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

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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.