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Caldwell HA, Yusuf J, Carrea C, Conrad P, Embrett M, Fierlbeck K, Hajizadeh M, Kirk SF, Rothfus M, Sampalli T, Sim SM, Tomblin Murphy G, Williams L. Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review. JBI Evid Synth 2024; 22:949-1070. [PMID: 38632975 PMCID: PMC11163892 DOI: 10.11124/jbies-23-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity. INTRODUCTION To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system. INCLUSION CRITERIA This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies). METHODS This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format. RESULTS Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems. CONCLUSIONS Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally. REVIEW REGISTRATION DalSpace dalspace.library.dal.ca/handle/10222/80835.
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Affiliation(s)
- Hilary A.T. Caldwell
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Joshua Yusuf
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Cecilia Carrea
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Patricia Conrad
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | | | - Katherine Fierlbeck
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- MacEachen Institute for Public Policy and Governance, Dalhousie University, Halifax, NS, Canada
- Dalhousie Libraries, Dalhousie University, Halifax, NS, Canada
| | - Mohammad Hajizadeh
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Sara F.L. Kirk
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Melissa Rothfus
- Department of Political Science, Dalhousie University, Halifax, NS, Canada
| | | | - Sarah Meaghan Sim
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | | | - Lane Williams
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
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Celano A, Keselman P, Barley T, Schnautz R, Piller B, Nunn D, Scott M, Cronin C, Franz B. National Overview of Nonprofit Hospitals' Community Benefit Programs to Address Housing. Med Care 2024; 62:359-366. [PMID: 38728676 PMCID: PMC11081473 DOI: 10.1097/mlr.0000000000001984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Housing is a critical social determinant of health that can be addressed through hospital-supported community benefit programming. OBJECTIVES To explore the prevalence of hospital-based programs that address housing-related needs, categorize the specific actions taken to address housing, and determine organizational and community-level factors associated with investing in housing. RESEARCH DESIGN This retrospective, cross-sectional study examined a nationally representative dataset of administrative documents from nonprofit hospitals that addressed social determinants of health in their federally mandated community benefit implementation plans. We conducted descriptive statistics and bivariate analyses to examine hospital and community characteristics associated with whether a hospital invested in housing programs. Using an inductive approach, we categorized housing investments into distinct categories. MEASURES The main outcome measure was a dichotomous variable representing whether a hospital invested in one or more housing programs in their community. RESULTS Twenty percent of hospitals invested in one or more housing programs. Hospitals that addressed housing in their implementation strategies were larger on average, less likely to be in rural communities, and more likely to be serving populations with greater housing needs. Housing programs fell into 1 of 7 categories: community partner collaboration (34%), social determinants of health screening (9%), medical respite centers (4%), community social determinants of health liaison (11%), addressing specific needs of homeless populations (16%), financial assistance (21%), and targeting high-risk populations (5%). CONCLUSIONS Currently, a small subset of hospitals nationally are addressing housing. Hospitals may need additional policy support, external partnerships, and technical assistance to address housing in their communities.
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Affiliation(s)
- Annalise Celano
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Pauline Keselman
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Timothy Barley
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Ryan Schnautz
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Benjamin Piller
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Dylan Nunn
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Maliek Scott
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio
| | - Cory Cronin
- College of Health Sciences and Professions, Ohio University, Athens, Ohio
| | - Berkeley Franz
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
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S Distelhorst K, Adams K, Lopez R. Food Insecurity, Neighborhood Disadvantage, and Hospital Readmission in Health System Adults: A Population Health Study. CLIN NURSE SPEC 2024; 38:40-48. [PMID: 38079144 DOI: 10.1097/nur.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
PURPOSE The purpose of the study was to examine the relationship between food insecurity, neighborhood disadvantage, and hospital readmission within 90 days of discharge for health system patients. DESIGN The study used a retrospective, correlational design with a single cohort. METHODS Records of adult patients with a health system primary care provider and discharged from hospital to home were included. Data were obtained from health system billing database, medical record, and publicly available population databases. A time-to-readmission analysis was conducted with a Kaplan-Meier plot, log-rank test, and Cox regression analysis. RESULTS The final sample included 41 566 records; the rate of food insecurity was 1.45%, and 90-day readmission rate was 16.7%. The mean area deprivation index score was 54.4 (SD, 26.0). After adjusting for patient demographics, comorbidity, and length of stay, food insecurity resulted in 1.94 times higher risk of readmission (hazard ratio, 1.94; 95% confidence interval, 1.69-2.23; P < .001). Neighborhood disadvantage and lower food access were not significant in final models. CONCLUSIONS Food insecurity should be identified and addressed as part of transitional care to improve patient outcomes. Future research should focus on models of care that ensure connection to community resources to resolve food insecurity and evaluate the impact on patient outcomes.
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Affiliation(s)
- Karen S Distelhorst
- Author Affiliations: Nurse Scientist (Dr Distelhorst), Office of Nursing Research & Innovation, Associate Chief Nursing Officer (Ms Adams), Care Management & Ambulatory Services, and Lead Biostatistician (Mr Lopez), Center for Populations Health Research, Qualitative Health Sciences, Cleveland Clinic, Ohio
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Hadley M, Oppong AY, Coleman J, Powell AM. Structural Racism and Adverse Pregnancy Outcomes Through the Lens of the Maternal Microbiome. Obstet Gynecol 2023; 142:911-919. [PMID: 37678901 PMCID: PMC10510805 DOI: 10.1097/aog.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 09/09/2023]
Abstract
Microbiome science offers a glimpse into personalized medicine by characterizing health and disease states according to an individual's microbial signatures. Without a critical examination of the use of race as a variable, microbiome studies may be susceptible to the same pitfalls as other areas of science grounded in racist biology. We will examine the use of race as a biological variable in pregnancy-related microbiome research. Emerging data from studies that investigate the intestinal microbiome in pregnancy suggest strong influence of a poor diet on adverse pregnancy outcomes. Differences in the vaginal microbiome implicated in adverse pregnancy outcomes are frequently attributed to race. We review evidence that links systemic racism to pregnancy health outcome differences with a focus on the vaginal and intestinal microbiomes as well as diet. We also review how structural racism ultimately contributes to inequitable access to healthy food and higher risk environmental exposures among pregnant people of lower socioeconomic status and exacerbates common pregnancy comorbidities.
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Affiliation(s)
- Megan Hadley
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; and the University of Chicago School of Medicine, Chicago, Illinois
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Trochez RJ, Sharma S, Stolldorf DP, Mixon AS, Novak LL, Rajmane A, Dankwa-Mullan I, Kripalani S. Screening Health-Related Social Needs in Hospitals: A Systematic Review of Health Care Professional and Patient Perspectives. Popul Health Manag 2023. [PMID: 37092962 DOI: 10.1089/pop.2022.0279] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Health outcomes are markedly influenced by health-related social needs (HRSN) such as food insecurity and housing instability. Under new Joint Commission requirements, hospitals have recently increased attention to HRSN to reduce health disparities. To evaluate prevailing attitudes and guide hospital efforts, the authors conducted a systematic review to describe patients' and health care providers' perceptions related to screening for and addressing patients' HRSN in US hospitals. Articles were identified through PubMed and by expert recommendations, and synthesized by relevance of findings and basic study characteristics. The review included 22 articles, which showed that most health care providers believed that unmet social needs impact health and that screening for HRSN should be a standard part of hospital care. Notable differences existed between perceived importance of HRSN and actual screening rates, however. Patients reported high receptiveness to screening in hospital encounters, but cautioned to avoid stigmatization and protect privacy when screening. Limited knowledge of resources available, lack of time, and lack of actual resources were the most frequently reported barriers to screening for HRSN. Hospital efforts to screen and address HRSN will likely be facilitated by stakeholders' positive perceptions, but common barriers to screening and referral will need to be addressed to effectively scale up efforts and impact health disparities.
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Affiliation(s)
- Ricardo J Trochez
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sahana Sharma
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Amanda S Mixon
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laurie L Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amol Rajmane
- IBM Watson Health, Cambridge, Massachusetts, USA
| | | | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Karran EL, G. Cashin A, Barker T, A. Boyd M, Chiarotto A, Dewidar O, Petkovic J, Sharma S, Tugwell P, Moseley GL. The ' what' and ' how' of screening for social needs in healthcare settings: a scoping review. PeerJ 2023; 11:e15263. [PMID: 37101795 PMCID: PMC10124546 DOI: 10.7717/peerj.15263] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023] Open
Abstract
Background Adverse social determinants of health give rise to individual-level social needs that have the potential to negatively impact health. Screening patients to identify unmet social needs is becoming more widespread. A review of the content of currently available screening tools is warranted. The aim of this scoping review was to determine what social needs categories are included in published Social Needs Screening Tools that have been developed for use in primary care settings, and how these social needs are screened. Methods We pre-registered the study on the Open Science Framework (https://osf.io/dqan2/). We searched MEDLINE and Embase from 01/01/2010 to 3/05/2022 to identify eligible studies reporting tools designed for use in primary healthcare settings. Two reviewers independently screened studies, a single reviewer extracted data. We summarised the characteristics of included studies descriptively and calculated the number of studies that collected data relevant to specific social needs categories. We identified sub-categories to classify the types of questions relevant to each of the main categories. Results We identified 420 unique citations, and 27 were included. Nine additional studies were retrieved by searching for tools that were used or referred to in excluded studies. Questions relating to food insecurity and the physical environment in which a person lives were the most frequently included items (92-94% of tools), followed by questions relating to economic stability and aspects of social and community context (81%). Seventy-five percent of the screening tools included items that evaluated five or more social needs categories (mean 6.5; standard deviation 1.75). One study reported that the tool had been 'validated'; 16 reported 'partial' validation; 12 reported that the tool was 'not validated' and seven studies did not report validation processes or outcomes.
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Affiliation(s)
- Emma L. Karran
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Aidan G. Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health and Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Trevor Barker
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Mark A. Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus University/Rotterdam, Rotterdam, Netherlands
| | - Omar Dewidar
- Bruyere Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Saurab Sharma
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health and Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter Tugwell
- Department of Medicine and School of Epidemiology, University of Ottawa, Ottawa, Canada
| | - G. Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
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Buitron de la Vega P, Dimitri N, Araujo Brinkerhoff C, Stern A, Damus K, Miselis H, Garg PS, Sarfaty S, Sprague Martinez L. Virtual Reality Simulated Learning Environments: A Strategy to Teach Interprofessional Students About Social Determinants of Health. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1799-1803. [PMID: 35703204 DOI: 10.1097/acm.0000000000004776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Physician assistants (PAs) and medical degree students (MDs) often lack training in addressing the social determinants of health (SDOH). Social work students (SWs), meanwhile, have extensive SDOH training; however, few medical professionals have opportunities to engage in interprofessional training with SWs. This study examined the feasibility, acceptability, and students' perceptions of an interprofessional virtual reality (VR) simulated learning environment (SLE) for teaching health professions students about the SDOH. METHOD In January 2020, 15 students at Boston University School of Medicine attended web-based video conferences focused on SDOH, health equity, and team-based care. Subsequently, student dyads participated in a case-based learning activity using an immersive VR SLE to develop teamwork skills. Evaluation included a postsurvey and a focus group examining their experiences in the course to gauge feasibility and acceptability. Thematic analysis of open-ended survey responses from the postsurvey and focus group data was conducted. RESULTS A total of 8 VR simulations were run. Findings indicated both MD and PA students learned patient engagement strategies from SW students, who enhanced their health care leadership capacity. Participants found the means of instruction acceptable, valued the hands-on VR interprofessional training, and expressed interest in learning more about the scope of one another's roles and the community resources available to patients. CONCLUSIONS VR SLE is a feasible and acceptable means of instruction. It allowed students to connect across programmatic and geographic boundaries in a collaborative working environment mimicking the team approach to care they will use in their professional life. This experience illustrated for students the strengths a multidisciplinary team has to offer.
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Affiliation(s)
- Pablo Buitron de la Vega
- P. Buitron de la Vega is assistant professor of medicine, Boston University School of Medicine, Boston, Massachusetts; ORCID: https://orcid.org/0000-0001-8359-8906
| | - Noelle Dimitri
- N. Dimitri is assistant professor of social work, Simmons University, Boston, Massachusetts. At the time this study was conducted, she was a doctoral student, Boston University School of Social Work, Boston, Massachusetts
| | - Cristina Araujo Brinkerhoff
- C. Araujo Brinkerhoff is a doctoral candidate, Boston University School of Social Work, Boston, Massachusetts
| | - Aliza Stern
- A. Stern is assistant professor of dermatology and director of didactic education, Boston University Physician Assistant Program, Boston, Massachusetts
| | - Karla Damus
- K. Damus is an administrator, Office of Human Research Affairs, Boston University School of Medicine, Boston, Massachusetts
| | - Heather Miselis
- H. Miselis is assistant professor of family medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Priya S Garg
- P.S. Garg is assistant professor of pediatrics and associate dean of medical education, Boston University School of Medicine, Boston, Massachusetts; ORCID: https://orcid.org/0000-0002-7219-476X
| | - Suzanne Sarfaty
- S. Sarfaty is associate professor of medicine and assistant dean of medical education, Boston University School of Medicine, Boston, Massachusetts
| | - Linda Sprague Martinez
- L. Sprague Martinez is associate professor and chair, Macro Department, and a research affiliate, Center for Innovation in Social Work and Health, Boston University School of Social Work, Boston, Massachusetts; ORCID: https://orcid.org/0000-0002-5070-7640
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Emeny RT, Zhang K, Goodman D, Dev A, Lewinson T, Wolff K, Kerrigan CL, Kraft S. Inclusion of Social and Structural Determinants of Health to Advance Understanding of their Influence on the Biology of Chronic Disease. Curr Protoc 2022; 2:e556. [PMID: 36200800 DOI: 10.1002/cpz1.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Social Determinants of Health (SDOH) consider social, political, and economic factors that contribute to health disparities in patients and populations. The most common health-related SDOH exposures are food and housing insecurity, financial instability, transportation needs, low levels of education, and psychosocial stress. These domains describe risks that can impact health outcomes more than health care. Epidemiologic and translational research demonstrates that SDOH factors represent exposures that predict harm and impact the health of individuals. International and national guidelines urge health professionals to address SDOH in clinical practice and public health. The further implementation of these recommendations into basic and translational research, however, is lagging. Herein, we consider a precision health framework to describe how SDOH contributes to the exposome and exacerbates physiologic pathways that lead to chronic disease. SDOH factors are associated with various forms of stressors that impact physiological processes through epigenetic, inflammatory, and redox regulation. Many SDOH exposures may add to or potentiate the pathologic effects of additional environmental exposures. This overview aims to inform basic life science and translational researchers about SDOH exposures that can confound associations between classic biomedical determinants of disease and health outcomes. To advance the study of toxicology through either qualitative or quantitative assessment of exposures to chemical and biological substances, a more complete environmental evaluation should include SDOH exposures. We discuss common approaches to measure SDOH factors at individual and population levels and review the associations between SDOH risk factors and physiologic mechanisms that influence chronic disease. We provide clinical and policy-based motivation to encourage researchers to consider the impact of SDOH exposures on study results and data interpretation. With valid measures of SDOH factors incorporated into study design and analyses, future toxicological research may contribute to an evidence base that can better inform prevention and treatment options, to improve equitable clinical care and population health. © 2022 Wiley Periodicals LLC.
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Affiliation(s)
- Rebecca T Emeny
- Department of Internal Medicine, Division of Molecular Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Kai Zhang
- Department of Environmental Health Sciences, School of Public Health, University at Albany, State University of New York, Rensselaer, New York
| | - Daisy Goodman
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alka Dev
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Terri Lewinson
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kristina Wolff
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Carolyn L Kerrigan
- Medical Director, Patient Reported Outcomes, Dartmouth-Hitchcock, Professor of Surgery, Active Emerita, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Sally Kraft
- Vice President of Population Health, Dartmouth Health, Lebanon, New Hampshire
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