Abstract
Objective. To describe a health equity curriculum created for pharmacy students and evaluate students’ perceptions and structural competency after completion of the curriculum.
Methods. A health equity curriculum based on transformative learning and structural competency frameworks was implemented as a 10-week mandatory component of the pass-no pass neuropsychiatric theme for second year pharmacy students. Each week, students reviewed materials around a neuropsychiatric-related health equity topic and responded to discussion prompts through asynchronous forums or synchronous online video discussions. The effectiveness of the health equity curriculum was evaluated through assessment of structural competency through a validated instrument, an objective structured clinical examination (OSCE), and a questionnaire.
Results. All enrolled second year pharmacy students (n=124) participated in the health equity curriculum. Of the 75 students who completed the structural competency instrument, 46 (61%) were able to identify structural determinants of health, explain how structures contribute to health disparities, or design structural interventions. Ninety-six of the 124 students (77%) were able to address their OSCE standardized patient’s mistrust in the health care system. Thematic analysis of student comments elucidated three themes: allyship, peer connection, and self-awareness. Students rated asynchronous discussion forums as significantly less effective than online video discussions and patient cases for achieving curricular objectives.
Conclusion. A mandatory curriculum delivered remotely throughout the didactic pharmacy curriculum using a blended learning approach was an effective way to incorporate health equity content and conversations into existing courses. Implementation of this or similar curriculums could be an important step in training pharmacy students to be advocates for social justice.
INTRODUCTION
Health disparities are preventable factors that exist across racial and ethnic groups and obstruct individuals from achieving optimal health outcomes.1 Implicit biases of health care providers have been shown to affect health care outcomes of minority patients and are likely a significant contributor to health disparities.2,3 The Accreditation Council for Pharmacy Education (ACPE) and Center for the Advancement of Pharmacy Education (CAPE) require that pharmacy students be able to “recognize social determinants of health to diminish disparities and inequities in access to quality care,” but provide little to no guidance on how to do this.4,5 With the continuing racial injustices that have been perpetuated and highlighted by the COVID-19 pandemic, there has been a long overdue call to educate pharmacists to be advocates for social justice.6
Most of the literature in pharmacy education around health disparities has centered on cultural competency or cultural humility, which can promote categorization of patients into groups and minimize the importance of other social and structural determinants of health.7,8 A new concept, structural competency, provides a framework for teaching students about structural causes of health disparities.9 The framework consists of five skill sets: recognizing structures that shape clinical interactions, developing extra-clinical language of structure, rearticulating “cultural” presentations in structural terms, observing and imagining structural interventions, and developing structural humility.9 Structural competency has been implemented in some medical and nursing curricula, but Avant and colleagues’ study is the only example of a structural competency curriculum in pharmacy students.10⇓⇓-13
To promote structural competency in pharmacy students, we piloted a health equity curriculum at the University of California, San Francisco School of Pharmacy based on Sukhera and colleagues’ transformative learning framework for reducing implicit bias in health care providers.14 Their framework describes a cycle of a disorienting experience, critical reflection, acquiring skills, and role modeling new behavior through sharing and dialogue with peers to reduce implicit bias.15 As a consequence of the COVID-19 pandemic, this curriculum was conducted completely remotely. The purpose of the curriculum was to teach students to identify and recognize structural causes of health disparities, design interventions to reduce structural causes, and engage in equitable, civil, and compassionate discussions about systemic racism and implicit biases. The objectives of this study were to describe student perceptions of the health equity curriculum at UCSF School of Pharmacy, determine which activities of the curriculum were most effective, and evaluate students’ structural competency after completion of the curriculum.
METHODS
Curriculum Design
The health equity curriculum was a 10-week mandatory component of the existing pass-no pass neuropsychiatric theme for second year pharmacy students and consisted of approximately one to two hours of student work per week. The neuropsychiatric theme was chosen as the context in which to introduce the health equity curriculum as this was the longest theme in the didactic curriculum and directed by the two faculty who were leading the development and implementation of the curriculum. To promote a safe space and comradery in the remote environment, the students were split into 21 longitudinal health equity groups of five to six students that were evenly distributed based on self-identified gender and ethnicity. To foster productive discussions and provide timely feedback, faculty recruited 13 second year students with experience in facilitating peer small groups or with a vested interest in health equity topics to serve as small-group facilitators. Additionally, five senior pharmacy students who were teaching assistants for the Applied Patient Care Skills course facilitated student small group discussions. Groups that were not assigned to a student or teaching assistant facilitator were monitored by the faculty leads. To provide a confidential and safe space for discussion, students and facilitators could only access their own groups, and with the exception of the two faculty leads, other UCSF faculty did not have access to these student groups.
The health equity curriculum used a blended learning model conducted in a remote environment.16 There were three main components: didactic material, asynchronous online small group discussion, and small group synchronous Zoom (Zoom Video Communications) discussions. Most of the material and discussions were delivered and conducted asynchronously because of constraints on available synchronous time within the course schedule. The asynchronous material and discussions were housed on the Collaborative Learning Environment, a component of Moodle, version 3.9.3 (www.moodle.org). All videos were uploaded to and provided via Vialogues, version 2.1.5 (www.vialogues.com), a platform which allows students to leave comments at specific points (timestamps) in the video and reply to other students’ comments. Given that this curriculum occurred during the neuropsychiatric theme, special care was given to identify topics related to health disparities in neurocognitive and psychiatric disorders. Activities and discussion prompts were designed using the transformative learning framework designed by Sukhera and colleagues.14 The topics chosen, materials used, activities, and assignments for the curriculum are provided in Table 1.
Content of a Health Equity Curriculum Incorporated Into an Existing Course in a Doctor of Pharmacy Curriculum
For each week of didactic material, students were given discussion prompts and one to two students in each subgroup were responsible for leading the group discussion on the Collaborative Learning Environment form. The discussion prompts asked students to reflect on and apply concepts covered in the didactic materials on patient cases from their Applied Patient Care Skills course, which involved specific health disparities related to the content for that week. Each student was required to post at least one reply for each discussion topic. To allow the students to engage in health equity topics in real time, three synchronous Zoom discussions were held throughout the curriculum: one during the two-hour didactic introduction to the curriculum, a one-hour discussion at the halfway point of the course, and a two-hour reflection session at the end of the curriculum. The students also participated in a session of the Applied Patient Care Skills course that focused on responding to and addressing microaggressions and providing patient-centered care to a patient with structural barriers to health.
Curriculum Evaluation
This was a mixed methods study that was approved by the UCSF Institutional Review Board as exempt. To evaluate students’ structural competency, the authors created and validated an instrument based on Metzl’s five structural competency skillsets, heretofore referred to as the Structural Competency Instrument.11,17 The Structural Competency Instrument used in this study was based on Metzl’s Structural Foundations of Health instrument and redesigned using Wilson’s construct modeling approach to measure domains of structural competency.17,18 The construct map and the Structural Competency Instrument were refined through consultation with measurement experts at the University of California, Berkeley. Using the measurement model, a construct map was created to map Metzl’s structural competency skillsets to levels of competency (Table 2). The Structural Competency Instrument was initially piloted with the 13 student facilitators and produced a reliability of 0.55. The instrument was then further refined through rewording of prompts and creation of items that more specifically targeted domains and demonstrated an improved reliability of 0.79 and Spearman’s rho of 0.81. Table 3 provides representative Structural Competency Instrument items and their corresponding structural competency domains. Students were asked to complete the structural competency instrument at the end of the health equity curriculum. The Rasch measurement model was used to examine instrument validity and standard setting for the competency levels.18,19 Wright maps and the statistical analysis used to validate the instrument were conducted using Berkeley Assessment System Software (Berkeley Evaluation and Assessment Research). A copy of the Structural Competency Instrument is available upon request.
Structural Competency Levels of Second Year Doctor of Pharmacy Students as Assessed Using the Structural Competency Instrument
Structural Competency Instrument Items and Corresponding Structural Competency Domains
Students were surveyed regarding their perceptions of the curriculum via Qualtrics immediately after completion of the course. The questionnaire included three open-ended prompts on what students learned about themselves, what they learned from their peers, and what changes they would make in the future based on what they learned in the health equity curriculum. A thematic qualitative analysis was conducted on the student comments. Two investigators (SH and RT) independently read one-third of the excerpts to identify initial codes. The investigators then met to discuss codes and create an initial codebook. They then independently coded all of the excerpts with the initial codebook and met to review coding, reconcile differences, and discuss new/redundant codes. All coding and qualitative analysis of code patterns were conducted in Dedoose. In the questionnaire, students used a five-point Likert-type scale (range: 1 = not at all effective to 5 = extremely effective) to rate the effectiveness of the Collaborative Learning Environment discussions, Zoom discussions, APCS patient cases/sessions, and overall curriculum in their ability to: reflect on and recognize their own biases, discuss topics around health equity, communicate with and provide equitable care to all patients, and design interventions to reduce health disparities. All questionnaires that included at least one response to one of the items were included in the analysis. An analysis of variance with post-hoc Bonferroni correction for multiple comparisons was conducted to evaluate differences between curricular aspects and objectives. All questionnaire statistical analyses were conducted in SPSS Statistics, version 26 (IBM).
To evaluate students’ ability to apply health equity communication techniques, students participated in an objective structured clinical examination (OSCE) at the end of the course. One of the OSCE cases involved interacting with a patient with significant distrust in the health care system as a result of structural factors (eg, institutional racism, discrimination, access to health care). Students were evaluated by UCSF faculty and residents trained to serve as standardized patients. Students were scored on whether they were able to address the patient’s concerns about the health care system using a dichotomous score (ie, yes or no). Students were also scored on their ability to respond to the patient’s needs and feelings on the following five-point Likert-type scale: 1 = unacceptable, 2 = borderline, 3 = acceptable, 4 = strong, and 5 = exceptional. Descriptive statistics for both OSCE items were calculated in SPSS.
RESULTS
In total, 124 second year pharmacy students participated in the health equity curriculum. One-hundred eleven students (90%) completed the demographic items on the questionnaire. Of these students, 58% identified as Asian/Pacific Islander, 19% as White/Caucasian, 7% as Hispanic/Latino, 6% as multiracial, 4% as other, and 3% as Black/African American. Of questionnaire respondents, 68% identified as female, 24% as male, 1% as transgender female, and 1% as gender non-conforming.
The 13 student facilitators were excluded from the Structural Competency Instrument analysis given their strong interest, participation in the instrument pilot, and potential high proficiency in structural competency. Of the 111 students surveyed, 75 (68%) of students completed the Structural Competency Instrument. Of these students, 13 (17%) were at the Unaware level, 16 (21%) were at the Recognize Cultural level, 21 (28%) were at the Recognize Structural level, 16 (21%) were at the Applying level, and 9 (12%) were at the Imagining level (Table 2) after completing the health equity curriculum.
One hundred four of the 124 students (84%) provided responses on the questionnaire regarding what they learned about themselves, what they learned from their peers, and what they would change as a result of completing the curriculum. Three primary themes were identified across all three prompts: allyship, peer connection, and self-awareness. The first theme, allyship, encompassed actions and approaches consistent with being an ally for marginalized groups. This included being an ally in the context of patient care by advocating on behalf of patients and providing equitable care. An additional subtheme under allyship was speaking up or starting conversations around inequities. The second theme, peer connection, encompassed connecting with peers through an appreciation of discussions, descriptions of shared experiences and goals with classmates, and recognizing both similar and differing perspectives and viewpoints. The third theme, self-awareness, included biases and a growth mindset. Students spoke of recognizing, evaluating, and changing their own and others’ biases. For growth mindset, students mentioned a desire to continue learning, self-reflecting, and improving skills around health equity. Statements regarding providing equitable care to patients (allyship) were often co-coded with biases, peer connection, and growth mindset. Growth mindset was also often co-coded with biases. Descriptions of the themes and subthemes and representative quotations from participants are provided in Appendix 1.
In the questionnaire, 101 (81%) of students ranked the effectiveness of three curricular aspects in improving their ability to recognize and reflect on biases, discuss topics related to health equity, communicate with and provide equitable care to patients, and design interventions to reduce health disparities (Table 4). On average, students rated the overall curriculum as very effective for teaching them how to reflect on and recognize biases, discuss topics, and communicate with and provide care to patients. Students also rated the overall curriculum as moderately to very effective for designing interventions (p < .01). For all three objectives, students rated discussions within the Collaborative Learning Environment as being significantly less effective than Zoom discussions and skills cases and practice (p < .001). There were no significant differences between the effectiveness of Zoom discussions and skills cases and practices across any objective (p > .05).
Student-Rated Effectiveness of Overall Curriculum and Curricular Aspects in Improving Ability to Reflect and Recognize Biases, Discuss Topics around Health Equity, Communicate with and Provide Equitable Care to All Patients, and Design Interventions to Reduce Health Disparities (N = 101)
All 124 students participated in the OSCE at the end of the course. Ninety-six students (77%) were able to address their standardized patient’s concerns about the health care system through empathetic listening and eliciting the patient’s perspective. The average student score on ability to respond to the patient’s needs and feelings was 4.0±0.8 out of a maximum score of 5, illustrating that, on average, students demonstrated “strong” communication skills in this area.
DISCUSSION
This curriculum builds upon social justice and structural competency curricula in medicine, nursing, and pharmacy literature.10,11,17,20 The literature in health professions education primarily describes social justice and/or structural competency elective courses that were conducted in-person and contained a mix of discussion and traditional didactic lectures.10,17,20 The health equity curriculum described here presents an innovative approach because it was integrated into an existing required course for all pharmacy students, delivered remotely, and consisted mostly of small-group peer learning. Another innovative aspect of this curriculum was the utilization of peer small-group discussion to drive learning, which is a key component of Sukhera’s transformative learning and social justice frameworks.8,15 This is the first curriculum we are aware of that uses these frameworks in pharmacy education in a remote learning environment.
At the end of the health equity curriculum, 61% of students who completed the Structural Competency Instrument were able to recognize structural determinants of health when presented with a patient case or health disparities. One limitation is that the Structural Competency Instrument consisted of 14 open-ended response items, which may have contributed to survey fatigue resulting in a lower assessed structural competency rating. In addition, because students did not complete a validated structural competency instrument prior to the curriculum, comparisons could not be made between student competencies prior to and after the curriculum.
The identified themes in the student comments aligned with Sukhera and colleagues’ framework of transformative learning theory for recognizing and managing implicit bias.14 Student comments about recognizing their own biases and having a desire to continue to self-reflect indicate that they had a disorienting experience and were engaging in critical reflection. Comments regarding providing equitable patient care and starting conversations around health equities align with the elements of acquiring skills and role modeling new behavior. Finally, many of these comments were in the context of peer discussion and dialogue, another key component of the framework. The growth mindset theme we identified further illustrates the transformative nature of this curriculum in that it prompted students to view their challenge of implicit biases as a lifelong process. Though only 12% of students scored into the Imagining level of the Structural Competency Instrument, 77% were able to apply and demonstrate equitable patient-centered communication in a formal assessment (OSCE). This suggests that, although students may require additional practice in imagining interventions, they had already begun to apply individual interventions such as patient-centered communication skills in addressing patients with structural determinants of health.
Among the different modalities used to deliver this curriculum, students preferred engaging in live discussion and applying what they had learned to patient cases over participating in asynchronous discussion forums. Although engaging in asynchronous discussions was still rated as moderately effective, doing so likely did not generate as much of a rich discourse or interaction as participating in synchronous discussions. Additionally, to track participation, students were required to complete their discussion posts by a certain time each week, which may have led to students perceiving the discussion posts as an assignment rather than an opportunity to critically reflect on and discuss the topic. Through this evaluation, we identified several areas for improvement. Though students expressed gratitude and interest in this topic, they felt overwhelmed at times with the workload the curriculum added to the didactic curriculum and extracurricular activities. This may have led to less thoughtful engagement by the students. For future iterations, we plan to spread the curriculum across multiple courses and themes and provide a better balance between asynchronous and synchronous discussions. This will reduce the amount of in-class time needed in an already packed curriculum and allow students to thoughtfully engage with the curriculum without feeling overwhelmed.
Limitations to our study include the lack of a pre- and post-intervention comparison and a control group, and only involving our school’s student population, which identified primarily as Asian/Pacific Islander and female, in the study. Given that this curriculum centers around individual biases and perspectives of marginalized and privileged groups, it may have a different impact if implemented in student populations with different demographics. Additionally, the assessments occurred mostly in the didactic setting. Though students did demonstrate equitable communication skills in their OSCE, this study did not evaluate whether students would use and apply structural competency to actual patient care. Future research should evaluate whether health equity curricular interventions impact students’ ability to communicate with and provide care to real patients with structural determinants of health.
CONCLUSION
A blended health equity curriculum based on structural competency and transformative learning frameworks for recognizing and managing implicit bias was piloted remotely during the neuropsychiatric theme to second year pharmacy students. Though this was a pilot program, we believe that this approach to a health equity curriculum could be implemented at other institutions as it requires minimal in-class time. This curriculum also builds upon existing health professions literature by demonstrating an effective, remote, mandatory model for social justice-oriented education through peer dialogue. From our experience, a health equity curriculum spread throughout the didactic curriculum with a blended approach may be an effective way to incorporate health equity conversations into existing programs and could be an important step in training student pharmacists to be advocates for social justice.
Appendix 1. Themes and Sub-themes Identified Through Qualitative Analysis of Student Open-ended Survey Responses with Representative Quotations
- Received February 7, 2021.
- Accepted May 27, 2021.
- © 2021 American Association of Colleges of Pharmacy
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