Structural competency in pre-health and health professional learning: A scoping review.

Structural competency training provides guidance to healthcare providers on recognizing and addressing structural factors leading to health inequities. To inform the evidence-based progression of structural competency curriculum development, this study was designed to map the current state of the literature on structural competency training with pre-health students, healthcare professional students, and/or healthcare professionals. We performed a scoping review and identified peer-reviewed, primary research articles assessing structural competency training interventions. The category of learners, timing of the structural competency training, types of teaching and learning activities used, instruments used to measure training outcomes, and evaluation criteria were examined. Eleven (n = 11) articles met inclusion criteria, addressing all training levels, and largely focused on medical education. Active learning strategies and researcher-developed instruments to measure training outcomes were most used. Evaluation criteria largely focused on trainees' affective reactions, utility assessments, and direct measure of the trainee learning. We suggest designing interprofessional structural competency education with an emphasis on active learning strategies and standardized training curricula. Evaluation instruments integrated at different points in the health professional learning trajectory are important for evidence-based progression in curriculum development focused on achieving structural competency.

Advancements in Undergraduate Medical Education: Meeting the Challenges of an Evolving World of Education, Healthcare, and Technology.

Restructuring of undergraduate medical education (UGME) has occurred from time to time over the past century. Many influences, including the persuasive report of Abraham Flexner in 1910, acted to reorganize medical education in the early twentieth century [1, 2]. In his report, Flexner called on American medical schools to enact higher graduation standards and to stringently adhere to the protocols of mainstream science in their teaching. Prior to this report, UGME had changed little over the previous century but over the last several decades, reform within medical education has become routine. This increasing rate of change has been challenging for those within the realm of undergraduate medical education and can be frustrating to those outside this sphere. Today, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) are typically the driving forces behind such changes, along with acceleration of advances in medical care and technology. The number of changes in the last decade is significant and warrants review by those interested or involved in education of medical students. This article aims to provide a summary of recent changes within UGME. Within the article, changes in both the pre-clerkship (1st and 2nd years) and clinical years (3rd and 4th) will be discussed. Finally, this review will attempt to clarify new terminology and concepts such as the recently released Core Entrustable Professional Activities (EPAs). The goal of these UGME changes, as with Flexner's reform, is to ensure future physicians are better prepared for patient care.

Educational Scholarship and Technology: Resources for a Changing Undergraduate Medical Education Curriculum.

Returning to the original emphasis of higher education, universities have increasingly recognized the value and scholarship of teaching, and medical schools have been part of this educational scholarship movement. At the same time, the preferred learning styles of a new generation of medical students and advancements in technology have driven a need to incorporate technology into psychiatry undergraduate medical education (UGME). Educators need to understand how to find, access, and utilize such educational technology. This article provides a brief historical context for the return to education as scholarship, along with a discussion of some of the advantages to this approach, as well as several recent examples. Next, the educational needs of the current generation of medical students, particularly their preference to have technology incorporated into their education, will be discussed. Following this, we briefly review the educational scholarship of two newer approaches to psychiatry UGME that incorporate technology. We also offer the reader some resources for accessing up-to-date educational scholarship for psychiatry UGME, many of which take advantage of technology themselves. We conclude by discussing the need for promotion of educational scholarship.

Psychiatry Resident Training in Cultural Competence: An Educator's Toolkit.

Resident physicians training in psychiatry in the U.S. are required to master a body of knowledge related to cultural psychiatry; are expected to adopt attitudes that endorse the principles of cultural competence; and finally are expected to acquire specific cultural competence skills that facilitate working effectively with diverse patients. This article first provides an overview of the Accreditation Council for Graduate Medical Education (ACGME) competencies related to cultural competence, as well as the American Academy of Child and Adolescent Psychiatry's (AACAP) recommendations for the cultural competence training of child/adolescent fellows. Next, numerous print and electronic resources that can be used in cultural competence education in psychiatry are reviewed and discussed. Finally, we conclude by providing recommendations for psychiatry residency programs that we culled from model cultural competence curricula.

Targeting cancer information to African Americans: the trouble with talking about disparities.

Cancer messages that are designed for African Americans often include information on Black-White cancer disparities to raise Black adults' perceived cancer risk and increase cancer screening. Whether disparities messages achieve this, and how Blacks feel about hearing that they are worse off than are Whites, largely remain unknown. This study examined Blacks' responses to two mock newspaper articles on colorectal cancer: a disparities article and a nondisparities article. A random sample of 400 Black adults read the articles and answered questions on their reactions to both. Results revealed that readers of the disparities article felt significantly more insulted, discouraged, and angry about it than did readers of the nondisparities article. Article type played no role in desires or intentions to have colon cancer screening among participants of screening age, and no role in perceived cancer risk or intentions to suggest colon cancer screening to family among participants of any age. These findings suggest that disparities messages might not increase perceived cancer risk or increase interest in cancer screening as widely theorized and intended; instead, they simply may elicit anger and discouragement among African Americans.

Increasing Underrepresented Minority Students in Medical School: a Single-Institution Experience.

PURPOSE: Underrepresented minority student recruitment initiatives from medical school admissions and diversity offices can bring equity for those learners underrepresented in medicine. Measuring growth of the applicant pool helps determine the impact of such initiatives in helping diversify the healthcare workforce. AIM: The authors evaluated underrepresented minority applicant pool growth at the Brody School of Medicine to determine whether predominantly White institutions or historically Black colleges and universities have accounted for the most growth in minority applicants in recent years. METHODS: Outreach outcomes across the state were obtained by comparing applicant and matriculant demographics. Data on all applicants and matriculants were retrieved from the school's institutional records and classified according to student self-identification as underrepresented minority. Using Chi-square tests, authors aimed to determine whether the proportion of minority students increased among applicants and matriculants since 2016, the year of restructuring outreach. In further analysis, the number of graduates from historically Black colleges and universities as compared to minority graduates from predominantly White schools was evaluated. RESULTS: The authors identified 7,848 applicants and 654 matriculants over the evaluation period. The proportion of learners identifying as underrepresented minority increased from 17% before 2016 (622/3,672) to 20% after 2016 (835/4,176; p = 0.001). The proportion of applicants who did not graduate from a historically Black college or university increased slightly after 2016 (89% of underrepresented minority applicants before 2016 vs. 92% of underrepresented minority applicants after 2016), but this increase was not statistically significant (p = 0.097). CONCLUSION: Applicant growth has been more significant for underrepresented minority applicants from predominantly White institutions. Graduates of targeted historically Black colleges and universities who applied to Brody School of Medicine were better prepared, resulting in increased chances of admission.

Measuring skin cancer risk in African Americans: is the Fitzpatrick Skin Type Classification Scale culturally sensitive?

OBJECTIVE: Fitzpatrick's Skin Type Classification Scale often is used to assess sun sensitivity and skin cancer risk. Because the scale was developed with Whites, its utility and validity with Blacks may be limited by its reliance on the European-cultural terms suntan and sunburn. We tested the hypothesis that most Blacks would be unable to classify their skin into the four Fitzpatrick skin types. DESIGN, SETTING, PARTICIPANTS: A random, statewide sample of 2085 California Black adults were administered a survey to categorize their skin into the Fitzpatrick types of always burn/never tan (I), usually burn/rarely tan (II), rarely burn/usually tan (III), and never burn/always tan (IV). We also added a response option not available in the scale, "none of the above describes me." Questions on sunscreen use and demographics were included. MAIN OUTCOME MEASURE: Self-reported skin type. RESULTS: 1231 (59%) selected none of the above, and only 559 (26.8%) categorized themselves as type IV. When the none option is removed and the 59% who chose it were excluded as non-responders, the 559 who selected type IV constitute 65.5% of the remaining sample. Those who selected none were significantly less likely than all others to use sunscreen, and income and residential segregation were the strongest predictors of type I/II skin. CONCLUSION: Standard administration of the Fitzpatrick Scale excludes the majority of Blacks, yields data that overestimate Black population prevalence of type IV skin, and excludes the Blacks who are least likely to use sunscreen. Suggestions are provided for improving the cultural sensitivity of the skin-type assessment.

Ethnic disparities in youth access to tobacco: California statewide results, 1999-2003.

The authors examined the role of youth ethnicity in youth access to tobacco with large, random samples of stores and large samples of ethnically diverse youths for the first time. From 1999 through 2003, White, Black, Latino, and Asian youths made 3,361 cigarette purchase attempts (approximately 700 per year) statewide. Analyses revealed that Black youths had significantly higher access than other youths and that access rates for Black and Asian (but not Latino or White) youths exceeded the Synar-mandated < or = 20%. Clerks who failed to demand youth proof of age identification (ID) sold 95% of the tobacco that youths received and sold significantly more often to minorities and to girls, whereas clerks who demanded youth ID sold equally infrequently to all youths. These findings highlight significant ethnic disparities in youth access to tobacco and imply that those might be eliminated by policies and interventions that increase clerk demands for youth ID.

Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools.

Importance: There continue to be low numbers of underrepresented minorities, including African Americans, in academic medicine. Historically Black medical colleges and universities are major sources of training for medical school graduates who are African American or who belong to other underrepresented minority groups. Several historically Black medical schools were closed during the period surrounding the 1910 Flexner report. The implications of these school closures with regard to the number of African American medical school graduates have not been fully examined. Objective: To examine the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. Design, Setting, and Participants: This observational economic evaluation used steady expansion and rapid expansion models to estimate the consequences associated with the closure of historically Black medical schools for the number of African American medical school graduates. The numbers of graduates from 13 historically Black medical schools that are now closed were obtained through historical records. Data on historically Black medical schools that are currently open were obtained from school-specific reports and reports published by the Association of American Medical Colleges. The study focused on projected estimates of outcomes from the hypothetical continued operation and expansion of 5 closed historically Black medical schools that were included in the Flexner report: Flint Medical College of New Orleans University, Knoxville Medical College, Leonard Medical School of Shaw University, Louisville National Medical College, and the University of West Tennessee College of Medicine and Surgery-Memphis. Main Outcomes and Measures: The main outcome was the estimate of the number of African American students who would have graduated from historically Black medical schools that were closed during the period surrounding the 1910 Flexner report. Results: Among the 5 historically Black medical schools that were closed, the estimated mean number of graduates per year was 5.27 students at Flint Medical College, 2.60 students at Knoxville Medical College, 11.06 students at Leonard Medical School, 4.17 students at Louisville National Medical College, and 6.74 students at the University of West Tennessee. If the 5 closed historically Black medical schools had remained open, the steady expansion and rapid expansion models indicated that these schools might have collectively provided training to an additional 27 773 graduates and 35 315 graduates, respectively, between their year of closure and 2019. In the analysis of Leonard Medical School and the University of West Tennessee only, the steady expansion and rapid expansion models indicated that these 2 schools would have provided training to an additional 10 587 graduates and 13 403 graduates, respectively, between their year of closure and 2019. An extrapolation based on the racial and ethnic self-identification of current graduates of historically Black medical schools indicated that if these closed schools had remained open, the number of graduating African American physicians might have increased by 355 individuals (29%) in 2019 alone. Conclusions and Relevance: To increase the number of African American medical school graduates, consideration should be given to creating medical education programs at historically Black colleges and universities. Such programs may start with small enrollment but could have positive consequences for the diversity of the physician workforce.

Separate and unequal: residential segregation and black health disparities.

There are well-known Black-White disparities in adverse birth outcomes, health behaviors, and chronic diseases such as asthma, diabetes, and hypertension. These disparities hold across socioeconomic status and have remained stable for the past 50 years despite efforts to reduce them. This theoretical review argues that such disparities may be largely a function of residential segregation, ie, the separate and unequal neighborhoods in which most Blacks and Whites reside irrespective of their socioeconomic status. We review evidence that Black neighborhoods have significantly poorer healthcare facilities staffed by less competent physicians, higher environmental exposures, and poorer built environments than do White neighborhoods, and we argue that these neighborhood disparities are 3 pathways through which segregation contributes to health disparities. We summarize the research needed on the role of segregation in health disparities and emphasize the hypothesis that these may be differences between Whites and segregated Blacks alone.

Racial Differences in the Predictors of Interest in Bariatric Surgery in the Rural, Southeastern USA.

BACKGROUND: Although African-Americans have a higher prevalence of severe obesity than Whites, they are less likely to have bariatric surgery. Demographic, healthcare, and knowledge variables contribute to this racial disparity but have not been examined separately by race. OBJECTIVES: Examine the role of demographic, healthcare, and knowledge variables in African-Americans' versus Whites' interest in bariatric surgery. METHODS: A random sample of 293 African-American and 259 White adults were surveyed door-to-door in the rural south. The survey assessed weight, height, demographics, access to healthcare, and knowledge of and interest in bariatric surgery. RESULTS: African-Americans had significantly lower knowledge of bariatric surgery than Whites but there were no racial differences in interest in the surgery. The logistic regression predicting African-Americans' interest in the surgery from demographic, healthcare, obesity, and knowledge variables revealed that obesity (OR = 4.7) and the health benefits (OR = 3.3) were the only predictors. The same regression for Whites found that knowing someone who had the surgery (OR = 3.7) was the sole predictor. CONCLUSIONS: Knowledge variables may be stronger than healthcare and demographic variables as predictors of interest in bariatric surgery among rural, southern, African-Americans and Whites. Whites' willingness to consider the surgery might be enhanced by favorable stories/blogs by those who had the surgery, whereas African-Americans' interest might be increased by information on the additional health benefits of the surgery. These culturally tailored messages from healthcare providers might increase utilization of and reduce racial disparities in bariatric surgery.

Acculturation and ethnic-minority health behavior: a test of the operant model.

OBJECTIVE: The Operant Model of Acculturation predicts that health behaviors that have a low prevalence (< 20%) among Traditional (low-acculturated) minorities increase in prevalence with acculturation and hence have a higher prevalence among their Acculturated counterparts. Alternatively, health behaviors that have a high prevalence (> 45%) among Traditional minorities decrease with acculturation and thereby have a lower prevalence among their acculturated cohorts. The purpose of this study was to test this model for the first time. DESIGN: Data on the 7,249 Mexican American adults in the 2001 California Health Interview Survey (CHIS), a statewide, random-digit-dial telephone survey, were used. MAIN OUTCOME MEASURES: Two proxies for acculturation (nativity, language spoken at home) were predictors in analyses of cigarette smoking, exercise, and 5 + daily fruit/vegetable consumption. RESULTS: For all three health behaviors, results were fully supportive of the Operant Model irrespective of acculturation-proxy and demographic variables. CONCLUSION: The Operant Model may provide a coherent framework for predicting and understanding the role of acculturation in ethnic minority health behavior. Findings are discussed in terms of tailoring and targeting interventions in a manner consistent with the acculturation-related changes in health behavior that are likely to occur.

Racial disparities in healthcare provider advice to quit smoking.

African-American/Black smokers are less likely than White smokers to be told to quit smoking by healthcare providers. This preliminary study examined the predictors of being told to quit separately by race for the first time to potentially highlight the source of this racial disparity. A random, household sample of 1670 Black and White adults from a southeastern county of the United States completed a brief survey on their demographics, smoking, access to healthcare, health status, and receipt of healthcare provider advice to quit smoking. Analyses are based on the 512 Black and White smokers in that sample. The logistic regression for all smokers revealed that after controlling for demographic, healthcare, and health status variables, White smokers were 2.39 times more likely than Black smokers to have ever been told to quit smoking. The regression for Black smokers revealed that women and older people were more likely to be told to quit, and that healthcare and health status did not contribute. In the regression for White smokers, no predictor was statistically significant. These findings suggest that one possible reason that African-Americans receive cessation advice less often than Whites is that such advice varies with their age and gender, whereas for Whites this is not the case.

Residential Segregation and Racial Cancer Disparities: A Systematic Review.

BACKGROUND: This paper provides the first review of empirical studies of segregation and black-white cancer disparities. METHODS: We searched all years of PubMed (through May 2016) using these terms: racial segregation, residential segregation, neighborhood racial composition (first terms) and (second terms) cancer incidence, mortality, survival, stage at diagnosis, screening. The 17 (of 668) articles that measured both segregation and a cancer outcome were retained. RESULTS: Segregation contributed significantly to cancer and to racial cancer disparities in 70% of analyses, even after controlling for socioeconomic status and health insurance. Residing in segregated African-American areas was associated with higher odds of later-stage diagnosis of breast and lung cancers, higher mortality rates and lower survival rates from breast and lung cancers, and higher cumulative cancer risks associated with exposure to ambient air toxics. There were no studies of many types of cancer (e.g., cervical). Studies differed in their measure of segregation, and 40% used an invalid measure. Possible mediators of the segregation effect usually were not tested. CONCLUSIONS: Empirical analysis of segregation and racial cancer disparities is a recent area of research. The literature is limited to 17 studies that focused primarily on breast cancer. Studies differed in their measure of segregation, yet segregation nonetheless contributed to cancer and to racial cancer disparities in 70% of analyses. This suggests the need for further research that uses valid measures of segregation, examines a variety of types of cancers, and explores the variables that may mediate the segregation effect.

Rural Shop-Based Health Program Planning: a Formative Research Approach Among Owners.

African American barbershops and beauty salons are settings that have been identified as a significant and culturally relevant venue to reach minority populations for health promotion activities. By being located in almost every town in the USA, this setting is a viable means to promote healthy lifestyles among African Americans. The purpose of this formative research project was to assess African American barbershop and beauty salon owners' perceptions of providing health promotion programming in their shops, as well as to obtain information on health topics of interest and strategies for implementation. Interviewees were recruited using snowballing among clientele and owner referrals, between November 2014 and August 2015. A total of 20 barbershop and salon owners, across 11 counties in eastern North Carolina, completed face-to-face interviews. Responses were stratified by barbershops and beauty salons. Across both groups, all owners stated it would be a good idea to have health programs/interventions within the shop setting. Most noted topics of interest included diet and nutrition, hypertension, and (wo)men's reproductive health. When asked further about these desired topics, both benefits and relevance to customers and the African American community were the reasons for their selections. In addition, across barbershops and salons, 90 % of owners stated interest in having a program implemented in their shop. This information will be used to guide the development of shop-based interventions, with the aid of a community advisory board composed of shop owners, individual barbers and stylists and customers.

Sociocultural correlates of cigarette smoking among African-American men versus women: Implications for culturally specific cessation interventions.

Low socioeconomic status, racial discrimination, and low acculturation are the major sociocultural correlates of smoking among African-American adults. This study is the first to examine all three variables simultaneously and to analyze gender differences in their association with smoking. Results for the sample revealed that low education and low acculturation predicted smoking but racial discrimination did not. For women, low acculturation was the sole predictor of smoking, whereas for men, socioeconomic status variables were the sole predictors. This suggests that low acculturation may be associated with smoking among African-American women only. Hence, culturally specific smoking cessation programs designed for low-acculturated African-Americans might be effective for African-American women alone.

Self-rated health, objective health, and racial discrimination among African-Americans: Explaining inconsistent findings and testing health pessimism.

African-Americans sometimes rate their health as Poor/Fair in the absence of chronic diseases. Theoretically, this lack of correspondence between self-rated health and objective health is due to racial discrimination that results in rating one's health negatively and in terms of social rather than health variables. We tested this Health Pessimism model with 2118 African-Americans. Results revealed that Poor/Fair self-rated health was predicted mostly by objective health for the Low Discrimination group but mostly by demographic variables for the High Discrimination group, in a manner consistent with Health Pessimism. Inconsistencies among prior studies might reflect differences in the prevalence of high discrimination among their samples.

Residential Segregation and Overweight/Obesity Among African-American Adults: A Critical Review.

The relationship between residential segregation and overweight/obesity among African-American adults remains unclear. Elucidating that relationship is relevant to efforts to prevent and to reduce racial disparities in obesity. This article provides a critical review of the 11 empirical studies of segregation and overweight/obesity among African-American adults. Results revealed that most studies did not use a valid measure of segregation, many did not use a valid measure of overweight/obesity, and many did not control for neighborhood poverty. Only four (36% of the) studies used valid measures of both segregation and overweight/obesity and also controlled for area-poverty. Those four studies suggest that segregation contributes to overweight and obesity among African-American adults, but that conclusion cannot be drawn with certainty in light of the considerable methodologic problems in this area of research. Suggestions for improving research on this topic are provided.

Advancing research on racial-ethnic health disparities: improving measurement equivalence in studies with diverse samples.

To conduct meaningful, epidemiologic research on racial-ethnic health disparities, racial-ethnic samples must be rendered equivalent on other social status and contextual variables via statistical controls of those extraneous factors. The racial-ethnic groups must also be equally familiar with and have similar responses to the methods and measures used to collect health data, must have equal opportunity to participate in the research, and must be equally representative of their respective populations. In the absence of such measurement equivalence, studies of racial-ethnic health disparities are confounded by a plethora of unmeasured, uncontrolled correlates of race-ethnicity. Those correlates render the samples, methods, and measures incomparable across racial-ethnic groups, and diminish the ability to attribute health differences discovered to race-ethnicity vs. to its correlates. This paper reviews the non-equivalent yet normative samples, methodologies and measures used in epidemiologic studies of racial-ethnic health disparities, and provides concrete suggestions for improving sample, method, and scalar measurement equivalence.

Residential segregation and obesity among a national sample of Hispanic adults.

We explored the role of residential segregation in obesity among a national sample of Hispanics for the first time. Data on the 8785 Hispanic adults in the 2000 Behavioral Risk Factor Surveillance System were linked to 2000 census data on the segregation of 290 metropolitan statistical areas. Multilevel modeling revealed that after controlling for individual-level variables, the odds of being obese for Hispanics residing in high-segregated metropolitan statistical areas were 26.4 percent higher than for those residing in low-segregated metropolitan statistical areas. This segregation effect might be mediated by the obesogenic features (e.g. paucity of recreational facilities and abundance of fast-food outlets) of segregated Hispanic neighborhoods.