The Built Environment
& Healthcare Practitioners
Pilot Two: Teaching Structural Competency
& Healthcare Practitioners
Pilot Two: Teaching Structural Competency
DISMANTLING DISCRIMINATION, RACISM AND STIGMA (DDRS)
THROUGH STRUCTURAL COMPETENCY
September 2021 to February 2023
U.S. healthcare systems teach non-medical determinants of health absent content that addresses these problems as structural issues. In fact, often times medical schools are trying to address the Social Determinants of Health (SDOH) or non-medical determinants of health with little idea of how to address the structural, systems level and policy based factors that get at the “causes of the causes”.
This pilot, Medical Schools Dismantling Discrimination, Racism and Stigma (DDRS) Through Structural Competency, was meant to help the medical students understand the complexities behind the origins of inequities, why medical tools are not enough to solve the problems, and potential solutions. The goal was to teach the students how to solve historical, systemic issues that result in health inequities.
Described in greater detail below and through several short videos, (Dismantling Discrimination, Racism and Stigma (DDRS) Through Structural Competency Playlist) the DDRS pilot was implemented across several interactive sessions with community leaders and subject matter experts over a five-month period. An example of these activities is the session on October 26th where medical students participated in a community immersion experience on the West Side of Charleston.
This day is documented in Session 4 & 5: Photovoice and Community Immersion Experience & Review of Community Immersion Field Trip below. Several medical students submitted photos and a written narrative. This reflection plus photo came from a first year, White female medical student (race determined by visual inspection).
We’ve spent the past few months examining and discussing a multitude of environmental, cultural, and historical factors that greatly impact the health of individuals and communities. Our society, healthcare system, and government currently address health issues from a bottom-up perspective, treating disease primarily through a medical lens rather than addressing lifestyle causes of disease that are shaped by environment and policy. Although the medical approach to treatment is essential and should be maintained, much more progress can be made toward effective and successful treatment and prevention by increasing our understanding of the non-medical determinants of health, how they have been shaped by history and future directions that can be taken to address such issues. The few lectures that we have had on this topic have been extremely eye-opening and impactful on my perspective not only as a future healthcare provider but also as a community member. I was truly shocked by much of the history we learned throughout the sessions, especially the information specific to Charleston, WV that was shared with us by Pastor Watts. Pastor Watts also spoke with my group about personal healthcare experiences he has had as an African American male which seems rather discriminatory and neglectful to the point of being life-threatening. He even mentioned that it did seem that the poor treatment he received seemed to be a result of implicit bias and was unintentional, however, the consequences of such are still just as detrimental and severe as those resulting from explicit discrimination based on race. This discussion specifically helped me to understand the mindset that many African Americans and other minorities possess in regards to seeking medical attention and what I can do differently as a future provider
Another example of what the medical students learned came from a final exercise to close out the pilot (see Session 7: DDRS Final Reflections from Students and Faculty). Students were invited to upload a short video explaining why it is important to fix both places and people or why addressing cultural competency and/or medical racism would be insufficient to remedy health inequities. The response below exemplifies what most of the students submitted.
White Female Student (race determined by visual inspection)
I chose to answer the second question. To address cultural competency that will bring awareness where there might have not been before and to address medical racism would improve behaviors of medical personnel in the way that they act and think consciously and implicitly with their patients.
However, it’s not addressing the root of the problem. It’s kind of like the symptoms that manifest from it. They’re the downstream effects that have stemmed from systemic policies and infrastructure that have built a very sturdy foundation for racism, classism, things like that. So policies change, that’s like a point that’s been harped on a lot, is that where you really get that real change and then you can see positive downstream effects. So it kind of trickles down. And then the issue is that policy and politics go hand in hand and that presents a lot of challenges, but hearing from community leaders and organizers has been very encouraging and it makes me realize that it’s not impossible. It’s something that we definitely need to try to achieve.
CULTURAL VS STRUCTURAL COMPETENCY
Cultural Competency over time has come to mistakenly extend the diagnosis of individual health to populations while masking the contributions of institutions, systems, policies, and markets in shaping the health of marginalized groups.
Structural Competency involves the recognition of structural and systemic issues as risk factors that contravene the production of health and individual clinical interventions.
Andress, Scalise, Wright, & Moore, 2018
Andress & Purtill, 2020
Two projects form the basis for this pilot Dismantling Discrimination, Racism and Stigma (DDRS) Through Structural Competency DDRS
First is the 2016 pilot, Imagining the West Side, that can be found at Pilot One: Community Voices & Lived Experiences – Place & Health in West Virginia (placeandhealthwv.com)
Second are research findings demonstrating how physicians feel hopeless, helpless, and even angry because they lack the tools to take on the systemic, structural, non-medical factors that shape health and disrupt the healthcare interventions and drugs that are used to treat illness.
To tackle these deficiencies in physician knowledge and skills along with the barriers that make it hard for communities like West Virginia’s West Side to address structural institutional and systemic factors the DDRS Pilot employed the notion of structural competency to help medical students connect social determinants of health (SDOH) to more precise tools/skills, evidence and data that achieve social justice and equity.
Program Components for this Pilot
The pilot Dismantling Discrimination, Racism and Stigma (DDRS) Through Structural Competency included 79 first year medical students. Of those students 64 were in state residents; 6 students were African American while five were Hispanic 1 native American and 56 students declared themselves to be White
The training broadened the traditional health curricula to include activities that teach them about inequitable institutional and systems-based programs, policies, and practices that disproportionately affect marginalized vulnerable communities.
The pilot began September 29th 2021 and ended with an assessment of the student’s awareness and knowledge using a self administered method in January 2022
Programmatic components included eight interactive zoom sessions with the first on September 29th featuring a discussion on structures and systems that influence health and ways of responding to harmful social factors.
The second session featured the Long Talk organization and an interactive discussion on the history of race and racism in the U.S.
On October 13th the third session featured a WVU historian presenting a critical analysis of historical events in West Virginia and how they intersected with poverty, racism and the states’ past and present-day health outcomes.
The cornerstone of the project was the October 26th community immersion experience featuring an interactive session conducted by community residents and leaders which included a walking tour of the community and a photovoice exercise. The essays were a required submission while photos were optional in recognition of the comfort students may or may not feel taking photos in the community.
Following that one day experience a 4th session occurred on December 2nd where students met in four groups to review the community immersion field trip; they discussed their essays and photos. In each session we also featured 1-2 community members to talk with students.
A final session took place on January 21st featuring three presentations on what it takes to redevelop a marginalized community. Each session of 45 minutes featured subject matter experts (SMEs) on community redevelopment; community organizing and the experiences with housing, drugs and the criminal justice system
To close out the pilot and collect qualitative assessment data the students were asked to record answers to two questions this is reviewed in the last short video segment, The two questions students had to select from were:
- Tell a story about fixing people and places. Why is it important that we do both?
- Why would addressing cultural competency and/or medical racism be insufficient to remedy health inequities?
What you will see in video format:
Greater Kanawha Valley Foundation
Marshall University Joan C. Edwards School of Medicine
Rev. Matthew J. Watts
HOPE Community Development Corporation
Lauri Andress, Ph.D.
West Virginia University School of Public Health