Structural competency is the ability to discern how issues defined clinically as symptoms, attitudes, or diseases—depression, hypertension, obesity, smoking, medication non-compliance, trauma, psychosis—are related to both clinical and extra-clinical* decisions. This includes healthcare and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, and even our very definitions of illness and health (AMA, 2021). Viewing healthcare in structural terms recognizes how social, economic, and political conditions produce health inequalities.
*Extra-clinical: incorporating terms and concepts from social, political, and economic theory into healthcare encounters. This is a key tenet of structural competency.
A structurally competent organization works to dismantle policies that reinforce an unjust social order. It shifts the focus from individual responsibility to societal responsibility and rejects the notion that social injustice is due to biological differences. Structurally competent organizations recognize the expertise of patients, build alliances with other disciplines, and work for social, economic, environmental, and health justice (Piñones-Rivera et al, 2024).
Structural competency training addresses five core competencies (AMA, 2021):
- Recognizing the structures that shape clinical interactions.
- Developing an extra-clinical language of structure.
- Rearticulating “cultural” formulations in structural terms.
- Developing structural interventions.
- Practicing structural humility.
Recognizing the structures that shape clinical interactions means healthcare providers are aware of the laws, funding mechanisms, and markets that affect clinical decisions. It helps healthcare professionals understand the wider structures governing their clinical work and identify and encourages providers to support patients in navigating structural barriers to care (Downey and Gómez, 2018).
Developing an extra-clinical language of structure means healthcare providers understand perspectives from different regions and disciplines. This includes similarities and differences among various frameworks—such as social medicine, collective health, structural competency, and others (Piñones-Rivera et al, 2024).
Rearticulating “cultural” formulations in structural terms means healthcare organizations and providers understand that the ways in which culture is defined and understood affects clinical interactions. Reimaging and redefining a patient’s health issues in terms of social, economic, and political conditions rather than cultural factors helps a provider understand larger issues that affect a patient’s health.
Developing structural interventions means clinicians are trained to see the impact of social structures on their patients. Alliances with organizations outside of the medical setting can have a profound impact on a patient’s health. Healthcare organizations can look at successful structural approaches from global health and fields outside of medicine.
Developing structural humility means health professionals understand that they are not alone—however knowledgeable and competent—and do not have all the answers. Rather, they must work in collaboration with patients and communities to address structural inequity. It requires healthcare providers to build alliances with communities, engage in political activism, foster creativity, and engage in lifelong learning (Melino et l., 2023).
9.1 Structural Competence in Clinical Interactions
For individual providers, structural competence means a provider is aware of the availability, quality, cost, and sustainability of an intervention and that race and ethnicity are not to be used as a proxy for a risk factor. If a socially constructed category of race is used as a risk factor, attention should be given to communicating why it is a risk factor to avoid misinterpretation (Lin et al., 2024).
The concept of “social structures” has been largely absent in the U.S. healthcare system. The dominance of biotechnological approaches to healthcare has overshadowed the recognition of social factors that contribute to poor health in both public policies and private healthcare investments (Piñones-Rivera et al, 2024).
Health inequities are ultimately determined by structural processes, such as political and economic power, the global distribution of wealth, and the oppressions derived from social class, structural racism, and sexism. Structural processes (and the inequities they produce) are the primary cause of who is healthy and who is sick. (Piñones-Rivera et al, 2024).
9.2 Structure Racism in the U.S. Healthcare System
There are four main payers or sources of healthcare financing: employers, insurance companies, the federal government, and the states. Laws and policies across various payers have created a two-tier healthcare system that limits racial and ethnic minority populations’ equitable access to high-quality care (Yearby et al., 2022).
Lack of equitable access to high-quality healthcare is in large part a result of structural racism in U.S. healthcare policy, which structures the healthcare system to advantage the white population and disadvantage racial and ethnic minority populations (Yearby et al., 2022).
The U.S. healthcare system is largely profit-driven system that prioritizes privatization and new biotechnical devices and pharmaceuticals. It tends to overlook social and structural causes of health issues and attributes health inequities to cultural disparities related to beliefs or behaviors of individuals and genetic differences between racial groups. Healthcare education and training also reflects this ideology with limited understanding of the social structures and their influence on health outcomes (Piñones-Rivera et al, 2024).
Social injustices and structural inequities contribute to high disease burdens in low income and minority communities. This creates difficulties accessing healthcare, and a lack of trust in the healthcare system. These complex and interconnected mechanisms can lead to physiological and psychological stress from repeated daily inequities, which can contribute to chronic diseases (Culhane-Pera et al., 2021).
Test Your Knowledge
You have an older, Spanish-speaking client who is concerned about her declining health and has come to you for counseling. She tells you she has been very depressed for more than a year. Your Spanish is less than adequate but you decide it’s good enough for this sweet old woman. Her granddaughter offers to translate but you decline and ask the granddaughter to wait outside. In terms of cultural competency, what have you already done wrong?
Answer Any person with limited English should be offered professional translation services. You have already made several inaccurate assumptions about this woman. You have stereotyped her as a sweet, old woman who probably just needs someone to talk to. You don’t feel the need to completely understand her needs and issues and will very likely be unable to draw her out due to your lack of fluency and lack of understanding of this woman’s cultural background.
What Should You Do? Ask if she would like to have a translator or see another counselor with a cultural background similar to hers. Refrain from infantilizing older women as sweet, cute, lonely, and inoffensive. Speak to her as a fellow adult, provide Spanish-language services, and offer educational materials in Spanish.