Building structural competency through community engagement

Context: The importance of addressing the social determinants of health (SDOH) in medical education has been ubiquitously recognised. However, current pedagogical approaches are often limited by inadequate or ahistorical exploration of the fundamental causes of health inequity. Community-engaged pedagogy and structural competency frameworks advocate for progressing from passive SDOH education to directly discussing systemic aetiologies of health inequity through reciprocal partnership with marginalised communities. Herein, we describe the development and exploratory evaluation of a community-engaged structural competency curriculum implemented in 2019 at the University of Nebraska Medical Center. Our curriculum explored the downstream impacts of sociopolitical structures on local health inequities. We engaged university, health system and community stakeholders throughout curriculum development, implementation and evaluation. Curricular components included didactic lectures, reflective writing assignments and a community-based, stakeholder-led experience in North Omaha. Methods: We used inductive thematic analysis to explore free-text responses to a post-curriculum survey. Results: Eighteen community stakeholders, eleven multidisciplinary UNMC facilitators, and all 132 first-year medical students were involved in the curriculum pilot, with 93% and 55.1% of students and faculty/community facilitators, respectively, responding to the post-session evaluation. Analysis revealed themes including widespread desire for community-engaged teaching, appreciation for the hyperlocal focus of curricular content and recognition of the importance of creating space for lived experiences of community members. Discussion: Co-created by a university-community coalition, our pilot findings highlight the crucial role of community-engaged pedagogy in promoting critical understanding of historic structural inequities and present-day health disparities. Our communities can and should be reciprocal partners in training the physicians of tomorrow.