Enhancing Structural Competency in School-Based Health Centers to Address LGBTQ+ Adolescent Health Equity

项目摘要 以学校为基础的保健中心（SBHC）处于保健服务和预防服务的第一线， 美国各地的年轻患者。SBHC为学龄青年提供重要服务，包括 行为、性和生殖保健，通常不考虑患者的保险状况或支付能力。 性别或性少数（GSM）的年轻患者更有可能遭受不良健康状况 结果比他们的顺性别和异性恋同龄人。结构性或社会性因素（例如，耻辱， 歧视、对他们的健康问题认识不足和不敏感）， 需要和护理质量较差的GSM青年。结构能力解决上游因素（社会 健康决定因素、治疗不足和分散、护理不平等）。 提高SBHC内的结构能力将改善GSM学生获得的护理，因此， 他们的健康新出现的结构能力框架要求培养以下方面的意识和能力： SBHC修改组织的服务提供环境，包括提供者和工作人员的知识， 行为，以影响这一社会边缘化的青少年群体的福祉。国家认可 培养结构能力的建议或指导方针包括：（1）采用、传播， 实施GSM支持性政策和程序;（2）为 GSM患者;（3）系统记录和使用性取向和性别认同（SOGI） 信息，以告知和改善临床服务;（4）对所有员工进行最佳实践的持续培训， 与GSM患者互动;和（5）临床劳动力发展，以鼓励提供高质量的 为GSM患者提供服务。这项社区参与的实施科学研究是由学校和 SBHC为基础的研究在农村进行，经济上的挑战，和文化丰富的新墨西哥州。 这项研究提供了一个坚实的基础，采用实施科学的方法，以促进和 使用动态适应过程（DAP）评估这些指南的采用情况，这是一个多方面的 实施战略我们将进行混合方法的准备评估，以确定内部和外部- 在SBHC中实施结构性能力变化的背景决定因素;使用阶梯楔形试验 设计以检查DAP启用的实施如何影响结构上胜任的 SBHC，学生（患者）和实施结果的变化;并评估关键的内部和外部的作用， 背景决定因素、桥接因素以及影响实施的相关中介和调节因素 过程和改善的结果GSM学生。这些成果包括减少护理障碍， 更大的满意度和参与护理。这项研究是实现我们长期目标的关键基石- 长期目标是为GSM青年提供高质量的护理，减少健康和行为健康方面的差距。

Project Summary School-based health centers (SBHCs) are at the frontlines of healthcare delivery and prevention services for young patients across the United States. SBHCs provide vital services to school-aged youth, including behavioral, sexual, and reproductive healthcare, often regardless of patients' insurance status or ability to pay. Young patients who are gender or sexual minority (GSM) are far more likely to suffer from adverse health outcomes than their cisgender and heterosexual peers. Structural or societal-based factors (e.g., stigma, discrimination, low awareness of and insensitivity towards their health concerns) contribute to greater unmet needs and poorer quality of care for GSM youth. Structural competency addresses the upstream factors (social determinants of health, inadequate and fragmented treatment, inequities in care) that affect GSM students. Enhancing structural competency within SBHCs will improve the care received by GSM students and, therefore, their health. Emerging structural competency frameworks call for the cultivation of awareness and capacities in SBHCs to modify organizational service delivery environments, including provider and staff knowledge and behaviors, to influence wellbeing within this socially marginalized adolescent population. Nationally recognized recommendations or guidelines for nurturing structural competency include (1) adoption, dissemination, and enforcement of GSM supportive policies and procedures; (2) creation of welcoming physical environments for GSM patients; (3) systematic documentation and use of sexual orientation and gender identity (SOGI) information to inform and improve clinical services; (4) ongoing training for all employees in best practices for interacting with GSM patients; and (5) clinical workforce development to encourage delivery of high-quality services to GSM patients. This community-engaged implementation science study is scaffolded by school- and SBHC-based research conducted in the rural, economically challenged, and culturally rich state of New Mexico. This research provides a solid foundation for employing implementation science approaches to facilitate and evaluate the adoption of these guidelines using the Dynamic Adaptation Process (DAP), a multifaceted implementation strategy. We will conduct mixed-method readiness assessments to determine inner- and outer- context determinants for implementing structurally competent changes in SBHCs; use a stepped-wedge trial design to examine how DAP-enabled implementation impacts the adoption and effect of structurally competent changes on SBHC, student (patient), and implementation outcomes; and assess the role of key inner- and outer- context determinants, bridging factors, and associated mediators and moderators influencing implementation processes and improved outcomes for GSM students. These outcomes include reduced barriers to care and greater satisfaction and engagement in care. This study represents a key steppingstone to achieving our long- term goal of high-quality care and decreased health and behavioral health disparities for GSM youth.