Structural Competency of Pre-health Students: Can a Single Course Lead to Meaningful Change?

Abstract

Scholars within the medical sciences recently have called on undergraduate educators to incorporate the social sciences in order to teach pre-health students structural competencies – or the ability to articulate how social structures produce racial, ethnic, gender, class, and other disparities – in order to better serve these populations medically. Authors used a semester-long course to assess how experiential learning focused on the topic of structural inequities improves structural competency. In Fall 2018, 27 students completed a hands-on, experiential, course focused on structural factors and health disparities. The authors conducted a mixed-methods, pre-/post-test design to solicit data on students’ views on the reasons for high rates of obesity, gender pay disparities, and racial/ethnic housing segregation. Using systematic qualitative data analysis and statistical analysis of coded answers, the authors were able to detect pre-/post-test differences in the number of times students identified structural reasons for the disparities. Statistical analysis showed that students were able to identify an average of 4.63 structural reasons at pre-test, and that increased to 5.93 reasons at post-test (statically significant (p = 0.007)), indicating an increase in structural awareness after participation in the course. Qualitative analysis, using systematic methods of coding and a modified constant comparison method, demonstrated that students’ ability to articulate structural reasons for inequality greatly improved. This experiential learning course, while relatively short, was found to increase students’ ability to identify structural factors and articulate them with deeper understandings. Future curriculum development should consider incorporating experiential learning to promote structural competency, rather than a more traditional passive, content-delivery method of training.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. 1.

    D’Eon M. Systems thinking and structural competence in and for medical education. Canad Med Edu Journ. 2017;8(1):e1.

    Google Scholar 

  2. 2.

    Downey MM, Gómez AM. Structural competency and reproductive health. AMA Journ of Ethics. 2018;20(3):211–23.

    Google Scholar 

  3. 3.

    Eichbaum Q, Rowthorn V, Allison J, Myser C. Challenging paradigms of global health education: examining critiques of competency-based education. In: Global Health experiential education. Abingdon, UK: Routledge; 2017. p. 23–31.

    Google Scholar 

  4. 4.

    Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci & Med. 2014;103:126–33.

    Google Scholar 

  5. 5.

    Tsevat RK, Sinha AA, Gutierrez KJ, DasGupta S. Bringing home the health humanities: narrative humility, structural competency, and engaged pedagogy. Acad Med. 2015;90(11):1462–5.

    Google Scholar 

  6. 6.

    Metzl JM, Petty J. Integrating and assessing structural competency in an innovative prehealth curriculum at Vanderbilt University. Acad Med. 2017;92(3):354–9.

    Google Scholar 

  7. 7.

    Metzl JM, Roberts DE. Structural competency meets structural racism: race, politics, and the structure of medical knowledge. AMA Journ of Ethics. 2014;16(9):674–90.

    Google Scholar 

  8. 8.

    Bourgois P, Holmes SM, Sue K. More structural vulnerability: operationalizing the concept to address health disparities in clinical care. Acad Med. 2017;92(3):299–307.

    Google Scholar 

  9. 9.

    Donald CA, DasGupta S, Metzl JM, Eckstrand KL. Queer frontiers in medicine: a structural competency approach. Acad Med. 2017;92(3):345–50.

    Google Scholar 

  10. 10.

    Donald C, Fernández F, Hsiang E, Mesina O, Rosenwohl-Mack S, Medeiros A, et al. Reflections on the intersection of student activism and structural competency training in a new medical school curriculum. In: Structural competency in mental health and medicine. New York, NY: Springer Publishing; 2019. p. 35–51.

    Google Scholar 

  11. 11.

    Krishnan A, Rabinowitz M, Ziminsky A, Scott SM, Chretien KC. Addressing race, culture, and structural inequality in medical education: a guide for revising teaching cases. Acad Med. 2019;94(4):550–5.

    Google Scholar 

  12. 12.

    Yates-Doerr E. Translational competency: on the role of culture in obesity and interventions. Med Anthro Theory. 2018;5(4):106–17.

    Google Scholar 

  13. 13.

    Hansen H, Metzl JM. New medicine for the US health care system: training physicians for structural interventions. Acad Med. 2017;92(3):279–81.

    Google Scholar 

  14. 14.

    Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–63.

    Google Scholar 

  15. 15.

    Geiger HJ. The political future of social medicine: reflections on physicians as activists. Acad Med. 2017;92(3):282–4.

    Google Scholar 

  16. 16.

    Mathis W, Cyrus K, Jordan A, Rohrbaugh R. Introducing a structural competency framework for psychiatry residents: drawing your neighborhood. Acad Psych. 2019:1–4.

  17. 17.

    Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press; 1980.

    Google Scholar 

  18. 18.

    Brewis A, Wutich A. Lazy, crazy, and disgusting: stigma and the undoing of Global Health. Baltimore, MD: Johns Hopkins University Press; 2019.

    Google Scholar 

  19. 19.

    National Academies of Sciences, Engineering, and Medicine (NASEM). A framework for educating health professionals to address the social determinants of health. Washington, DC: National Academies Press; 2016.

  20. 20.

    Metzl JM, Petty J, Olowojoba OV. Using a structural competency framework to teach structural racism in pre-health education. Soc Sci & Med. 2018;199:189–201.

    Google Scholar 

  21. 21.

    Rabinowitz MR, Prestidge M, Kautz G, et al. Assessment of a peer-taught structural competency course for medical students using a novel survey tool. Med Sci Edu. 2017;27(4):735–44.

    Google Scholar 

  22. 22.

    Bromage B, Encandela JA, Cranford M, Diaz E, Williamson B, Spell VT, et al. Understanding health disparities through the eyes of community members: a structural competency education intervention. Acad Psych. 2019;43(2):244–7.

    Google Scholar 

  23. 23.

    Hunnicutt G. Varieties of patriarchy and violence against women: resurrecting “patriarchy” as a theoretical tool. Viol Against Women. 2009;15(5):553–73.

    Google Scholar 

  24. 24.

    Bolin B, Grineski S, Collins T. The geography of despair: environmental racism and the making of South Phoenix, Arizona. USA Hum Eco Rev. 2005:156–68.

  25. 25.

    Wutich A, Ruth A, Brewis A, Boone C. Stigmatized neighborhoods, social bonding, and health. Med Anthro Quart. 2014;28(4):556–77.

    Google Scholar 

  26. 26.

    Brewis A, Trainer S, Han S, Wutich A. Publically misfitting: extreme weight and the everyday production and reinforcement of felt stigma. Med Anthro Quart. 2017;31(2):257–76.

    Google Scholar 

  27. 27.

    Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med. 2018;16(1):123.

    Google Scholar 

  28. 28.

    Bernard HR, Wutich A, Ryan GW. Analyzing qualitative data: systematic approaches. Thousand Oaks, CA: SAGE Publications; 2016.

    Google Scholar 

  29. 29.

    Neff J, Holmes SM, Strong S, Chin G, De Avila J, Dubal S, Duncan LG, Halpern J, Harvey M, Knight KR, Lemay E. The structural competency working group: Lessons from iterative, interdisciplinary development of a structural competency training module. In: Structural Competency in Mental Health and Medicine. Eds. Hansen H, Metzl J. New York, NY: Springer Publishing; 2019:53–74.

  30. 30.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Hoboken, NJ: Biometrics; 1977. p. 159–74.

    Google Scholar 

  31. 31.

    Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual and Quan. 2002;36(4):391–409.

    Google Scholar 

  32. 32.

    Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. Lanham, MD: Rowman & Littlefield; 2017.

    Google Scholar 

  33. 33.

    Kolb AY, Kolb DA. Experiential learning theory: a dynamic, holistic approach to management learning, education and development. The SAGE HndBk. 2009:42–68.

  34. 34.

    Kolb A, Kolb D. Eight important things to know about the experiential learning cycle. Aus Edu Lead. 2018;40(3):8.

    Google Scholar 

  35. 35.

    Kim BS, Lyons HZ. Experiential activities and multicultural counseling competence training. Journ of Counsel & Develop. 2003;81(4):400–8.

    Google Scholar 

  36. 36.

    Kohlbry PW. The impact of international service-learning on nursing students’ cultural competency. Journ of Nurs Scholar. 2016;48(3):303–11.

    Google Scholar 

  37. 37.

    Lockhart JS, Resick LK. Teaching cultural competence. Nurse Edu. 1997;22(3):27–31.

    Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Alissa Ruth.

Ethics declarations

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Approval

This study was approved by the Arizona State University’s Institutional Review Board in Fall 2018 (STUDY00008248). All research activities were performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Statement of Informed Consent

Informed consent was obtained from each participant included in this study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

ESM 1

(PDF 3.22 mb)

ESM 2

(PDF 2.05 mb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ruth, A., SturtzSreetharan, C., Brewis, A. et al. Structural Competency of Pre-health Students: Can a Single Course Lead to Meaningful Change?. Med.Sci.Educ. 30, 331–337 (2020). https://doi.org/10.1007/s40670-019-00909-9

Download citation

Keywords

  • Structural competencies
  • Pre-health
  • Experiential learning
  • Curriculum development