How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK.

BACKGROUND: Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system's level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions. METHODS: In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach. RESULTS: Interviews (n = 14) with wide representation from local authority (n = 8), NHS (n = 5) and voluntary, community and social enterprise (VCSE) sector (n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system's approach to reducing health inequalities was evident as was collective action and involving people, with links to a "strong third sector". Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system. CONCLUSION: We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system's working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Coproduction of a resource sharing public views of health inequalities: An example of inclusive public and patient involvement and engagement.

BACKGROUND: UNderstanding Factors that explain Avoidable hospital admission Inequalities-Research study (UNFAIR) addresses how to reduce health inequalities, particularly for avoidable hospital admissions. Our Patient and Public Involvement and Engagement (PPIE) members broached that health inequalities are complex, challenging to understand and communicate. They identified a need to explore diverse views, including people who have a higher risk of health inequalities. With limited public-facing resources relating to the public's understanding or emotions around health inequalities, this project aimed to fill this gap using co-leadership and co-production. METHODS: Members of the public worked with researchers to co-produce and run PPIE workshops. This project was co-led by a member of the public and a researcher. One online workshop open to anyone in England accompanied by three face-to-face workshops were held. Public contributors, including people living in diverse communities, were invited. Inclusive involvement opportunities were offered including flexible ways of involvement and remuneration. To strengthen the key messages' rigour, transcriptions of the audio-recordings from each workshop, with facilitator notes, were analysed using thematic analysis. From the key messages, an animation was co-produced with public contributors with the public's voice being integral throughout. KEY MESSAGES: A total of 58 people took part capturing intersecting and multiple dimensions of marginalisation including people with a range of ages, genders, ethnicities, socioeconomic backgrounds, and members of communities who face exclusion (including people with learning difficulties and experiencing ill-health). The animation highlighted powerful lived experience, for example, some people are dying earlier than expected. Health inequalities conjured up powerful emotions, such as anger and hopelessness. Public views of how to address health inequalities included respecting, accepting and valuing everyone, regardless of, for example, where people live. The animation is publicly available for use by anyone, including decision makers across the health and care system. CONCLUSIONS: Through co-leadership and co-production, this project is an example of inclusive PPIE. This project provided a way for the public's voice to influence policy and practice to inform understanding and action to address health inequalities. The animation provides powerful insights into what health inequalities mean to people with examples of lived experience and corroborates the moral argument for action by decision makers. PATIENT AND PUBLIC CONTRIBUTION: Members of the public, including people who were affected or at higher risk of health inequalities, co-led this project and were involved as co-creators and developers from the inception of the project to completion. Their involvement was integral and documented in full throughout the project.

Realities of opioid and gabapentinoid deprescribing in socioeconomically disadvantaged communities: qualitative evaluation.

BACKGROUND: Opioid and gabapentinoid prescribing has increased substantially in recent years despite having limited effectiveness in treating chronic primary pain. This is concerning with the prescribing rates and adverse effects of these medications being higher in more socioeconomically disadvantaged groups. Guidance for prescribing and deprescribing these medications exists but the understanding of how deprescribing is operationalised especially in areas of socio-economic disadvantage is limited. AIM: To explore primary healthcare professionals' views and experiences of designing and implementing an intervention to reduce opioid and gabapentinoid prescribing. DESIGN & SETTING: A qualitative evaluation, using participant observation and semi-structured interviews with primary healthcare professionals working in practices serving areas of substantial socio-economic disadvantage. METHOD: Interviewees were purposively recruited with subsequent snowballing with participant observation of the peer-support meetings. Interviews transcripts and notes from the participant observation were inductively coded and thematically analysed. RESULT: Thirteen healthcare professionals from five practices were interviewed. Person-centred care with shared decision-making was strived for which was time consuming due to the complexity of the problem and patients. Where shared-decision making was not possible due to patient refusal or non-engagement, risk was used to determine the appropriate action. This work involved an emotional toll on staff and patients but was at times conversely easier and more rewarding than expected. Ultimately, demedicalising pain with a culture change is required to ensure patients are not prescribed these medications for inappropriate reasons or doses. CONCLUSION: This study demonstrates key operational aspects to consider when undertaking opioid and gabapentinoid deprescribing in primary care.

Animal-Assisted Interventions for the Improvement of Mental Health Outcomes in Higher Education Students: A Systematic Review of Randomised Controlled Trials.

BACKGROUND: The aim of this systematic review was to evaluate the effectiveness of Animal-Assisted Interventions (AAIs), particularly Animal-Assisted Therapy (AAT) and Animal-Assisted Activity (AAA), in improving mental health outcomes for students in higher education. The number of students in higher education reporting mental health problems and seeking support from universities' student support services has risen over recent years. Therefore, providing engaging interventions, such as AAIs, that are accessible to large groups of students are attractive. METHODS: MEDLINE, PsycINFO, Embase and Cochrane Library were searched from relative inception to end of April 2020. Additionally, a grey literature search was undertaken. Independent screening, data extraction and risk of bias assessment were completed, with varying percentages, by two reviewers. RESULTS: After de-duplication, 6248 articles were identified of which 11 studies were included in the narrative synthesis. The evidence from randomised controlled trials suggests that AAIs could provide short-term beneficial results for anxiety in students attending higher education but with limited evidence for stress, and inconclusive evidence for depression, well-being and mood. For the non-statistically significant results, the studies either did not include a power calculation or were under-powered. CONCLUSIONS: Potential emerging evidence for the short-term benefits of AAI for anxiety, and possibly stress, for students in higher education was found.