Evaluating the impact of an educational intervention on the history of racism in America for teaching structural competency to medical academicians.

BACKGROUND: A challenge facing many Academic Health Centers (AHCs) attempting to revise health professions education to include the impact of racism as a social and structural determinant of health (SSDoH) is a lack of broad faculty expertise to reinforce and avoid undermining learning modules addressing this topic. To encourage an institutional culture that is in line with new anti-racism instruction, we developed a six-part educational series on the history of racism in America and its impact on contemporary health inequities for teaching structural competency to health professions academicians. METHODS: We developed a six-hour elective continuing education (CE) series for faculty and staff with the following objectives: (1) describe and discuss race as a social construct; (2) describe and discuss the decolonization of the health sciences and health care; (3) describe and discuss the history of systemic racism and structural violence from a socio-ecological perspective; and (4) describe and discuss reconciliation and repair in biomedicine. The series was spread over a six-month period and each monthly lecture was followed one week later by an open discussion debriefing session. Attendees were assessed on their understanding of each objective before and after each series segment. RESULTS: We found significant increases in knowledge and understanding of each objective as the series progressed. Attendees reported that the series helped them grapple with their discomfort in a constructive manner. Self-selected attendees were overwhelmingly women (81.8%), indicating a greater willingness to engage with this material than men. CONCLUSIONS: The series provides a model for AHCs looking to promote anti-racism and structural competency among their faculty and staff.

Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.

Decision-Making Across Cultures.

This chapter surveys the range of different orientations toward decision-making, common clinical scenarios, and considerations to bear in mind when caring for culturally diverse patients at the end of life. While this chapter draws on the cultural competency literature, its primary goal is to articulate an approach to end-of-life care that is rooted in cultural humility and structural competency. Medical providers, as representatives of the social institution of medicine, have their own cultural values that often come into conflict with patients' cultural values, especially when patients and providers have different unspoken visions of the "good death," or when patients wish to receive interventions that their providers deem futile. In the final section of the chapter, we seek to move away from this confrontational paradigm by analyzing two case studies of decision-making across cultures in order to empower providers to engage in value-based shared decision-making and thereby achieve goal-concordant care.

Accounting for agency in structural competency.

To emphasize to learners how factors outside individual control impact health, scholars introduced the concept of structural competency. Structural competency refers to the development of analytical skills that reveal the larger societal context beyond the patient-clinician interaction that shapes health outcomes. The growing adoption of structural competency curricula, however, has revealed that prelicensure and early career health professionals can feel overwhelmed by the mismatch between the wide scale of entrenched problems and the limited scope of their therapeutic skills. In this Reflections paper, I draw on theories from Giddens, Bourdieu, and Foucault to restore a role for individual agency in promoting health. Conceiving of structure and agency as mutually constituting suggests that structures are human-made and can be vulnerable to challenge. Structures, however, disperse power to such an extent that people internalize their rules and discipline themselves to follow them without explicit enforcement. It is precisely in those local sites of power that health professions learners and educators can intervene to interrupt the reproduction of structures harmful to health. As I demonstrate with an example from a reproductive health emergency, being structurally competent may also include contesting agreed upon norms at the level of the learning and clinical environments rather than only macro-level societal forces. Rewriting norms within health professions education and clinical practice is not necessarily a simpler task, but it provides learners and educators with more accessible targets for action.

Toward a moral reckoning on structural racism: Examining structural factors, encouraging structural thinking, and supporting structural intervention.

The racial reckoning of 2020 involved the largest social movement protest in U.S. history, but support for the Black Lives Matter movement declined shortly after. To advance a moral reckoning on structural racism that dismantles racialized structures and redresses racial inequities, we call on scholar activists within the field of community psychology to realign their own practices by (a) examining structural factors; (b) encouraging structural thinking; and (c) supporting structural intervention for racial justice. Two structural factors-political determinants and commercial determinants-maintain the status quo of structural racism, undermining efforts for racial equity. As a result, we encourage the development of structural thinking, which provides a structural analysis of racism and leads to support for structural intervention. With an intersectional race and class perspective, we detail how structural thinking could be developed among the professional managerial class (through structural competency) and among the oppressed class (through critical consciousness). Finally, we discuss structural intervention factors and approaches that can redress racial inequities and produce structural change. Ultimately, we provide a pathway for community psychologists to support activists building a multiracial, multiclass coalition to eliminate structures and systems of racial, political, and economic injustice.

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.

The Structural Analysis: Incorporating Structurally Competent Clinical Reasoning into Case-Based Presentations.

Structural and social determinants of health account for the health disparities we see along social hierarchies, and their impact has been made more evident by the recent COVID-19 pandemic. There have been increasing calls to incorporate structural competency into medical education. The structural and social context, however, has yet to be fully integrated into everyday clinical practice and little has been published on how to concretely imbed structural competency into clinical reasoning. The authors provide a framework for structural analysis, which incorporates four key steps: (1) developing a prioritized clinical problem list, (2) identifying social and structural root causes for clinical problems, (3) constructing and documenting a prioritized structural problem list, and (4) brainstorming solutions to address structural barriers and social needs. They show how structural analysis can be used to operationalize structural reasoning into everyday inpatient and outpatient clinical assessments.

Structural vulnerability among patients with HIV and SARS-CoV-2 Co-infection: descriptive case series from the U.S. Midwest.

HIV and COVID-19 disproportionately impact marginalized populations, especially racial and ethnic minorities. This descriptive case series from an HIV clinic in the U.S. Midwest explores the sociodemographic and clinical characteristics of 37 individuals with HIV and SARS-CoV-2 co-infection. All 37 had suppressed viral loads prior to diagnosis with COVID-19, and all 37 survived. Relative to our overall HIV clinic population, over twice as many Hispanic patients, three times as many undocumented patients, and four times as many refugee patients contracted COVID-19, highlighting the structural vulnerability of these sub-populations.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem.

BACKGROUND: A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance. METHODS: A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days. RESULTS: There were differences between Jewish and Arab patients' social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty. CONCLUSION: The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Neutrality, conflict, and structural determinants of health in a Jerusalem emergency department.

BACKGROUND: Medical neutrality is a normative arrangement that differentiates a zone of medical treatment disconnected from the field of politics. While medical neutrality aims to ensure impartial healthcare for all and to shield the healthcare personnel from political demands, it can also divert attention away from conflicts and their effects on health inequity. This article analyzes how healthcare professionals understand and negotiate the depoliticized space of the emergency department (ED) through their views on neutrality. It also examines how medical staff use depoliticized concepts of culture to account for differences in the health status of patients from disadvantaged groups. These questions are examined in the context of the Israeli-Palestinian conflict. METHODS: Twenty-four in-depth, semi-structured interviews were conducted with healthcare personnel in a Jerusalem hospital's ED. All but one of the participants were Jewish. The interviews were analyzed using qualitative content analysis and Grounded Theory. RESULTS: The ED staff endorsed the perspective of medical neutrality as a nondiscriminatory approach to care. At the same time, some medical staff recognized the limits of medical neutrality in the context of the Israeli-Palestinian conflict and negotiated and challenged this concept. While participants identified unique health risks for Arab patients, they usually did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of cultural and behavioral differences. Culture served as a non-controversial way of acknowledging and managing problems that have their roots in politics. CONCLUSIONS: The normative demand for neutrality works to exclude discussion of the conflict from clinical spaces. The normative exclusion of politics is a vital but under-appreciated aspect of how political conflict operates as a structural determinant of health. Healthcare personnel, especially in the ED, should be trained in structural competency. This training may challenge the neglect of issues that need to be solved at the political level and enhance health equity, social justice, and solidarity.

'It's not just to treat everybody the same': A social justice framework for caring for larger patients in healthcare practice.

Drawing on semi-structured interviews with larger bodied patients (n = 20) and their healthcare practitioners (n = 22) in Canada, this paper combines micro and macro approaches in outlining a social justice approach to caring for larger patients in healthcare practice. Theoretically, we draw upon structural competency and critical consciousness to address the question of how social justice is enacted, experienced, and understood in interactions between clinicians and larger patients. Our findings highlight four key themes that provide a framework for integrating social justice into healthcare practice: (1) an awareness of one's simultaneous experience of marginalisation and privilege in the clinical interaction; (2) navigating between additive and interactive understandings of intersectionality; (3) micro and macro approaches to change; and (4) straddling the line between equity and equality. The synergies in participants' perspectives across social identities suggests that the cultivation of social justice awareness potentially mitigates some blinders of privilege. Furthermore, practitioners' social justice orientation positively impacted patient experience, with most patients expressing appreciation for having their various histories of trauma and social challenges handled compassionately during appointments.

Developing a Structural Intervention for Outpatient Mental Health Care: Mapping Vulnerability and Privilege.

The Mapping Vulnerability and Privilege (MVP) exercise is a clinical intervention based on a structural competency framework that emphasizes societal structures-social determinants of health and of biology, behavior, and culture-and their impact on health outcomes. The exercise comprises the MVP Tool, Visual Guide, and Processing Guide. It was created with the goals of helping clinicians to develop structural humility and introducing a structural lens for viewing the therapeutic milieu and the structural barriers that affect both intrapsychic experiences and interactions with the health care system, while encouraging patients and clinicians to take action to address the systemic and structural issues that affect patients' well-being. This article provides an overview of the development of the MVP exercise as an educational and clinical intervention.

Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults.

PURPOSE: Although we know that racial and ethnic minorities are more likely to have mistrust in the health care system, very limited knowledge exists on correlates of such medical mistrust among this population. In this study, we explored correlates of medical mistrust in a representative sample of adults. METHODS: We analyzed cross-sectional study data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We ascertained race/ethnicity, health status, perceived discrimination, demographics, socioeconomic factors, and medical mistrust. For data analysis, we used multinomial logistic regression models. RESULTS: Analyses were based on 704 non-Hispanic Black adults, 711 Hispanic adults, and 913 non-Hispanic White adults. Racial/ethnic background was significantly associated with the level of medical mistrust. Adjusting for all covariates, odds of reporting medical mistrust were 73% higher (adjusted odds ratio [aOR] = 1.73; 95% CI, 1.15-2.61, P <.01) and 49% higher (aOR = 1.49; 95% CI, 1.02-2.17, P <.05) for non-Hispanic Black and Hispanic adults when compared with non-Hispanic White adults, respectively. Perceived discrimination was also associated with higher odds of medical mistrust. Indicating perceived discrimination due to income and insurance was associated with 98% higher odds of medical mistrust (aOR = 1.98; 95% CI, 1.71-2.29, P <.001). Similarly, the experience of discrimination due to racial/ethnic background and language was associated with a 25% increase in the odds of medical mistrust (aOR = 1.25; 95% CI, 1.10-1.43; P <.001). CONCLUSIONS: Perceived discrimination is correlated with medical mistrust. If this association is causal, that is, if perceived discrimination causes medical mistrust, then decreasing such discrimination may improve trust in medical clinicians and reduce disparities in health outcomes. Addressing discrimination in health care settings is appropriate for many reasons related to social justice. More longitudinal research is needed to understand how complex societal, economic, psychological, and historical factors contribute to medical mistrust. This type of research may in turn inform the design of multilevel community- and theory-based training models to increase the structural competency of health care clinicians so as to reduce medical mistrust.

Conceptualisations of the social determinants of health among first-year dental students.

BACKGROUND: Social conditions have a significant impact on the health of individuals and populations. While the dental curriculum is focused on teaching students about the diseases that affect the dentition and oral structures from a biomedical perspective, education about the social determinants of health is frequently regarded as less important. Thus, it occupies a smaller and disconnected part of the dental curriculum. The aim of this study was to explore the ways dental students conceptualised the social determinants of health after one year in dental school. METHODS: Reflective statements written by first year dental students at the end of the first year of study were collected. This qualitative study has an interpretivist basis and a thematic analysis of the reflections was conducted by two researchers. Metzl's structural competencies were used as a further analytic device. RESULTS: Four inter-related themes were identified: First, professional attitudes taken up by students influence their conceptions. Second, structural barriers to students understanding social determinants of health generate partial understandings. Thirdly, the social gulf that exists between the student body and people of different circumstances provides context to understanding the student's perspectives. Finally, we described how students were learning about the social determinants of health over the academic year. CONCLUSIONS: Dental students face several challenges when learning about the social determinants of health, and translating these learnings into actions is perhaps even more challenging. Metzl's structural competencies provide a framework for advancing students' understandings. One of the most important findings of this research study is that coming to an understanding of the social determinants of health requires sustained attention to social theories, practical experiences as well as institutionalised attitudes that could be achieved through an intentional curriculum design.

Structural competency in mental health nursing: Understanding and applying key concepts.

Achieving mental health equity requires that nursing address structures that impede the ability of individuals and populations to achieve optimal mental health. Consistent with calls for structural change, this paper intends to promote structural competency in mental health nursing by applying this concept to the field. The first half of the paper discusses structural competency and key concepts vital for its development, namely, structure, social influencers of mental health, equity, structural justice, and historical understanding. In the second half we apply structural competency to mental health nursing at the educational, practice and system levels and conclude with recommendations for change.

Structural competency: A pilot study.

OBJECTIVE: The objective of this study is the use of structural competency (SC) as a tool to broaden the view of nursing students beyond individual, behavioral, biological, and cultural frameworks to encompass the structural determinants of health. DESIGN: This mixed-methods pilot study consists of a concurrent nested strategy in which close-ended, forced-choice questions are the drivers while open-ended questions are embedded therein. SAMPLE: The sample consists of second-year doctor of nursing practice students. MEASURES: The short-term impact is measured through the use of a survey tool. INTERVENTION: The 3-hr SC educational module focuses on six learning objectives: knowledge of structural terms, identifying SC effects on population and patient health; strategizing responses to these influences, student readiness to create change at the individual, organizational, and systems-level, identifying needed tools, and assessing empowerment and burnout. RESULTS: Students understand structural terms and are willing to create systemic change but lack necessary tools which may result in burnout. CONCLUSIONS: Careful thought about curricula incorporating SC and skills to offset the potential impact of burnout is needed.

'You certainly don't go back to the doctor once you've been told, "I'll never understand women like you."' Seeking candidacy and structural competency in the dynamics of domestic abuse disclosure.

A reticence on the part of women to disclose domestic abuse (DA) to family doctors, allied to front-line responses that do not always reflect an understanding of the structure and dynamics of DA, hampers the provision of professional support. Using data from 20 qualitative interviews with women who have experienced DA, this paper explores their discourse about interacting with family doctors. It is the first study to explore firsthand accounts of these interactions through Dixon Woods' lens of candidacy. It finds disclosure to be inherently dynamic as a process and expands the candidacy lens by considering the: (i) conflicting candidacies of victims and perpetrators; (ii) diversionary disclosure tactics deployed by perpetrators and, (iii) the potential role of General Practitioner (GPs) in imagining candidacies from a structural perspective. By exploring the dynamics of disclosure through the concept of 'structural competency' it finds that in encounters with women who have experienced abuse GPs ineluctably communicate their views on the legitimacy of women's claims for support; these in turn shape future candidacy and help-seeking. Greater GP awareness of the factors creating and sustaining abuse offers the potential for better care and reduced stigmatisation of abused women.

Overcoming the barriers migrants face in accessing health care.

Migrants face many barriers when accessing health care, both structural and political, leading to unmet need and poor quality care. Yet these barriers often can be overcome. This short communication reports a workshop confronting these issues at the First World Congress on Migration, Ethnicity, Race and Health. It explores the structural factors that create barriers and the competencies that health professionals need to overcome them. It then examines how one non-governmental organization did confront, successfully, a restrictive policy adopted in the United Kingdom, through advocacy and practical action. It concludes by examining the related issue of cultural competency, drawing on experiences of a mental health unit in Athens, Greece.

The Secret Drama at the Patient's Bedside-Refusal of Treatment Because of the Practitioner's Ethnic Identity: The Medical Staff 's Point of View.

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

A pedagogy of social justice for resilient/vulnerable populations: Structural competency and bio-power.

BACKGROUND: Nursing schools frequently assert the importance of social justice curriculum, but little information is available about specifics for such a class. PURPOSE: The purpose of this article is to describe a class that builds a foundation for the understanding of social justice and the pedagogical frameworks on which it rests. METHODS: The authors develop a class grounded in bio-power and structural competency. DISCUSSION: Described are topics presented to students, the rationale for their selection along with class activities and implementation challenges. Highlighted is the use of praxis as students incorporate the components of structural competency and bio-power. The focus is on the potential for public health and advanced practice registered nurses to recognize and evaluate structural factors in patient and population-based care. CONCLUSION: Faculty meet substantive challenges in teaching social justice, including lack of recognition of societal forces which affect student's ability to provide care. Focused effort incorporating newer structural and philosophical frameworks in a social justice class may improve the provision of health services. The frameworks of structural competency and bio-power provide a critical paradigm salient in social justice pedagogy.