A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic

Abstract

The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the interrelations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.

Structural competency in emergency medical education: A scoping review and operational framework

“…21,[53][54][55][56][57][58][59][60][61][62][63][64] The remaining articles (9/51) were case studies, case reports, descriptions of implemented curricula, reviews of the literature, or a combination thereof. [16][17][18]20,[65][66][67][68][69] The papers examined and conceptualized structural competency as an interdisciplinary framework that requires learners and educators to continually reflect on issues of power, privilege, difference, and identity in their professional development and care delivery. However, the papers varied in their operationalization of structural competency.…”

“…In contrast, Wear et al 50 proposed incorporating film, literature, written texts, bioethics, and clinical and community experiences to guide students in their learning and clinical care. Finally, Sudak et al 46 Of these, 10 studies 21,52,54,56,57,59,61,64,67,69 defined an outcome as an affective or cognitive change in the learner, and two studies 17,63 examined changes to clinical practice as a result of a specific intervention. None of the studies took place within an ED setting (e.g., learners or patient population).…”

“…11 Structural vulnerability manifests in myriad ways, including chronic diseases (e.g., diabetes and hypertension), 12 traumatic injuries (e.g., in people experiencing homelessness), 13 and stigma within the health care encounter. 14,15 A variety of journals have published curricula, 16,17 recommendations, [18][19][20] and research studies 21 on incorporating structural competency and vulnerability into medical education. 22 However, publications in the EM literature are relatively few.…”

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

“…Another group had health professional students (e.g., medicine and pharmacy) provide education about PrEP to public health providers, contributing to an increase in PrEP prescriptions, including for PrEP-eligible at-risk groups who previously were not given prescriptions (Bunting et al, 2020). An underway pilot targets training primary care providers to better understand historical influences of structural factors, assess structural vulnerability among patients, create a more integrated system of care (e.g., opioid use and HIV risk) and empathy and nonjudgement in patient interactions (Bagchi, 2020). There is strong precedent for this, given that significant effects were noted in creating affirming environments for sexual and sex minority youth, including improvements in providers' and staff's knowledge and attitudes, clinical practices, individual practices, and perceived environmental friendliness/safety (Jadwin-Cakmak et al, 2020).…”

Effectiveness of Interventions for Prevention of Common Infections Among Opioid Users: A Systematic Review of Systematic Reviews

“…Users of illegally obtained pharmaceutical (approved for medical purposes in humans) (6) or non-pharmaceutical opioids, especially persons who inject drugs (PWID), are at an increased risk for serious bacterial infections (infective endocarditis, osteomyelitis, septic arthritis, pneumonia, meningitis, cellulitis, abscesses etc.) requiring lengthy treatment courses and expensive hospital stays (7)(8)(9). Commonly discussed examples of viral OUAIs in PWID are Hepatitis C (HCV) and human immunodeficiency viruses (HIV).…”