Structural competency in epidemiological research: What’s feasible, what’s tricky, and the benefits of a ‘structural turn’

Figures & data

Table 1. Intercultural and structural competency domains and definitions.

Domain 1: Cultural awareness and reflexivity	Domain 2: Cultural and linguistic validation	Domain 3: Sensitivity to cultural diversity and structural vulnerabilities	Domain 4: Representativeness of minoritised groups and excluded populations
Defined as the capacity of the research team to reflexively analyse how their cultural, ethnic, social and expert backgrounds interact with those of the participants, and can affect research questions, design, recruitment, data collection, data analysis, and dissemination activities. One of the bases of reflexivity is cultural humility and the ability to recognise in others a variety of knowledge, whether lay knowledge and/or that based on experience. Reflexivity is an intangible domain that has to do with attitudes and predispositions and influence the quality of research. For example, reflexivity on cultural and social gaps between the research team and the populations under study can provide new clues for reducing bias.	Defined as the linguistic and cultural adaptation of instruments, tools, informed consents, participant information sheets, questionnaires, interactions between researchers and participants and dissemination outputs addressed to the participants. Crucially, this refers not only to a translation into the participants’ language(s), but also to adapting to a discourse that is intelligible to them, thus avoiding the usual biases in the use of questionnaires that participants do not understand, as well as situations of exclusion due to immigration, low level of education, disability, or a combination of these.	Defined as the incorporation of variables and relevant information on cultural diversity and structural vulnerabilities of the groups under study in any of the phases of epidemiological research. This is the most comprehensive domain as it includes team training in intercultural and structural competency, the cultural and social knowledge of populations under study, and knowledge about the medical history of the country/community in which the research is taking place and of the medical research legacy for ethnic minorities and hidden populations. This also includes the use of social determinations of health and structural vulnerability issues in the study design.	Defined as the ability to favour the representativeness of minoritised groups and excluded populations throughout the various phases of the study, such as the composition of the research team, the selection of the sample and the development of dissemination activities. This includes assessing social and cultural barriers to their participation, as well as promoting the involvement of these groups in the dissemination process with the aim, for example, of strengthening their agency.

Table 2. The Structural and Intercultural Competency for Epidemiological Studies (SICES) guidelines.

PHASES	Guide questions
Research team building and research questions	Has the research team identified its ethnic, cultural, and social composition and compared it with that of the study population? Has the research team considered the potential impact that these differences or similarities may have on the research? Does the research team have any tools or means to facilitate reflexivity, e.g. fieldnotes or regular meetings for this purpose? Does the research team consider the lay views on the topics of study? Has the research team assessed whether the use of concepts such as race, ethnicity, or culture (among others) in the study is adequate? Have the research team’s training needs in intercultural and structural competence been assessed? Does the research team have cultural and social knowledge of the populations under study, including ethnic minoritized and marginalised groups and lay perspectives on the topics of study? Has the research team considered the medical history of the country in which the research is taking place and the legacy that medical research has on ethnic minorities/hidden populations? Has the research team established an advisory board which includes representatives of different cultural and/or ethnic groups, including lay participants representing civil society and/or minoritized collectives?
Study design, recruitment, data collection and data analysis	Is the research team aware of cultural and social biases from previous research done on a similar topic/population that they are using as a research background? Has the research team considered social and cultural sources of potential bias or imprecision? For example, if the research hypothesis, the objectives of the study, the theoretical-conceptual framework, or the sample gives rise to possible sensitive cultural issues or ethnocentric statements? Has the association of missing data with sociocultural characteristics of populations under study been considered? Are the informed consent and the questionnaires, scales, and instruments understandable to the participants and/or culturally validated or tailored to the population under study? Has qualitative research or mixed methods been included in the design of the study, i.e. for the selection of the instruments or for the collection of qualitative data on the research subject? Have cultural variables been included in the study design such as ethnicity, cultural identity, religious beliefs, or acculturation, among others? In addition, and following the Bridging Research Integrity and Global Health Epidemiology (BRIDGE) Guidelines, have the different causal mechanisms associated to these variables been considered and the limitations of using these variables as proxies for more complex categories been acknowledged? Does the study address how symptoms, clinical problems, diseases and/or attitudes toward patients, populations and/or health systems are influenced by social determinants of health and structural vulnerabilities? For example, but not limited to discrimination, lack of financial security, lacking safe/stable place, risk environments, difficulty in food access, lack of social network, problems with legal status and/or lack of formal education. Has local knowledge been considered in interpreting the results of the study, i.e. local ideas on aetiology and disease transmission? Does the sample consider subsamples of cultural minoritized groups, groups subject to health disparities, and/or historically underrepresented? And if so, in what way, i.e. has the analysis been disaggregated for such variables or have they been considered as confounder/effect modifiers? Have barriers to participation in the study arising from structural vulnerabilities been analysed? If so, has the inclusion of these participants been facilitated in any way?
Dissemination	Does the dissemination plan include the groups under study? Does this plan include reflexivity and awareness on potential linguistic, cultural, and social gaps? As part of the dissemination of the results, has any output (i.e. publication or audio-visual document) been addressed and culturally tailored to the population studied (i.e. tested in a focus group)? Have the cultural and social specificities of the studied groups been considered in the conclusions, recommendations, and in the implementation of the results? Is there a dissemination or Responsible Research and Innovation (RRI) plan considering the active role of participants and stakeholders? If so, have barriers to participation been assessed and active participation been facilitated?