LEARNING GUIDE: VALUES AND ETHICS (STRUCTURAL COMPETENCY)

OVERVIEW

The topic of structural competency introduced in this lesson builds on earlier knowledge concerning Social Determinants of Health (SDOH), cultural competency, and implicit bias.  This content may be a review, but it is intentionally included to strengthen a student’s professional identity development.

When students explore of structural competency, we often get this request for clarification, “We were wondering if you could give us an example of structural competency.”  It is assumed that the questioner is wondering about how SDOH, cultural competency, and structural competency are related.  These three frameworks, SDOH, cultural competency, and structural competency as layers in an onion:

• In the center of the onion is SDOH which are directly related to the patient – such as, a patient’s resources at hand, their social support system, the patient’s understanding of their health (health literacy), genetics, and risk factors.
• Overlapping and in the center and/or in parallel with SDOH, is the healthcare providers’ knowledge and understanding of their own culture and the patient’s culture as well as how these influence interactions with patients/families and other healthcare team members – such as language, communication customs, and other cultural customs that impact self-care associated with health/wellness and disease management.
• In the outer layer of the onion that outside of the patient and healthcare provider is the greater healthcare system/community/society (structure) – such as disparities related to access to insurance, dental care/healthcare/mental healthcare, shelter, banking (checking accounts, credit cards, loans), transportation, technology (telephones, computers/internet), news and information, childcare, education, access to medications/treatments, access to caregivers in the home, equity in policing/criminal justice, access to services, and access to businesses owned by persons of the same race/background/chosen culture(s), and living in an area of the city where there is a food desert.

Next, consider the examples of implied by questions that apply to structural competency that examine upstream structures/systemic biases:

• Why does a person who is homeless keep coming back to the Emergency Department for the health/illness problem?
• Why are there disparities concerning postpartum maternal mortality between women of color and Caucasian women?
• Why is COVID-19 causing more illness and death in persons of color?
• What was happening during the summer of 2020 in terms of policing and Black Lives Matter demonstrations?
• Why are there disparities concerning remote learning among children in K-12 grades?
• Why are there discussions in the news about disparities in access to COVID-19 vaccines?

OBJECTIVES

This week you will:

1. Compare and contrast cultural competency, SDOH, and structural competency.
2. Describe how Transformation Activism can be applied to implicit bias in healthcare.
3. Discuss how structural humility is practiced by a healthcare profession.

COMPETENCIES

Core Structural Competencies (Metzl & Hansen):

1. Recognizing the structures that shape clinical interactions.
2. Developing an extra-clinical language of structure.
3. Re-articulating “cultural” presentations in structural terms.
4. Observing and imagining structural interventions.
5. Developing structural humility.

IPEC Competencies

DEFINITIONS

Implicit Bias – “An attitude or internalized stereotype that affects an individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic” (Michigan Public Health Code – General Rules, 2022, Rule 338.7001(c)).

Structural Competency – the ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, obesity, smoking, medication ‘non-compliance,’ trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructure, medicalization, or even about the very definitions of illness and health (Metzl & Hansen, 2014).

Structural Humility – The orientation emphasizing collaboration with patients and populations in developing responses to structural vulnerability, rather than assuming the health professionals alone have all of the answers.  This includes awareness of interpersonal privilege and power hierarchies in healthcare (Metzl & Hansen, 2014).

Structural Violence – the one way of describing social arrangements that put individuals and populations in harm’s way.  The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people (Farmer, 2006).

Structural Vulnerability – The risk that an individual experiences as a result of structural violence – including their location in socioeconomic hierarchies.  It is not caused by, nor can it be repaired solely by individual agency or behaviors (Neff et al., 2020).

LEARNING ACTIVITIES

• The following sources with study guides have been curated for student learning.
• For application and demonstration of learning, lab exercises can be found in the second half of this online education resource, Lab Exercises.

WATCH: Implicit Bias — how it effects us and how we push through

Study Guide:   Funchess concisely talks about implicit bias and action points, Transformation Activism.  Gaining self-awareness is a significant first step in attaining structural competency as a healthcare provider.

REFERENCE:  TED. (2014, October 14).  Implicit bias-How it effects us and we push through/Melanie Funchess.  [Video].  YouTube.

READ:  Social Determinants of Health, health equity, and vision loss

Study Guide:  Although this article by the CDC focuses on how the Social Determinants of Health (SDOH) applies to vision loss, the CDC succinctly offers a summary figure of the 5 domains of  SDOH:

• Health Care Access and Quality – include access to primary care, heatlh insurance coverage, and health literacy
• Social and Community Context – include community cohesion, civic participation, discrimination, conditions in the workplace, and incarceration
• Education Access and Quality – include educational attainment – graduating from high school and enrollment in higher education – language literacy, and early childhood education and development
• Economic Stability – includes poverty, employment, food and nutrition security, and housing stability
• Neighborhood and Built Environment – include neighborhood crime and violence, quality of housing, access to transportation, availability of healthy foods, and air and water quality

REFERENCE:  Center for Disease and Prevention (2021, June 21).  Social Determinants of Health, health equity, and vision loss.

REVIEW:  Figure 3. Elements of Cultural Competence

Study Guide:  In their literature review of cultural competence, Watt, Abbott,  and Reath  found that education concerning this practice of cultural competency can be broken down into 3 elements as shown in Figure 3; the knowledge, skills, and attitudes (KSAs).

REFERENCE:  Watt, K., Abbott, P., & Reath, J.  (2016).  Developing cultural competence in general practitioners:  an integrative review of the literature.  BMC Family Practice, 17(158).

REVIEW:  Health equity + structural competency

Study Guide:  In this PowerPoint presentation, Cabello-De la Garza explains how structural competency builds on cultural competency and why there is a need for this framework that addresses health equity.

REFERENCE Cabello-De la Garza, A. B. (2021, May 06). Health equity + structural competency [PowerPoint slides].

LESSON REFERENCES

Farmer, P. E., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural violence and clinical medicine. PLoS medicine, 3(10), e449. https://doi.org/10.1371/journal.pmed.0030449

Interprofessional Education Collaborative Expert Panel.  (2011). Core competencies for interprofessional practice:  Report of an expert panel.  Washington, D.C.:  Interprofessional Education Collaborative

Metzl, J. M., & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality.  Social Science & Medicine,1982 (103), 126–133. https://doi.org/10.1016/j.socscimed.2013.06.032

Neff, J., Holmes, S. M., Knight, K. R., Strong, S., Thompson-Lastad, A., McGuinness, C., Duncan, L., Saxena, N., Harvey, M. J., Langford, A., Carey-Simms, K. L., Minahan, S. N., Satterwhite, S., Ruppel, C., Lee, S., Walkover, L., De Avila, J., Lewis, B., Matthews, J., & Nelson, N. (2020). Structural competency: Curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities. MedEdPORTAL : the journal of teaching and learning resources, 16, 10888. https://doi.org/10.15766/mep_2374-8265.10888