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BACKGROUND: The contribution of Social Determinants of Health to health disparities and patient outcomes is widely acknowledged. Much less has been done to characterize provider SDOH, and in particular their effect on delivery of structurally competent care. Differing lived experiences create blind spots to the critical upstream factors contributing to health. OBJECTIVES: The primary objective of this study was to examine the association between Structural Awareness (SA) and Social Determinants of Health (SDOH) when controlling for year of first licensure, primary setting of pharmacy practice, race, and gender. The secondary objective was to examine the difference in mean SA scores with four stand-alone predictor variables: reliance on public transportation, insurance coverage gaps, food insecurity, and housing insecurity. METHODS: This study is a cross-sectional web-based survey of 606 Minnesota pharmacists. SDOH risk and SA scores were assessed using modified versions of the PRAPARE and CCSAQ tools, respectively. The association of these scores was assessed using a multiple linear regression model and the association with stand-alone variables was done using t-tests. RESULTS: SDOH risk was significantly associated with SA at the 95% confidence level with a p-value of 0.0016. Food and housing insecurity were also significantly associated with SA score while reliance on public transportation and insurance coverage gaps were not. CONCLUSION: Pharmacy and other healthcare professional training programs should create opportunities for exposure to the SDOH experienced by their patients through immersive learning and/or experiential education.

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The purpose of this perspective is to discuss the imperative for curricular change that focuses on the utilization of structural competency to promote excellence in physical therapist professional education, transform society, and achieve health equity. Pedagogy centered around biomedical and social determinants of health (SDOH) models are limited in that they lack self-reflexivity, encode social identities like race and gender as risk factors for poor health, fail to examine structural causes of health inequity, conflate SDOH and the structural forces that shape their unequal distribution, and overlook instances of injustice. Promoting health equity will require structural competency, an approach that considers drivers of health beyond the individual and their conditions of daily living (ie, SDOH). Utilizing this approach in physical therapist professional education will help learners understand the evolving needs of society in a deeper, more holistic way: one that considers structural determinants of health as the primary drivers of health equity and inequity. IMPACT STATEMENT: This paper provides a perspective on how physical therapist professional education can promote health equity for all by embracing an equity-focused, structurally competent pedagogy/approach.

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The delivery of culturally competent health care is recognized as critical to providing quality, equitable care for marginalized groups. This includes immigrant patients and families who experience significant barriers to health care and poor health outcomes. However, operationalization of cultural competence challenges health care delivery. Complementary concepts have also emerged such as cultural humility, cultural safety, and structural competence, recognizing the need for multi-level approaches involving patients, families, clinicians, health care organizations, the larger community, and policymakers. In this review, we define cultural competency and related frameworks and their applicability to immigrant patients and families. The evolution in terminology reflects an increasingly more comprehensive approach to understanding culture as multidimensional and shaped by social and structural factors. We then highlight strategies at each level, focusing on clinicians and organizations to leverage loci of control most directly within clinicians' reach. Community-level strategies include community engagement (ie, vis-à-vis community health workers or community advisory boards) for clinical and research practice. Organization-level strategies include "immigrant-friendly," or "immigration-informed" policies aimed at reducing immigration-related stressors, like limiting cooperation with immigration enforcement agencies or developing medical-legal partnerships to assist with patients' legal needs. Lastly, policy-level strategies seek to change local and federal policies to address needs beyond health care (eg, education, housing, other social services), taking a "Health in All" policies approach that articulates health considerations into policymaking across sectors. Finally, we conclude with suggestions for future directions that center the experiences of immigrants, with the ultimate goal of sustainably meeting the complex needs of immigrant patients and families.

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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.

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This special issue aims to help fill two critical gaps in the growing literature as well as in practice. First, to bring together scholars and practitioners from around the world who develop, practice, review, and question structural competency with the aim of promoting a dialogue with related approaches, such as Latin American Social Medicine, Collective Health, and others, which have been key in diverse geographical and social settings. Second, to contribute to expanding structural competency beyond clinical medicine to include other health-related areas such as social work, global health, public health practice, epidemiological research, health policy, community organisation and beyond. This conceptual expansion is currently taking place in structural competency, and we hope that this volume will help to raise awareness and reinforce what is already happening. In sum, this collection of articles puts structural competency more rigorously and actively in conversation with different geographic, political, social, and professional contexts worldwide. We hope this conversation sparks further development in scholarly, political and community movements for social and health justice.

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Although the acceptance of sex positivity centering pleasure and justice has grown, clinical and public health strategies for sexually transmitted infection management have remained focused on risk and adverse outcomes. To promote sex-positive health care practice in clinical settings and beyond, health care practitioners should use an integrated, patient-centered approach to sexual health. These strategies include initiating discussions, continued sexual health education, providing informative material for patients, and knowledge of different communication strategies. Patient-provider interactions might be enhanced by using such methods.

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Athletes at all levels of participation, including athletes of color, have no natural immunity to mental health challenges. There is considerable evidence to support that no matter the level of participation, athletic identity including race, may be linked to psychological distress. This article provides the clinical context needed to offer therapeutic interventions to athletes and recommendations for how training programs can prepare psychiatrists for this work and opportunities for future development and inclusion of psychiatrists as members of the "medical" team, especially when working to address the needs of the increasingly diverse population of athletes today.

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This commentary on the special issue of Global Public Health on structural competency in global perspective asks: what is specific to the U.S. about structural competency, and what is its utility beyond the U.S., especially in the 'global south'? Why are biomedical practitioners the focus of U.S. structural competency? And what can U.S. structural competency advocates learn from the deep and rich social medicine traditions of Latin America? And is there anything that Latin American and other non-U.S. social medicine traditions might learn from U.S. structural competency? The commentary identifies the crucial insights from international comparisons include that racial justice movements are Social Medicine innovators in the U.S., that cultivating allies within biomedicine can enhance the impact of community health movements, and that cross-fertilising U.S. Structural Competency and social medicine traditions across regions should be a priority for the fields.

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There is an ongoing diagnostic and treatment challenge for migrant youth with posttraumatic stress disorder (PTSD) that many clinicians face. Current studies have helped clinicians to develop a better understanding of the migrant youth's journey including potentially traumatic and adverse events they encounter. This includes determining if premigration, migration, and postmigration stressors have had an impact on the individual. This has also helped clinicians, educators, and legal advocates to use a collaborative approach to address the migrant youth's needs for managing the severity of PTSD symptoms.

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The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

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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.

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BACKGROUND: The American Association of Medical Colleges has called for incorporation of the health humanities into medical education, and many medical schools now offer formal programs or content in this field. However, there is growing recognition among educators that we must expand beyond empathy and wellness and apply the health humanities to questions of social justice - that is, critical health humanities. In this paper we demonstrate how this burgeoning field offers us tools for integrating social justice into medical education, utilizing the frameworks of critical consciousness and structural competency. PRACTICE OF HEALTH HUMANITIES: Critical health humanities can be applied at multiple levels of learners, and in a variety of contexts. We are two physician-writers who have developed several educational programs that demonstrate this. We taught a seminar that introduced first-year and second-year undergraduates to concepts such as social determinants of health, intergenerational trauma, intersectionality, resilience, and cross-cultural care through works of fiction, poetry, film, podcasts, stand-up comedy, and more. Through creative projects and empathic reflection, students engaged with the complexities of structural forces that create and maintain health disparities. Medical students in their clinical years can engage in critical health humanities learning experiences as well. We teach several multidisciplinary electives that address social (in)justice in medicine, as well as mentor fourth-year students engaged in independent electives that foster critical awareness around health equity and ethics. Beyond the classroom, we have actively engaged in critical health humanities practices through story slams, literary journal clubs, conference presentations, and Grand Rounds. Through these activities we have included learners at GME and CME levels. These examples also demonstrate how community engagement and multidisciplinary partnerships can contribute to the practice of critical health humanities. CONCLUSION: In this paper, we explore the growing field of critical health humanities and its potential for teaching health equity through narrative practices. We provide concrete examples of educational activities that incorporate critical consciousness and structural competency - frameworks we have found useful for conceptualizing critical health humanities as a pedagogical practice. We also discuss the strengths and challenges of this work and suggest future directions.

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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.

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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.

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The implementation of coordinated specialty care in the U.S. over the past decade has led to the improvements of clinical and functional outcomes among individuals in the early stages of psychosis. While there have been advancements in the delivery of early intervention services for psychosis, it has almost exclusively focused on short-term change at the individual level. In light of these advancements, research has identified gaps in access to care and delivery of services that are driven by different levels of determinants and have the biggest impact on historically excluded groups (e.g., ethnoracial minoritized communities). Interventions or efforts that place an emphasis on community level (structural or sociocultural) factors and how they may influence pathways to care and through care, specifically for those who have been historically excluded, have largely been missing from the design, dissemination and implementation of early psychosis services. The present paper uses a structural violence framework to review current evidence related to pathways to care for early psychosis and the physical/built environment and conditions (e.g., urbanicity, residential instability) and formal and informal community resources. Suggestions on future directions are also provided, that focus on enriching communities and creating sustainable change that spans from pathways leading to care to 'recovery.' In all, this lays the groundwork for a proposed paradigm shift in research and practice that encompasses the need for an emphasis on structural competency and community-driven approaches.

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ABSTRACTThis article explores the meaning, manifestations, and ramifications of medical neutrality in conflict zones. We analyse how Israeli healthcare institutions and leaders responded to the escalation of the Israeli-Palestinian conflict in May 2021 and how they represented the role of the healthcare system in society and during conflict. Based on content analysis of documents, we found that healthcare institutions and leaders called for cessation of violence between Jewish and Palestinian citizens of Israel, describing the Israeli healthcare system as a neutral space of coexistence. However, they largely overlooked the military campaign that was simultaneously taking place between Israel and Gaza, which was considered a controversial and 'political' issue. This depoliticised standpoint and boundary work enabled a limited acknowledgement of violence, while disregarding the larger causes of conflict. We suggest that a structurally competent medicine must explicitly recognise political conflict as a determinant of health. Healthcare professionals should be trained in structural competency to challenge the depoliticising effects of medical neutrality, with the aim of enhancing peace, health equity, and social justice. Concomitantly, the conceptual framework of structural competency should be broadened to include conflict-related issues and address the needs of the victims of severe structural violence in conflict areas.

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Structural competency is used to train health professionals on how social, political, and economic dynamics create conditions that negatively impact a population's health. In the Global South, this approach has historical roots in social movements, popular education, social medicine, and human rights. In 1982, during a time of extreme poverty, inequality, and violence under the Chilean military dictatorship, Educación Popular en Salud (EPES), developed a programme for training community health promoters to address common illnesses and analyse the underlying causes of poor health. In 2010, EPES began using the same model to train international and Chilean health professionals. The approach advanced four competencies. Evaluations show that training contributes to transforming health professionals' mindsets and leads them to question their practices. However, educating practitioners does not change the underlying structures that generate poor health. This article examines the intersection between EPES' competencies and the structural competency framework, highlighting two major contributions of EPES to structural competency: a methodology that narrows the gap between a theoretical analysis of social determinants of health and implementing action plans; and organic long-term links with social movements that strengthen collective action in poor neighbourhoods to advance social justice.

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This study explores COVID-19 vaccine acceptance among prison security staff and the extent to which they trust varied sources of information about the vaccines. Cross-sectional survey data were obtained from a state-wide sample of corrections officers (COs, hereafter; n = 1208) in February 2021. Group differences, disaggregated by demographic characteristics, were examined using F-tests and t-tests. Despite the comparatively limited risk of contracting the virus, non-security staff reported they would accept a COVID-19 vaccine at no cost (74%), compared to their more vulnerable CO counterparts (49%). We observed vaccine refusal correlations between COs' reported gender, age, and length of time working as a CO, but none with their self-reported race. Vaccine refusal was more prevalent among womxn officers, younger officers, and those who had spent less time working as prison security staff. Our findings also suggest that the only trusted source of information about vaccines were family members and only for officers who would refuse the vaccine; the quality of trust placed in those sources, however, was not substantially positive and did not vary greatly across CO racial groups. By highlighting characteristics of the observed gaps in COVID-19 vaccine acceptance between COs and their non-security staff coworkers, as well as between corrections officers of varied demographic backgrounds, these findings can inform the development of responsive and accepted occupational health policies for communities both inside and intrinsically linked to prisons.

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ABSTRACTStructural competency is a recent framework for understanding and addressing the structural drivers of disease. Latin American Social Medicine and Collective Health is a decades-long movement similarly concerned with the study and transformation of social structures to achieve health equity. In this paper, we put insights from Latin American Social Medicine and Collective Health into conversation with the developing structural competency framework. We focus specifically on insights from Jaime Breilh's new article summarising his theoretical work on medical ethics and rights in this special issue and his new book, Critical Epidemiology and the People's Health. This paper is comprised of three parts. Part 1 provides an introduction to the structural competency framework. Part 2 provides an overview of the Latin American Social Medicine and Collective Health movement, along with a summary of the social determination of health paradigm. Part 3 places insights from these works into conversation with structural competency and considers ways in which Latin American Social Medicine and Collective Health might inform the further development of structural competency, and potentially vice versa. The paper closes by calling for greater attention to Latin American Social Medicine and Collective Health among those committed to health equity within the anglophone world.

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The hyper-neoliberal era has seen the collapse of the ethos of life and the formation of a civilisation of extreme greed. In this global context, the pre-eminence of a technologically endowed but epistemologically and ethically misguided form of science has contributed to forms of 'scientific illiteracy' and strategies of planned ignorance that nourish a neo-conservative form of governance. The challenge of transforming the paradigm of bioethics and the right to health beyond the biomedical horizon is an urgent priority. Building on the strengths of a social determination approach and a meta-critical methodology and rooted in critical epidemiology, this essay proposes powerful tools for a radical shift in thought and action linked to rights and ethics. Together, medicine, public health, and collective health provide a path forward to reform ethics and advance the rights of humans and nature.

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