Address Health Inequities Research Articles

Using simulation modelling to transform hospital planning and management to address health inequalities

Health inequalities are a perennial concern for policymakers and in service delivery to ensure fair and equitable access and outcomes. As health inequalities are socially influenced by employment, income, and education, this impacts healthcare services among socio-economically disadvantaged groups, making it a pertinent area for investigation in seeking to promote equitable access. Researchers widely acknowledge that health equity is a multi-faceted problem requiring approaches to understand the complexity and interconnections in hospital planning as a precursor to healthcare delivery. Operations research offers the potential to develop analytical models and frameworks to aid in complex decision-making that has both a strategic and operational function in problem-solving. This paper develops a simulation-based modelling framework (SimulEQUITY) to model the complexities in addressing health inequalities at a hospital level. The model encompasses an entire hospital operation (including inpatient, outpatient, and emergency department services) using the discrete-event simulation method to simulate the behaviour and performance of real-world systems, processes, or organisations. The paper makes a sustained contribution to knowledge by challenging the existing population-level planning approaches in healthcare that often overlook individual patient needs, especially within disadvantaged groups. By holistically modelling an entire hospital, socio-economic variations in patients' pathways are developed by incorporating individual patient attributes and variables. This innovative framework facilitates the exploration of diverse scenarios, from processes to resources and environmental factors, enabling key decision-makers to evaluate what intervention strategies to adopt as well as the likely scenarios for future patterns of healthcare inequality. The paper outlines the decision-support toolkit developed and the practical application of the SimulEQUITY model through to implementation within a hospital in the UK. This moves hospital management and strategic planning to a more dynamic position where a software-based approach, incorporating complexity, is implicit in the modelling rather than simplification and generalisation arising from the use of population-based models.

DYNAMICS OF MORTALITY FROM DISEASES OF THE CIRCULATORY ORGANS IN BULGARIA, SOUTH CENTRAL REGION AND PLOVDIV PROVINCE

In the European Union, Bulgaria ranks first in terms of mortality and last in terms of life expectancy. According to Eurostat data for 2018 in Bulgaria, from 2011 until this moment, the coefficients of both preventable mortality with good prevention and mortality preventable with good treatment are higher than the corresponding values for the EU as a whole. There are no prospects for their improvement. The rate of preventable mortality with good prophylaxis reached 226 per 100,000 population, which is significantly higher than the value of the rate in the whole EU (160 per 100,000). On the one hand, weak primary prevention and health promotion, and on the other hand, the need to improve protocols for diagnosis and treatment of the leading causes of death can be pointed out as reasons.The aim of the present study is to perform a comparative analysis of the dynamics of mortality from diseases of the circulatory organs for Bulgaria, its South Central Region and the Plovdiv province as part of this region.Materials and methods: documentary analysis - based on data from the National Statistical Institute; inductive and deductive methods; comparative analysis; structural analysis; economical analysis; statistical methods - analysis of the dynamics of phenomena, tabular and graphic analyzes - to visualize the obtained results.Results: Both for Bulgaria as a whole, as well as for its South Central region and the Plovdiv province, there is a trend of increasing mortality (per 100,000 people of the population) from diseases of the circulatory organs.Conclusion: From the data of our study, it is clear that, in general, for the observed 10-year period, and more specifically for the last of the years under consideration - 2022, for the entire country, the highest relative share in mortality (per 100,000 population) is occupied by other diseases of the heart. For the South Central region, the mortality rate from ischemic heart disease is the highest. The situation is similar for the Plovdiv province, as part of this region, where the relative share is also the highest - a noticeable 44.0% of the mortality from IHD.Recommendations: A comprehensive approach and addressing health inequities in all areas aimed at reducing the burden of cardiovascular disease as part of non-communicable chronic diseases is imperative. Of primary importance is the fact that health promotion and disease prevention can lead to a significant reduction in this burden.

How Interprofessional Community Mobile Healthcare and Service-Learning Work Together to Identify and Address Chronic Health Disparities.

Residents of the State of Delaware experience high levels of health inequities. Service-learning programs provided jointly by universities and community partners can address health disparities through documentation of disparities and service provision that sees patients where they are. Benefits accrue for both students and communities experiencing health inequities. HEALTH for All (H4A) mobile unit clients can receive a variety of services at sites co-located with community based organizations (CBOs). Between September 2023 and January 2024, H4A clients had their blood pressure assessed by a trained healthcare provider. Demographic and ZIP Code of residence data were collected by a trained graduate student. Data were recorded and analyzed using Microsoft Excel Version 16.5 (Redmond, WA, USA). All documentation was reviewed and approved by the University of Delaware's Institutional Review Board (IRB #1567044-3). Between September 2023 and January 2024, 152 clients participated. Most participants were female (72.27%; 104 of 143) and identified as White (68.66%; 92 of 134). The largest group of clients were in Stage 1 Hypertension (34.21%; 52 of 152), followed by Elevated (23.68%; 36 of 152), Normal (22.37%; 34 of 152), and Stage 2 Hypertension (19.74%; 30 of 152). Black or African American clients had higher systolic and diastolic blood pressure compared to other racial and ethnic groups. There were also differences in the share of clients with hypertension by ZIP Code of residence. Interprofessional service-learning in a mobile health context provides students with practical field experience and real-world insights into community perspectives and needs, including addressing health inequities. Academic-community partnerships and mobile health programs should be prioritized in the future to address health inequities and foster the development of socially engaged, community-minded future professionals.

Highlighting models of Indigenous leadership and self-governance for COVID-19 vaccination programmes

The COVID-19 pandemic has disproportionately impacted Indigenous populations worldwide placing much importance on rapid and equitable vaccination. Nevertheless, many Indigenous communities have reported high vaccine hesitancy and low COVID-19 vaccine uptake. This may be attributed to various factors, including a lack of support for Indigenous leadership efforts to protect their communities and the pervasive infodemic targeting First Nations Peoples. In August 2022, we hosted an international symposium to bring together Indigenous and non-Indigenous community leaders, clinicians, and researchers to discuss pandemic experiences and lessons learnt. This commentary highlights examples of harnessing Indigenous leadership and self-governance to design and deliver tailored community-based and culturally appropriate COVID-19 vaccination programmes that improved vaccine uptake in Australia and Canada. These case studies demonstrate that Indigenous social-governance systems need to be valued, respected, and upheld if we are to make meaningful efforts to address health inequities among Indigenous communities during future pandemics.

Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009–19: an ecological study

Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic. In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models. Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]). Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA. Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation.

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Deaths among adults under supervision of the England and Wales’ probation services: variation in individual and criminal justice-related factors by cause of death

BackgroundThe mortality rate among people under probation supervision in the community is greater than that among incarcerated people and that among the general population. However, there is limited research on the distinct vulnerabilities and risks underlying the causes of death in this population. In this retrospective cohort study, we examined the individual and criminal justice-related factors associated with different causes of death. Factors were assessed in relation to the type of supervision, distinguishing between those under post-custodial release and those serving a community sentence.ResultsThe study utilised the official data held by His Majesty’s Prison and Probation Service in England and Wales on the deaths of men and women under probation supervision between 01 April 2019 and 31 March 2021 where the cause of death had been definitively recorded (n = 1770). The high risk of deaths primarily caused by external factors (i.e., suspected suicide (10%), homicide (5%), and drug-related death (26%)) in this population was confirmed. A Gaussian Graphical Model (GGM) demonstrated unique relationships with suspected suicide and drug-related deaths for known suicide risk, history of drug use and recent (< 28 days of death) enforcement action due to a breach of probation conditions. Our findings suggest that that familial violence and abuse may be relevant in suicide and drug-related deaths and that minority groups may experience disproportional risk to certain types of death.ConclusionsThis study identified unique risk indicators and modifiable factors for deaths primarily caused by external factors in this population within the health and justice spheres. It emphasised the importance of addressing health inequalities in this population and improved joint-working across health and justice. This involves ensuring that research, policies, training, and services are responsive to the complex needs of those under probation supervision, including those serving community sentences. Only then can we hope to see lower rates of death within this population.

Neighborhood-level inequalities and influencing factors of COVID-19 incidence in Berlin based on Bayesian spatial modelling

Numerous studies have explored influencing factors in COVID-19, yet empirical evidence on spatiotemporal dynamics of COVID-19 inequalities concerning both socioeconomic and environmental factors at an intra-urban scale is lacking. This study, therefore, focuses on neighborhood-level spatial inequalities of the COVID-19 incidences in relation to socioeconomic and environmental factors for Berlin-Neukölln, Germany, covering six pandemic periods (March 2020 to December 2021). Spatial Bayesian negative binomial mixed-effect models were employed to identify influencing factors and risk patterns for different periods. We identified that (1) influencing factors and relative risks varied across time and space, with sociodemographic factors exerting a stronger influence over environmental features; (2) as the most identified predictors, the population with migrant backgrounds was positively associated, and the population over 65 was negatively associated with COVID-19 incidence; (3) certain neighborhoods consistently faced elevated risks of COVID-19 incidence. This study highlights potential structural health inequalities within migrant communities, associated with lower socioeconomic status and a higher risk of COVID-19 incidence across diverse pandemic periods. Our findings indicate that locally tailored interventions for diverse citizens are essential to address health inequalities and foster a more sustainable urban environment.

Are We the Problem? A Call to Action for Addressing Institutional Challenges to Engaging Community Partners in Research.

Community-engaged research (CEnR) is a potent tool for addressing health inequities and fostering equitable relationships among communities, researchers, and institutions. CEnR involves collaboration throughout the research process, demonstrating improvements in study recruitment and retention, intervention efficacy, program sustainability, capacity building among partners, and enhanced cultural relevance. Despite the increasing demand for CEnR, institutional policies, particularly human participation protection training (HPP), lag behind, creating institutional barriers to community partnerships. Here, we highlight challenges encountered in our ongoing study, Fostering Opportunities in Research through Messaging and Education (FOR ME), focused on promoting shared decision-making around clinical trial participation among Black women diagnosed with breast cancer. Grounded in CEnR methods, FOR ME has a partnership with a community-based organization (CBO) that addresses the needs of Black women with breast cancer. Our CBO partner attempted to obtain HPP training, which was administratively burdensome and time-consuming. As CEnR becomes more prevalent, academic and research institutions, along with researchers, are faced with a call to action to become more responsive to community partner needs. Accordingly, we present a guide to HPP training for community partners, addressing institutional barriers to community partner participation in research. This guide outlines multiple HPP training pathways for community partners, aiming to minimize institutional barriers and enhance their engagement in research with academic partners.

Navigating Gene Therapy Access: The Case of Bulgaria in the Context of the EU Regulatory Landscape.

Gene therapies (GTs) have recently emerged as revolutionary personalized therapeutic options. Despite their promising potential, challenges such as uncertainty regarding long-term health benefits and safety, along with extreme price tags, pose significant obstacles to patient access. Within the EU, the European Medicines Agency plays a pivotal role with regards to GT market authorization. However, national authorities are responsible for pricing and reimbursement, which results in fragment patient access within the EU. This study aimed to provide an overview of the complex landscape of post-market authorization accessibility for GT products in Bulgaria, comparing it with neighboring EU countries. We applied a mixed-methods approach, including desk research, public data requests, and list price comparisons. As of 1 April 2023, 14 GTs had a valid market authorization at the EU level. In Bulgaria, Kymriah® was the only GT included in the Positive Drug List (PDL), with an official list price of EUR 335,636.94. Similar results were found in Romania, whereas five GTs were included in Greece's PDL. Additionally, Zolgensma® was found accessible in Bulgaria through an alternative individual access scheme at an estimated price of EUR 1,945,000.00. In conclusion, this study emphasized targeted policy interventions to address health inequalities and to ensure timely access to GTs within the EU.

Large-Scale Telemedicine Implementation for Outpatient Clinicians: Results From a Pandemic-Adapted Learning Collaborative.

Learning collaboratives are seldom used outside of health care quality improvement. We describe a condensed, 10-week learning collaborative ("Telemedicine Hack") that facilitated telemedicine implementation for outpatient clinicians early in the COVID-19 pandemic. Live attendance averaged 1688 participants per session. Of 1005 baseline survey respondents, 57% were clinicians with one-third identifying as from a racial/ethnic minoritized group. Practice characteristics included primary care (71%), rural settings (51%), and community health centers (28%). Of three surveys, a high of 438 (81%) of 540 clinicians had billed ≥1 video-based telemedicine visit. Our learning collaborative "sprint" is a promising model for scaling knowledge during emergencies and addressing health inequities.

The association between rurality, dual Medicare/Medicaid eligibility and chronic conditions with telehealth utilization: An analysis of 2019-2020 national Medicare claims.

Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries. We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization. We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased. We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services.

Education Scholarship Assessment Reconsidered: Expansion of Glassick's Criteria to Incorporate Health Equity.

Recent events have ignited widespread attention to structural racism and implicit bias throughout the U.S. health care system and medical institutions, resulting in a call for antiracism approaches to advance health equity. Medical education leaders are well-positioned to advance health equity, not only through their training of fellows, residents, and medical students, but also in their approach to scholarship. Education scholarship drives innovation and critical evaluation of current practices; it impacts and intersects with multiple factors that have the potential to reduce health inequities. Thus, it is critical to prioritize the assessment of education scholarship through a health equity lens. Medical education scholarly dissemination has markedly expanded over the past 2 to 3 decades, yet medical educators have continued to embrace Boyer's and Glassick and colleagues' definitions of scholarship. The authors propose an approach to medical education scholarship assessment that expands each of Glassick's 6 existing criteria to address health inequities and adds health equity as a seventh criterion. With this, medical educators, researchers, reviewers, and others can consider how education scholarship affects diverse populations and settings, direct educational products and scholarship to address health inequities, and raise the importance of advancing health equity in medical education scholarship. By expanding and standardizing the assessment of scholarship to incorporate health equity, the medical education community can foster a cultural shift that brings health equity to the forefront of education scholarship.

Feasibility, acceptability and impact of a clinical decision support tool among primary care providers in an urban, rural and remote site in the Philippines

IntroductionStrengthening primary care helps address health inequities that continue to persist in the Philippines. The Philippine Primary Care Studies pilot-tested interventions to improve the primary care system. One intervention was...

Responses to Sexual and Gender Identity Measures in Population-Level Data by Birth Cohort: A Research Note

The measurement of sexual and gender identity in the United States has been evolving to generate more precise demographic estimates of the population and a better understanding of health and well-being. Younger cohorts of sexual- and gender-diverse adults are endorsing identities outside of the lesbian, gay, bisexual, and transgender (LGBT) labels. Current population-level surveys often include a category such as “something else” without providing further details, and doing so inadequately captures these diverse identities. In this research note, our analysis of the most recent federal data source to incorporate sexual and gender identity measures—the Household Pulse Survey—reveals that younger birth cohorts are more likely to select “something else” for their sexual identity and “none of these” for their gender identity. The observed sexual and gender identity response patterns across birth cohorts underscore the importance of developing and applying new strategies to directly measure sexual- and gender-diverse adults who identify with identities outside of those explicitly captured on surveys. The integration of sexual and gender identity measures in population-level surveys carries broader implications for civil rights and for addressing health inequities and therefore must be responsive to cohort differences in identification.

Bringing abstract concepts to life: A health humanities-based approach to teaching social determinants of health.

To address health inequities, emergency physicians must understand the structural underpinnings of health disparities, including social determinants of health (SDoH), and must critically reflect on the integration of SDoH into clinical practice. SDoH education should include reflective knowledge acquisition, while incorporating systemic sociohistorical forces and individual factors, such as bias, which propagate inequities but are rarely emphasized in graduate medical education (GME). The health humanities (HH), an inclusive transdisciplinary field combining arts, humanities, and social justice, may represent a novel unexplored approach toward incorporating SDoH in GME. We sought to implement and evaluate a GME HH-based curriculum focused on SDoH. An interprofessional team applied Kern's framework to create a longitudinal HH curriculum integrating narrative medicine and visual thinking strategies with evidence-based practices for addressing SDoH in clinical practice. This curriculum was implemented for 52 residents in an EM program in 2019-2020; sessions were initially held in the classroom and community and then virtually during the COVID-19 pandemic. Objectives included encouraging (1) critical thinking about SDoH, (2) engagement with patients and communities, (3) self-reflection, and (4) translation of SDoH to patient care. Descriptive statistics and a constructivist paradigm were applied to results of a postcurriculum survey and focus group, respectively. A curriculum evaluation survey completed by 32/52 residents (61.5%) revealed agreement (75%-90%) that objectives were met. 93.1% of respondents thought humanities were important in residency training. Qualitative analysis of a focus group with 10 participants revealed additional impacts on individual growth, transformation of departmental culture, and transformation of patient care. Curriculum implementation was inexpensive and relied on interprofessional collaboration. The HH represent a promising collaborative framework for integrating SDoH in GME and may inspire transformation of learners' attitudes and practices in EM, though clinical impacts still need to be established.

The Radical Welcome Engagement Restoration Model and Assessment Tool for Community-Engaged Partnerships.

People experiencing addiction, houselessness, or who have a history of incarceration have worse health outcomes compared with the general population. This is due, in part, to practices and policies of historically White institutions that exclude the voices, perspectives, and contributions of communities of color in leadership, socio-economic development, and decision-making that matters for their wellbeing. Community-based participatory research (CBPR) approaches hold promise for addressing health inequities. However, full engagement of people harmed by systemic injustices in CBPR partnerships is challenging due to inequities in power and access to resources. We describe how an Allentown-based CBPR partnership-the Health Equity Activation Research Team of clinicians, researchers, and persons with histories of incarceration, addiction, and houselessness-uses the Radical Welcome Engagement Restoration Model (RWERM) to facilitate full engagement by all partners. Data were collected through participatory ethnography, focus groups, and individual interviews. Analyses were performed using deductive coding in a series of iterative meaning-making processes that involved all partners. Findings highlighted six defining phases of the radical welcome framework: (a) passionate invitation, (b) radical welcome, (c) authentic sense of belonging, (d) co-creation of roles, (e) prioritization of issues, and (f) individual and collective action. A guide to assessing progression across these phases, as well as a 32-item radical welcome instrument to help CBPR partners anticipate and overcome challenges to engagement are introduced and discussed.

Exploring the Influence of Social Class and Sex on Self-Reported Health: Insights from a Representative Population-Based Study.

This study investigates the intricate interplay between social class, sex, and self-reported health (SRH) using data from the European Health Survey of Spain 2020 (EESE2020). Employing a cross-sectional design and a representative sample of 22,072 individuals, the analysis explores the persistence of disparities after adjusting for covariates, focusing on health-related variables. The study employs logistic regression models and directed acyclic graphs (DAGs) to delineate the direct effects of social class and sex on SRH, identifying a minimum adjustment set to control for confounding variables. Results reveal a gradient effect of social class on SRH, emphasizing the enduring impact of socioeconomic factors. Sex-based disparities in SRH diminish after considering additional health-related variables, highlighting the importance of a holistic approach. DAGs serve as transparent tools in disentangling complex relationships, guiding the identification of essential covariates. The study concludes that addressing health inequalities requires comprehensive strategies considering both individual health behaviours and socio-economic contexts. While recognizing limitations, such as the cross-sectional design, the findings contribute to a nuanced understanding of health disparities, informing evidence-based interventions and policies for a more equitable healthcare system.

Social needs screening in primary care: A tool in the fight for health equity?

Progress on addressing health inequalities is slow and in many places around the world the gap between the privileged and the disadvantaged is widening. This is driven largely by an unfair and unequal distribution of the social determinants of health. While upstream policy and agenda commitment is needed to improve social determinants of health at a population level, healthcare also has a role. Currently social information is sporadically collected and used in healthcare. Improving our understanding of social problems is crucial in targeting services and to reduce the overreliance on area-level measures of deprivation. This has the potential to improve patient care as well as more accurately capture socio-economic disadvantage. Here we argue that there is a role for primary care in screening for social needs to help address inequalities.Social needs screening, more commonly used in North America than Europe, aims to systematically collect social information in health and care settings. Healthcare professionals ask patients about social issues including employment, finances, housing, education and social isolation and this information is used to prompt referral to community services to address any need identified.Social needs screening has potential to address negative impacts of social determinants of health at an individual and population level. Providing a reliable measure of social need, screening gives healthcare professionals an opportunity to tailor and improve quality of care for patients and offer individualised support. It has been shown to improve individual social and health outcomes and positively impact healthcare utilisation. At a population level, social needs screening can improve the data on social determinants of health and therefore support policy makers and service delivery leaders to target resources and services more effectively to the communities most in need. Implementing social needs screening must take account of local healthcare service capacity and available community resources but where sustainable, effective programmes can be introduced, the potential benefits are manifold.While primary care alone cannot solve the root causes of health inequalities, we argue it could be a powerful actor in the fight for health equity.

Shedding new light for nurses: Enhancing pressure injury prevention across skin tones with sub-epidermal moisture assessment technology.

To assess the effectiveness of sub-epidermal moisture (SEM) assessment technology in the detection of early-stage pressure damage in a critical care unit (CCU) and dark skin tone patients and its impact on hospital-acquired pressure injury (HAPI) incidence. Quality improvement study employing Kurt Lewin's change model emphasizing planning, implementation, evaluation and sustainable change. The study evaluated 140 adult patients admitted to the CCU over a 24-week period, from July to December 2022. Retrospective analysis of standard PI care pathways was performed in 90 patients admitted during a 12-week pre-implementation period. Fifty patients were admitted through the subsequent 12-week implementation period. SEM assessments were performed daily at the sacrum and heels and interventions were applied based on SEM assessments; SEM delta ≥0.6 indicating localized oedema or persistent focal oedema. Statistical analyses were performed on anonymized data. Pre-implementation HAPI incidence was 8.9% (N = 8/90). All eight patients were African American with varying skin tones. A 100% reduction in HAPI incidence was achieved in the implementation period which included 35 African American patients. The relative risk of HAPI incidence was 1.6 times higher in the pre-implementation group. Implementing SEM assessment technology enabled equitable PI care for all population types and resulted in a 100% reduction of PIs in our CCU. Objective SEM assessments detected early-stage PIs, regardless of skin tone and enabled providing interventions to specific anatomies developing tissue damage as opposed to universal preventive interventions. PI care pathways relying on visual and tactile skin assessments are inherently biased in providing equitable care for dark skin tone patients. Implementing SEM assessments empowers healthcare practitioners in driving objective clinical interventions, eliminates bias and enables positive PI health outcomes. Implementing SEM assessment technology had three main effects: it detected early tissue damage regardless of skin tone (detection effect), enabled anatomy-specific interventions (treatment effect) and prevented PIs across all population types (prevention effect). The authors have adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. No patient or public contribution. What does this paper contribute to the wider global clinical community? Addressing health inequities in pressure injury prevention; Demonstrated effectiveness across patient populations; Resource optimization and enhanced patient safety.