Paper short abstract:

This institutional ethnography explores how structural competency requires that healthcare workers, from physicians to community health workers, are drawn into more frequent and more complex collaboration in ways that can reinforce and reshape harmful medical hierarchies.

Paper long abstract:

Structural competency in health services has emerged as a potential solution to mediate unjust and avoidable differences in mortality and morbidity and to address structural barriers to health equity. Practice models that link clinical care and structural forces may improve the prevention and detection of illness and disease, patient safety, and job satisfaction among nurses, social workers, physicians, and community health workers. These models may also improve access to services that address some of the most prominent factors impacting health status, such as food, housing, education, employment, income, or environmental conditions. However, the literature base for interprofessional collaboration and addressing structural factors remains inchoate. This paper describes an ethnographic study in a maternal and child health (MCH) setting in the United States as its frontline workers attempt to intervene upon longstanding health inequities and their social determinants while negotiating a medical hierarchy that privileges biomedical approaches to social needs. I focus on this setting both because of the persistent nature of MCH inequities around the world and the role of MCH as a “litmus test” for the overall functioning of health and social welfare systems. I argue that effective implementation of structural competency requires the collaboration of a diverse range of health and social service workers using exploring frontline workers' perspectives. I situate these workers as part of the emerging structural competency workforce, examining their collaboration strategies to build on and inform recommendations and best practices for structural competency while both working within and challenging naturalized medical hierarchies.