Understanding Health Inequalities Research Articles

A study of the enablers and barriers to the collection of sociodemographic data by public health units in Ontario, Canada during the COVID-19 pandemic

BackgroundCollection and use of sociodemographic data (SDD), including race, ethnicity and income, are foundational to understanding health inequities. Ontario’s public health units collected SDD as part of COVID-19 case management and vaccination activities. This research aimed to identify enablers and barriers to collecting SDD during COVID-19 case management and vaccination.MethodsAs part of a larger mixed-method research study [1], qualitative methods were used to identify enablers and barriers to SDD collection during the COVID-19 pandemic. Purposive sampling was used to recruit participants from Ontario’s 34 public health units. Sixteen focus groups and eight interviews were conducted virtually using Zoom. Interview data were transcribed and analyzed using inductive and deductive qualitative description.ResultsSDD collection enablers included: legally mandating SDD collection and having dedicated data systems, technological and legal supports, senior management championing SDD collection, establishing rapport and trust between staff and clients, and gaining insight from the experiences from local communities and other jurisdictions. Identified barriers to SDD collection included: provincial data systems being perceived as lacking user-friendliness, SDD collection “was not a priority,” time and other constraints on building staff and client rapport, and perceived discomfort with asking and answering personal SDD questions.ConclusionA combination of provincial and local organizational strategies including supportive data systems, training, and frameworks for data collection and use, are needed to normalize and scale up SDD collection by local health units beyond the context of the COVID-19 pandemic.

How do communities define “work precarity” and “labour exploitation”? Lessons for research from participatory research in high economic hardship communities in Chicago, Illinois/USA

Abstract Labour migration has both social and economic drivers that channel workers into jobs that are less desirable to citizens of the receiving countries. Immigrant workers find jobs through contacts from their home countries, including temporary staffing companies. These workers tend to co-locate in segregated communities and coalesce in jobs that entail hard work, low wages, and limited social benefits. As such, labour migration adds a dimension to the structural and social determinants of health (SDOH) that can broaden our understanding of health inequities, and that can point us toward policies and practices to enhance the health and wellbeing of migrant workforces. However, to generate evidence, align interventions with workers’ needs and priorities, and move evidence to action, it is crucial to engage communities. This presentation describes a community-university research partnership that co-investigates the relationship between work and health as experienced at the community level in two high-economic-hardship neighbourhoods in Chicago, Illinois/USA. The academic and practice partners co-developed and tested a conceptual model of the interrelations among migration, work and health, conducted an inventory of local employers, and executed a street-level survey of 497 workers in these two communities. The research findings helped enhance existing models of the structural/social determinants of health and of work precarity, thus informing methodological approaches to measure work precarity, labour exploitation, and their health effects. The community-based participatory research further led to several action-research projects that are ongoing. This presentation will describe the development of the community-university research partnership and its work, the subsequent enhancements made to the worker precarity and SDOH models, and preliminary findings of the partnership’s current action-research projects.

9.D. Practice session: Luton, a Marmot town – Lessons from using a whole-system approach to tackle health equity

Abstract Objective To share learnings from our Health Equity Town journey, including opportunities and challenges. To allow stimulating discussion on whole system approaches to health inequalities and the social determinants of health. To include discussion on where and how public health influences or leads, the importance of impact measures, and of shared vision. Added value Luton’s 2040 strategy, and being a health equity town, are long term visions. It has been 18 months since we launched Luton’s health equity ambition, and during that time we have taken great strides forward in how we deliver against the Marmot principles and create a movement around health equity in Luton. Organisations nationally and internationally are grappling with approaches to doing this. This workshop will provide an opportunity to discuss some of the key learnings, challenges and opportunities so far in taking this approach, and how to continue to maintain momentum and buy in across sectors at local level. The workshop will include discussion on the following: 1. Taking a whole-system approach to health inequalities - working across system leaders and strategic partners including health, care, voluntary sector, businesses, housing, police and others, as well as across the local authority departments. This takes clear articulation of the problem and actions, as well as clarity on where public health professionals are most effective to support, influence, and lead. 2. There is increasing recognition of the building blocks of health and the importance of ensuring action to improve health outcomes is taken across the whole system to tackle health inequalities - including employment, education, and housing. Discussion on specific actions being taken in some of these areas to tackle health inequalities as part of the health equity town approach. 3. Working with the community to understand health inequalities. 4. How we will measure progress. 5. The concept of proportionate universalism is now well known, however making this a reality is a challenge. 6. East London Foundation Trust, the mental health provider in Luton, is also embedding Marmot Policy objectives across the Trust, and is a key partner in Luton. Work is underway to establish projects with joint aims such as skills passport to increase employment in mental health service users. Format Presentation followed by opportunity for question and answer and discussion with panel. Key messages • Whole system approaches to tackling health equity are possible through shared vision and coordinated approach. • Action across the building blocks of health is vital, the complex and long term nature is challenging.

A Toolkit to Facilitate the Selection and Measurement of Health Equity Indicators for Cardiovascular Disease.

Cardiovascular disease (CVD) is the leading cause of illness and death in the US and is substantially affected by social determinants of health, such as social, economic, and environmental factors. CVD disproportionately affects groups that have been economically and socially marginalized, yet health care and public health professionals often lack tools for collecting and using data to understand and address CVD inequities among their populations of focus. The Health Equity Indicators for Cardiovascular Disease Toolkit (HEI for CVD Toolkit) seeks to address this gap by providing metrics, measurement guidance, and resources to support users collecting, measuring, and analyzing data relevant to their CVD work. The toolkit includes a conceptual framework (a visual model for understanding health inequities in CVD); a comprehensive list of health equity indicators (metrics of inequities that influence CVD prevention, care, and management); guidance in definitions, measures, and data sources; lessons learned and examples of HEI implementation; and other resources to support health equity measurement. To develop this toolkit, we performed literature scans to identify primary topics and themes relevant to addressing inequities in CVD, engaged with subject matter experts in health equity and CVD, and conducted pilot studies to understand the feasibility of gathering and analyzing data on the social determinants of health in various settings. This comprehensive development process resulted in a toolkit that can help users understand the drivers of inequities in their communities or patient populations, assess progress, evaluate intervention outcomes, and guide actions to address CVD disparities.

Relationship Between Neighborhood-Level Socioeconomic Status and Functional Outcomes After Hip Arthroscopy

Background: Despite the growing volume of neighborhood-level health disparity research, there remains a paucity of prospective studies investigating the relationship between Area Deprivation Index (ADI) and functional outcomes for patients undergoing hip arthroscopy. Purpose: To investigate the relationship between neighborhood-level socioeconomic status and functional outcomes after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed on patients aged ≥18 years with minimum 1-year follow-up who underwent hip arthroscopy for the treatment of symptomatic labral tears. The study population was divided into ADILow and ADIHigh cohorts according to ADI score: a validated measurement of neighborhood-level socioeconomic status standardized to yield a score between 1 and 100. Patient-reported outcome measures (PROMs) included the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports-Specific Subscale, 33-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Results: A total of 228 patients met inclusion criteria and were included in the final analysis. After patients were stratified by ADI score (mean ± SD), the ADILow cohort (n = 113; 5.8 ± 3.0; range, 1-12) and ADIHigh cohort (n = 115; 28.0 ± 14.5; range, 13-97) had no differences in baseline patient demographics. The ADIHigh cohort had significantly worse preoperative baseline scores for all 5 PROMs; however, these differences were not present by 1-year follow-up. Furthermore, the 2 cohorts achieved similar rates of the minimal clinically important difference for all 5 PROMs and the Patient Acceptable Symptom State for 4 PROMs. When controlling for patient demographics, patients with higher ADI scores had greater odds of achieving the minimal clinically important difference for all PROMs except the 33-item International Hip Outcome Tool. Conclusion: Although hip arthroscopy patients experiencing a greater neighborhood-level socioeconomic disadvantage exhibited significantly lower preoperative baseline PROM scores, this disparity resolved at 1-year follow-up. In fact, when adjusting for patient characteristics including ADI score, more disadvantaged patients achieved greater odds of achieving the minimal clinically important difference. The present study is merely a first step toward understanding health inequities among patients seeking orthopaedic care. Further development of clinical guidelines and health policy research is necessary to advance care for patients from disadvantaged communities.

Use of Intersectionality as a tool in the development of interventions, protocols and advanced health analyzes associated with people living with HIV. A Scoping Review

Introduction: Intersectionality has been used as a tool to understand and address health inequalities, especially in the context of health care for people with HIV. However, its application in the development of intervention strategies and care protocols is scarce.Methods: a systematic scoping bibliographic review was carried out to identify studies that use intersectionality in the field of health, as a tool for the development of advanced information analysis, development of instruments and protocols associated with people with HIV. Databases such as Scopus, PubMed and Clarivate Analytics Wos of Science were used.Results: Intersectionality has been used as a tool for the development of basic frameworks for the development of protocols and measurement instruments, its use in the development of intervention programs is scarce.Conclusions: Intersectionality is a valuable tool to understand health inequalities, but its application in the development of intervention strategies and care protocols is limited. It is necessary to develop research that uses intersectionality to create health intervention and professional training programs that address health inequalities and reduce the stigma associated with HIV.

Community-engaged Research Partnerships as Healing Spaces for Health Professionals and Researchers

Abstract: Drawing from collective experiences in our capacity building project: Health Equity Activation Research Team for Inclusion Health, we argue that while community-engaged partnerships tend to focus on understanding health inequities and developing solutions, they can be healing spaces for health professionals and researchers. Data were obtained from a 15-month participatory ethnography, including focus groups and interviews. Ethnographic notes and transcripts were coded and analyzed using both deductive and inductive coding. Practices of radical welcome, vulnerability, valuing the whole person, acknowledging how partnerships can cause harm, and centering lived experience expertise in knowledge creation processes were identified as key characteristics of healing spaces. Ultimately, health professionals and researchers work within the same social, political and economic contexts of populations with the worst health outcomes. Their own healing is critical for tackling larger systemic changes aimed at improving the well-being of communities harmed by legacies of exclusion.

Understanding health inequalities through emergency department walk-in data

Understanding health inequalities through emergency department walk-in data

Adapting an Adolescent and Young Adult Program Housed in a Quaternary Cancer Centre to a Regional Cancer Centre: Creating Equitable Access to Developmentally Tailored Support.

Adolescents and young adults (AYAs) with cancer, representing those between 15 and 39 years of age, face distinctive challenges balancing their life stage with the physical, emotional, and social impacts of a cancer diagnosis. These challenges include fertility concerns, disruptions to educational and occupational pursuits, issues related to body image and sexual health, and the need for age-appropriate psychosocial support within their communities. The Princess Margaret Cancer Centre (PM), a quaternary care center, established a specialized AYA program in 2014, offering holistic and developmentally tailored psychosocial support and currently, efforts are underway to expand this to other regions in the province to address the need for equitable access. The establishment process involves securing funding, conducting an environmental scan, identifying service gaps, developing clinical pathways, and implementing AYA supportive care. An accessible AYA program should also consider social determinants of health, social location, intersectionality, and an interdisciplinary health approach in understanding health inequities in AYA oncology care. This paper describes the processes implemented and challenges faced in creating a community-based AYA program beyond major resource-rich cities and efforts to address intersectionality.

Understanding Health Inequalities Research Capacities: Insights and Recommendations From Comparing Two High Income Settings.

Generating evidence on health inequalities (HI) is necessary to raise awareness of these issues, describe and monitor their evolution, analyze their causes, and inform interventions aiming to improve health equity. Yet not all cities and countries have the capacity to produce this type of research. Recent research provides new contextual and causal insights into this research production process, and in-depth understanding on why and how this type of research is produced in certain settings. This article aims to analyze two recent case studies that have uniquely explored this process in two high producers of HI research and high-income country settings to identify learning and distil recommendations, which may be insightful for other settings. Expanding and investing in this line of research is critical, particularly in places with lower HI research output and related capacity, in order to identify key contextual conditions and mechanisms that may enable or hinder this process. This new knowledge could guide the development of new HI research capacity strengthening strategies to foster this research in different settings, worldwide. More understanding is also needed on the relationship between HI research, policy, and action in order to tackle HI.

Environmental Justice Index and adverse pregnancy outcomes

The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood. This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors. This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language. A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people. Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.

Challenges and Future Directions for Promoting Intersectional Quantitative Studies in Physical Activity Research.

Understanding health inequalities is essential for improving social justice. Intersectionality refers to a theoretical framework for studying the intersection of multiple social categorizations that create unique experiences and related social inequalities. Currently, the majority of the intersectional studies in the physical activity field have a qualitative design; thus, there is a need for quantitative intersectional studies. This commentary aims to explore primary obstacles impeding intersectional quantitative research and provide recommendations for overcoming these obstacles in physical activity research. In the commentary, we discuss that the lack of accessibility of large-scale and diverse data sets, and suboptimal social categorizations and intersectionality-related questions may contribute to the scarcity of intersectional quantitative research in the field. To facilitate intersectional quantitative analyses, we advocate for making large-scale data sets accessible for intersectional secondary analyses, diverse sampling, standardizing questions and categories related to intersectionality, promoting inclusive research designs and methods, and using the appropriate questions and social categorization that reflect the distinct experiences of each subgroup. By addressing these challenges, researchers may gain new insights into health disparities, making physical activity research more inclusive and contributing to more equitable health outcomes.

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review

ObjectivesLung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address...

Intersectionality and public understandings of health inequity in England: learning from the views and experiences of young adults

ObjectivesAttempts to reduce health inequities in England frequently prioritise some equity dimensions over others. Intersectionality highlights how different dimensions of inequity interconnect and are underpinned by historic and institutionalised power imbalances. We aimed to explore whether intersectionality could help us shed light on young adults’ understanding of health inequities. Study designThe study incorporatedqualitative thematic analysis of primary data. MethodsOnline focus groups with young adults (n = 25) aged 18–30 living in three English regions (Greater London; South Yorkshire/Midlands; North-East England) between July 2020 and March 2021. Online semistructured interviews (n = 2) and text-based communication was conducted for participants unable to attend online groups. ResultsYoung adults described experiencing discrimination, privilege, and power imbalances driving health inequity and suggested ways to address this. Forms of inequity included cumulative, within group, interacting, and the experience of privilege alongside marginalisation. Young adults described discrimination occurring in settings relevant to social determinants of health and said it adversely affected health and well-being. ConclusionIntersectionality, with its focus on discrimination and identity, can help public health stakeholders engage with young adults on health equity. An upstream approach to improving health equity should consider multiple and intersecting forms of discrimination along with their cultural and institutional drivers.

Because its power remains naturalized: introducing the settler colonial determinants of health.

Indigenous people suffer earlier death and more frequent and severe disease than their settler counterparts, a remarkably persistent reality over time, across settler colonized geographies, and despite their ongoing resistance to elimination. Although these health inequities are well-known, they have been impervious to comprehensive and convincing explication, let alone remediation. Settler colonial studies, a fast-growing multidisciplinary and interdisciplinary field, is a promising candidate to rectify this impasse. Settler colonialism's relationship to health inequity is at once obvious and incompletely described, a paradox arising from epistemic coloniality and perceived analytic challenges that we address here in three parts. First, in considering settler colonialism an enduring structure rather than a past event, and by wedding this fundamental insight to the ascendant structural paradigm for understanding health inequities, a picture emerges in which this system of power serves as a foundational and ongoing configuration determining social and political mechanisms that impose on human health. Second, because modern racialization has served to solidify and maintain the hierarchies of colonial relations, settler colonialism adds explanatory power to racism's health impacts and potential amelioration by historicizing this process for differentially racialized groups. Finally, advances in structural racism methodologies and the work of a few visionary scholars have already begun to elucidate the possibilities for a body of literature linking settler colonialism and health, illuminating future research opportunities and pathways toward the decolonization required for health equity.

Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline

BackgroundAddressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension.MethodsWe assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels.DiscussionAchieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

Applying Rapid Qualitative Analysis for Health Equity: Lessons Learned Using "EARS" With Latino Communities.

Qualitative research amplifies the voices of marginalized communities and thus plays a critical role in shaping our understanding of health inequities and their social determinants. Traditional qualitative approaches, such as grounded theory or thematic analysis, require extensive training and are time- and labor-intensive; as such, they may not be adequately suited to address healthy equity issues that require a swift response. Rapid qualitative analysis (RQA) is an action-oriented approach to qualitative data analysis that may be used when findings are needed to quickly inform practice. RQA capitalizes on using a team to summarize key points from qualitative data into matrices to explore relevant themes efficiently and systematically. In this paper, we provide case examples from our work applying RQA to health equity research with Latino communities to address community needs, such as responses to public health emergencies and the development of service delivery and technology interventions for infectious and chronic diseases. We draw from our collective experiences to share lessons learned and provide the following specific recommendations ("EARS") to researchers interested in applying RQA for health equity research: (1) Employ RQA to address rapidly evolving, urgent, health equity challenges; (2) Assure quality and rigor throughout the RQA process; (3) Respond to barriers and problem-solve as needed; and (4) Strengthen community relationships before, during, and after using RQA. Overall, we advocate for the use of RQA to promote health equity due to its ability to integrate the vital perspectives of marginalized communities and efficiently respond to their needs.

Mixed-Immigration Status Families During the COVID-19 Pandemic.

To understand how mixed-immigration status families-families with a mixture of people with and without documentation-in the United States (U.S.) fared during the COVID-19 pandemic. Specifically, this study highlights how health inequities were exacerbated during the height of the pandemic due to the implementation of anti-immigration policies such as Public Charge Rule, which stipulates that receiving public benefits is grounds for inadmissibility for immigrants seeking naturalization. In-depth semistructured interviews were conducted over Zoom with 14 members of mixed-status families between February and April 2021. The interviews were audio recorded, transcribed, and analyzed using Atlas.ti. Using grounded theory, we assessed the level of awareness about Public Charge Rule and the health challenges these families faced during the COVID-19 pandemic. Themes that emerged included financial problems, job insecurity, housing insecurity, food insecurity, mental health problems, distrust of government and health officials, and a fear of Public Charge Rule. We present a framework for understanding health inequities for mixed-status families during the COVID-19 pandemic. Public Charge Rule caused fear and confusion for mixed-status families during the COVID-19 pandemic, resulting in individuals not receiving public benefits they urgently needed. This created heightened mental health problems due to job, housing, and food insecurity. We discuss how trust between mixed-status families and the government needs foundational rebuilding. In addition to streamlining the process for these families to apply for legal status, it is important to protect and support mixed-status families through programs and policies during public health emergencies.

An art therapy education response: linking inequality and intersectional identity

ABSTRACT Background An account of how one Art Therapy training course links information about inequalities with the theory of intersectionality. In trying to understand intersectionality, the course community questions how clients and therapists respond to and experience health inequalities and discrimination. For both, there may be the pain of being ‘othered’ and the effects of unconscious privilege. Nevertheless, there are examples to be celebrated of how some people manage to use their identity in moving forward. Context Bizarrely, how identities link to socio-political conditions is not readily acknowledged within therapy professions. The focus of therapy has tended to stay on the inner world. Also, since the end of the second world war, there has been a gradual decoupling of political approaches concerned with social justice and the redistribution of resources and political approaches concerned with identity recognition. Approaches When health inequalities and identity issues became sharply visible during the Covid 19 pandemic, the profession responded with adaptations to its educational and therapeutic work. It is possible to see how clients, students, art therapists and colleagues adapt, consult and collaborate. The paper provides descriptions of students' adapted and collaborative practice. Outcomes, conclusions and implications for research The use of culture, art and identity-aware supervision in art therapy are ways of developing our understanding of health inequalities and intersecting identities. The research implications for Art Therapy are that generic knowledge of research about discrimination and glaring health inequalities is a valuable foundation for research in our discipline. Plain-language summary This paper discusses how one Art Therapy training course links information about health and social inequalities with ideas about intersecting identities. The course community explores and questions how clients and therapists experience health inequalities and discrimination. There are discussions about the pain of feeling unwanted and the response of people who are not conscious of their inherited privileges simply because they are born into specific societal structures. Whilst recognising that feelings about identity may be painful and a source of shame, the course also considers how it is that some people manage to acknowledge and use self-reflection about their less privileged identities in moving forward. It is strange how the effects of social and health inequalities are rarely acknowledged within psychological disciplines, including art therapy. That seems to be because the focus of therapy has tended to stay on the inner world. Also, since the end of the second world war, there has been a gradual shift in political approaches concerned with social justice and the redistribution of resources and political approaches concerned with identity recognition. When existing health inequalities and identity issues became sharply visible during the Covid 19 pandemic (the Health Foundation, 2020) the profession responded with adaptations that took its educational and therapeutic work online. There is hope because it is increasingly possible to see how clients, students, art therapists and colleagues consult one another and collaborate over adaptations in therapeutic approaches. The paper provides descriptions of some adapted student practices from placements. The use of culture and art, together with supervision in art therapy, are ways of developing our understanding of health inequalities and our intersecting identities. Nevertheless, the pace of social and cultural change can be slow, sometimes moving forward and sometimes backwards. The research implications for the Arts Therapies are that broad knowledge of research about discrimination and glaring health inequalities is valuable in the push for change. Also, research from other disciplines is often the foundation on which the research contribution of the Arts Therapies in this area and others can be built.

Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis

Indicative evidence suggests that minoritised ethnic groups have higher risk of developing multiple long-term conditions (MLTCs), and do so earlier than the majority white population. While there is evidence on ethnic inequalities in single health conditions and comorbidities, no review has attempted to look across these from a MLTCs perspective. As such, we currently have an incomplete understanding of the extent of ethnic inequalities in the prevalence of MLTCs. Further, concerns have been raised about variations in the way ethnicity is operationalised and how this impedes our understanding of health inequalities. In this systematic review we aimed to 1) describe the literature that provides evidence of ethnicity and prevalence of MLTCs amongst people living in the UK, 2) summarise the prevalence estimates of MLTCs across ethnic groups and 3) to assess the ways in which ethnicity is conceptualised and operationalised. We focus on the state of the evidence prior to, and during the very early stages of the pandemic. We registered the protocol on PROSPERO (CRD42020218061). Between October and December 2020, we searched ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, Web of Science, OpenGrey, and reference lists of key studies/reviews. The main outcome was prevalence estimates for MLTCs for at least one minoritised ethnic group, compared to the majority white population. We included studies conducted in the UK reporting on ethnicity and prevalence of MLTCs. To summarise the prevalence estimates of MLTCs across ethnic groups we included only studies of MLTCs that provided estimates adjusted at least for age. Two reviewers screened and extracted data from a random sample of studies (10%). Data were synthesised using narrative synthesis. Of the 7949 studies identified, 84 met criteria for inclusion. Of these, seven contributed to the evidence of ethnic inequalities in MLTCs. Five of the seven studies point to higher prevalence of MLTCs in at least one minoritised ethnic group compared to their white counterparts. Because the number/types of health conditions varied between studies and some ethnic populations were aggregated or omitted, the findings may not accurately reflect the true level of ethnic inequality. Future research should consider key explanatory factors, including those at the macrolevel (e.g. racism, discrimination), as they may play a role in the development and severity of MLTCs in different ethnic groups. Research is also needed to ascertain the extent to which the COVID19 pandemic has exacerbated these inequalities.