Health Equity Issues Research Articles

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

BackgroundFinancial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.MethodsPatients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.DiscussionIf effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.Trial registrationClinicalTrials.gov NCT04766190. Registered on February 23, 2021

Suboptimal iron deficiency screening in pregnancy and the impact of socioeconomic status in a high-resource setting

AbstractIron deficiency (ID) anemia in pregnancy is associated with poor maternal and childhood outcomes, yet ferritin testing, the standard test for ID, is not considered part of routine prenatal bloodwork in Canada. We conducted a retrospective cohort study of 44 552 pregnant patients with prenatal testing at community laboratories in Ontario, Canada, to determine the prevalence of ferritin testing over 5 years. Secondary objectives were to determine the prevalence and severity of ID and to identify clinical and demographic variables that influence the likelihood of ID screening. A total of 59.4% of patients had a ferritin checked during pregnancy; 71.4% were ordered in the first trimester, when the risk of ID is lowest. Excluding patients with abnormally elevated ferritins, 25.2% were iron insufficient (30-44 µg/L) and 52.8% were iron deficient (≤29 µg/L) at least once in pregnancy. A total of 8.3% were anemic (hemoglobin <105 g/L). The proportion of anemic patients with a subsequent ferritin test in pregnancy ranged from 22% to 67% in the lowest and highest anemia severity categories, respectively. Lower annual household income was negatively associated with the odds of a ferritin test; compared with those in the fifth (ie, highest) income quintile, the odds of ferritin testing for patients in the first, second, and fourth quintiles were 0.83 (95% confidence interval [CI], 0.74-0.91), 0.82 (95% CI, 0.74-0.91), and 0.86 (95% CI, 0.77-0.97), respectively. These data highlight gaps in prenatal care and issues of health equity that warrant harmonization of obstetrical guidelines to recommend routine ferritin testing in pregnancy.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map.

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value. This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence. We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov). Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps. We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist. After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues. There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

\u201cWe are not hard to reach, but we may find it hard to trust\u201d \u2026. Involving and engaging \u2018seldom listened to\u2019 community voices in clinical translational health research: a social innovation approach

BackgroundPublic involvement in clinical translational research is increasingly recognised as essential for relevant and reliable research. Public involvement must be diverse and inclusive to enable research that has the potential to reach those that stand to benefit from it the most, and thus address issues of health equity. Several recent reports, however, indicate that public involvement is exclusive, including in its interactions with ethnic groups. This paper outlines a novel community-led methodology – a community sandpit – to address the inclusion of ethnic groups in public involvement in research, reports on its evaluation, findings, legacy and impact.MethodsThrough detailed planning – thinking through and taking into account all stakeholders perspectives in the planning and design of the sandpit, relationship-building, co-design and co-delivery between the Public Programmes team based at Manchester University NHS Foundation Trust and the Greater Manchester Black and Minority Ethnic Network - the community sandpit was held in July 2018.ResultsFifteen community organisations took part in the two-day event, as well as six researchers, and six creative practitioners. Six community-based partnership projects were seed-funded; four of these received additional funding from other sources also.ConclusionsEvaluation of the sandpit showed the format to be well-received by all: it levelled power relationships between community organisations, health researchers and research infrastructure; it developed capacity amongst researchers about the accessibility, role and potential of community organisations. Described as “not another community seed fund” by community partners, the sandpit offered community partners, equitable avenues for collaboration within Greater Manchester translational research and led to the formation of the Black, Asian and Minority Ethnic Research Advisory Group (BRAG Vocal Website information, - https://www.wearevocal.org/opportunities/black-asian-and-minority-ethnic-research-advisory-group-brag/, 2021). The method has the potential to be replicated elsewhere to support inclusive public involvement in research and inclusive research.

Do COVID-19 Apps Address Diabetes Mellitus and Health Equity Issues

Purpose: To evaluate if COVID-19 apps address risk factors such as diabetes, hypertension, race, gender, sexual orientation, language. Background: In 2019, there were 204 Billion app downloads and 3.7 billion downloads of ehealth apps. COVID-19 affects ethnic minority patients with diabetes, hypertension, and other risk factors. Spanish is the second most commonly used language after English in the U.S.. African Americans, Hispanic Americans, and Asian Americans are at an increased risk of COVID-19. LGBTQ+ communities are also at higher risk for COVID due to historically poor access to healthcare. Methods: The search term, “COVID,” in Google Play store and Apple App store was used to find the most popular COVID-19 apps. App inclusion criteria: 1) Contains COVID-19 information and/or COVID symptom tracker, 2) Marketed and designed for the general public, 3) Free, 4) Android (DROID): 100,000+ Downloads; Apple (iOS): highest star ratings. Apple does not provide a number of downloads. App features: COVID-19 information, COVID-19 symptom questionnaire (QN), Diabetes, Hypertension, Cardiovascular disease, Languages (Spanish, Chinese), Race, Gender, and Sexual Orientation. Results: The top 10 DROID apps in descending order are: 1) GuideSafe, 2) CO Exposure Notifications, 3) Care19 Diary, 4) Care19 Alert, 5) Crush COVID RI, 6) MI COVID Alert, 7) DC CAN, 8) CombatCOVID MDC, 9) CombatCOVID PBC, 10) Stronger than C19. The top 10 iOS apps in descending order are: 1) SlowCOVIDNC, 2) COVIDWISE, 3) COVID Alert Pennsylvania, 4) COVID Alert DE, 5) COVID Alert NY, 6) Covid Watch Arizona, 7) Apple COVID-19, 8) COVID Alert NJ, 9) COVID Trace Nevada, 10) CDC. Of the 20 apps: COVID 19 information: 20/20; COVID-19 symptom QN: 8/20; DM: 2/20; HTN: 1/20; CardioVasc: 2/20; Spanish: 11/20 (2/11 of the Spanish apps have Chinese as well). Race: 5/20. Gender: 8/20; Sexual Orientation: 3/20; Age: 10/20. Conclusion: 1) Most apps do not ask about important risk factors such as DM, HTN, and Race. 2) Smartphone apps are not uniform in their health education features. 3) Healthcare providers should continue to play an important role in public education despite the ubiquity of mobile apps.

Iron deficiency and anemia in pregnancy: a health equity issue

Objectives We compared iron supplementation and hematologic parameters in pregnancy between women living in low-income neighbourhoods (median household income ≤$50,000/year) and non-low-income neighbourhoods (median household income >$50,000/year). Methods We performed a baseline audit of the 1st 100 eligible patients to deliver at a tertiary care centre in January 2020. Using their postal codes, patients were stratified to low income neighbourhoods and non-low-income neighbourhoods. Patients were excluded if they had an alternate cause of anemia (e.g. hemoglobinopathy) or were followed elsewhere for their pregnancy prior to delivery. We compared baseline characteristics, hematologic parameters and iron supplementation between the two groups. Results 109 patients were screened: 37 patients from low income neighbourhoods and 63 patients from non-low-income neighbourhoods were included; 9 patients were excluded (2 with chronic kidney disease, 7 followed elsewhere during pregnancy). Women living in low income neighbourhoods had lower ferritin values before 20 weeks GA (mean 49.4 ug/L vs. 75.4 ug/L, p=0.01), lower hemoglobin levels and mean corpuscular volumes at admission to labour and delivery (LD 87.6 fL vs. 90.4 fL, p=0.03) and more frequent anemia ( Conclusions Women living in low income neighbourhoods have lower ferritin values at the start of pregnancy and more frequent anemia at delivery. This highlights a critical opportunity for early intervention to address iron deficiency anemia amongst individuals of lower socioeconomic status who are at higher risk in pregnancy .

Tackling social inequalities in health: acceptability and feasibility of a systematic approach toward health impact assessment of urban projects.

The general objective of this research project was to explore the feasibility and acceptability of an original method intended to systematically identify urban planning projects whose potential impacts on health and social inequalities in health (SIH) would be most damaging. An approach based on a short meeting and a tool would help to discuss whether or not to engage in a more comprehensive health impact assessment. A tool was developed by the research team based on various tools reported in the literature and modified with urban planners. Meetings were organized for each development project with the volunteer planners, who were working on the projects selected. Reviews of six projects at different stages of design made it possible to assess the acceptability and feasibility of this approach to identify public health and social equity issues in health. The process and the use of the tool were found to be feasible. The tool was easily understandable, adapted to the practices of planners and usable without real training other than a quick introduction to tool usage. It was also found to be acceptable. Despite an interest in the inclusion of SIH, the integration of the relationship between SIH and urban development was not easy for most of the urban planners. This exploratory work suggests that a systematic approach to assessing the impact of urban projects on health and SIH is feasible and acceptable. Dealing with SIH was not found to be easy by the urban planners.

Advancing Energy Justice as a Climate and Public Health Solution

Energy justice is a climate and health issue. Energy systems contribute to greenhouse gas emissions and negative health outcomes from energy extraction to consumption. Just as climate change disproportionately affects certain populations, energy also is a health equity issue. The U.S. energy sector faces a critical challenge of energy access and affordability that limits communities’ ability to achieve good health. As alternative energies become cost‐competitive, there is a need to monitor, evaluate, and support a transition to a healthier energy system. By pursuing energy justice as a priority, public health professionals can play a role in challenging health inequities, as well as mitigating the adverse health effects of climate change. Through a roundtable convening, public health leaders developed pathways for public health professionals to promote a just energy future. Considering public health upfront in energy system decision making may result in multidisciplinary thinking and solutions to improve health outcomes.

Intersectionality and syndemics: A commentary

This commentary addresses the possibilities and pitfalls of putting intersectionality and syndemics into conversation with each other. We engage with two studies published in this issue: the first on the health-related vulnerabilities among LGBTQ + Latinx men in Orlando after the Pulse nightclub shooting, and the other on syndemic health issues brought about by social and structural inequities among young Black gay, bisexual, and other men who have sex with men (GBM). Both manuscripts suggest that intersectionality and sydemics can be integrated or possibly merged to build effective health equity focused interventions for marginalized populations. We, however, argue that there are several methodological, ontological, and epistemological challenges in bringing together intersectionality and syndemics. Our argument coalesces around three key points. First, we contend that while it is feasible to think of their integration as useful to the study of health disparities, syndemics offers no added benefit to health scholarship grounded in intersectional analysis. Second, we argue that assumptions of common ground between intersectionality and syndemics rest on equating theories of interaction and additivity with critiques of mutual configurations of ideology, power structures, and social categories. Finally, we maintain that if intersectionality and syndemics are to be in conversation with each other, it must be done with the recognition and examination of where each framework situates itself relative to methodology, praxis, and power. Using our own work and those of intersectional feminist scholars, we demonstrate how the stakes of intersectionality diverge radically from those of syndemics, and how syndemics has the potential to undermine the significance of intersectionality for addressing issues of health equity.

Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland

INTRODUCTION Gout remains a health equity issue; Māori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM This study aims to understand the perspectives of the mainly Māori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Māori and Pacific community with high burden of gout. METHODS Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Māori providers to do more for the same amount of resource may not be effective.

An ethical analysis of obesity as a determinant of pediatric heart transplant candidacy.

Inclusion of BMI as criterion in the determination of heart transplant candidacy in children is a clinical and ethical challenge. Childhood obesity is increasing and children with heart disease are not spared. Currently, many adult heart transplant centers consider class II obesity and higher (BMI>35kg/m2 ) to be a relative contraindication for transplantation due to risk of poor outcome after transplant. No national guidelines exist regarding consideration of BMI in pediatric heart transplant and outcomes data are limited. This leaves decisions about transplant candidacy in obese pediatric patients to individual institutions or on a case-by-case basis, allowing for bias and inequity. We review (a) the prevalence of childhood obesity, including among heart transplant candidates, (b) the lack of existing BMI guidelines, and (c) relevant literature on BMI and pediatric heart transplant outcomes. We discuss the ethical considerations of using obesity as a criterion using the principles of utility, justice, and respect for persons. Existing transplant outcomes data do not show that obese children have different or poor enough outcomes compared to non-obese children to warrant exclusion. Moreover, obesity in the United States is unequally distributed by race and socioeconomic status. Children already suffering from health disparities are therefore doubly penalized if obesity denies them access to life-saving transplant. Insufficient data exist to support using any BMI cutoff as an absolute contraindication for heart transplant in children. Attention should be paid to health equity issues when considering excluding a patient for transplant based on obesity.

Associations Between Socioeconomic Context and Congenital Heart Disease Related Outcomes in Adolescents and Adults

Little is known about the relation between socioeconomic factors and health outcomes in adults and adolescents with congenital heart defects (CHD). Population-level data from the Colorado CHD surveillance system from 2011 to 2013 was used to examine the association between area deprivation and outcomes including hospitalizations, emergency department visits, cardiac procedures, all-cause and cardiac-related mortality, and major adverse cardiac events. Socioeconomic context was measured by the Area Deprivation Index at census tract level. Missing race/ethnicity was imputed using the Bayesian Improved Surname Geocoding algorithm. Generalized linear models were utilized to examine health disparities across deprivation quintiles after adjusting for insurance type, race/ethnicity, age, gender, urbanicity, and CHD severity in 5,748 patients. Cases residing in the most deprived quintile had 51% higher odds of inpatient admission, 74% higher odds of emergency department visit, 41% higher odds of cardiac surgeries, and 45% higher odds of major adverse cardiac events compared with cases in the least deprived quintile. Further, rates of hospitalizations, emergency department admissions, and cardiac surgeries were elevated in the most deprived compared with the least deprived quintile. Mortality was not significantly different across quintiles. In conclusion, findings suggest significant health equity issues for adolescent and adults with CHD based on area-based deprivation.

The hunger-obesity paradox: Exploring food banking system characteristics and obesity inequities among food-insecure pantry clients.

PurposeHeightened obesity risk among food-insecure food pantry clients is a health equity issue because the co-occurrence of obesity and hunger is deeply-rooted in systematic social disadvantage and historical oppression. This qualitative study examined key stakeholders’ perspectives of the relationship between the U.S. food banking system and obesity disparities among food insecure clients.MethodsWe conducted in-depth, semi-structured interviews with 10 key stakeholders (e.g., food bank director, food bank board member, advocate) who are familiar with food bank operations. Data were transcribed verbatim, coded in NVivo [v11], and analyzed using thematic analysis.ResultsMultiple themes emerged drawing linkages between structural characteristics of the food banking system and disparities in the dual burden of food insecurity and obesity: [a] access to unhealthy food from donors; [b] federal emergency food policy and programming; [c] state-level emergency food policy and programming; [d] geography-based risk profiles; and [e] inadequate food supply versus client need. Interviewees also identified social challenges between system leaders and clients that maintain disparities in obesity risk among individuals with very low food security including: [a] media representation and stereotypes about food pantry clients; [b] mistrust in communities of color; [c] lack of inclusion/representation among food bank system leaders; and [d] access to information.ConclusionFuture efforts to alleviate obesity inequities among clients chronically burdened by food insecurity, especially among certain subpopulations of clients, should prioritize policy, systems, and environmental strategies to overcome these structural and social challenges within the food banking system.

CDC Deployments to State, Tribal, Local, and Territorial Health Departments for COVID-19 Emergency Public Health Response - United States, January 21-July 25, 2020.

Coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by SARS-CoV-2. During January 21-July 25, 2020, in response to official requests for assistance with COVID-19 emergency public health response activities, CDC deployed 208 teams to assist 55 state, tribal, local, and territorial health departments. CDC deployment data were analyzed to summarize activities by deployed CDC teams in assisting state, tribal, local, and territorial health departments to identify and implement measures to contain SARS-CoV-2 transmission (1). Deployed teams assisted with the investigation of transmission in high-risk congregate settings, such as long-term care facilities (53 deployments; 26% of total), food processing facilities (24; 12%), correctional facilities (12; 6%), and settings that provide services to persons experiencing homelessness (10; 5%). Among the 208 deployed teams, 178 (85%) provided assistance to state health departments, 12 (6%) to tribal health departments, 10 (5%) to local health departments, and eight (4%) to territorial health departments. CDC collaborations with health departments have strengthened local capacity and provided outbreak response support. Collaborations focused attention on health equity issues among disproportionately affected populations (e.g., racial and ethnic minority populations, essential frontline workers, and persons experiencing homelessness) and through a place-based focus (e.g., persons living in rural or frontier areas). These collaborations also facilitated enhanced characterization of COVID-19 epidemiology, directly contributing to CDC data-informed guidance, including guidance for serial testing as a containment strategy in high-risk congregate settings, targeted interventions and prevention efforts among workers at food processing facilities, and social distancing.

코로나19 유행의 건강형평성, 건강도시에서의 함의

Objectives: The coronavirus disease (COVID-19) pandemic has disrupted the livelihood of many, however, its impacts on health and the determinants of health are disproportionate to different population subgroups. This study aims to explore the health equity issues related to COVID-19 and identify areas in which local governments can lead to ensure health equity in pandemic preparedness, response and recovery. Methods: This study explores the topic through a narrative review of the literature. Results: Health inequities due to the COVID-19 pandemic arise through multiple mechanisms, such as differential risk to infection and severity, and differential social and economic consequences due to stringent social distancing measures. Moreover, the elements of vulnerability are intersectional and based on the underlying structural and systemic inequities. Therefore, local government action require investment in the structural and systemic determinants in addition to the rapid downstream mitigation measures. Conclusions: Cities and local governments play key roles in ensuring health equity in both the rapid responses to mitigate disproportionate adverse health impacts and also serve as advocates for change in the upstream structural factors.

6.A. Round table: Protecting borders and preparing for a pandemic: responses around the world to COVID19

COVID19 challenges every dimension of public health systems, from research and health care treatment to public communication, coercive mechanisms such as quarantine, and respect for individual rights. This round table has 3 key objectives: To understand patterns in responses across countries, and in particular the different ways that authoritarian and democratic regimes responded;To identify comparative lessons for understanding the European experience from other high-income health systems;To draw conclusions about the politics of effective public health intervention and likely lessons of COVID19.Burris will present on how although initial control efforts took the form of travel restrictions, quarantine and isolation, sustained human-to-human community transmission of COVID-19 in the United States pushed authorities to move from these traditional tools to the challenge of promoting social distancing behavior and managing a surge in demand for health care. These challenges posed new and urgent questions of practical regulation and distributive justice as underlying social disparities created differing levels of vulnerability. This presentation reviews the first six months of the response in the US from a legal and social justice standpoint, focusing on issues of equity. Fafard will analyze the communications role of senior public health officials during the COVID-19 outbreak in five countries; their public messaging across a range of media platforms, including how they deal with misinformation; and the extent to which members of the public receive, understand, and trust this messaging. Kavanagh will discuss how relative democratic and autocratic political institutions have influenced early responses to the novel coronavirus outbreak. Using evidence from process tracing in China, Iran, the United States, South Korea, and Italy, this presentation evaluates the hypothesis advanced or implied by many global public health officials that authoritarian governments have an advantage in disease responsePeralta will discuss how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic highlighted the heterogeneity in the measured used for containment and mitigation by governments. Where authoritarian states, that theoretically have more policy options for containment and mitigation, have an advantage in an epidemic event remains unclear. This presentation will compare measures taken by governments and health authorities in five selected authoritarian states and five democracies and evaluate the capacity of epidemic containment. Willison will highlight how political elites in the United States define public health threats; how partisanship and party competition define public health responses, including expenditure and coordination; and how party and media elites draw on established tensions in American politics to frame outbreaks in ways advantageous to the parties.Key messages We will focus on similarities and differences in responses to COVID-19 around the world, highlight effective measures, and reflect on lessons learned in the first few months of this novel coronavirus.We will draw attention to issues of human rights and health equity among government responses. Panelists: Scott Burris Temple University, Philadelphia, USAContact: scott.burris@temple.edu Patrick Fafard University of Ottawa, Ottawa, CanadaContact: pfafard@uottawa.ca Matthew Kavanaugh Global Health Policy & Governance Initiative at the O'Neill Institute for National and Global Health, Washington DC, USAContact: matthew.kavanagh@georgetown.edu André Peralta-Santos University of Washington, Seattle, USAContact: aperalta@uw.edu Charley Willison University of Washington, Seattle, USAContact: Willison@hcp.med.harvard.edu

Practitioner perceptions of the health of Australian First Nations' Peoples: Preliminary findings.

To probe health practitioner perceptions of Australian First Nations' Peoples' health and to compare these with reported burden of disease, social determinants and culturally safe health systems data. An online survey tool was used to collect self-reported responses from health practitioners to answer literature-derived questions regarding underlying issues in Australian First Nations' Peoples' health. Responses to the survey were sought from rural and urban health service locations across all Australian states and territories. Allied health, nursing, pharmacy, psychology, social work and related discipline students and practitioners currently working or studying in Australia. Degrees of correspondence between health discipline student and practitioner perceptions on 'major health issues' and 'health systems issues' and published population health and health systems data. Metrics for 'connectedness to' and 'preparedness to engage with' Australian First Nations' Peoples were also reported. Significant differences between practitioner perceptions of 'major health issues' and the disease burden/social determinants published evidence, and with the 'culturally safe health systems' published evidence, were noted. Positive impacts of social and professional relationships (connectedness) between practitioners and First Nations' Peoples were demonstrated. The inclusion of basic population health and culturally safe health systems training in curricula for all genres of health practitioners appears to be indicated by these findings. Further, a meaningful role for the intentional nurture of social and professional relationships with Australian First Nations' Peoples across all health disciplines is suggested as part of efforts to address health systems and equity issues.

Over half of the WHO guidelines published from 2014 to 2019 explicitly considered health equity issues: a cross-sectional survey

ObjectiveTo evaluate how and to what extent health equity considerations are assessed in World Health Organization (WHO) guidelines. Study Design and SettingWe evaluated WHO guidelines published between January 2014 and May 2019. Health equity considerations were assessed in relation to differences in baseline risk, importance of outcomes for socially disadvantaged populations, inclusion of health inequity as an outcome, equity-related subgroup analysis, and indirectness in each recommendation. ResultsWe identified 111 WHO guidelines, and 54% (60 of 111) of these used the Evidence to Decision (EtD) framework. For the 60 guidelines using an EtD framework, the likely impact on health equity was supported by research evidence in 28% of the recommendations (94 of 332). Research evidence was mostly provided as differences in baseline risk (23%, 78/332). Research evidence less frequently addressed the importance of outcomes for socially disadvantaged populations (11%, 36/332), considered indirectness of the evidence for socially disadvantaged populations (2%, 5/332), considered health inequities as an outcome (2%, 5/332) and considered differences in the magnitude of effect in relative terms between disadvantaged and more advantaged populations (1%, 3/332). ConclusionThe provision of research evidence to support equity judgements in WHO guidelines is still suboptimal, suggesting the need for better guidance and more training.

Analyzing the Landscape: Community Organizing and Health Equity

In this paper we describe landscape analysis, a participatory research method for public health scholars interested in identifying and elucidating trends, opportunities, and gaps in the field. We used this method to understand the environmental and social conditions of primarily under-resourced communities of color, and identify key organizing strategies and practices used by community organizers to fight for policy and systems change around childhood health equity issues. Using a community-based participatory research approach, we developed and implemented a structured landscape analysis process among a national sample of 45 community-based organizations (CBOs). We discuss in detail our sampling procedures, protocol development, and analysis process. The resulting landscape analysis revealed similar challenges (e.g., lack of adequate housing, poor early childhood education resources) across diverse communities, and the best practices and innovative solutions used by CBOs to address these challenges. The landscape analysis process underscores the important role that social justice grassroots CBOs play in addressing the root causes of health inequity even though they may not identify, or be identified, as “public health” organizations.

Achieving Health Equity in Embedded Pragmatic Trials for People Living with Dementia and Their Family Caregivers.

Embedded pragmatic clinical trials (ePCTs) advance research on Alzheimer's disease/Alzheimer's disease and related dementias (AD/ADRD) in real-world contexts; however, health equity issues have not yet been fully considered, assessed, or integrated into ePCT designs. Health disparity populations may not be well represented in ePCTs without special efforts to identify and successfully recruit sites of care that serve larger numbers of these populations. The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory's Health Equity Team will contribute to the overall mission of the collaboratory by developing and implementing strategies to address health equity in the conduct of ePCTs and ensure the collaboratory is a national resource for all Americans with dementia. As a first step toward meeting these goals, this article reviews what is currently known about the inclusion of health disparities populations of people living with dementia (PLWD) and their caregivers in ePCTs, highlights unique challenges related to health equity in the conduct of ePCTs, and suggests priority areas in the design and implementation of ePCTs to increase the awareness and avoidance of pitfalls that may perpetuate and magnify healthcare disparities. J Am Geriatr Soc 68:S8-S13, 2020.