How Do Social and Environmental Disparities Affect Outcomes in Wound Care?

Dr. Laura Swoboda discusses how a lack of equity in wound care leads to poor outcomes among a variety of populations.

Transcript:

Kirra Fedyszyn:

Welcome to Speaking of Wounds, a podcast by the Wound Care Learning Network. I'm Kirra Fedyszyn, associate digital editor for Wound Care, and we're happy to have you listening today. Just as a reminder, this podcast is intended as an informational tool for medical professionals and is not intended to diagnose or treat any medical conditions. Our guest today is Dr. Laura Swoboda, who will be speaking with us about social and environmental disparities in wound care. Welcome to the podcast, Dr. Swoboda.

Dr. Laura Swoboda:

Hi, I'm Dr. Laura Swoboda, family nurse practitioner and professor of translational science with Froedtert & the Medical College of Wisconsin. Thank you for joining me with Speaking of Wounds. We're discussing how social and environmental disparities affect wound care. There are physiologic, social, and environmental etiologic mechanisms for disparate health outcomes. Access to not only advanced therapies, but also just standard of care is not equitably distributed across populations. Disparities in social determinants of health, bias, chronic exposure to stress, and generational traumas lead to clinically relevant alterations in wound occurrence and wound healing.

Looking at social and environmental basis for disparate outcomes, even if care inequities were eliminated, disparities in wound healing would persist. When we're looking at the concept of health equity, health equity acknowledges that everyone does not start from the same place or require the same interventions. This concept is evidenced by the fact that 80% of health outcomes are related to the environment and social conditions our patients live within, and not due to the healthcare that is delivered.

Our environment also significantly impacts our health. This includes our local environment, environmental variables, social variables, and those are things like toxin exposure, the microbes we live within, looking at rural versus urban populations, our experiences of stress, uncertainty, social isolation, and social injustices. These environments lead to neurohormonal responses. And those neurohormonal responses affect gene transcription and regulation, and ultimately, all of our cellular processes, including wound healing. These life stressors and the stressors that have occurred throughout the patient's life can contribute to physiologic changes and altered health behaviors. And both of those factors can lead to toxic cellular microenvironments that create the potential for the development of wounds, as well as negative healing outcomes.

Our environment can prohibit and promote access to healthcare services. This influences health outcomes, and I think this is how most people are thinking about our environment and how it impacts our health. The environment also provides support or barriers to health services, including the high cost of care in certain areas and in most areas, I would say, unavailability of services in a community, and also a lack of culturally competent care. So access to wound care for vulnerable populations is not equitable. Even amongst wound specialists, if you can get in to see a wound specialist, there's a lack of consistent guidelines and a lack of guidelines being followed. And this leads to massive differentiation in standard of care that's delivered to patients. So then we have, in addition to this very variable standard of care, we have disparities in accessing. So disparities in accessing wound dressing types, cleansers, advanced therapies, specialty referral, and skilled treatment. And this really compounds all of that and leads to variability in healing outcomes.

Outcomes are also influenced by proximity to specialized care and the expertise of those providing that care. For example, increased wound clinic visit frequency is associated with better healing outcomes. Amongst multiple potential etiologies for augmented healing due to this, due to wound clinic visit frequency, it's reasonable that both the elevated care that people are receiving as well as a sense of belonging and social interaction that can produce these positive biochemical responses. So just the fact of seeing people coming to the clinic, getting out of the house, talking, having positive social actions can help with healing. We know that social isolation decreases our tolerance for stress and it's a known corollary and delayed wound healing. Social isolation impacts the expression of over 200 genes. So having that increased interpersonal support can really benefit healing in our patients. In addition to our direct interpersonal social interactions, these social constructs, both historical and current, of the communities and nations that our patients are living within, impact their health.

Generational trauma and adverse childhood experiences have been linked with a number of chronic diseases. And those include things like autoimmune diseases, cancer, COPD, ischemic heart disease, as well as mental health disorders like depression, hallucinations, somatic disorders. These are all associated, they're stress-linked disorders. These chronic diseases and their treatments are associated with conditions that create wounds as well as delayed wound healing. So a lot of these, like cancer, you may be more likely to get wounds, things like peripheral arterial disease, autoimmune diseases. You can get wounds from those diseases. And once you have the wounds, you can have issues with healing them.

Trauma-related events have also occurred in the context of service provision, so that creates the potential for mistrust in majority groups and government-funded services. This has also occurred in the context of research. It's the reason why IRBs exist. And it's also occurred in the context of healthcare, including mental healthcare. So for members of communities impacted by these historical traumas, daily reminders of discrimination can exacerbate their responses to trauma, their stress response. This is a multifaceted issue, but it is in part at least due to historical traumas and mistrust, whereby vulnerable populations were unethically experimented upon and thus developed suspicion of healthcare providers and medical research. It's led to a direct lack of inclusivity in research.

A source to increase diversity in research would be to make sure that we're sampling as many populations. Obviously, we have informed consent requirements now. And we want to include the diverse wound etiologies and patient presentations that occur in wound centers as approval for new therapeutics, or generally respected to the demographics of the population that's been included in clinical studies. There are also delivery of care disparities. So healthcare providers exhibit the same levels of implicit bias as the wider population. This is something that's been studied thoroughly. And high levels of implicit bias are associated with lower quality of care. So implicit bias is different than other forms of bias.

Other forms of bias we can mask for the purposes of social benefits. If we want to not expose our biases in a social interaction, we can mask that. But our implicit bias, we're not even cognizant of it, essentially. So this is something that's also seen in healthcare providers at an equal level to the general population. The use of standardized tools and standardized care is often a frustration for clinical staff, but it can assist in reducing the impact of assumptions and bias in the delivery of care. So I think about the airline industry increasing safety by using checklists, which is the famous implementation of standardization. But it's a source, something that we could look to in the wound care industry as well.

Other sources of delivery of care disparities are looking at wound care education. So wound care education has focused on skincare presentation and treatment in light skin tones. This produces disparate diagnoses of certain medical conditions where skin tone impacts visual assessments, such as pressure injuries, infection, looking at erythema in different skin tones, neonatal jaundice, which I just learned about, as well as evidence of abuse, ecchymosis. So those cutaneous findings that you're looking at from a visual assessment have different findings across skin tones. And when wound care education is traditionally focused on light skin tones, you may be missing these important visual findings amongst darker skin tones. The utility of technological advances in wound care is both a source and a potential mitigator of disparate care.

So novel technologies have the potential to augment our visual assessment and identify important physiologic findings. We have technologies like near-infrared spectroscopy and thermography, which may have scientific limitations in darker skin tones just due to how the technology functions. But this needs to be further elucidated in future research. The other technologies like subepidermal moisture scanners, the SEM scanner, and fluorescence imaging do have published evidence on their utility, their ability to provide equitable assessment techniques across skin tones, which is good.

In conclusion, disparities in wound prevalence and outcomes are due to a constellation of physiologic, biochemical, environmental, and social factors. Today, we just looked primarily at our environmental and social factors, really skimming the surface here. But future healthcare priorities should focus on preventing illness through supporting access to the structural drivers of health. Those are things like safe housing, food education, and healthcare access, that includes mental healthcare access, instead of solely treating the diseases that result from the deficits of these.

While we have the ability to modify what we perceive as stressful and how we respond to it can decrease our negative health outcomes associated with stress, the profound prevalence of social injustices continues to exert really an insurmountable burden among marginalized populations. The health of our patients and ourselves is influenced by so much more than what we're able to address during an office visit or an inpatient stay. And this asks the important question, where does our role in the facilitation of the health of our patients end? Thank you for joining me.

Kirra Fedyszyn:

Thank you so much for joining us today, Dr. Swoboda. That wraps up our discussion for today. But for more information on today's topic, we invite our listeners to explore all of the resources available online at the Wound Care Learning Network. Thanks for joining and enjoy the rest of your day.