Maturity Scale (0\u0026ndash;3) capturing institutionalization depth. Guided by the principle of functional equivalence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], this approach compares how curricula across contexts fulfil shared educational functions (e.g., cultivating structural awareness), rather than judging them against a single normative model.\u003c/p\u003e \u003cp\u003eApplying this framework, we conducted a scoping review of MH/HH curricula (2016\u0026ndash;2024) across three purposively selected settings: the United States, Japan, and China. These cases represent analytically contrasting contexts reflecting distinct ethical-institutional configurations\u0026mdash;rights-based pluralism, relational collectivism, and governance-centered public responsibility\u0026mdash;rather than hierarchical stages of development. This review addresses three questions:\u003c/p\u003e \u003cp\u003e \u003cp\u003e1. How are MH/HH curricula institutionally embedded across differing governance contexts (G1\u0026ndash;G3)?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e\u003cp\u003e2. How is the \"structural turn\" operationalized through distinct ethical-institutional configurations?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cp\u003e3. How can structural maturity and curricular integration be assessed using context-sensitive analytic tools?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBy foregrounding institutional embedding and function-based comparison, this study offers a practical framework for researchers and educators to examine, compare, and adapt HH curricula across heterogeneous systems without presuming a single maturity trajectory.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a scoping review following Arksey and O\u0026rsquo;Malley [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and subsequent refinements [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], reporting in accordance with PRISMA-ScR [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This approach was chosen to map conceptual orientations and curricular structures in a heterogeneous, evolving field, rather than to evaluate intervention effectiveness [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRationale for Case Selection: Purposive Maximum-Variation Sampling\u003c/h3\u003e\n\u003cp\u003eThe United States, Japan, and China were selected via purposive maximum-variation sampling [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] to examine how HH institutionalization manifests under contrasting conditions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. They represent distinct configurations: (1) U.S. rights-based pluralism shaped by accreditation and decentralized governance; (2) Japanese relational collectivism emphasizing harmony and narrative reciprocity; and (3) Chinese governance-centered public responsibility characterized by policy mandates aligning education with national health priorities. These serve as an analytic lens, not as fixed national essences.\u003c/p\u003e\n\u003ch3\u003eSearch Strategy and Data Sources\u003c/h3\u003e\n\u003cp\u003eWe searched PubMed, Web of Science Core Collection, ERIC, CINAHL, and CNKI for publications from January 1, 2016, to December 31, 2024. The start date was selected to capture literature following the consolidation of \u0026ldquo;structural turn\u0026rdquo; frameworks in health professions education, with structural competency serving as a key conceptual anchor [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Search strategies combined terms for (i) MH/HH, (ii) structural/cultural/ethical constructs, (iii) curriculum/medical education, and (iv) national identifiers. Full strategies are in Supplementary Tables S1\u0026ndash;S5. Representative strings are shown below.\u003c/p\u003e\n\u003ch3\u003ePubMed (representative):\u003c/h3\u003e\n\u003cp\u003e(\"students medical\"[MeSH] OR \"faculty medical\"[MeSH] OR \"health personnel\"[MeSH] OR \"physicians\"[MeSH] OR \"internship and residency\"\u003c/p\u003e \u003cp\u003e[MeSH] OR \"medical student*\"[tiab] OR \"resident*\"[tiab] OR \"physician*\"\u003c/p\u003e \u003cp\u003e[tiab] OR \"medical educator*\"[tiab])\u003c/p\u003e \u003cp\u003eAND (\"cultural competency\"[MeSH] OR \"health equity\"[MeSH] OR \"cultural humility\"[Title] OR \"structural competency\"[Title] OR \"structural violence\"[Title] OR \"medical humanities\"[Title] OR \"cross-cultural\"[Title] OR \"health humanities\"[Title] OR \"narrative medicine\"[Title])\u003c/p\u003e \u003cp\u003eAND (\"education medical\"[MeSH] OR \"curriculum\"[MeSH] OR \"teaching\" [Title] OR \"assessment\"[Title] OR \"competency-based education\"[Title])\u003c/p\u003e \u003cp\u003eAND (\"China\"[All Fields] OR \"Japan\"[All Fields] OR \"United States\"[All Fields] OR \"USA\"[All Fields])\u003c/p\u003e \u003cp\u003eAND 2016/1/1:2024/12/31[pdat]; English/Japanese/Chinese\u003c/p\u003e\n\u003ch3\u003eCNKI (representative):\u003c/h3\u003e\n\u003cp\u003e(TI='医学人文' OR AB='医学人文' OR KY='医学人文' OR TI='健康人文'AB='健康人文' OR KY='健康人文' OR TI='叙事医学' OR AB='叙事医学' OR KY='叙事医学' OR TI='医学叙事' OR AB='医学叙事' OR KY='医学叙事' OR TI='叙事反思' OR AB='叙事反思' OR KY='叙事反思' OR TI='文化谦逊' OR AB='文化谦逊' OR KY='文化谦逊' OR TI='文化敏感性' OR AB='文化敏感性' OR KY='文化敏感性' OR TI='跨文化' OR AB='跨文化' OR KY='跨文化' OR TI='文化能力' OR AB='文化能力' OR KY='文化能力' OR TI='结构能力' OR AB='结构能力' OR KY='结构能力' OR TI='结构性暴力' OR AB='结构性暴力' OR KY='结构性暴力' OR TI='健康公平' OR AB='健康公平' OR KY='健康公平')\u003c/p\u003e \u003cp\u003eAND (TI='医学生' OR AB='医学生' OR KY='医学生' OR TI='医学教师' OR AB='医学教师' OR KY='医学教师' OR TI='医务人员' OR AB='医务人员' OR KY='医务人员' OR TI='临床医师' OR AB='临床医师' OR KY='临床医师' OR TI='住院医师' OR AB='住院医师' OR KY='住院医师' OR TI='医学教育者' OR AB='医学教育者' OR KY='医学教育者')\u003c/p\u003e \u003cp\u003eAND (TI='课程' OR AB='课程' OR KY='课程' OR TI='教学' OR AB='教学' OR KY='教学' OR TI='教育' OR AB='教育' OR KY='教育' OR TI='课程改革' OR AB='课程改革' OR KY='课程改革' OR TI='能力本位教育' OR AB='能力本位教育' OR KY='能力本位教育' OR TI='反思写作' OR AB='反思写作' OR KY='反思写作' OR TI='人文素养' OR AB='人文素养' OR KY='人文素养')\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAND 20160101\u0026ndash;20241231\u003c/h2\u003e \u003cp\u003eTargeted policy documents referenced by included curricula were reviewed for G3 contextualization only and were not analyzed as empirical studies.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria and Study Selection\u003c/h3\u003e\n\u003cp\u003eIncluded studies:(1) described a structured MH/HH curriculum/module/\u003c/p\u003e \u003cp\u003eprogram; (2) were embedded in undergraduate, graduate, or residency medical education in the U.S., Japan, or China; (3) linked activities to competencies/frameworks addressing structural, cultural, or ethical dimensions of care. We excluded opinion pieces, single workshops without institutional embedding, and instrument-validation studies without curricular implementation.\u003c/p\u003e \u003cp\u003eTwo reviewers independently screened titles/abstracts and full texts. Discrepancies were resolved through discussion or third-reviewer adjudication. The selection process is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDiagram description: Database searches yielded 4,140 records; 14 additional records were identified. After deduplication (n\u0026thinsp;=\u0026thinsp;3,473 screened), 112 publications were included in the qualitative synthesis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Extraction\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData were extracted using a standardized matrix capturing: ethical orientation; curricular structure and embedding level (G1\u0026ndash;G3); pedagogical modalities; assessment strategies; and referenced structural/ethical frameworks. Two reviewers independently extracted data and assigned structural maturity scores, resolving discrepancies through iterative discussion. The data extraction matrix was pilot-tested on a subset of studies and refined prior to full extraction.\u003c/p\u003e\n\u003ch3\u003eConceptual Definitions and Analytic Framework\u003c/h3\u003e\n\u003cp\u003eStructural ethics refers to the institutionalization of ethical commitments through curricular structures and governance. The principle of functional equivalence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] guided comparison, focusing on how curricula fulfil shared educational functions rather than comparing surface features.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe integrated analytic framework comprised\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cp\u003e1. G1\u0026ndash;G3 Embedding Model: Micro (G1), Meso (G2), Macro (G3).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cp\u003e2. Structural Maturity Scale (0\u0026ndash;3): capturing varying depths of institutionalization rather than hierarchical stages of development.\u003c/p\u003e \u003c/li\u003e \u003cp\u003e(1)0 = Isolated activity\u003c/p\u003e\n\u003cp\u003e(2)1 = Described curriculum without formal institutionalization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(3)2 = Institutionalized curriculum with weak/inconsistent assessment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(4)3 = Fully institutionalized curriculum with formal assessment and explicit alignment to a structural-ethical framework.\u003c/p\u003e \u003cp\u003eMaturity scores were assigned based on published evidence through iterative reviewer consensus.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Synthesis\u003c/h2\u003e \u003cp\u003eSynthesis occurred in two stages:(1) within-case mapping of G1\u0026ndash;G3 distributions, pedagogical/assessment patterns, and maturity scores; (2) cross-case interpretation linking institutionalization patterns to the three ethical-institutional configurations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOverview of Included Studies\u003c/h2\u003e \u003cp\u003eAfter screening,112 publications met eligibility criteria (U.S.: n\u0026thinsp;=\u0026thinsp;67; China: n\u0026thinsp;=\u0026thinsp;32; Japan: n\u0026thinsp;=\u0026thinsp;13) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most described formally embedded curricula (e.g., longitudinal threads, required modules) linking objectives to competency frameworks addressing ethical, cultural, or structural dimensions. A subset addressed emerging themes like digital health ethics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDistribution of HH curricula across structural embedding levels (G1\u0026ndash;G3)\u003c/h2\u003e \u003cp\u003eDistinct national patterns emerged in how curricula were distributed across embedding levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG1 (Micro)\u003c/strong\u003e \u003cp\u003eInitiatives across all settings emphasized empathy, narrative medicine, and reflective practice. In Japan, G1 studies often involved developing empathy/cross-cultural competence instruments, with variable integration into routine assessment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG2 (Meso)\u003c/strong\u003e \u003cp\u003eRequired modules and longitudinal threads were reported more in the U.S. and China than Japan. U.S. studies described equity-oriented longitudinal curricula aligned with accreditation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Chinese studies reported reforms integrating \"humanized care\" into structured curricula, with variable assessment formalization [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG3(Macro)\u003c/strong\u003e \u003cp\u003eIntegration differed substantially. In Japan, national competency frameworks (e.g., Model Core Curriculum 2022) articulated outcomes, but translation into sustained program structures varied [28,38]. In China, curricula were explicitly linked to national policy and licensure requirements [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the U.S., studies reflected accreditation standards and professional expectations within a decentralized model.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStructural maturity (0\u0026ndash;3) and institutionalization patterns\u003c/h2\u003e \u003cp\u003eMaturity scores indicated systematic cross-national differences across embedding levels and institutionalization dimensions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eUnited States\u003c/strong\u003e \u003cp\u003eCurricula frequently met Level 3 criteria at G2/G3,\u003c/p\u003e \u003c/p\u003e \u003cp\u003echaracterized by longitudinal integration, credit-bearing status, and formalized assessment aligned with accreditation and equity goals [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eJapan\u003c/b\u003e: A bimodal pattern was observed: strong policy-level articulation (G3) coexisted with concentrated G1 activity, while sustained, mature G2 program architectures were less commonly reported [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChina\u003c/strong\u003e \u003cp\u003eCurricula were most often Level 2, reflecting clear policy-driven embedding (G3) and programmatic integration (G2), alongside evolving but inconsistently formalized assessment at G1/G2 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003eTaken together, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA visually captures a central pattern: institutionalization profiles vary in form and emphasis across contexts, aligning with distinct governance\u0026ndash;ethical configurations rather than reflecting a linear hierarchy of curricular maturity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA. \u003cb\u003eComparative structural maturity and institutionalization of HH curricula across the United States, Japan, and China.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Left) Mean structural maturity scores (0\u0026ndash;3) across three embedding levels: G1 (micro-level pedagogical practices), G2 (meso-level programmatic integration), and G3 (macro-\u003c/p\u003e \u003cp\u003elevel institutional/governance alignment).\u003c/p\u003e \u003cp\u003e(Right) Radar chart summarizing cross-national institutionalization profiles across three dimensions: curricular integration, formalization of assessment mechanisms, and alignment with external standards. Scores reflect patterns derived from qualitative synthesis and indicate relative institutionalization patterns across contexts rather than a linear or hierarchical ordering of performance. Scores are interpretive summaries of institutionalization patterns reported in the literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFunctional equivalence and ethical\u0026ndash;institutional configurations\u003c/h2\u003e \u003cp\u003eGuided by functional equivalence, analysis identified three configurations fulfilling the shared function of cultivating structural awareness (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eRights-Based Pluralism (United States)\u003c/b\u003e: Emphasizes social accountability, equity, anti-racism, and structural competency [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eRelational Collectivism (Japan)\u003c/b\u003e: Emphasizes emotional attunement, narrative reciprocity, and relational interdependence [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGovernance-Centered Public Responsibility (China; hereafter\u003c/b\u003e, \u003cb\u003epublic-responsibility logic\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e: Aligns humanistic competencies with national policy priorities, social trust, and collective welfare through state-mediated adaptation of global concepts [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis figure summarizes three dominant ethical orientations identified in the included curricula: rights-based pluralism (United States), relational collectivism (Japan), and governance-centered public responsibility (China). Each configuration represents a distinct pattern of ethical assumptions, pedagogical emphases, and assessment tendencies. Arrows indicate conceptual dialogue and recurring points of tension among the configurations, illustrating how the \u0026ldquo;structural turn\u0026rdquo; is translated across cultural and governance contexts without implying a directional or hierarchical relationship.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCross-cutting implementation patterns and recurrent structural tensions\u003c/h2\u003e \u003cp\u003eNarrative and reflective pedagogies were widely reported. Community-engaged learning was prominent in U.S. curricula [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Assessment varied: U.S. studies reported mixed-methods and validated tools [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e]; Japanese studies emphasized qualitative feedback [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]; Chinese curricula reported policy-aligned exams and growing use of competency-based tools [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFour recurrent, structurally produced tensions were identified across contexts (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eC):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eT1: Experiential Depth vs. Measurability\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eT2: Policy Ambition vs. Institutional Capacity\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eT3: Clinical Productivity vs. Reflective Practice\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eT4: Self-Culture vs. Other-Culture Reflexivity\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eTheir salience varied: T2 and T3 were dominant in China; T1 was prominent in the U.S.; T4 was often implicit in Japan. When interpreted through the axes of the tension matrix, these tensions operate at different relational loci. T1 (experiential depth versus measurability) and T3 (clinical productivity versus reflective practice) were more closely associated with internal curricular design choices and pedagogical trade-offs. In contrast, T2 (policy ambition versus institutional capacity) and T4 (self-culture versus other-culture reflexivity) were more strongly shaped by external governance, policy environments, and sociocultural contexts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe matrix depicts four recurrent tensions observed across contexts: (T1) experiential depth versus measurability, (T2) policy ambition versus institutional capacity, (T3) clinical productivity versus reflective practice, and (T4) self-culture versus other-culture reflexivity. These tensions represent structurally produced features of embedding reflective and ethical education within biomedical training systems rather than remediable implementation barriers. They may co-occur across embedding levels and national contexts, and the matrix emphasizes their relational nature \u003cb\u003eby situating them along internal\u0026ndash;external and pedagogical\u0026ndash;systemic dimensions\u003c/b\u003e, rather than a linear pathway toward resolution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSynthesized cross-national comparison\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e synthesizes findings across the three contexts and functions as a non-normative audit heuristic, enabling educators and curriculum leaders to identify context-specific leverage points and vulnerabilities without implying hierarchical superiority.\u003c/p\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCross-National Comparison of Health Humanities (HH) Curricular Models\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eJapan\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eEducational Implications\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDominant Ethical Orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eRights-based pluralism; structural justice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eRelational collectivism; attunement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ePublic responsibility; collective welfare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eTailor pedagogy to local ethics for stronger PIF\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrimary Ethical Focus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eStructural inequities; anti-racism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eInterdependence; relational responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eDuties to state/institution; social trust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eIntegrate with interprofessional education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStructural Embedding (G1\u0026ndash;G3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eStrong G2\u0026ndash;G3; longitudinal/system-level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003ePredominantly G1/G3; limited G2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eStrong G2\u0026ndash;G3; policy-driven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eUse G1\u0026ndash;G3 to audit local embedding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStructural Maturity Pattern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eHigh Level 3; accreditation-aligned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eBimodal; fragmented G2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ePredominantly Level 2; evolving assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eTarget maturity gaps for faculty development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTypical Pedagogical Modalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCommunity-engaged; equity threads\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eNarrative; emotion-focused reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eNarrative; professionalism modules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eAdapt modalities to cultural reflexivity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRole of Humanities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCritical structural analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eCultivating empathy/harmony\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eReinforcing virtue/public duty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eLink to clinical simulations for transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAssessment Strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMixed-methods; validated tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eQualitative; research instruments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eExaminations; emerging competencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eDevelop hybrid tools aligned with accreditation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRecurrent Tensions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eT1, T3 prominent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eT1 salient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eT2, T3 dominant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eBuild tension-navigation into reflective portfolios\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFunctional Contribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAdvocacy-oriented clinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eRelationally attuned practitioners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eGovernance-aligned clinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eFoster adaptable professionals for global practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eA non-normative, structurally grounded framework for comparing HH curricula\u003c/h2\u003e \u003cp\u003eThis study makes a substantive methodological contribution to comparative health professions education by developing and applying a non-normative, structurally grounded framework for analyzing Health Humanities (HH) curricula. Moving beyond implicit Western benchmarks [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and guided by the principle of functional equivalence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], we reconceptualize HH not as a universal curricular model but as a structurally contingent practice\u0026mdash;shaped by deeply embedded ethical traditions and governance arrangements. Our findings from the United States, Japan, and China demonstrate that distinct ethical-institutional logics generate functionally comparable, yet institutionally divergent, pathways for cultivating structural awareness. This approach directly counters deficit-oriented comparisons and provides a generative \u0026ldquo;comparative grammar\u0026rdquo; for the field.\u003c/p\u003e \u003cp\u003eBy integrating the Structural Maturity Scale with the G1\u0026ndash;G3 embedding model, this study provides a \"comparative grammar\" linking ethical orientation to observable institutionalization patterns (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This framework reframes cross-national variation as alternative moral and institutional settlements concerning professional responsibility and medicine's role in society, rather than ranking curricula by presumed advancement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFrom ethical orientation to institutional configuration\u003c/h2\u003e \u003cp\u003eThe differences in structural maturity and G1\u0026ndash;G3 distributions illustrate how ethical commitments are translated into curricular form under specific governance conditions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn the United States\u003c/b\u003e, high maturity was associated with strong cross-level alignment: accreditation and social justice advocacy (G3) supported longitudinal program structures (G2), enabling sustained critical pedagogies (G1) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn China\u003c/b\u003e, strong G2\u0026ndash;G3 coupling with Level 2 maturity suggests top-down policy mandates effectively institutionalize HH at program/system levels, while pedagogical depth and consistent competency-based assessment at G1 remain under active development [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This pattern reflects known challenges, such as formalized assessment structures and uneven faculty preparation for humanities teaching.\u003c/p\u003e \u003cp\u003e \u003cb\u003eJapan\u0026rsquo;s\u003c/b\u003e bimodal pattern\u0026mdash;robust G3 frameworks and rich G1 practices but fewer sustained G2 structures\u0026mdash;reflects an institutional ecology where ethical cultivation is often embedded implicitly rather than programmatically [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This aligns with survey evidence showing rapid compliance with national curriculum revisions but heterogeneous meso-level restructuring across schools [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollectively, these findings underscore that curricular institutionalization is a sociopolitical process mediated by governance and culturally embedded norms of professionalism, not merely a matter of pedagogical design.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eStructural competence as a culturally mediated construct\u003c/h2\u003e \u003cp\u003eThese patterns challenge the notion of structural competence as a culturally neutral construct. What counts as \"structural,\" where ethical responsibility is located, and how clinicians should act on systemic determinants vary substantially (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eU.S. curricula frame it through social justice and critical theory, positioning physicians as advocates [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eJapanese curricula cultivate structural sensitivity indirectly through narrative reciprocity and emotional attunement, emphasizing relational harmony [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChinese curricula situate it within a logic of public responsibility, aligning practice with population health and state governance priorities [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese differences highlight the risks of superficial curriculum transfer without ethical-pedagogical translation, a concern heightened by emerging debates on digital health and AI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Effective education for structural competence thus requires culturally literate faculty development that connects local ethical vocabularies to shared structural challenges.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eRecurrent structural tensions as features of institutionalization\u003c/h2\u003e \u003cp\u003eThe four recurrent tensions(T1-T4) should be understood as enduring features of embedding a reflective field within efficiency-oriented biomedical training systems, not as remediable barriers. Effective HH curricula institutionalize pedagogical spaces where learners can recognize, analyze, and navigate these tensions. This process itself constitutes a core dimension of structural awareness, fostering a pragmatic, reflexive professional orientation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eOperationalizing the framework: toward a Public-Responsibility HH model for China\u003c/h2\u003e \u003cp\u003eBuilding on comparative insights, we propose an operational Public-Responsibility HH (PR-HH) model tailored to China (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This model illustrates how ethical commitments can be stabilized through coordinated G1-G3 alignment, leveraging governance capacity while addressing identified gaps in assessment and pedagogy.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG3 (Macro)\u003c/strong\u003e \u003cp\u003eNational policy, licensure exams, and certification standards\u003c/p\u003e \u003c/p\u003e \u003cp\u003eprovide legitimacy and resources.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG2 (Meso)\u003c/strong\u003e \u003cp\u003eInterdisciplinary core courses and longitudinal threads translate policy into sustained programs, mitigating the policy-capacity tension (T2).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eG1 (Micro)\u003c/strong\u003e \u003cp\u003ePedagogies like narrative reflection on policy-clinic interfaces and scenario-based assessment operationalize public-responsibility ethics, addressing clinical productivity tensions (T3) while strengthening competency development (T1).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eCrucially, the model conceptualizes faculty development and competency-based assessment as bidirectional infrastructures. Downward policy alignment is complemented by upward evaluative feedback, enabling data from G1/G2 teaching to inform curricular governance and policy refinement at G3. This creates a reflexive institutional ecology relevant to other policy-driven systems. Taken together, these analyses clarify both the methodological and practical implications of the proposed framework.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eResearch Significance\u003c/h2\u003e \u003cp\u003eThis study makes two key contributions:\u003c/p\u003e \u003cp\u003e \u003cspan\u003e \u003cp\u003e \u003cb\u003e1. Theoretical/Methodological\u003c/b\u003e: It advances comparative HH scholarship by providing a non-normative framework centered on functional equivalence and structural embedding. The counters Western-centric evaluative tendencies and offers a transferable diagnostic tool.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e\u003cp\u003e \u003cb\u003e2. Practical\u003c/b\u003e: For educators and policymakers, the G1-G3 model and Maturity Scale serve as an audit toolkit to identify misalignments between reflective practices, program design, and institutional support. The PR-HH model offers a concrete example of context-sensitive curriculum development.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis figure illustrates a vertically integrated PR-HH framework spanning the macro (G3), meso (G2), and micro (G1) levels, supported by two cross-cutting infrastructures: interdisciplinary faculty development and competency-based assessment. The model depicts how ethical commitments are operationalized through coordinated alignment across governance, curriculum, and pedagogy. At the micro level (G1), illustrative pedagogical and assessment practices may include narrative-based reflective exercises and scenario-informed assessments (e.g., narrative OSCEs), demonstrating how public-responsibility ethics can be translated into observable competencies.\u003c/p\u003e \u003cp\u003eArrow legend: Downward arrows indicate policy-driven curricular alignment, institutional mandate, and resource support flowing from G3 to G2 and G1; upward arrows represent evaluative feedback generated from teaching and assessment practices at G1 and G2, which informs continuous curricular adjustment and policy refinement at the macro level. The framework operationalizes the structural\u0026ndash;ethical logic identified in the comparative analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eImplications for global HH education and research\u003c/h2\u003e \u003cp\u003eBeyond the cases examined, this review underscores the importance of de-centering Western paradigms in HH. By demonstrating functionally equivalent manifestations of the \"structural turn,\" it affirms the legitimacy of diverse ethical-institutional pathways.\u003c/p\u003e \u003cp\u003eFor global medical schools, the framework offers a practical diagnostic toolkit. It is extensible to other settings (e.g., welfare-state or resource-constrained systems). The PR-HH model, in particular, illustrates how policy-aligned systems can leverage governance mandates while building assessment capacity and faculty expertise\u0026mdash;an urgent task amid digital and AI-driven transformations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Implementation will require phased, context-sensitive adoption to address challenges related to faculty capacity and variable policy enactment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations should be acknowledged.\u003c/p\u003e \u003cp\u003eFirst, restricting the review to literature published between 2016 and 2024 may underrepresent earlier curricular developments. Second, the three national cases were purposively selected using a maximum-variation sampling strategy to support theory building on the relationship between governance\u0026ndash;ethics configurations and curricular institutionalization. While this design does not aim for global representativeness, it strengthens internal validity and enhances the transferability of the analytic framework by clarifying the boundary conditions under which different institutionalization pathways emerge. Third, reliance on published literature may introduce publication bias and underrepresent informal or undocumented curricular practices. Finally, despite searches in English- and Chinese-language databases, language bias remains possible, particularly with respect to Japanese publications that may not be indexed in the databases searched.\u003c/p\u003e \u003cp\u003eThese limitations should be considered when interpreting the findings, which are intended to support analytic comparison and framework development rather than exhaustive global mapping.\u003c/p\u003e \u003cp\u003eFuture studies could extend this framework to additional governance types, including European welfare-state systems and resource-constrained health systems. Further research is also needed to examine how emerging domains such as digital health ethics and AI-mediated care can be meaningfully integrated into HH curricula across diverse institutional contexts. In addition, future research should empirically test the utility of the G1\u0026ndash;G3 embedding model and Structural Maturity Scale as an audit framework in diverse medical schools, assessing how their application informs curriculum planning, faculty development, and cross-level alignment over time.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review demonstrates that the transition from MH to HH is not a linear global progression but a context-dependent transformation shaped by national ethical traditions and institutional logics. We identified three coherent ethical-institutional configurations in the U.S., Japan, and China that provide distinct yet functionally valid pathways for cultivating structural awareness.\u003c/p\u003e \u003cp\u003eBy introducing a non-normative comparative framework integrating curricular embedding(G1\u0026ndash;G3) with structural maturity, this study advances methodological tools for HH research and evaluation beyond Western-centric standards. From a practical standpoint, the framework offers a diagnostic tool for auditing curricula and identifying alignment gaps. While subject to the limitations of scoping reviews, these findings establish a foundation for future longitudinal and outcome-oriented research.\u003c/p\u003e \u003cp\u003eUltimately, the sustainability of Health Humanities in global medical education depends on developing context-sensitive, institutionally grounded, and ethically pluralistic curricula capable of preparing clinicians for the complex structural realities of contemporary care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHH, Health Humanities\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;MH, Medical Humanities\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;PR-HH, Public-Responsibility Health Humanities\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors made the following contributions using the CRediT (Contributor Roles Taxonomy).\u003c/p\u003e\n\u003cp\u003eMingzhu Yang: Conceptualization, Methodology, Formal analysis, Writing \u0026ndash; original draft, Project administration, Funding acquisition.\u003c/p\u003e\n\u003cp\u003eShuang Chai: Methodology, Investigation, Data curation.\u003c/p\u003e\n\u003cp\u003eJunxin Li: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAngela Chang Chiu: Investigation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eJinsong Pan: Data curation.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and informed consent were not required because this scoping review used only published literature and publicly available policy documents and did not involve human participants or identifiable personal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files. Additional information is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Shanghai Jiao Tong University (SJTU) Humanistic Research Program (Grant No. JYSR25213) under the project \u0026ldquo;Cross-Cultural Medical Humanities Education: A Comparative Study\u0026rdquo; (2025\u0026ndash;present).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank members of the research team for their contributions to data collection and project coordination. We also thank Stella for assistance with literature searching and development of the search strategy.\u003c/p\u003e\u003cp\u003eConflict of Interest\u003c/p\u003e\n\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\n\u003cp\u003eSubmission Note\u003c/p\u003e\n\n\u003cp\u003eThis manuscript has not been published elsewhere and is not under consideration by another journal.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrmond, M., \u0026amp; Lunt, N. (2020). Transnational medical travel: patient mobility, shifting health system entitlements and attachments. Journal of Ethnic and Migration Studies, 46(20), 4179\u0026ndash;4192. https://doi.org/10.1080/1369183X.2019.1597465 \u003c/li\u003e\n\u003cli\u003eKoehn PH. Globalization, migration health, and educational preparation for transnational medical encounters. Global Health. 2006 Jan 30;2:2. doi: 10.1186/1744-8603-2-2. PMID: 16441899; PMCID: PMC1403753. \u003c/li\u003e\n\u003cli\u003eMetzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014 Feb;103:126-133. doi:10.1016/j.socscimed. 2013.06.032. PMID: 24507917; PMCID: PMC4269606. \u003c/li\u003e\n\u003cli\u003eCharon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001 Oct 17;286(15):1897-902. doi: 10.1001/jama.286.15.1897. PMID: 11597295.\u003c/li\u003e\n\u003cli\u003ePalla I, Turchetti G, Polvani S. Narrative Medicine: theory, clinical practice and education - a scoping review. BMC Health Serv Res. 2024 Sep 27;24(1):1116. doi: 10.1186/s12913-024-11530-x. PMID: 39334149; PMCID: PMC11428871. \u003c/li\u003e\n\u003cli\u003eViney W, Callard F, Woods A. Critical medical humanities: embracing entanglement, taking risks. Med Humanit. 2015 Jun;41(1):2-7. doi: 10.1136/medhum-2015-010692. PMID: 26052111; PMCID: PMC4484495. \u003c/li\u003e\n\u003cli\u003eKlugman CM, Bracken RC, Weatherston RI, et al. Developing New Academic Programs in the Medical/Health Humanities: A Toolkit to Support Continued Growth. J Med Humanit. 2021 Dec;42(4):523-534. doi: 10.1007/s10912-021-09710-5. Epub 2021 Sep 16. PMID: 34528169; PMCID: PMC8443396. \u003c/li\u003e\n\u003cli\u003eCrawford P. Introduction: global health humanities and the rise of creative public health. In: Crawford P, ed. The Routledge Companion to Health Humanities. London: Routledge; 2020:1\u0026ndash;8. https://doi.org/10.4324/9780429469060-1\u003c/li\u003e\n\u003cli\u003eAtkinson S, Evans B, Woods A, Kearns R. \u0026apos;The medical\u0026apos; and \u0026apos;health\u0026apos; in a critical medical humanities. J Med Humanit. 2015 Mar;36(1):71-81. doi: 10.1007/s10912-014-9314-4. PMID: 25502919; PMCID: PMC4352602. \u003c/li\u003e\n\u003cli\u003eAtkinson, Sarah et al., eds. The Edinburgh Companion to the Critical Medical Humanities. Edinburgh: Edinburgh University Press, 2018. Web.\u003c/li\u003e\n\u003cli\u003eTumuhimbise W, Theuring S, Atukunda EC, et al. Opportunities and challenges of integrating digital health into medical education curricula: A scoping review. Res Sq [Preprint]. 2025 Mar 25:rs.3.rs-6254999. doi: 10.21203/rs.3.rs-6254999/v1. PMID: 40195979; PMCID: PMC11975014.\u003c/li\u003e\n\u003cli\u003eBleakley A. Medical humanities and medical education: how the medical humanities can shape better doctors. London: Routledge; 2015. https://doi.org/10.4324/9781315771724 \u003c/li\u003e\n\u003cli\u003eFitzgerald D, Callard F. Social Science and Neuroscience beyond Interdisciplinarity: Experimental Entanglements. Theory Cult Soc. 2015 Jan;32(1):3-32. doi: 10.1177/0263276414537319. PMID: 25972621; PMCID: PMC4425296. \u003c/li\u003e\n\u003cli\u003eThome H. Comparative historical social research. 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Syst Rev. 2021 Oct 8;10(1):263. doi: 10.1186/s13643-021-01821-3. PMID: 34625095; PMCID: PMC8499488.\u003c/li\u003e\n\u003cli\u003eTricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018 Oct 2;169(7):467-473. doi: 10.7326/M18-0850. Epub 2018 Sep 4. PMID: 30178033.\u003c/li\u003e\n\u003cli\u003ePalinkas LA, Horwitz SM, Green CA, et al. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015 Sep;42(5):533-44. doi: 10.1007/s10488-013-0528-y. PMID: 24193818; PMCID: PMC4012002. \u003c/li\u003e\n\u003cli\u003ePatton MQ. Qualitative research and evaluation methods. 4th ed. Thousand Oaks: Sage; 2015. \u003c/li\u003e\n\u003cli\u003eShirai C, Nonaka D, Kobayashi J. Evaluating the cross-cultural competence instrument for healthcare professionals (CCCHP) among nurses in Okinawa, Japan. BMC Health Serv Res. 2024 Mar 23;24(1):369. doi: 10.1186/s12913-024-10814-6. PMID: 38521940; PMCID: PMC10960992. \u003c/li\u003e\n\u003cli\u003eLee KW. 150 Years of Medical History Education in Japan: History and Challenges. Uisahak. 2023 Aug;32(2):661-696. English. doi: 10.13081/kjmh.2023.32.661. PMID: 37718565; PMCID: PMC10556414.\u003c/li\u003e\n\u003cli\u003eBalhara KS, Regan L, Chopra E, Irvin N. Bringing abstract concepts to life: A health humanities-based approach to teaching social determinants of health. AEM Educ Train. 2024 Feb 9;8(1):e10934. doi: 10.1002/aet2.10934. PMID: 38510731; PMCID: PMC10950014. \u003c/li\u003e\n\u003cli\u003eLiu EY, Batten JN, Merrell SB, Shafer A. The long-term impact of a comprehensive scholarly concentration program in biomedical ethics and medical humanities. BMC Med Educ. 2018 Aug 28;18(1):204. doi: 10.1186/s12909-018-1311-2. PMID: 30153822; PMCID: PMC6114241. \u003c/li\u003e\n\u003cli\u003eLiang X, Wan C, Chu C. 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Available from: http://www.gov.cn/zhengce/zhengceku/202410/content_6979036.htm [cited 2025 Dec 27]. \u003c/li\u003e\n\u003cli\u003eZhai H, Xue J, Wu H, et al. A national perspective: integrating medical humanities to address burnout and stress in Chinese medical education. BMC Med Educ. 2025 Feb 25;25(1):304. doi: 10.1186/s12909-025-06875-8. PMID: 40001154; PMCID: PMC11863532. \u003c/li\u003e\n\u003cli\u003eCarr SE, Noya F, Phillips B, et al. Health Humanities curriculum and evaluation in health professions education: a scoping review. BMC Med Educ. 2021 Nov 10;21(1):568. doi: 10.1186/s12909-021-03002-1. PMID: 34753482; PMCID: PMC8579562. \u003c/li\u003e\n\u003cli\u003eDallaPiazza M, Ayyala MS, Soto-Greene ML. Empowering future physicians to advocate for health equity: A blueprint for a longitudinal thread in undergraduate medical education. Med Teach. 2020 Jul;42(7):806-812. doi: 10.1080/0142159X.2020.1737322. Epub 2020 Mar 17. PMID: 32180494. \u003c/li\u003e\n\u003cli\u003eWhite-Davis T, Edgoose J, Brown Speights JS, et al. Addressing Racism in Medical Education An Interactive Training Module. Fam Med. 2018 May;50(5):364-368. doi: 10.22454/FamMed.2018.875510. PMID: 29762795. \u003c/li\u003e\n\u003cli\u003eVolpe R, Aprile J, Cooper A, et al. Reforming a Health Humanities curriculum: Incorporating social justice into medical education[J]. Studi di Sociologia, 2023: 65-82. https://doi.org/10.26350/000309_000176\u003c/li\u003e\n\u003cli\u003eKagawa Y, Ishikawa H, Son D, et al. Using patient storytelling to improve medical students\u0026apos; empathy in Japan: a pre-post study. BMC Med Educ. 2023 Jan 27;23(1):67. doi: 10.1186/s12909-023-04054-1. PMID: 36707818; PMCID: PMC9881337. \u003c/li\u003e\n\u003cli\u003eBano S, Xia Q, Dirkx J. Developing Intercultural Competency in a Public Health Study Abroad Program: What Does Cultural Learning Mean for Undergraduate Chinese Students?[J]. Journal of Comparative and International Higher Education, 2022, 14(4): 6-21. \u003c/li\u003e\n\u003cli\u003eHaruta J, Urushibara-Miyachi Y, Ito S, et al. The impact of core curriculum revisions on Japanese medical schools: Navigating curriculum evolution. Med Teach. 2024 Sep;46(sup1):S67-S75. doi: 10.1080/0142159X.2024.2346366. Epub 2024 Nov 15. PMID: 39545501. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health Humanities, Medical Humanities, Structural Ethics, Structural Competence, Functional Equivalence, Curriculum Institutionalization, Cross-National Comparison, Medical Education, Public Responsibility","lastPublishedDoi":"10.21203/rs.3.rs-8469352/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8469352/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn response to health systems demanding clinician engagement with structural determinants of health, Health Humanities (HH) has emerged as a framework integrating structural ethics and institutional accountability. However, cross-national comparison of HH curricula remains constrained by normative benchmarks and inadequate tools for analyzing institutional embedding.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a scoping review (2016\u0026ndash;2024) of HH/Medical Humanities curricula in the United States, Japan, and China. We applied a novel diagnostic framework integrating a three-level embedding model (G1: micro, G2: meso, G3: macro) and a Structural Maturity Scale (0\u0026ndash;3, capturing varying depths of institutionalization, without implying hierarchy). Analysis was guided by functional equivalence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 112 included publications, curricula were prevalent at the micro-level (G1) across settings, but meso- and macro-level embedding varied significantly. U.S. curricula showed high maturity (Level 3) with longitudinal, accreditation-aligned integration. Japan exhibited a bimodal pattern (strong G3/G1, limited G2). China demonstrated strong policy-driven embedding (G3/G2) with Level 2 maturity, indicating evolving assessment. We identified three ethical-institutional configurations (rights-based pluralism, relational collectivism, governance-centered public responsibility) and four cross-cutting structural tensions (e.g., depth vs. measurability).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHH institutionalization follows context-dependent pathways shaped by governance and ethics. The integrated G1-G3 and Maturity Scale framework provides a non-normative, transferable tool for curriculum audit. The proposed Public-Responsibility HH model for China demonstrates how policy-aligned systems can leverage mandates to strengthen pedagogy and assessment.\u003c/p\u003e","manuscriptTitle":"From Medical to Health Humanities: A Cross-National Scoping Review of Structural–Ethical Curricular Models in the United States, Japan, and China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 21:32:00","doi":"10.21203/rs.3.rs-8469352/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-12T11:10:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T09:27:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83137197023595434299391994887972191293","date":"2026-05-04T16:16:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119692701693455585920985894993034265180","date":"2026-05-03T03:18:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22052062836583513407650868673248949279","date":"2026-05-01T15:21:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T18:02:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205834231298083518200790124034796626127","date":"2026-04-30T11:26:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22937424644904645213661494146223186537","date":"2026-04-30T11:03:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T12:38:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-20T10:27:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-01T21:56:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-01T21:56:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-29T05:15:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1a91e18-d86a-40b6-8e59-78bc52b93f1a","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-12T11:10:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T09:27:45+00:00","index":61,"fulltext":""},{"type":"reviewerAgreed","content":"83137197023595434299391994887972191293","date":"2026-05-04T16:16:48+00:00","index":60,"fulltext":""},{"type":"reviewerAgreed","content":"119692701693455585920985894993034265180","date":"2026-05-03T03:18:45+00:00","index":59,"fulltext":""},{"type":"reviewerAgreed","content":"22052062836583513407650868673248949279","date":"2026-05-01T15:21:57+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T18:02:48+00:00","index":55,"fulltext":""},{"type":"reviewerAgreed","content":"205834231298083518200790124034796626127","date":"2026-04-30T11:26:40+00:00","index":54,"fulltext":""},{"type":"reviewerAgreed","content":"22937424644904645213661494146223186537","date":"2026-04-30T11:03:53+00:00","index":53,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T11:26:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 21:32:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8469352","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8469352","identity":"rs-8469352","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}