Applying a Structural-Competency Framework to the Implementation of Strategies to Reduce Disparities for Sexual and Gender Minority Youth

Optimizing Sexual and Gender Minority Adolescent Health: Putting Evidence into Practice

INTRODUCTION

Sexual and gender minority (SGM) adolescents are at higher risk for adverse health outcomes compared to their cisgender and heterosexual peers.

METHODS

Guided by the EPQA standardized reporting system, we implemented an evidence-based practice (EBP) initiative centered on affirmative healthcare for adolescents in two pediatric primary care sites. This initiative revolved around: (1) provider training on healthcare needs of SGM adolescents, (2) the use of two new EHR charting tools for SGM needs, and (3) examination of the EBP initiative using quantitative and qualitative analyses.

RESULTS

Quick-texts tools were used 165 times in 3 months (20.4% compliance). Findings also show providers screened Hispanic patients at a proportionately lower rate (p = .043) as compared to other races and ethnicity. Providers perceived the EBP initiative as informative, feasible, without workflow disruption with suggestions for improvement.

DISCUSSION

This EBP initiative has implications for advanced nursing practice, organizational policy, and health equity.

Associations Between Nonsuicidal Self-Injury and School-Based Health-Promotive Factors for Sexual and Gender Minority Youth and Their Peers

Purpose: The purpose of this study was to identify associations between school-based, health-promotive factors and nonsuicidal self-injury (NSSI) for sexual and gender minority youth and their heterosexual and cisgender peers. Methods: Using data from the 2019 New Mexico Youth Risk and Resiliency Survey (N = 17,811) and multilevel logistic regression to account for school-based clustering, we compared the effect of four school-based health-promotive factors on NSSI for stratified samples of lesbian/gay, bisexual, and gender-diverse (hereafter, gender minority [GM]) youth. Interactions were examined to evaluate the impact of school-based factors on NSSI for lesbian/gay, bisexual, (compared with heterosexual) and GM (compared with cisgender) youth. Results: Stratified analyses showed that three school-based factors (adult at school who listens, adult at school who believes they will be successful, clear school rules) were associated with lower odds of reporting NSSI for lesbian/gay and bisexual youth, but not GM youth. Interaction effects showed that lesbian/gay youth demonstrated greater reductions in odds of NSSI when reporting school-based supports compared with heterosexual youth. Associations between school-based factors and NSSI were not significantly different for bisexual compared with heterosexual youth. GM youth appear to experience no health-promotive effect on NSSI of school-based factors. Conclusions: Our findings underscore the potential of schools to provide supportive resources that reduce the odds of NSSI for most youth (i.e., heterosexual and bisexual youth), but are particularly effective in reducing NSSI among lesbian/gay youth. However, more study is needed to understand the potential impact of school-based health-promotive factors on NSSI for GM youth.

A critical review of cultural competence frameworks and models in medical and health professional education: A meta-ethnographic synthesis: BEME Guide No. 79

BACKGROUND

Cultural competence resides at the core of undergraduate and postgraduate medical and health professional education. The evolution of studies on cultural competence has resulted in the existence of multiple theoretical frameworks and models, each emphasising certain elements of culturally appropriate care, but generally lacking in providing a coherent and systematic approach to teaching this subject.

METHODS

Following a meta-ethnographic approach, a systematic search of five databases was undertaken to identify relevant articles published between 1990 and 2022. After citation searching and abstract and full article screening, a consensus was reached on 59 articles for final inclusion. Key constructs and concepts of cultural competence were synthesised and presented as themes, using the lens of critical theory.

RESULTS

Three key themes were identified: competences; roles and identities; structural competency. Actionable concepts and themes were incorporated into a new transformative ACT cultural model that consists of three key domains: activate consciousness, connect relations, and transform to true cultural care.

CONCLUSION

This critical review provides an up-to-date synthesis of studies that conceptualise cultural competence frameworks and models in international medical and healthcare settings. The ACT cultural model provides a set of guiding principles for culturally appropriate care, to support high-quality educational interventions.

Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth

Introduction

Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth.

Methods

Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques.

Results

The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented.

Conclusion

Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.

A Concept Analysis of Structural Competency

Structural competency is a concept that offers a way to understand and respond to health inequities and work toward antiracism in health care. This article undertakes a concept analysis of structural competency using Rodgers' evolutionary method. Based on this analysis, structural competency refers to the ability to recognize and act on structural inequities, skill development, multidisciplinary collaboration, and the reproduction of inequity over time. The meanings and use of this concept differ among disciplines. Multidisciplinary applications of structural competency offer insight into how this concept can foster health equity and antiracism in nursing care, education, research, and health services delivery.