Health Equity Gaps Research Articles

Dietary and Physical Activity Behaviors in 2021 and Changes from 2019 to 2021 Among High School Students - Youth Risk Behavior Survey, United States, 2021.

The fall of 2021 was the first school semester to begin with widespread in-person learning since the COVID-19 pandemic began. Understanding dietary and physical activity behaviors of adolescents during this time can provide insight into potential health equity gaps and programmatic needs in schools and communities. This report uses data from the 2021 national Youth Risk Behavior Survey conducted among a nationally representative sample of U.S. public and private school students in grades 9-12 to update estimates of dietary and physical activity behaviors among U.S. high school students overall and by sex and race and ethnicity. In addition, 2-year comparisons (2019 versus 2021) of these behaviors were examined. In 2021, daily consumption of fruits, vegetables, and breakfast during the past 7 days remained low and decreased overall with specific disparities by sex and race and ethnicity from 2019 to 2021. The overall prevalence of students attending physical education classes daily, exercising to strengthen muscles on ≥3 days/week (i.e., met the guideline for muscle-strengthening activity), and playing on at least one sports team decreased from 2019 to 2021; whereas being physically active for ≥60 minutes/day on all 7 days (i.e., met the guideline for aerobic activity) and meeting both aerobic and muscle-strengthening guidelines remained low but did not change. These findings underscore the need for strategies to increase healthy dietary and physical activity behaviors both in the recovery phase of COVID-19 and longer term.

PREDICTORS OF PARTICIPATION IN A TELEPHONE-BASED SOCIAL CONNECTEDNESS INTERVENTION FOR OLDER ADULTS

Abstract Background Social isolation is a well-documented contributor to poor mental and physical health, and interventions promoting social connectedness have been shown to be protective. This study examined predictors of participating in a telephone-based social connectedness intervention for socially isolated older adults. Methods Data was obtained from a social connectedness intervention that paired students with older adults. Eligible participants included Houston area older adults, 65 years or older, enrolled in Medicare Advantage plans. Eligible participants were contacted telephonically and asked to complete the 3-item UCLA Loneliness Scale. Those who screened positive for loneliness were invited to participate in the social connectedness intervention. Logistic regression models, that accounted for sociodemographic, clinical and functional indices, were used to identify predictors of participation. Results Females (OR: 1.23, 95% CI: 1.04-1.45), and racial/ethnic minorities (African American OR: 1.39, 95%CI: 1.16-1.68; Hispanic OR: 1.43, 95%CI: 1.04-1.99) were more likely to participate in a telephone-based social connectedness intervention. Older adults with a disability (OR: 2.37, 95%CI: 1.96-2.87), higher CMS Hierarchical Condition Category risk scores (OR: 1.15, 95%CI: 1.06-1.25) and those who reported having 1+ social needs (OR: 1.38, 95%CI: 1.14-1.66) were more likely to participate. Of all Charlson Comorbidity Index flags examined, diabetes was the single strongest predictor of participation (OR=2.49, p=0.02). Older adults who reported functional comorbidities for anxiety and depression were also more likely to participate. Conclusion Telephone-based social connectedness interventions can reach vulnerable older adults with clinical and social needs, and can be useful in addressing racial/ethnic health equity gaps in socially isolated older adults.

Abstract 14303: Disparities in Mechanical Circulatory Support Utilization in Patients With End Stage Heart Failure

Despite optimum guideline directed medical therapy, one-year mortality rate of patients with end stage heart failure exceeds 50%. The use of mechanical circulatory support (MCS) has been shown to improve the overall quality of life in patients with advance stage heart failure. Studies have explored disparities in clinical outcome of patients undergoing mechanical circulatory support for acute myocardial infarction and cardiogenic shock. Data on sex-specific, racial, and socioeconomic disparities in patients with end stage heart failure requiring MCS as a bridge-to-transplant or destination therapy is limited. Using the most recent National Inpatient Sample database, we hypothesized that disparities found among other patient populations also exist in patients with end stage heart failure needing MCS. In our study, 1.5% of patients with end stage heart failure underwent MCS with a mean age of 55±16 yrs. Females accounted for 20.7% (20.69% vs 79.3%, p =0.002). Patients who received MCS had lower comorbities; Diabetes (38.8% vs 43.5%, p =0.308), COPD (8.6% vs 24.9%, p <0.001), CKD (47.4% vs 63.1%, p =0.001), and Hyperlipidemia (43.1% vs 47.5%, p =0.347). Among patients with end stage heart failure, mean charlson index by race were 4.4 vs 4.6 vs 4.5 for Whites, Blacks, and Hispanics respectively, p =0.008. After controlling for age, comorbities, charlson index, insurance types, household income and place of residence, compared to Whites, Blacks and Hispanic with end stage heart failure were significantly less likely to undergo MCS (Blacks: aOR=0.50, 95% CI: 0.29-0.87, p =0.014) (Hispanics: aOR=0.68, 95% CI: 1.48, p =0.337). Females compared to males also had lower odds of receiving MCS in end stage heart failure (aOR=0.56, 95% CI: 0.34-0.92, p =0.021). We observed patients with end stage heart failure who received MCS were younger and had less comorbidities. After controlling for age, comorbidities and potential confounders, the odds of females and minority patients with end stage heart failure receiving MCS was about half. These findings underscore the importance of addressing social determinants of health in minority populations. Further implementation studies are required to help bridge the health equity gap in patients with end stage heart failure.

Health systems and health equity: Advancing the agenda

Despite a compelling body of evidence and decades of policy recommendations, deep inequities in health persist with historically marginalized groups. Operationalizing strategies to achieve equity in health and health care continues to remain elusive to health systems. We propose several focus areas; attention to semantics and concepts, building knowledge of health inequities, redesigning care and transforming cultures, to advance health equity work by health system nurse leaders and clinical nurses. Health equity frameworks, traditionally applied in population and public health, are also discussed to tackle health equity issues and formulate, implement and evaluate solutions to inequities. Examples illustrate ongoing work in our health system in targeted areas and challenges in advancing health equity work. Future efforts by health system nurse leaders should concentrate on technology for point of care health screening and data acquisition, data-driven decisions, and organizational performance measures to narrow health equity gaps.

The Impact of Global Health Disparities on Atopic Dermatitis in Displaced Populations: Narrowing the Health Equity Gap for Patients with Skin of Color.

Atopic dermatitis (AD) is a relatively common inflammatory skin disease marked by eczematous lesions and pruritus often leading to significant morbidity and quality of life impairment for those affected. Recent studies have shown that patients with skin of color (SOC) carry a larger disease burden than patients of European descent. In the USA, these disparities are partly due to structural, environmental, and interpersonal racism. From a global perspective, there is a paucity of research on the burden of atopic dermatitis and other inflammatory skin diseases experienced by the record numbers of refugees, migrants, and asylum seekers around the world. Although it is still unclear whether the true prevalence of AD in displaced communities is higher compared with the general population, those who are displaced suffer from unique risk factors that render them especially vulnerable. In this review, we outline a number of factors contributing to AD susceptibility and/or aggravation in displaced communities. These include poor living conditions, climate change events, psychological stress, and lack of access to medical care and health-related behaviors.

Invited Commentary: Learning about Breast Cancer Outcomes in Asian Women to Close the Health Equity Gap.

Invited Commentary: Learning about Breast Cancer Outcomes in Asian Women to Close the Health Equity Gap.

Complexity in Global Health- Bridging Theory and Practice.

Increasingly, health reflects an integrated outcome of a growing globalized system. Economic, political, cultural, environmental, and other global processes profoundly influence how we understand and approach health challenges. As these occur in a webbed, dynamic, and interdependent fashion, health can be viewed as a complex issue. Drawing from this understanding, in this viewpoint, I assert applying complexity theory to produce a definition of the field of global health. Complexity theory tenets such as non-linearity, transdisciplinarity, open-system analysis, and global-local phenomenology can provide a theoretical basis for a substantive understanding of global health phenomena and a richer instrumental approach to global health challenges. Harmonization between complexity theory and global health may provide the foundation to close the health equity gap put forth by the global health agenda.

187-LB: Leveling Health Disparities through Digital Health—Associations between Risk for Health Inequity and Diabetes App Satisfaction, Use, and Outcomes

Introduction: Disparities in health outcomes are well documented in the literature, with factors such as race, education and income increasing the risk of inequity. Mobile health (mHealth) may help bridge the health equity gap. This study investigates use and attitudes toward One Drop's mHealth program for type 2 diabetes (T2D) as it relates to cumulative risk for health inequity. Methods: Members with T2D using One Drop completed a health survey in exchange for a $20 gift card. We tested relationships between cumulative risk for inequity, calculated as a count of risks related to race/ethnicity, income, education, insurance and employment, and One Drop attitudes, use and outcomes. Results: Members (N=149) reported a median of 1 risk factor. Risk was positively associated with reported helpfulness of the One Drop app, educational topics, reminders and actual views of lessons, while negatively related to past-month glucose logging (p’s<.05) . No associations were found for helpfulness of glucose analysis or coaching, use of coaching, self-reported A1C and actual past-month blood glucose (p’s>.05) . Discussion: Higher risk for health inequity was associated with reporting greater helpfulness of One Drop's app and the use of some of its features. Combined with the absence of an association between risk for inequity and self-reported A1C and glucose, results suggest mHealth apps may be creating equitable outcomes by providing trusted content and greater accessibility. mHealth platforms should ensure this population has access to education emphasizing regular glucose monitoring as part of diabetes self-care. Disclosure S. D. Imrisek: Employee; One Drop. H. Nagra: Employee; One Drop, One Drop. J. R. Hoy-rosas: None. M. Lee: Employee; One Drop. D. Goldner: Employee; One Drop. J. Dachis: Board Member; One Drop, Employee; One Drop, Stock/Shareholder; One Drop. L. Sears: Employee; One Drop.

942-P: Disparities in Telemedicine Use among Pediatric Patients with Type 1 and Type 2 Diabetes

Despite the increase in telehealth services in diabetes care during the COVID-pandemic, studies have found disparities in telemedicine (TM) use among patients. Our Diabetes Clinic currently cares for 1400 patients with type 1 diabetes (T1D) with 46% being publicly insured and for 375 patients with type 2 diabetes (T2D) , 88% being publicly insured. We have previously shown a significantly lower number of completed TM encounters between March and July 2020 by publicly insured patients when compared with privately insured and a threefold increase in no-shows and same day TM visit cancelations by the publicly insured group. Between January and March 2021 we surveyed families who had never attended a TM visit to better understand barriers to TM use. Of the 7patients who received care during this period, 162 (22.8%) had never attended a TM visit. Of the 39 surveyed patients, 84.6% had T1D and 15.4% had T2D. There were 46.2% who self-identified as Non-Hispanic White, 35.9% as Hispanic, 5.1% as Asian, 2.6% as Non-Hispanic Black, and 10.3% as Other. Additionally, 48.7% had public insurance, 23.1% had no EMR access and 15.4% did not speak English as their primary language. Out of patients with T1D, 63.6% used a CGM and 33.3% used an insulin pump. Reported reasons not to attend a TM visit included: preference for in-person care (43.6%) , not being offered a TM visit (17.9%) , technology issues (12.8%) , scheduling conflicts or forgetting about the appointment (17.9%) and 20.5% preferred not to provide a reason. In conclusion, more than half of our surveyed patients with diabetes who never attended a TM visit were from racial and ethnic minority groups. The COVID-pandemic has highlighted disparities related to access to and use of technology to improve diabetes care. Our results show the importance of ensuring all families are aware of TM options and receive support with TM technology. Further research into TM perception and adoption barriers should be conducted to prevent disparities in care and to close health equity gaps. Disclosure K.Chan: None. C.Demeterco-berggren: None.

Pairing Project ECHO and patient navigation as an innovative approach to improving the health and wellness of cancer survivors in rural settings.

We conducted a 12-month pilot study of 2 complementary strategies for improving rural cancer survivorship outcomes: (1) Project ECHO, a telementoring model to increase knowledge and skills about cancer survivorship among multidisciplinary health care provider teams in rural areas and (2) patient navigation (PN) services to connect rural cancer survivors with resources for enhancing health and wellness. We recruited 4 CDC-funded National Comprehensive Cancer Control Program sites to implement Project ECHO and PN interventions for a defined rural population in each of their jurisdictions. Sites received ongoing technical assistance and a stipend to support implementation. We conducted a mixed-methods evaluation consisting of quantitative performance monitoring data and qualitative interviews with site staff to assess implementation. Site teams delivered 21 cancer survivorship ECHO sessions to rural providers resulting in 329 participant encounters. Almost all (93%) ECHO participants reported enhanced knowledge of cancer survivorship issues, and 80% reported intent to apply learnings to their practices. Site teams engaged 16 patient navigators who navigated 164 cancer survivors during the study period. Successful implementation required strong partnerships, clear avenues for recruitment of rural providers and cancer survivors, and activities tailored to local needs. Fostering ongoing relationships among sites through community of practice calls also enhanced implementation. Sites successfully implemented a novel approach for enhancing care for cancer survivors in rural communities. Pairing Project ECHO to address structural barriers and PN to address individual factors affecting survivorship may help bridge the health equity gap experienced by cancer survivors in rural communities.

A school-based health centre partnership: Faculty practice, nursing student learning and wellness in youth, families and community.

This paper describes the development of a SBHC with an innovative model of care that grew out of a partnership between a public-school district and a university nursing programme in the midwestern region of the United States. Persistent barriers to health and health care experienced by youth are well documented. School-based health centres (SBHCs) can improve educational and health outcomes, positively impacting health equity. Academic systems are positioned to address health care needs of the school-aged population, yet educators face challenges of accessing quality learning placements for students and faculty practice sites. A community-based collaborative methodology guided the planning phases that were driven by priority needs identified by families and stakeholders. With the mission of "partnering with students, families, and communities in the promotion of health and wellness through engagement in practice, education, and research," an ongoing dialogue over a two-year period led to articulating a vision, designing a plan and implementing a nurse-managed SBHC. The Standards for Reporting Qualitative Research (SRQR) checklist was considered in the preparation of this paper. In three years, this SBHC has addressed and identified priority needs and served individual youth and families. The SBHC provides opportunities for the faculty to fulfil a practice requirement for certification and accreditation. Nursing students engage with youth and families in health education and health promotion while strengthening their technical and relational skills. Family nurse practitioner students gain valuable clinical experience. Faculty with expertise in family nursing guide family assessments, support family resiliency and direct therapeutic conversations with family units. SBHCs serve youth, families, and community. This academic-practice partnership has the added benefit of providing faculty practice opportunities and nursing student experiential learning. SHBCs provide practice opportunities that address needs in individuals, families, and communities. Partnerships should be considered at academic nursing programmes to support their needs and fulfil commitments to address health equity gaps.

Effects of Healthcare Policies and Reforms at the Primary Level in China: From the Evidence of Shenzhen Primary Care Reforms from 2018 to 2019.

Countries worldwide are making efforts to achieve health equity. China focuses on the implementation of the policy goal of “improving the primary level” to eliminate the health equity gap. The main purpose of this study is to examine the effects of the healthcare reforms at the primary level in China and to analyze the key factors that can help to improve their effectiveness. From the perspectives of the policy attention mechanism and public policy analysis, this study will explore primary care reforms from policy formulation to policy implementation on the basis of grounded theory and empirical research on primary care reforms in Shenzhen, China, that was conducted from 2018 to 2019. The present study found that the government pays close attention to the medical level and service level of primary care services at the policy formulation phase but less attention to talent level and information sharing. At the same time, this study combined with empirical data from primary care centers in Shenzhen for the period covering 2018 to 2019 evaluates policy implementation and its effect. Multiple regression analysis revealed that the medical level, talent level, service level, and information sharing helped to develop primary care services and improved health equity. Nevertheless, this study reflects a deviation between policy formulation and policy implementation for the development of primary care policies. Empirical experience shows that the development of talent level and information sharing can significantly promote primary care services and health management. Therefore, this study implies that in the process of promoting the health equity at the primary level, more attention should be paid to the consistency between policy formulation and policy implementation. Additionally, the policy promotion and influence mechanism can be improved, particularly in terms of talent development and information sharing, in order to effectively promote the development of health equity at the primary level.

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.

Commentary: Access to Virtual Care Matters: The Problem with Giving to Some and Not All.

Expedited in the midst of the COVID-19 pandemic, virtualization of healthcare is becoming an inevitable norm. While this conveys hope for improving health systems performance, inequitable access could result in consequences that intensify health disparities and increase the burden on the health system. Nurse leaders are optimally positioned to tactfully influence policy directions on virtual care and shape a comprehensive research agenda that includes virtual nursing care in all domains of practice. With virtual care advancing into the mainstream, it is time to mind the health equity gap and co-design virtualized care that ensures the needs of all are met.

Law and urban governance for health in times of rapid change.

SummaryGovernance is an important factor in urban health, and law is an important element of healthy governance. Law can be an intervention local government wields to influence behavior and shape environments. Law can also be an important target of health promotion efforts: Law and the enforcement and implementation behaviors it fosters can promote unhealthy behaviors and environmental conditions, and can act as a barrier to healthy interventions or practices. Finally, law is a design and construction tool for the organization of governance. Law is the means through which cities are formally established. Their powers and duties, organizational structure, boundaries and decision-making procedures are all set by law. Regardless of the form of government, cities have legal levers they can manipulate for health promotion. Cities can use tax authority to influence the price of unhealthy products, or to encourage consumption of healthy foods. Cities can use their legal powers to address incidental legal effects of policies that they themselves cannot control. Cities may also have the authority to use law to address deeper determinants of health. The overall level of income or wealth inequality in a country reflects factors well-beyond a local government’s control, but city government nonetheless has levers to directly and indirectly reduce economic and social inequality and their effects. A renewed focus on law and urban governance is the key to assuring health and well-being and closing the health equity gap.

Low-Cost Optodiagnostic for Minute-Time Scale Detection of SARS-CoV-2.

The COVID-19 pandemic has exacerbated our society’s tremendous health equity gap. Disadvantaged populations have been disproportionally affected by COVID-19, lacking access to affordable testing, a known effective tool for preventing viral spread, hospitalizations, and deaths. Here, we describe COVID-19 Low-cost Optodiagnostic for Rapid testing (COLOR), a colorimetric biosensor fabricated on cotton swabs using gold nanoparticles modified with human angiotensin-converting enzyme 2 (ACE2), which costs 15¢ to produce and detects SARS-CoV-2 within 5 min. COLOR detected very low viral particle loads (limit of detection: 0.154 pg mL–1 of SARS-CoV-2 spike protein), and its color intensity correlated with the cycle threshold (Ct) values obtained using reverse transcription polymerase chain reaction (RT-PCR). The performance of COLOR was assessed using 100 nasopharyngeal/oropharyngeal (NP/OP) clinical samples, yielding sensitivity, specificity, and accuracy values of 96%, 84%, and 90%, respectively. In summary, each COLOR test can be manufactured for 15¢ and presents rapid minute-time scale detection of SARS-CoV-2, thus providing a solution to enable high-frequency testing, particularly in low-resource communities.

Tracking Blood Pressure Control Performance and Process Metrics in 25 US Health Systems: The PCORnet Blood Pressure Control Laboratory.

BackgroundThe National Patient‐Centered Clinical Research Network Blood Pressure Control Laboratory Surveillance System was established to identify opportunities for blood pressure (BP) control improvement and to provide a mechanism for tracking improvement longitudinally.Methods and ResultsWe conducted a serial cross‐sectional study with queries against standardized electronic health record data in the National Patient‐Centered Clinical Research Network (PCORnet) common data model returned by 25 participating US health systems. Queries produced BP control metrics for adults with well‐documented hypertension and a recent encounter at the health system for a series of 1‐year measurement periods for each quarter of available data from January 2017 to March 2020. Aggregate weighted results are presented overall and by race and ethnicity. The most recent measurement period includes data from 1 737 995 patients, and 11 956 509 patient‐years were included in the trend analysis. Overall, 15% were Black, 52% women, and 28% had diabetes. BP control (<140/90 mm Hg) was observed in 62% (range, 44%–74%) but varied by race and ethnicity, with the lowest BP control among Black patients at 57% (odds ratio, 0.79; 95% CI, 0.66–0.94). A new class of antihypertensive medication (medication intensification) was prescribed in just 12% (range, 0.6%–25%) of patient visits where BP was uncontrolled. However, when medication intensification occurred, there was a large decrease in systolic BP (≈15 mm Hg; range, 5–18 mm Hg).ConclusionsMajor opportunities exist for improving BP control and reducing disparities, especially through consistent medication intensification when BP is uncontrolled. These data demonstrate substantial room for improvement and opportunities to close health equity gaps.

Improving lung cancer screening: An equitable strategy through a tobacco treatment clinic

Annual screening with low dose chest tomography has been adopted for those at high risk to aid in the early detection of lung cancer. In addition to screening, it is recommended that such persons receive evidence-based smoking-cessation. However, both lung cancer screening and evidence-based smoking-cessation strategies are underutilized in the US. We review the impact of a dedicated Tobacco Treatment Clinic (TTC), delivering evidence-based smoking cessation strategies, on lung cancer screening enrollment. Patients of the TTC, aged 50 years or older, having a minimum 20-pack-year smoking history were included. All patients had records reviewed to see if they had received lung cancer screening; if their lung cancer screening was achieved through the TTC, this was documented as “initial screening” versus “continued screening or surveillance”. Sociodemographic variables were collected as well. As for results, between January 2019 to February 2020, 92 patients enrolled in the TTC and fulfilled criteria for lung cancer screening. The mean age was 65.7 ± 8.3 years old, with 58 (63.0%) of the patients being female. Seventy-five (81.5%) patients were African American. Of the 92, 68 (73.9%) patients had lung cancer screening, with 51 patients receiving their first lung cancer screening scan through the TTC. In conclusion, through enrollment in a dedicated TTC, a significant proportion of patients were able to access lung cancer screening for the first time. Further, many of these patients were of minority status. Having a dedicated TTC may improve current health equity gaps in lung cancer screenings in certain US populations.

Closing the health equity gap: A role for implementation science?

Beryne Odeny discusses strategies to improve equity in health care and health research.

Invisible and unequal: Unincorporated community status as a structural determinant of health

Despite increasing awareness of the importance of political determinants of health, place-based research has not interrogated one of the most common political statuses: the impact of living in a community without municipal incorporation. In 2010 an estimated 37% of the U.S. population lived in an unincorporated area; despite their ubiquity, unincorporated communities are largely absent from the public health literature. Residents of unincorporated areas typically do not have their own local (e.g., city or municipal) government. This lack of representation leads to political exclusion and diminished access to resources, especially for low-income communities of color, Furthermore, by not disaggregating health data to unincorporated communities, residents are subsumed into county or census tract data that may not be reflective of their community's composition or context. Without jurisdictional distinction in research, there is no accountability for the manufacturing of health inequities in unincorporated communities . In the absence of empirical research on unincorporated communities, this paper uses the Commission on Social Determinants of Health (CSDH) Framework of the World Health Organization to argue that lack of municipal status is a structural determinant of health responsible for social conditions which generate cumulative health risks for residents. This includes using existing evidence on social conditions typical of unincorporated communities to describe patterns of residential segregation, neighborhood disadvantage, and environmental hazards that may increase residents' exposure to unhealthy environments in unincorporated communities. Finally, we provide an agenda for future public health research that can begin to address this health and racial equity gap for low-income unincorporated communities of color who have, until now, been absent in health equity discourse.