Structural competency in New Mexico: Moving outside of medical education

ABSTRACT

In 2019, the Doña Ana Wellness Institute (DAWI), Doña Ana County, New Mexico’s health council, sponsored two trainings in structural competency by the Structural Competency Working Group. One focused on health care professionals and learners; the other focused on government, non-profit organisations, and elected officials. DAWI and New Mexico Human Services Department (HSD) representatives attended the trainings and identified the structural competency model as useful for the health equity work both groups were already engaging. These trainings provided the foundation for DAWI and HSD to develop additional trainings, programmes, and curricula founded on structural competency and focused on supporting health equity work.

This article describes how DAWI and HSD used the structural competency framework to deepen our work, including how we have expanded the concept beyond its original orientation to support strategic planning, improve communication, and build structurally competent communities. We illustrate how the framework strengthened our existing community and state work and how we adapted the model to better fit our work. Adaptations included changes in language, the use of the lived experiences of organisation members as a foundation for structural competency education, and a recognition that policy work happens at multiple levels and in multiple ways for organisations.

KEYWORDS:

• Structural competency
• health equity
• community-based organisations
• government

Introduction

New Mexico has long ranked at the bottom or near the bottom among all US states on many health-related indicators, including alcohol-induced death, children in poverty, suicide death, high school completion, and infant low birth weight (New Mexico Department of Health, 2019). Doña Ana County, in the south-central part of the state, and bordering El Paso, Texas and Ciudad Juarez, Chihuahua, Mexico, ranks low, particularly in its rural areas, on many health indicators among counties within New Mexico, including obesity, children in poverty, prenatal care, and unemployment (Despres, 2019). The county is one of the most resource-poor counties in the United States (Center for Community Analysis, 2020), and health disparities are complex problems to overcome. The region also has many strengths, including many organisations successfully addressing food insecurity, relatively high rates of civic participation, and strong social cohesion within many communities (Despres, 2019). One of the region’s key strengths is the expertise, knowledge, and advocacy within local communities. Given the unique strengths and challenges of the region, community and state-level organisations need collaborative strategies that share resources and build upon strengths. The authors have found the structural competency model to be a valuable way of building on these existing strengths to address communities’ inequitable health outcomes.

Structural competency was first described for use in medical education. Scholars described it as ‘a shift in medical education … toward attention to forces that influence health outcomes at levels above individual interactions’ (Metzl & Hansen, 2014, p. 126). It highlights the importance of moving past social determinants of health and cultural competency towards the upstream understanding of how structures influence patients’ lives and their ultimate outcomes. This includes the understanding that social determinants are the sequelae of a host of financial, legal, governmental, and political structures which must be engaged to improve overall health outcomes. Knowledge of the impact of social structures on our communities also applies outside of medical education. This article describes the lessons learned as two organisations – a community coalition and a state government agency - built their health equity work based on the structural competency framework after attending a shared training by the Structural Competency Working Group (Structural Competency Working Group, n.d.). In sharing these lessons, the authors illustrate adaptations to the original framework to meet the specific needs and structures of their organisations.

Organisation backgrounds

The Doña Ana Wellness Institute (DAWI) emerged from growing concern that community resources to address health inequities were fractured, duplicative, and ineffectively utilised. Over the last eight years, DAWI has grown to include general membership from health, social, and educational agencies, as well as healthcare providers and an advisory board that represents multiple sectors including education, health care, and community development, and is supported by local county government. It has tackled inequities in access to mental health services, trained elected officials to take a ‘health in all policies’ approach, collaborated with New Mexico State University to connect health professions students with community initiatives, and most recently funded the development of a structural competency course for professionals who work with communities to address health inequities from a variety of perspectives including the judicial system, social work, policy making, and health system administration.

The mission of New Mexico’s Human Services Department (HSD) is ‘to transform lives. Working with our partners, we design and deliver innovative, high-quality health and human services that improve the security and promote independence for New Mexicans in their communities.’ HSD provides services and benefits to over half of New Mexicans (1,076,746 customers, as we call them at HSD, as of January 2023) through programmes including Medicaid, Supplemental Nutrition Assistance Programme, Child Support, and Behavioural Health (New Mexico Human Services Department, 2022). HSD’s policies, programming, benefits, and services impact the lives of over half of New Mexicans, including many who are historically targets of oppression, such as people with disabilities, Native families, undocumented individuals, mixed-status families, residents of rural and frontier communities, and lower-income people. In a majority nonwhite, lower-income state, addressing the structural determinants of health and wellbeing and dismantling inequities is a critical undercurrent running through the HSD strategic plan. Because of its significant footprint in the state, HSD has a unique opportunity to focus attention on the variety of multilevel intersectional structures that influence community life and are important to consider in the development and administration of policies, programmes, and services. It is important to focus attention on the root causes of disparities and consider how a structural lens allows HSD to amplify its impact on the lives of the communities it serves.

Implementation of structural competency framework

For both organisations, the structural competency model supported moving beyond older models, such as cultural competency and social determinants of health. The concept of cultural competency was introduced in the late 1980s by Terry Cross and colleagues to improve services for ‘minority children who are severely emotionally disturbed’. They defined cultural competence as ‘a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals, and enable that system, agency or those professionals to work effectively in cross-cultural situations’ (Cross et al., 1989, p. 13). They defined culture as a discrete set of patterns of human behaviours identified within specific racial, ethnic, religious, or social groups. Since Cross and colleagues developed the cultural competency model, it has been widely critiqued. Cultural competency models often focus too narrowly on culture, often blaming cultural values, beliefs, and practices for poor health behaviours and health outcomes (Jenks, 2011; Kleinman & Benson, 2006; Shepherd, 2019; Willen & Carpenter-Song, 2013). The model has also often focused solely on immigrant and minoritized communities and led to stereotyping rather than understanding (Kirmayer, 2012; Shepherd, 2019).

Similarly, while social determinants of health continue to be a central part of much health equity work, a focus on social determinants of health is limited in its ability to support a deep analysis of the structural root causes of those social determinants. Often, social determinants of health become a kind of black box for all non-medical causes of poor health, although the original conceptualisation of the term makes specific links between particular social determinants and health outcomes. In addition, the concept has been critiqued for lacking a focus on the centrality of power in explanations of the root causes of differences in social determinants of health (Herrick & Bell, 2020).

Metzl and Hansen (2014, p. 128) have described structural competency as ‘the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases … 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 infrastructures, medicalisation, or even about the very definitions of illness and health.’ While the concept has its own limitations, particularly related to the lack of specificity about the mechanisms that link upstream causes with downstream results, the framework addresses many of the concerns associated with the previously mentioned terms. It maintains a focus on the broader structures of power that have created and sustained racial inequity (i.e. structural racism) and other forms of social inequities that lead to poor health outcomes and recognises culture as only one of many potential influences. Initial writing about structural competency was largely conceptual and explained using academic language that was helpful for those working in academic settings in which this language was relatable and meaningful. Later, the Structural Competency Working Group and others (Hansen & Metzl, 2019) operationalised this conceptual framework to include more specific guidance on intervention development. At this point, scholars introduced specific levels of intervention that build on the socioecological model of health (Bronfenbrenner, 1979; McLeroy et al., 1988) - individual, interpersonal, community, institution, research, and policy (Richard et al., 2011).

Eliminating, or even reducing, health inequities often seems to be a vague and unachievable goal given the complexity of the root causes of these inequities. The authors of this paper, who regularly work in health equity spaces, have experienced a sense of being overwhelmed by the magnitude of the issues faced in our communities and a sense of incompetency to address them. These experiences are reflected by those with whom the authors work as well. They saw the value of the structural competency framework to address health inequities in structures outside of medicine and thus invited the Structural Competency Working Group to conduct two trainings for our community - one for health care professionals and the other for community agencies and government officials.

HSD and DAWI are very different types of organisations. HSD is a large, formal, multi-department, state government agency with more than 1,400 employees. DAWI is a small county coalition consisting of volunteer members and supported by county government. HSD’s employees may work in the organisation for different reasons and have different goals for their professions. DAWI invites people to participate who share the organisation's goals and are interested in supporting its mission. Within DAWI, members regularly speak directly to one another in meetings or as they work together physically within the county on related initiatives and programmes. HSD employees are more geographically dispersed and may or may not work directly together regularly. Finally, HSD is starting its structural competency work by focusing on training and building a foundation for future implementation. At the same time, DAWI has a longer history of engaging the framework and is now focusing on implementation and extending training beyond its organisation. The two organisations have learned similar lessons as they have implemented the structural competency model despite these differences, including the value of the framework for developing an actionable strategic plan, the importance of negotiating and intentionally developing shared languages for communicating health equity work, and the need to build structurally competent communities beyond our individual organisations.

Lessons learned

Value of structural competency in strategic planning

The structural competency framework is useful in guiding strategic planning for complex health equity goals in community and state organisations. Both DAWI and HSD utilised the levels of intervention based on the socioecological model described above to inform and focus their strategic planning, creating actionable goals that take clear steps towards health equity at multiple levels. Utilising these levels of intervention allowed each participant in the strategic planning process to identify the area in which they could be most effective immediately and areas in which they would need to engage in longer-term efforts. It also provided a structure for evaluating the comprehensiveness of strategic planning, ensuring that plans included the range of strategies necessary to address the complexity of health inequities. The organisations, therefore, used the framework to think systematically through clear, actionable steps and to engage their members or staff at the level at which they can act.

For example, DAWI utilised the levels of intervention as a framing device for organising its 2020 strategic planning retreat. The retreat centred on the question: ‘What will DAWI do in the next 1–2 years to improve people’s health and wellness in Doña Ana County?’ During part of the retreat, participants worked in small groups to identify strategic priorities organised by levels of intervention. One example of a strategic priority was developing stronger relationships with the public schools, a goal that emerged from a small group discussion about community level interventions. The group identified education as a key factor in health outcomes and recognised the value of partnering with the local school district to identify ways that DAWI could support students through offering educational experiences outside of the traditional classroom, such as participating in HOSA-Future Health Professionals students organisations events at each high school. Another strategic priority emerged from the group thinking about how DAWI could engage with research. The group identified creating a network to support collaborative approaches to health equity research in partnership with the local university as a key priority of DAWI. A third example from the individual level was to contribute to community members’ education about health equity by developing a locally based online training using the structural competency framework. By using the language and framing of structural competency to develop the strategic plan, members of DAWI viewed all of its efforts through this framework, as well as identifying ways they could use the framework within their own organisations. Efforts have continued to the present in each of these areas, some of which are presented below.

Starting in January 2021, HSD reimagined the structural competency framework for application in a state governmental health and human services agency, starting by aligning the framework with the strategic plan. The authors affiliated with HSD felt that leveraging the structural competency framework would allow HSD to transform lives more effectively. They have found that explicitly connecting the framework to their mission and goals supports the HSD team and other stakeholders in understanding structural competency’s value to their work and customers. Two of these goals include creating effective communication to enhance public trust and promoting mutual respect, trust, and communication for staff to grow and achieve their goals. HSD collaborators felt structural competency could provide an important foundation for these two goals. The first goal, which focuses at the interpersonal level, could help to socialise the structural competency language across the organisation and begin to recognise structures while also communicating that learning to outside stakeholders. The second goal, which focuses at the individual level, would allow for individual growth and learning with the framework, an important step before working with customers, community partners, or other stakeholders.

HSD felt that health and wellbeing inequities needed to be conceptualised in relation to the institutions and conditions that determine socioeconomic, wellbeing, and health-related resources. HSD benefitted from a shift in thinking about how variables such as class, gender identity, sexual orientation, race and ethnicity, and others are shaped both by the one-on-one interactions with a customer, and by the larger structural contexts in which their interactions take place. This requires skills that help recognise how social and economic determinants, biases, inequities, and blind spots shape health, wellbeing, and socioeconomic status long before clients reach HSD offices. This opportunity required a paradigm shift, because governmental institutions have long played a role (often inadvertently) in exacerbating disparities by serving as gatekeepers to services, resources, and technologies that facilitate or constrain the autonomy, choice, and power of those HSD serves. While not part of a formal strategic planning process, HSD used the structural competency framework to refocus the goals and framing of their work.

Importance of intentional language and communication

While the levels of intervention that the two organisations learned during their training helped with prioritisation and framing of goals and objectives, both organisations also found that they needed to reframe some levels of intervention and think carefully about the specific language they used when communicating with each other and with the broader community. Some of this reframing occurred in how each organisation conceived of the levels of intervention. Other reframing work included considering that some terms may be unnecessarily technical, discipline specific, or jargon laden for some community partners.

For example, HSD struggled to describe the institutional level of intervention. As a government organisation, they wondered whether the institution was HSD, the broader parent organisation, the governmental department, or the state government itself. Additionally, when the institution is a policymaking body, there is a clear overlap with the policy level. HSD had to consider how to navigate between the clarity of the conceptual intervention-focus framework and the complexity of their actual on-the-ground work and organisational structure. At the level of use of specific terms or language, DAWI understood that ‘research’ is not a friendly term for all the communities with whom DAWI members work. Research emanating from higher education institutions, for example, is frequently conducted without the partnership of community members or organisations, data and results are not shared, and programmes end when funding ends.

Both organisations independently developed trainings for their members or customers that drew on this thoughtful consideration of how to communicate the structural competency framework using language that would be most relatable to learners. In developing its training, HSD focused on careful building of foundations based on lived experience of employees and customers to first demonstrate the concept in action and then name it. DAWI’s training began by describing important concepts that may or may not be familiar to their members and then illustrated them in case studies describing a community member acting at a specific level of intervention. Both organisations concluded that the term ‘structural competency’ itself may not be necessary. While this term makes sense in its original medical education context where ‘core competencies’ are already a key part of medical education, it may be less useful in other contexts. Each organisation continues to work with multiple concepts such as health inequities and structural determinants of health and to incorporate other important ideas such as wellbeing, particularly for those members of each organisation who may not see their work as directly related to health. Two examples illustrate the thought processes of the organisations in this area.

The course that DAWI designed in partnership with the local university built on what DAWI learned in training and implementation of the structural competency framework as well as experiences working in diverse communities across Doña Ana County. It provides foundational knowledge and skills-building in supporting work towards health equity and to be broadly accessible to anyone working in health and health equity-related fields, such as health care professionals, non-profit community agency representatives, judicial professionals, people working in government offices, and elected officials. The approach DAWI took in developing the course was to use the term ‘structural competency’ in the course's title alongside the more familiar term ‘health equity’. The first module of the course explains the origins of the term ‘structural competency’ to familiarise learners with the concept and help them connect this idea with their own experiences and frameworks within the health equity arena.

The course then focuses on how learners might use the levels of intervention - individual, interpersonal, institutional, community, research, and policy - to strategize their own health equity work. Each module utilises case studies to illustrate how people in local communities have worked at the different levels of intervention to address health equity issues. The case studies highlight challenges that people have faced, community strengths and resources that they have drawn upon, and reflections about the process.

For example, in the module that focuses on policy level interventions, one of the case studies describes the work of a county-wide workforce collaborative that developed a proposal for a Medicaid 1115 waiver to support payment for services provided by community health workers and other similar health care professionals. By grounding the discussion of policy level work in a real example from the local community rather than in more conceptual academic framings of policy work, this module illustrates for learners how people they may know in the local community have already started this work.

HSD took a different approach. HSD training designers did not use the term ‘structural competency’ at all. They also focused on areas they considered to be most accessible to the very large staff of the organisation. Thus, instead of thinking across all levels of intervention, they organised their training around the individual and interpersonal levels of intervention to help staff learn the structural competency language and reflect on and shift what they know. HSD staff hoped to shift the view from the customer to the conditions customers are forced to operate and to build more empathy and understanding for the experiences of lower-income New Mexicans. This meant illuminating that everyone exists within unique circumstances and identities and experiences different structural forces that reinforce exclusion or inclusion from society. The training included sessions on poverty; identity and intersectionality; power, privilege, and oppression; bias; and learning to connect structures to HSD customer stories. Each training provided an overview of the topic, followed by exercises connecting the topic to structural competency and to HSD customers.

For example, one session focuses on first understanding one’s identity, including types of identity such as inherited, acquired, visible, and invisible. Participants discussed how it is natural for humans to try to organise what we see, to draw connections, and make relationships, which essentially includes sorting people into categories, many of which are social constructs. Participants watched a video of the doll test, which was created in the 1940s by two psychologists to study the psychological effects of segregation on children and, ultimately how their perceptions of race might influence their development of self-esteem. Children in the video answer questions about whether the doll is pretty/ugly, nice/mean, good/bad and there are clear connections between the answers and the skin colour of the doll (and implications based on the skin colour of the participating children themselves). HSD staff then introduced intersectionality (Collins & Bilge, 2020; Crenshaw, 2017; Eisenstein, 1978) and connected this concept to HSD customers experiencing poverty who often hold multiple other identities that are discriminated against as well as exist within structures that reinforce their exclusion from society.

Need to build structurally competent communities

Both DAWI and HSD work with many constituencies and community partners to forward the critical work of addressing health inequities across the county and state. As they have developed the strategic plans and trainings discussed above, it has become increasingly apparent to the authors and those with whom they work closely that building structural competency within partner organisations is key to effective collaboration and developing common goals.

For example, HSD is currently exploring tools to integrate a structural lens in policymaking, programme development and evaluation, provision of services, customer interactions, community engagement, and contracting with Medicaid Managed Care Organisations, including clinical care practices. They believe there are existing tools that can be adapted and employed that will enable them to bring a structural lens to their work and change the way they operate. Staff plan to choose one to two tool(s) to pilot in a cross-cutting context that affects the entire organisation in 2023. They will evaluate the pilot, explore additional tools, and begin using them across the organisation more widely in 2024, pending additional funding and resources. They expect this process will lead to an examination of institutional decision-making and accountability and offers a means to transform the lives of those HSD serves.

While HSD has focused on expanding training within governmental institutions and partners, DAWI has most recently focused on new ways of collaborating with public health scientists and other researchers to develop health policy briefs utilising a structural lens and considering a ‘health in all policies’ approach (Centers for Disease Control and Prevention, 2015). DAWI approaches writing these briefs thinking about both the community and policy levels of interventions - partnering with community members to better understand the issues that affect them and then collaborating to influence policy that will address those issues. Some of DAWI’s efforts to date include a policy letter to legislators to support New Mexico HB40, which would place a moratorium on the development of new private prisons in the state, a policy brief shared with county officials arguing for increased support for medication-assisted treatment, and a paper advocating for enhanced policy to improve indoor air quality in our county.

Developing policy briefs has increased DAWI’s connections to local, regional, state, and national elected officials, some of whom attend DAWI general membership meetings. DAWI is becoming an organisation that elected officials look to for perspectives on health policy. In addition, DAWI members increasingly connect policy work to the day-to-day work of their agencies and identify additional opportunities to influence policy development. While DAWI has engaged in this process for years, organisation leaders are now considering how a common understanding of the structural competency framework across all partners in the development of policy briefs would facilitate the equitable participation of all members and support organised and actionable asks within each policy brief.

Conclusion

This article describes how two separate and unique organisations in New Mexico modified the structural competency framework, including levels of intervention, and applied it to conceptualise and act upon the oppressive structures within their communities. Both organisations continue to learn, adapt, and modify this important framework to meet the needs of each organisation and the communities they serve.

Building on the structural competency framework, DAWI understood that to have a substantial and lasting impact on health equity in the community, it was necessary to address the normalised oppressive structures in the community’s policies and institutions. DAWI has taken several actions to implement the structural competency framework within our community. One example is that of health policy briefs that were produced by the organisation incorporating both community and policy level interventions. In addition, they collaborated with New Mexico State University in research involving some of the community’s most marginalised populations, which incorporated research-level interventions. DAWI believes that to be most effective, they must partner with institutions, agencies, and individuals in the community who are also structurally competent. Thus, DAWI has worked to provide structural competency education to community leadership. DAWI presented this framework to the State’s Health and Human Services legislative committee, other community leaders, and county health councils. To become more effective in providing this education, DAWI, in collaboration with New Mexico State University, is developing an online structural competency course designed for community leaders.

Representatives from the Human Services Department were present at DAWI’s initial presentation, and they have taken this framework to a large state institution. They have provided education to leadership on structural competency, which has changed the lens of focus from an individual approach to a structural approach. HSD has taken several steps to address structural competency within the organisation and continues a process with interventions at multiple levels. HSD finds it important that the agency serving a largely marginalised community must understand how social and economic determinants, bias, inequity, and other structural factors affect their customers.

There were three key lessons learned from the adoption of the structural competency framework in New Mexico. First was the value of utilising the structural competency framework in strategic planning. It is common that social structures appear distant, permanent, and immovable to individuals working in community organisations. Using the levels of intervention described by the Structural Competency Working Group in their strategic planning allowed both organisations to identify interventions at various levels and develop actionable goals; thus, recognising that these oppressive social structures are neither permanent nor immovable.

A second important lesson learned was the importance of adapting an intentional language that was meaningful to the specific groups engaged in structural competency work. The language of the structural competency framework can be academic and has the potential to create tensions and misunderstandings in community settings. Addressing these concerns with specific intentional language was important in moving these concepts forward in non-academic community settings.

One last important lesson learned from working with the structural competency framework in New Mexico was that we need to build structurally competent communities. We need to work with various constituencies and community partners to become structurally competent themselves. To address the inequities more comprehensively in health and wellbeing that exist within our communities, we must work to create structurally competent institutions, agencies, and individuals within our community.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

New Mexico State University funded a portion of the online course mentioned in this article. Doña Ana Wellness Institute