Uncovering Root Causes: A life-course study to explore health disparities among single parents. A community-centered approach.

Marieke Breed, Sam Schrevel, Jet Bussemaker, Sanne de Vries, Matty Crone & Nienke Slagboom

Background: Achieving health equality requires a deep understanding of the root causes of health inequalities. In a specific deprived neighborhood in The Netherlands, our research found that single parents -in particular- face complex and intersecting health- and social challenges across their life course, increasing the likelihood of health disparities for them and their children. This study explores how social- and structural stressors shape the way these single parents approach life and how this approach impact the way health and social outcomes are intertwined and embodied (syndemic suffering).

Approach: Using a participatory action research approach involving 7 single parents as co-researchers, we sought to incorporate diverse perspectives. We conducted 10 life-course interviews with other single parents in this deprived neighborhood, which were analyzed and elucidated in close collaboration with the co-researchers during 8 group sessions.

Results: The interviews demonstrate that life-course challenges and events -such as financial insecurity, housing instability, (domestic) violence and institutional distrust- form the root causes of health disparities for these single parents. Single parents describe how they understand and approach life because of the ongoing challenges and events during their life-course. Although there are slight differences in the life-courses of this single parents, they all share a history of instability and violence before and during they came to live in this deprived neighborhood The most common health complaints of this single parents (chronic stress, musculoskeletal pain and signs of depression) seem both related to the ongoing life-course events and the way the participants and co-researchers explain their responses used to cope with these challenges.
This single parents in this deprived neighborhood developed a structured way of navigating life because of the challenges and events they face. They seem to navigate life with the notion of ‘being on guard’. This way of navigating life has become a way of understanding life; a structured way of responding. This structured response helps us to underscore the complexity of syndemic suffering: while this automatic responses are essential for short-term survival, they may, paradoxically, entrench this single parents into cycles of chronic stress, musculoskeletal pain and depression by not seeking support and therefor reinforcing their health and social vulnerability.

Implications: This research underscores the importance of understanding health disparities through a life-course lens. Recognizing how structural and social factors shape life, health and the way single parents cope with life-course challenges -by being on guard- provides a foundation for developing more community-centered solutions. This means shifting the focus from interventions from merely treating health symptoms towards a focus on understanding the structural conditions that lead to single parents’ structured responses. In collaboration with the co-researchers, we now translate a Theory-of-Change into a community-centered approach in which health and support services offer relational, stable, long-term support, carefully building on confidence and health for these single parents with an increased vulnerability for syndemic suffering.

1. Background
Eliminating health disparities is crucial in global aging, yet comprehensive summaries of integrated care pilot programs for promoting health equity remain lacking.
2. Approach
This study focused on the community-dwelling elderly population (aged ≥60 years) in megacities, aiming to elucidate the status of health disparities and promote integrated care strategies. Firstly, We used 2020 CHARLS data and Stata 17.0 and SPSS software to analyze differences in health equity indicators between elderly individuals in urban and rural areas of megacities. Secondly, we employed theoretical analysis, literature review and interviews with authorities to gain insights into successful integrated care experiences, constructing a preliminary theoretical framework and summarizing initial strategies to eliminate health inequities. The intervention involved government, community organizations, healthcare providers, and elderly residents, incorporating a co-design approach to ensure relevant stakeholders participated in every phase of design and implementation.
3. Results
Firstly, the study revealed several disparities among elderly individuals in megacities:
1）Health Status: Rural elderly individuals had poorer self-rated health and more severe depressive symptoms (64.7%) compared to urban elderly (33.1%), although no significant difference in daily life capabilities was found.
2） Health Insurance: No significant differences in social medical insurance coverage rates were observed, but a higher proportion of individuals purchased insurance with out-of-pocket expenses.
3） Service Utilization: There was no urban-rural difference in biennial physical examination rates.
4）Social Participation: Rural elderly individuals were more likely to still be working, with no significant difference in willingness to work further; however, nearly half of all elderly had no social activities in the past month, and internet usage was low among rural elderly.
Seconedly, a preliminary theoretical framework for integrated care services that can promote health equity:Integrated community home-based care in megacities involves government, market, social organizations, communities, and families, ensuring high-quality care through structural and functional integration. By reinforcing distributive justice, this framework aims to promote health equity across access, process, and outcomes, ultimately advancing health promotion.
Thirdly, Integrated care strategies to promote health equity include: 1) Establishing community-centered care models and optimizing care quality; 2) Enhancing care coordination in urban-rural fringe areas to reduce disparities, leveraging models like Gaobeidian's day care and Lucheng's medical-nursing alliance; 3) Promoting service integration through government-led healthcare collaborations; 4) Using information platforms for elderly health monitoring and care delivery; 5) Leveraging traditional Chinese medicine in integrated care; 6) Achieving full coverage of basic medical insurance.
4. Implications
In the past decade, Chinese government measures have reduced urban-rural health disparities in megacities. Moving forward, authorities should focus on rural elderly health, especially mental health, and implement localized measures to enhance integrated care quality and efficiency. The authors will continue monitoring health disparities, summarizing best practices, and developing a community-based integrated care model for the elderly in megacities to promote health equity.

• Background: Managing chronic conditions such as diabetes or long COVID requires an integrated primary care approach due to its complexity which is exacerbated for culturally diverse and low socioeconomic communities.
• Approach: We gathered information about needs and expectations for managing chronic conditions from stakeholder and community participants in a culturally diverse community in a low socioeconomic urban area in Australia. We engaged with 35 people living with or caring for people living with chronic conditions, as well as with 16 healthcare providers and stakeholders from the Community Primary Health Network through focus groups and semi-structured interviews. We undertook a thematic analysis and used a systems thinking lens to make sense of the themes.
• Results: We identified five key activities associated with integrated primary care, and determined how these activities relate to one another to perform optimally and improve integrated care for managing chronic conditions. The five key activities were managing chronic conditions (by consumers and carers), providing medical care, social prescribing, supporting care, and coordinating care. By mapping needs to and from key activities, we identified gaps and barriers in the provision of community services. We found that the activity of coordinating care was centred around personal liaising between the different services to deliver care that met the needs and circumstances of the patient; the profile of the liaison person varied depending on the medical and social needs. A key finding was the need for coordinating primary care with welfare and wellbeing services, which involved identifying organisations serving the community and developing collaborative relationships with primary care health services. Another salient need identified by patients was sufficient time for being heard or listened to. One avenue for increased collaboration might be to co-design a space within an integrated health care centre for community, welfare organisations and support services to augment the centre and enhance the consumer experience of belonging to a community. Another key finding was the need for cultural matching between the consumer and the providers, whether clinicians or welfare and wellbeing services. This might be achieved by adding information about culture, language and modality of care preferences to the patient health record, together with service providers, and creating a matching recommendation system.
• Implications: Improving integrated primary care for managing chronic conditions is a team endeavour which requires teaming within primary health care services and beyond with community welfare and wellbeing organisations. This requires a collaborative mindset and participatory leadership.

Background
East Toronto Health Partners (ETHP), an Ontario Health Team serves 400,000 individuals, of whom over 50% are immigrants. Significant disparities exist in cancer screening rates across ETHP's 21 neighborhoods, with rates 15-25% lower in areas with higher concentrations of immigrants and lower socioeconomic status. Barriers for underserved populations include difficulty accessing services, language constraints, lack of knowledge about the importance of screening, and cultural factors influencing health practices. Addressing misinformation and improving early cancer detection through primary care providers (PCPs) is essential for enhancing population health outcomes. However, with 70% of PCPs experiencing burnout and significant administrative burdens, preventative care often becomes deprioritized.

Approach
In 2023, East Toronto Health Partners (ETHP) collaborated with the eHealth Center of Excellence to launch Poppy-bot, a robotic process automation tool designed to work within primary care electronic medical records (EMRs). Poppy-bot identifies individuals due or overdue for cancer screening and segments them by postal code and language to enable targeted outreach. In East Toronto, Poppy has identified over 15,000 individuals eligible for cancer screening.

Flemingdon Health Centre (FHC), located in two underserved neighborhoods with lower cancer screening rates, leads a multi-agency Community Health Ambassador (CHA) program. This peer-based initiative hires local residents from equity-deserving communities to provide outreach and peer support.

Recognizing the complementary strengths of Poppy-bot and CHAs, ETHP integrated these initiatives to address cancer screening challenges and support underserved communities to get screening completed.

Culturally sensitive outreach was a priority and therefore we engaged with Health Commons Solution Lab and Behavioural Insights Team to co-design educational materials with CHAs and community members through focus groups and workshops ensuring relevance and receptiveness. Behavioral science principles, conversational receptiveness, and motivational interviewing techniques informed the development of a Cancer Screening Guide. The guide was tailored for use in in multiple languages including Arabic, Bengali, Dari, Pashto, Slovak, and Urdu. Trained CHAs used this guide to have one-on-one conversations with residents flagged by Poppy-bot, explaining the importance of screening, what to expect during the process, and how to interpret results. Access to nursing staff was also available to support CHAs in addressing concerns.

Results
This initiative demonstrated the successful integration of digital tools with community outreach to improve cancer screening rates in underserved populations. Over one month, CHAs had one-to-one conversations with over 400 individuals, addressing barriers and fostering trust. Particularly, Slovak-speaking CHAs engaged their community, resulting in 43 individuals agreeing to screenings; overcoming long-standing barriers of access and healthcare system distrust.

The team received an innovation award from MARS and the Canadian Cancer Society, funding the development of the Cancer Screening Guide. Beyond screening, CHAs identified other health-related questions and barriers, shaping future program developments and outreach strategies.

Implications
The evaluation phase includes new focus groups to refine the Cancer Screening Guide and implement improvements. Lessons from Poppy-bot's deployment are enhancing its functionality. This initiative demonstrates the value of empowering CHAs in preventive care and integrating digital tools with culturally sensitive, community-based outreach to address health inequities effectively.

Background:
Health inequalities in Hounslow reflect national disparities in England, where people in the most deprived areas live nearly a decade less than those in the least deprived areas. The NHS CORE20PLUS5 strategy, launched in 2022, provides a framework to systematically reduce these inequalities by focusing on the most deprived 20% of the population (CORE20) and underserved groups (PLUS), targeting five key clinical priorities. By utilising extensive resident engagement and population health data analysis, Hounslow Borough Based Partnership has adopted this strategy to improve health outcomes and address inequalities within its diverse community.
Approach:
Hounslow implemented a systematic approach to understanding and addressing the needs of its CORE20 residents. This involved a population health management strategy combining data analysis with extensive resident engagement. Twelve areas in Hounslow were identified as CORE20, encompassing approximately 26,000 residents.
Nine local voluntary and community sector (VCSE) organisations were commissioned to engage 340 residents from these areas, gathering insights on the determinants of health and wellbeing, barriers to accessing services, and potential solutions. Findings from this engagement were triangulated with integrated care system data (WSIC), including health outcomes, as well as data on wider determinants of health.
Results:
The findings revealed significant barriers faced by CORE20 residents, including poor access to healthcare services, lower levels of employment, and inadequate housing. Residents highlighted the impact of environmental factors, noting the advertisement of unhealthy food influenced their health and wellbeing. Field observations conducted in high streets within CORE20 areas showed a significantly higher density of unhealthy food advertisements (10 per 0.2 miles) compared to non-CORE20 areas (8 per 2.7 miles). Residents overall know what it takes to be healthy but highlighted the important issues which impact health such as trust in healthcare providers, the need for culturally appropriate services, and support for improving their local environment. Residents in CORE20 areas had higher levels of food insecurity and longer travel times to key services like GPs and pharmacies. Data confirmed these challenges, showing higher rates of A&E attendances, smoking, obesity, mental health conditions, and chronic illnesses among CORE20 residents compared to the wider Hounslow population.
In response, targeted interventions were implemented, such as outreach NHS Health Checks for adults aged 25-40, redesigned weight management and smoking cessation services focused on CORE20 areas, and increased GP incentives to enhance service uptake resulting in uptake of health checks amongst CORE20 residents growing from 6% to 30% in one year. These actions have begun addressing the identified barriers, with early indications of improved access and engagement.
Implications:
This project underscores the importance of combining data-driven insights with community-led engagement to address health inequalities. By focusing on CORE20 residents, Hounslow has demonstrated how targeted, locally tailored interventions can begin to bridge the gap in health outcomes. Future steps include scaling up successful models, enhancing integrated care approaches through integrated neighbourhood teams, and continuing to involve residents in shaping solutions.
This initiative provides a replicable framework for tackling inequalities and ensuring that the most deprived communities are prioritised in health and care strategies.

Background: Israel’s northern region, the Galilee, is a social geographic periphery. Seventeen percent of the country’s population reside in this region. It is predominantly Arab, poor, and has the lowest rate of physicians per residents in the country. This region is also marked by a significant higher prevalence of chronic diseases and a 4-year difference in lifespan compared to the center of the country. Over 14% of the population suffers from type 2 diabetes, in comparison to 10% in the center of the country. A significant percentage of these patients have poor control of their diabetes, leading to the highest markers of diabetes complications in Israel including lower limb amputations, blindness and kidney failure resulting in dialysis.
Approach: In November 2021, the Azrieli Faculty of Medicine, located in the Galilee, launched SPHERE – Social Precision Medicine Health Equity Research Endeavor – A 10-year initiative, the first of its kind in Israel. The aims of SPHERE are to be socially accountable to our partner communities in the Galilee; develop and implement innovative models to reduce diabetes and obesity related health inequities; and improve Galilee residents’ health outcomes. To do so we developed the Municipal Engine for Social Health (MESH) platform for interventions. MESH supports implementation of interventions with healthcare providers, implementation of new municipal health units, as well as creating a new integrated eco-system in which healthcare providers and municipalities work together to reduce inequities.
Results: Today, SPHERE is already running over 60 interventions. We began with 5 pilot towns in 2021 and are now working with 23 cities and towns, with SPHERE’s unique MESH platform adopted as the national model by Israel’s Ministry of Health. Health units have been set up, a comprehensive in-depth mapping of each town was conducted to identify the network using social network analysis and the extent to which an infrastructure of health policy and interventions exists among different eco-system partners, including the education sector, health, municipal departments, local NGOs etc. Towns showed disperse networks with minimal policies and action regarding issues such as physical activity or healthy nutrition. Following these data, a comprehensive strategic plan tailored to each town was written together with the partner communities. These plans are now being implemented. Additionally, to overcome the disparities in access to diabetes and obesity specialists, we created programs such as diabetologist and obesity training for family physicians from these towns (n=50 trained), as well as a professional support network (n=170 health professionals). Interventions to improve the standard of care are implemented with these providers and are already showing impressive outcomes. For example, a pilot intervention to increase identification and delivery of standard of care for pre-diabetic patients (n=514) led to halving the percentage of patients who transition from pre-diabetes to diabetes. This is now being implemented at scale.
Implications: In northern Israel SPHERE is implementing a unique platform that expands knowledge, provides tools, and creates unique community based integrated interventions to improve the health of Galilee residents.