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Office for Disparities Research and Workforce Diversity Webinar Series: Innovations in Social Determinants of Health: Applying the Structural Competency Framework to Mental Health Care and Mental Health Care Research


DAWN MORALES: Welcome everyone to the NIMH 2022 Webinar Series from the NIMH office for Disparities Research and Workforce Diversity. I am your moderator, Dawn Morales, Chief of American Indian, Alaska Native, and Rural Mental Health. And today's talk is Innovations in Social Determinants of Health: Applying the Structural Competency Framework to Mental Health Care and Mental Health Care Research.

Structural competency is an innovative educational framework for training healthcare providers to recognize and respond to disease and its unequal distribution as the outcome of social structures, such as laws, institutions, policies, and systems. We have two of the leading scientists working in this area to talk about their research, but they will also consider what a framework for mental health research might look like and what it might accomplish.

And without any further ado, I would like to welcome Dr. Michael Harvey, who is Assistant Professor in Public Health at Temple University, but who is about to be affiliated with Brown University, and Dr. Kelly Knight, who is professor in the Department of Humanities and Social Sciences and the Center for Vulnerable Populations at the University of California, San Diego. Dr. Harvey, please go ahead.

MICHAEL HARVEY: Great. Well, thank you Dr. Morales for the introduction and thank you to everyone for being here. As was mentioned, the title of this session is Innovations and Social Determinants of Health: Applying the Structural Competency Framework to Mental Health Care and Mental Health Care Research.

My name is Michael Harvey. So the learning objectives for this session are fourfold. The first is to introduce the structural competency - introduce structural competency and some key concepts that are part of this framework. The second is to build skills for recognizing structural determinants of mental health, stigma, and addiction. The third is to understand application of structural competency to research on mental health, stigma, and addiction. And the fourth is discuss strategies for addressing structural determinants of mental health, stigma, and addiction.

So let's get started. We'll begin by talking about structural competency broadly and some key concepts that comprise this framework as we define it. And then the second half when Dr. Knight takes over, it'll be a bit more applied. So kind of higher level, and then more kind of examples later on in this, in this session.

So what is structural competency? The term was first used by Dr. Jonathan Metzl who's at Vanderbilt. But the kind of touchstone article was written by Dr. Metzl and Dr. Helen Hansen, who is at UCSF, both are physicians, both are trained psychiatrists, and they wrote in a 2014 Social Science and Medicine article calling for a shift in medical education toward attention to forces that influence health outcomes at levels above individual interactions. And they define structural competency. And this is the definition we'll use going forward, as the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures. And we'll talk more about Dr. Metzl and Dr. Hansen's work a little bit later in this presentation.

So this work comes out of the Structural Competency Working Group. It was established in 2014, and it focused on taking this idea of structural competency that had been kind of proposed by Dr. Hansen and Dr Metzl, and really kind of incorporating it and, and developing incorporating it into training and practice for healthcare providers. And so we are a pretty diverse group of health professionals, scholars in medical, social sciences, like medical anthropologists and medical sociologists, community health activists, people working in administration, in various kind of graduate and professional students across many different disciplines, you know, my own public health, the social work, nursing and all various kind of backgrounds.

To date we've completed about a hundred, or more than a hundred, structural competency trainings for all kinds of health professionals, across many different stages of training. People who have been working in their fields for a long time, and then people who are still, you know, in, in the early stages of their work.

And I should say that this is an abbreviation of a much longer training. And so we'll have some big concepts that will we'll throw at you, but just know that there are kind of longer trainings out there, and much more to dive into if this is of interest to you.

So we like to start out these trainings talking about the social determinants of health. This figure comes from the 2020 Healthy People Report, and it kind of represents the social determinants of health in terms of things like neighborhood, and built environment, economic stability, education, but gets at this idea that the social determinants of health are all about those health relevant social conditions in which we are born into, we work in, we live our lives in, and we have recreation and all of this. So just kind of like the conditions of everyday life that are relevant to our health outcomes.

And so we like to begin with that as a kind of foundation for building kind of this larger framework for talking about structural competency.

We also know that there is a social gradient when it comes to these social conditions and health outcomes. We know that there's a close association with health disparity or health disease burdens, I should say, and socioeconomic status, things like poverty, various measures of deprivation. We see that things like diabetes, prevalence of diabetes map onto county level poverty, things like maternal mortality, similarly map onto poverty rates across the United States. And so this is a long recognized relationship, this kind of social gradient and health, and you know, the ideas that the unequal distribution of these social determinants of health result in unequal or inequitable health outcomes.

So that's kind of the, this kind of standard social determinants of health discussion where you have things like poverty, inequality, unequal, social conditions that result in unequal health outcomes disparities. And so what we really like to do in structural competency is to push this analysis a little bit further upstream and say well, let's look at those policies that produce and unequally distribute things like poverty, and that can exacerbate inequality. Let's look at those economic systems, institutions and social hierarchies and social forces, like things like racism, and how all of these things play a role in creating poverty, creating these unequal - these social conditions in unequally distributing them across populations. And so these are kind of the structures that we are trying to emphasize within these trainings, policies, economic systems, laws, institutions, and social, various forms of social hierarchy and social forces like racism that can be harmful to health.

And so this is kind of, you know, structural competency in a nutshell. It's kind of a nice overview of kind of the purpose of these trainings. See if there's anything else here? No, I think that was it. Okay.

So we like to use this term the structural determinants of the social determinants of health to emphasize that, you know, it's, it's good to recognize the social determinants of health. It's good to recognize that social conditions produce - unequal social conditions produce unequal health outcomes, but we want to push it further upstream to look at those policies, to interrogate those economic systems and social hierarchies, that we see (as) ultimately responsible for producing these social determinants of health.

So a concept that is very central to this framework is the idea of a social structure. And this is a term that's been used for a long time in the social sciences, but the definition that we use within structural competency is the policies, the economic systems, and other institutions like judicial systems and schools that have produced and maintain modern social inequities, as well as health disparities, often along the lines of social categories, such as race, class, gender, sexuality, and ability. So that's kind of our working definition of social structures.

In addition to social structure, there's a number of other concepts that we use to kind of develop a structural sensibility and also a structural analysis ultimately, of society and of health disparities. And so these are some of the concepts that we use within that kind of comprise this framework, and I'll go through them now, but I also want to recognize that these are kind of big ideas that we could spend a lot more time on. But as a kind of introduction to them, we'll go through them in the following slides.

So the first concept we have here, again, to kind of sensitize people to the role of structures in producing health inequities is structural violence. And while this term wasn't first coined by Dr. Paul Farmer, it was certainly popularized. I think I would arguably say popularized by him and his work. I should say, the late Dr. Paul Farmer, whose work has certainly influenced a lot of the structural competency work that we've been involved in. In a 2006 article, Dr. Farmer and colleagues write that structural violence is one way of describing social arrangements that put individuals and populations in harm's way. The arrangements are structural because they're embedded in the political and economic organization of our social world, and they're violent because they cause injury to people. So we, this is you know, along with social structure, a kind of fundamental concept for the trainings that that we've developed.

I think, the helpfulness of structural violence takes this idea of violence that we oftentimes conceptualize at the level of the interpersonal violence and expands it to think about the violence that policies can enact, the harm that institutions can bring, and that broader systems can create. A kind of inequitable healthcare system results in some people getting care and other people not getting care, and that causes harm to people. And so to think about violence in that more expanded sense.

Another term that is really, or concept that's really central to the structural competency framework is that of structural racism. This is a term that is not new, but certainly within the last 10 years has been used more in I guess, more mainstream discourse and increasingly within health services research as well. This is a quote that I'll read from a book by Kwame Ture (or, Stokley Carmichael) and Charles Hamilton from 1967, where they write, when white terrorists bomb a black church and kill five black children, that is an act of individual racism, widely deplored by most segments of society. But they go on to write, provocatively, but when that same city, Birmingham, Alabama, with in that same city, 500 black babies die each year because of lack of power, food, shelter, medical facilities, and thousands more destroyed and maimed physically, emotionally, and intellectually because of the conditions of poverty and discrimination in the black community, that is a function of institutional (or structural) racism.

And so here the authors are not downplaying certainly, the role of interpersonal violence or individual racism, here referring to the 1963 bombing by the KKK of a church in Birmingham. But again, calling for a more expansive definition of racism that also takes into account those policies that are creating these inequitable social conditions that are causing harm, that are causing violence to the black community in Birmingham.

There have been more contemporary definitions of structural racism. This one provided by Keeanga-Yamahtta Taylor, a professor at Princeton who writes that “Institutional racism, or structural racism,” terms that are sometimes used interchangeably, “can be defined as the policies, programs, and practices of public and private institutions that result in greater rates of poverty, dispossession, criminalization, illness, and ultimately mortality of African Americans. More importantly, it is the outcome that matters not the intentions of the individuals involved.

And this last line is one that I think is important that when we're talking about social structures, when we're talking about structural violence or structural racism, it might not be that the authors of a policy or those who are participating in a system have racist intentions, explicitly racist intentions, or that they want to necessarily do harm. And yet the outcome of a system is nonetheless violent and harmful and inequitable. And so thinking about kind of the outcome of policy and systems, regardless of any intentions that might have gone into them good or bad, I think is an important aspect of this definition that's provided here.

One example that we use within the training is looking at homeowner’s loan corporation maps that were used in the 1930s and forties, to grade communities and determine which communities were worthy of getting federally subsidized grants from the federal government. This map is the one that was created for the Oakland and Berkeley area where many of these trainings are, are done. And, you know, the outcome of these maps were that neighborhoods that were whiter, that were wealthier, got much higher grades than those neighborhoods that were poorer, that had a larger proportion of people of color, in this case black people and, and Asian people. And that as a result, federal dollars were funded into these wealthier or whiter communities, and they were denied from other communities that prevented people from keeping their homes, from purchasing homes in the first place. And we know that home ownership is a huge aspect of wealth creation and intergenerational wealth transfer. There's been a lot of research that's looked at how these maps still are relevant today, that the patterns that they've kind of entrenched in terms of racial and economic segregation are still very much with us and have very significant health consequences.

Okay. Keep eye at my warnings. Okay. Another concept that we use within the framework is structural vulnerability. And I'll spend less time on this, but I'll just define it as the risk an individual experiences as a result of structural violence, including their location in multiple socioeconomic hierarchies. And the thing I want to emphasize here is that structural vulnerability, that is risk of structural violence, is not caused by nor can it be repaired solely by individual agency or behavior. And so that to address the risk that people have of being harmed by structural violence, we need more collective responses that get at the structures themselves, and don't just focus on individuals and how they behave and how they act and individual level resources but thinking more broadly about policy change and systems change.

Another concept that we use, and I'll go through this relatively quickly because I'm getting a time warning is that of intersectionality, which was developed by Kimberle Williams Crenshaw, and intersectionality holds that the classical conceptualizations of oppression within society, all these isms that I think we’re, you know, more or less familiar with, things like racism, sexism, classism, ableism, homophobia, transphobia, xenophobia, and forms of bigotry based on belief, do not act independently of each other. We're not just in a particular class, or we're not just a particular gender, or we're not just you know, disability we may or may not have. But that we exist kind of at the intersection of these realities and of these categories and of these social hierarchies. And so as this definition says, instead, these forms of oppression interrelate, they create systems of oppression that reflect the intersection of multiple forms of discrimination.

And so this quote comes from Kimberle Williams Crenshaw herself. who I didn't mention, is a faculty member at Columbia. She says, it's not simply that there's a race problem here, a gender problem here, and a class or LGBTQ problem there, many times that framework, that kind of individualizing framework erases what happens to people who are subject to all of these things. She goes on to say that intersectionality can be used as a blanket term to mean, ‘well, it's complicated.’ Sometimes ‘it's complicated’ is an excuse not to do anything. And we want to move beyond that idea.

So really it's about a recognition that people are not just their socioeconomic status, or they're not just their racial background, or they're not just their gender. They exist in multiple social categories. They're subject to multiple social hierarchies at risk of various forms of structural violence at any one time.

So in the last minute or two that I have, I just want to talk about this idea of naturalizing inequality. That has been really influential in my own thinking, in some of my own research. This refers to the sometimes subtle, sometimes explicit ways that structural violence is overlooked. Oftentimes this happens through claims of cultural difference, behavioral shortcomings, or abstract racial categories, which distract from the structural causes of harm.

And we say that these operate through implicit frameworks, which are these kind of taken for granted ways of seeing the world that oftentimes individualized disease, they make disease seem like it's a kind of cultural phenomenon. That they treat disease as kind of biological abstractly biological, or the outcome of genetic factors, rather than forms of social organization, social structures, for example, policies and systems and institutions.

And so some of these are, are kind of vague definitions of culture, which have been critiqued in kind of the critical cultural competency literature appeals to individual behavior for explaining why some people are sick and other people are healthy, appeals to biological differences or genetic differences. I think that's all I have here.

So I'll just last slide I have, just some research that I've done looking at public health education and looking at kind of the theories that are taught within master's level public health courses, and finding that there's a real focus on health behavior theories, kind of explanations of health that rely on kind of concepts related to behavior and appeals to behavior, and very little in the way of social theory, and you know, what we kind of suggest this does is that it trains people who are very kind of behaviorally oriented, who are asking questions that are behaviorally oriented, who are choosing methods that are very behaviorally oriented, and interpreting their findings in a way that really emphasize behavior, and who don't have this kind of sensitivity to structure that we're trying to develop within these structural competency trainings.

And I've called in various places for kind of the incorporation of more social theory within specifically public health instruction. So with that, I will turn things over to my colleague Dr. Kelly Knight, who will take some of these abstract ideas that kind of have been discussing and kind of apply it to some of her own work.

KELLY KNIGHT: Great, thanks so much, Michael for getting us all started, I'm really happy to be here today. And I'm going to sort of transition us from the conceptual work that Michael did around structural competency and some of the history of where the framework came from, to talk a little bit more specifically about the ways that it can show up both in clinical spaces and training, and also in research.

So I want to start by looking at a couple of studies that I've led looking at chronic non-cancer pain and substance use in primary care safety net settings. So I've had a series of RO1s examining this, and I'm going talk a little bit about the methodologies that we use to really be able to think about how can we make structure visible and the impacts of structure on health disparities visible in in our NIH research.

And I just want to acknowledge my teams because it takes a lot more than just me to get this work done. And I've worked with an incredible team of folks who do data collection and analysis with me over time, on both of these RO1 studies. I want to start with an example because sometimes when we talk about what's the relationship between the social determinants of health and the structural determinants of health? The structures are still hard to identify.

And so I want to take an example from the primary care safety net clinical settings, where I've been doing this research of a specific patient trajectory to sort of see how we use multiple methods. And these in my work, I'm trained as a medical anthropologist, so I do primarily qualitative led work and then do mixed methods research. And I'll talk in another example of a body of research where we've used quantitative and qualitative work together to really capture where structures are producing health in those settings.

But in this study we do qualitative interviews with providers. We do qualitative interviews with patients with chronic non-cancer pain and opioid use disorder. And then we do clinic observations where we observe the interactions in clinical space to see how opioid use management and pain management, opioid prescribing, is being managed. And then we look at we go to home visits with patients to see and examine issues around functionality and community level factors are impacting their care and health. And then we also do interviews with a set of key informants, which include people who are responsible for preauthorization payments and insurance payments to cover treatments for pain that might be alternatives to opioids, to DEA officials, who are responsible for monitoring opioid prescribing at a state and federal level, to local harm reduction providers who are helping people who might have left primary care safety net as a result of changing prescribing policies and really include all of that in the analysis to be able to identify the structures. But let's take a particular case.

So this is a particular person, this is an aggregate, of course, for confidentiality reasons, but this is a particular person who had poorly managed chronic non-cancer pain and left primary care after having a positive neuro toxicology screening for cocaine and a subsequent opioid taper. So this is kind of, in many ways, this is sort of all you can get, or one way if you're just focusing on what the patient's experience is in a standard medical history. And I want to take us a little bit farther out from there and start with the medical history that I just shared. What a provider who's in a clinical space may just know about this patient, or if, if we're doing a research study that just focuses on clinic access and utilization, this may be all we learn. But what's the social determinants of health? What are the social histories?

So in this particular case of this patient, he was arrested and incarcerated after being severely beaten by the police as a young teenager. He developed a drug and alcohol use disorder as a result of some of those traumatic interactions and also became gang affiliated to protect himself. He grew up in an area of California where there was widespread police violence of this nature, as he was growing up, and he became reincarcerated. He experienced multiple leg fractures to his leg and back during a prison work project and was prescribed opioids as a result. The opioid doses were escalated by his primary care provider. He was in a physical conflict with his spouse and evicted from his home. He engaged in construction work for a friend in exchange for housing when he became housing vulnerable or at risk for homelessness. And he was re-injured during that construction work and began to use cocaine as an analgesic to be able to manage the escalated pain, had the positive UTOX screen, experienced a taper and left care.

So that's the social context, the broad sort of circumstances that we need to understand to see how sort of a patient ended up in this place or in this setting, right. But what are the structural determinants? One of them is racial profiling and institutionalized police violence, which as I mentioned, has been documented and legislated or gone through the legal system in terms of adjudication for the policing systems in the neighborhood in California, where this person grew up. We have mandatory minimum sentencing policies for nonviolent drug offenses, which meant that being involved in the drug economy and having a substance use disorder increased the likelihood of extended periods of time being incarcerated in prison for this individual. Work swaps is a systemic form of prison labor that uses untrained inmates to fight fires in California, for example, which is really common, which led to this person's injury.

We're now widely aware of the pharmaceutical company push for opioid prescribing that influenced the primary care provider at a structural level to escalate opioid doses. The medical literature supported this. So we had the medical sort of the scientists, the NIH, and other funded researchers like myself, really supported opioids for chronic non-cancer pain, which contributed structurally to the experience of this patient, unregulated low wage labor markets contributed to the kind of work that this person could engage in when they were housing vulnerable, lack of effective funding for effective treatment for cocaine use disorder or stimulant use disorder is a structural issue that many people, particularly polysubstance using opioid and stimulant users face when they're trying to manage their stimulant use and come up with alternatives, the change in guidelines for opioid prescribing at the clinical level. Particularly the CDC guidelines of 2016 meant that this person experienced a rapid opioid taper as a result of a positive cocaine. And we see in the recent JAMA article that was just released the mental health and overdose risks that produced for many patients, including the risk of patients leaving care, which is precisely what happened as a result of, or partially contributed by, the limited funding options for alternative treatments in the safety net setting.

So this is the, the red is the structure, and this is what we're trying to attend to when we're doing research to understand what are the structural determinants of health or structurally competent research. We see here in this diagram, just another way of understanding this is just the structural factors and inequities contributing to structural violence, which is harmful to mental health.

We get the naturalizing inequalities component happening where it's really, the patient is really blamed, or it's a highly individualized discussion around poor choices, rather than an understanding of the sort of the conditions of possibility that made - that constructed those choices for the patient and for the provider in terms of their prescribing behaviors and access to alternative treatments. And this contributes to trauma and social suffering, and you kind of get into a cycle here, unless you can, what we argue in instructional competency is research and try and inform the policies and structures that are informing this. How do we address the cycle? And I'm going to talk about that through research.

I just want to briefly touch on something that Michael raised earlier, is that this really came from the Helena Hansen and Jonathan Metzl wrote The Protest Psychosis, which was a book that really identified the overdiagnosis of schizophrenia among black men during the civil rights movement, as a way to medically manage appropriate social protests to ongoing structural and interpersonal racism that so many were experiencing at that time.

And this is where he first coined structural competency, to really identify the ways in which mental health, and psychiatry specifically, has a long history of associating behaviors with racialized or gendered or ableist stereotypes. And this is an old Haldol ad that was in archives of General Psychiatry in 1974, and then associating medical solutions or medicalization solutions for, for social problems. Whereas Helena Hansen points us toward “…clinical training must focus its gaze from the exclusive focus on individual encounter to include organizations, institutions, and policies, neighborhoods, and cities…” We can address that. And so I'm going to share with you a second example from research that I've done, where we really try and sort of drill down on what that would actually mean to try and reorganize a structurally competent response to complex social problems.

And one of the ways, and I'll just say both Helena Hansen, who is at UCLA, not UCSF, I should say. I'm at UCSF, not UC San Diego, but all the UCS sometimes get all scrambled up. I know we are many medical schools. But is to understand that both Jonathan and Helena Hansen, Jonathan Metzl and Helena Hansen, are psychiatrists and a historian on Jonathan Metzl’s part in a medical anthropologist. So they're both position scholars who are really deeply aware of mental health and particularly the intersection of stigma, mental health, and addiction, as a point of critical intervention for structurally competent clinical care and research.

And one of the frameworks that we want to think about when we think about this, is to think about stigma as a way in which stigma operates on the individual level. And so I just, I'm not going to go through this whole slide, but I wanted to share this article with you because I think it really does a great job of sort of parsing out the levels of stigma from anticipated stigma that structurally marginalized people may experience, that in healthcare settings, for example, that makes them mistrustful or reluctant to engage in healthcare because they anticipate that they will be stigmatized based on their various social positions and behaviors to enacted stigma, which is where providers, or researchers, or others are, are, are enacting stigma in the ways that they're interacting with patients or research participants.

Two levels of public stigma, which is so critical when we think about mental health and addiction and their intersection, is the ways that stereotypes, for example, about people with opioid use disorder, such as perceived dangerousness or perceived moral failings, really translate into the ways in which they infiltrate and translate into the ways in which we conduct research and care for communities of people that share those symptoms or diagnoses.

And all the way up to structural stigma, which is of course critical for structural competency work in the ways that we can understand what are the systems, institutions, policies, that are codifying or normalizing these forms of stigma that are allowing them to perpetuate and be unaddressed, and research has a really important role to play in this.

And so I want to go into the second example I have, before we get to questions, to really drill down a little bit, as I said, into some of the studies that I've done on mental health, drug use, and social structural marginalization, and some of those have been NIH studies or studies funded by foundations and state agencies, to really try and understand the complex relationship between mental health, drug use, and socio-structural marginalization, particularly in the context of housing vulnerability, which is my area of research.

And again, getting back to the methodological question, it really becomes an issue of understanding that to have a structurally competent research portfolio or approach, doesn't mean that you're sort of setting everything and nothing. It's, it's a set of well-organized research questions and methodologies that then you can apply often in a mixed methods context. I advocate for that. I think that's most successful to be able to make structures visible, which sometimes really requires a quantitative or a big, big data analysis approach to really see how systems are affecting wide swathes of a population. And then also do the qualitative work and the ethnographic work to really understand how people are having differential experiences based on their interactions with institutions and systems.

And so I'm just going to share one piece of work. This is from our NIDA work that looked at violence and victimization among a population of HIV positive and HIV negative women-identified people, and we looked at it in both of those ways. So on the one side, I don't know if it'll be your left or your right, we have the paper we published in the American Journal of Public Health that was quantitative, that looked at the relationship between violent experiences that participants experienced in their housing settings and are well, unsheltered, and levels of psychiatric comorbidity to really demonstrate that there were some strategies that the participants in our study were using to isolate themselves from forms of violence that they were experiencing.

And on the other side, here's our paper that was primarily qualitative and ethnographic, where we demonstrated the role of the built environment, the types of housing that was available to our research participants and the way that that housing was funded. And the policies around that - the specific policies around the ways that that housing was available and organized really contributed to both risk for victimization amongst the people in our study, and also the ways in which they can manage their psychiatric comorbidities or their psychiatric symptoms  and the ways in which they felt that they could manage or have control over their substance use, which we know those are highly correlated in terms of being in a trauma informed, calm space for people who are experiencing a lot of housing vulnerability.

So that's one example of ways you can sort of use mixed methods to be able to really identify the structures. The second example I'm going to draw on was also related to work that was happening at this time, but is related directly, and comes directly from a book that I did, which was a four-year ethnography of pregnant people who were unstably housed and living in single room occupancy hotels that were again, organized by various types of funding streams. So some were government funded and organized, and some were privately organized, and had really different outcomes in terms of being able to protect people and have better pregnancy outcomes.

And so we took a case from that study and I collaborated with Andrea Jackson, here at the top, Ashish Premkumar and Laura Duncan, who were all OBGYN faculty and attendings at UCSF at the time, to create a case for the New England Journal, that was really focused on how do we transform medical education and research to change the way in which the trajectories happen for the people that are experiencing this intersecting or intersecting forms of oppression.

So this was a case, and I'll just read it here, this is the case note. So similar to the opioid case that I just shared with you, where you get sort of, this is what the clinician would write, or this is maybe sometimes the limits of the research that gets collected. And then I'm going to share a second quote from the nursing staff that this individual overheard while they were being hospitalized.

So this is the note. “39-year-old African American woman. Opioid user. Possibly homeless. Preterm birth at approximately 24 weeks of pregnancy, most likely due to cervical insufficiency, resulting in a neonatal demise.”

It's a very clinical summation of an experience of a healthcare interaction experience that happened with the person we call Ms. W in this case. This is what she overheard when she was in the hospital when two nursing staff outside the door, we're discussing her case. And one said to the other, “This, sadly, is a typical case. These women are in such a bad way. It feels like there's very little we can do. They should be given an IUD along with their methadone. It's terrible to say, but it might be a blessing that the baby didn't survive. It probably would've just ended up in foster care anyway, after going through opioid withdrawal.”

So that's a really heavy statement to sit with and has multiple, multiple forms of enacted stigma and structural violence involved in it. It led to Miss W leaving AMA, which is against medical advice. She also lost access to her methadone maintenance treatment because it was linked to her pregnancy. And so when she was no longer pregnant as a result of her baby dying at 24 weeks, she lost access to her treatment. In a subsequent pregnancy she avoided prenatal care and she had a second obstetric emergency and ended up with a second stillbirth.

So terrible, terrible health disparities that we know are reflective both of black infant mortality, and not in her case, but also contribute to black maternal mortality, which are at incredibly disproportionate rates in this country. And so this is a case where we can really examine both the forms of stigma that Ms. W. experiences. I already mentioned enacted stigma. She experienced anticipatory stigma in the sense that she avoided prenatal care for her subsequent pregnancies because of her treatment and the assumptions that were made about her treatment. And in terms of structural factors beyond the forms of intersecting forms of structural oppression that she experienced during her clinical interaction, which were so significant, including the outright non acknowledgment of her loss, or of her parenting goals, which happens over and over again, particularly among black parenting people in the United States. She also lost access to her drug treatment to her methadone, which was linked through a funding stream, again, a structural or policy decision.

So what can we do, I'll wrap up in my last minute here to just talk about some of the strategies that we have in place, because there's multiple forms of intervention that can change the outcome. And what we talk about in structural competency is them on levels, because there's the intrapersonal level, which is the sort of - the shorthand for that is the work we need to do on ourselves. What we need to do, how we need to educate ourselves and be aware of the ways in which we might be causing harm in our research, what we need to be more aware of, and who we need to be collaborating with, to do more structurally competent work.

Interpersonal has to do with that communication piece. The clinic level is about what can we change about the way clinical care or healthcare is organized to be more structurally competent and to match better to the needs of structurally vulnerable people. Community is where are our partnerships who are doing this aligned work along these intersectional forms of marginality and oppression that we can collaborate with.

Research, I've been talking about already, and that's really my wheelhouse as a researcher, and then policy of course is, you know, how can we be directly speaking to policy?

So in Miss. W’s case, at the intrapersonal level, we have person first and clinically appropriate language. And this is where we work at UCSF through the Repair Project, and also through other medical education efforts, to ensure that we're using appropriate language in clinical settings and recognizing internalized biases and where they come from, and really focusing on medical education.

At the interpersonal level, it's really having language. And in the research setting, I think it has to do with thinking about the ways in which we're asking research questions and are research questions that we're asking, getting at systems are still perpetuating the idea that this is an individuating phenomenon or that this is only about individuals and their behavior, that their health outcomes are only linked to that.

At the clinic setting, it's really being aware of what setting we're working in. So I think about this a lot, again, as a researcher of am I capturing all of the important clinical settings to really u nderstand the phenomenon that I'm trying to understand. If it's pregnancy outcomes among people who have substance use disorders and are unstably housed, or if it's chronic non-cancer pain management with people who have co-occurring opioid use disorder. What are all the clinical settings that they may interact in? And, and how can I capture that in my research?

I mentioned on the community level, it's really, who are your allies and who are you working with and collaborating with? In my research context, that means community engaged research, both in its production and dissemination. And at the research level, I highlighted multi method research. And I think that's really - we can talk more about this if people have questions in the Q&A, but really there's a lot of different strategies for being able to get at this. And a lot of my work at UCSF, particularly with the Benioff Housing and Homelessness Initiative, is to do direct outreach to policy makers, and really make sure that they have the media, the evidence to be able to inform the larger conversation, both at the policy and the media level, so that we're not perpetuating structural stigma that really influences care outcomes for people.

So I want to leave time for discussion. So I'll just go over our take home messages, and then Michael and I can take your questions. Our first take home is, you know, structural competency is a framework that addresses the structural factors. And so we want to stay in structural factors and really hold onto those institutional relationships, policies, and hierarchies, that are producing health inequity.

Applying a structural competency framework involves methodological interventions. And I've made this point a couple of times. I really can't say this enough, that there are many strategies for doing structurally competent research, but the most important starting point is really understanding your own positionality and what you need to sort of how you need to educate yourself to be able to do this work effectively. Who do you need to partner with, and then what are the methodologies, research questions, and specific aims? And how are those framed? Are they framed from a structural analysis perspective or are, you know, are they falling short there? And then how do, how do we make sure that we make the structures visible? So I will stop there and get ready for some questions.

DAWN MORALES: Thank you, Dr. Knight and Dr. Hardy, I invite you to unmute yourself and start up your video whenever you're ready. I do see a handful of interesting questions in the Q&A. So I urge our viewers to please write additional questions because we're looking forward to tackling as many as we can. I'd like to read a question to you all, both from Brittany Beasley. And I suspect that this might be most appropriate for Dr. Knight, but I'm not positive.

She asks, how do you research and locate policies that contribute structural violence? For example, if someone does a case conceptualization, how would they find policies that could be impacting the client and may represent social determinants of mental health? And if Brittany will forgive me, I wouldn't mind tacking on an additional layer to the question. She's talking about it from the perspective of clinical provider trying to provide good care. But I'd be interested in knowing how a funding agency such as the NIH or the NIMH, might fund research that located policies that contributed to structural violence, if you mind giving a part A and part B to the question. Who wants to take this one, Michael or Kelly?

KELLY KNIGHT: I can start, and then Michael, please jump in. So first of I'll answer it as a researcher, and then maybe I can answer it, some ideas around NIMH or NIH. As a researcher, one way to start is usually to make sure that your research is following the money. You know, in our healthcare system specifically, and what I mean by that is if you're dealing with a case specifically, to try and understand the ways in which an individual's access to mental healthcare or other forms of healthcare, other housing and education and employment, is determined by their level of the resources and the systems that are in place that sort that out.

So I'll give you a specific example in my book, one of the things that I was really attending to was the way that diagnoses particularly of bipolar disorder and PTSD among the pregnant people I was working with, were linked to certain forms of welfare benefit. And so within that system, they created a system of care where a diagnosis of a mental health condition became a really important lever to create social benefit. And so, because the funding was linked, just like the pregnancy, the funding for the methadone maintenance in Ms. W's case was linked to her pregnancy status. Anytime you see, you know, a mental health condition linked to a funding stream, that's one way to look to see structure. So you can see what are the policies that were created to limit that or to create the categories around it? Who's making those policies?  Where did they come from, and do they need to be changed because they're producing a health disparity or do they need to be interrogated and revalued? So that's just one basic tenet of you know, really. And then I do work with policy makers. So I always, I always want the policymaker's voice at the table. And so when I do research with key informants, I want to talk to the people because they're often well aware of the structural constraints within the work that they do.

You know, getting to the question of intention that Michael raised around structural racism. It's not that they, sometimes they're aware that the unintended consequences are coming from the policies and programs that they're creating, and sometimes they're not. So really that dialogue is important to include them in the research. Don't just include people who have, you know a mental health condition, but also include all the people who are responsible for their care.

From an NIH perspective. I think it's really, and I'm seeing more of this and I'm, I'm really encouraged by it is RFAs and other forms that are really making applicants who are writing proposals really articulate the ways in which their research is going to be beneficial to the communities that they're studying or collaborating with, hopefully, and not just studying.

And also that they're going to have research methodologies that identify beyond the individual. And so when that's written into a RFA, when that demand, it's really powerful, because of course, as a prospective grantee like myself, I'm paying attention to the NIH priorities and making sure that my proposals, my RO1 one proposals match that demand.

So that's just one suggestion that I think they can take a more organized stance on at the NIH.

DAWN MORALES: Michael, do you have anything additional to add?

MICHAEL HARVEY: No. I've been answering some questions in the Q&A. I'll just be sensitive to time and just recognize Kelly's expertise on this. And there's nothing I can add.

DAWN MORALES: I'll take the moderators prerogative Kelly and Michael, and answer a question of my own, or ask a question of my own. Pardon me. What do you see as the role of basic biological science, neuroscience, physiology hormonal levels and genomic research, in understanding how social structures produce health inequity? Either one of you, whoever wants to take a swing at that one.

MICHAEL HARVEY: Sure. I'll say a word or two, and then let Kelly add. That's such a great question and I’m someone who does work in theory, and so I, I immediately think about Dr. Nancy Krieger's work in social epi at Harvard and her emphasis on this concept of like embodiment and how we kind of embody the social world around us, the kind of social structural world around us.

And I think she's one of these people who really, I feel like tries to bridge this kind of the biological, the genetic, the epigenetic, with this kind of structural analysis as well, and not treat them as two separate domains, but as thinking of them as kind of part of a continuum. She even kind of chides a lot of social, social theorists for neglecting kind of the biological and how we physically incorporate the conditions of our of our lives. So that's one person's work who I feel like is kind of grappling with these questions, which as the question implies, I think, treats these two domains as separate, whereas they oughtn’t be.

KELLY KNIGHT:  And I would just add that this is a really active project at UCSF right now, specifically through the Repair Project, which I mentioned, and I know we wanted to put some resources into the Q&A or into the chat of some links both to the structural comp, the National Structural Competency Work webpage, which has links also to the training, the three, four hour training, which is all open source. So for people who want more information about that, I wanted to mention that. And also to acknowledge the Repair Project, where we're really thinking actively about the role of the basic science, both in perpetuating bad race science basically, and really using race as a category inappropriately in clinical and community epi, as well as grappling with sort of where do we, where do we have a structurally competent or an anti-racist research platform that can incorporate productively the basic science?

So on the Repair Project, on our steering committee, we intentionally have people who are social scientists and basic scientists really trying to think through. It's a huge question and a really critical one. And I would love to see some actual, some research on actually how to, how to do that and how to move that conversation forward, because it's an active question for us in medical education at UCSF.

DAWN MORALES: Fascinating. It just seems like we never have enough time for questions. I'd like to mention to it, perhaps it's Thania Galvan, or perhaps it's the Neo Galvan that the links that Michael Harvey just posted in the link, will help you figure out how to get ahold of that fuller, more complete training that was mentioned earlier.

And I hope that the others of you found the questions that were answered in the Q&A to be as interesting as I did.

The upcoming webinars in this series, we have the National Institute of Mental Health James Jackson Memorial Award speaker, which is to be determined, but will be on July 27th. We have Advancing Methods and Measures to Examine the Underlying Mechanisms of Violent Death for LGBTQ Populations. And we have the Research Workforce Diversity Program. Both of those are scheduled for September. And you can register at the same website where you registered to hear this webinar.

I'm grateful to all for attending and for the excellent questions that were posed. I would like to thank our speakers, Dr. Kelly Knight and Dr. Michael Harvey, for a fascinating, substantive, and thoughtful presentation. For programmatic questions and information about webinar recordings, feel free to write us at the web at the email address listed on the slide. And thank you.