Introduction

There are physiologic, social, and environmental etiologic mechanisms for disparate health outcomes. Disparities in social determinants of health (SDH), bias, chronic exposure to stress, and generational traumas lead to clinically relevant alterations in wound occurrence and wound healing. Access to not only advanced therapies but standard of care is not equitably distributed across populations.^1-3

Social and Environmental Basis for Disparate Outcomes

If care inequities were eliminated, disparities in wound healing would persist. 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 health care delivered.^1,2

How Does Environment Impact Patient Health?

Our environment significantly impacts our health. It includes local, environmental, and social variables such as:

• Toxins
• Microbes
• Experience of stress
• Uncertainty
• Social isolation
• Social injustice

These variables lead to neuro-hormonal responses that affect gene transcription and regulation.⁴ Stressors that have occurred throughout the patient’s life can contribute to physiologic changes and altered health behaviors that lead to toxic cellular micro-environments, creating the potential for the development of wounds and negative healing outcomes.^4-9

One’s environment can prohibit or promote access to health care services, influencing health outcomes. Environmental barriers to health services include:

• The high cost of care
• Unavailability of services in a community
• A lack of culturally-competent care

Access to wound care for vulnerable populations is not equitable.³ Even among wound specialists, a lack of consistent guidelines leads to massive differentiation in standard of care delivery. Variability in healing outcomes can result from disparities in access to:

• Wound dressing types
• Cleansers
• Advanced therapies
• Specialty referral
• Skilled treatment

Outcomes are also influenced by proximity to specialized care and provider expertise. For example, patients residing in vascular-intensive communities are less likely to have lower limb amputations.^10,11 Transportation is frequently identified as a barrier, even though we know increased wound clinic visit frequency is associated with better healing outcomes.^12,13 While there are many potential etiologies of augmented wound healing associated with increased wound clinic visit frequency, it is reasonable that elevated care and a sense of belonging and social interaction produces positive biochemical responses. Social isolation decreases our stress tolerance and is a known corollary in delayed wound healing.^14,15

In addition to direct interpersonal social interactions, the social constructs, both historical and current, of the communities and nations we live within impact health. Generational trauma and adverse childhood experiences have been linked with several chronic diseases including autoimmune diseases,⁵ cancer,⁶ COPD,⁷ ischemic heart disease,⁸ and mental health disorders such as depression, hallucinations, and somatic disorders.⁹ These chronic diseases and their treatments are associated with conditions that create wounds as well as delayed wound healing.

Trauma-related events often occur in the context of service provision, creating the potential for mistrust in majority groups and government-funded services. This trauma can also occur in the context of research and health care, including mental health care. For members of communities impacted by these historical traumas, daily reminders of discrimination can exacerbate individual responses to trauma.¹⁶ While multifaceted, this issue is due to historical trauma and mistrust; whereby vulnerable populations were unethically experimented upon and thus developed suspicion of health care providers and medical research.¹⁷ A direct path to increase inclusivity in wound research would include the diverse wound etiologies and patient presentations that occur in wound centers as approval for new therapeutics are generally restricted to the demographics of the population in clinical studies.¹⁸

Delivery of Care Disparities

Health care providers exhibit the same levels of implicit bias as the wider population, and high levels of implicit bias are associated with lower quality of care.¹⁹ The use of tools to standardize care is often a frustration to clinical staff but can assist in reducing the impact of assumptions and bias in the delivery of care.

Wound care education mainly has focused on skin care presentation and treatment of light skin tones. This narrow scope produces disparate diagnoses of certain medical conditions where skin tone impacts visual assessments such as pressure injuries, infection (erythema), neonatal jaundice, and evidence of abuse (ecchymosis).

The utility of technological advances in wound care is both a source and potential mitigator of disparate care. Novel technologies have the potential to augment visual assessment and identify important physiologic findings. Near-infrared spectroscopy and thermography have scientific limitations in darker skin tones, which must be further elucidated in future research. Some novel technologies including the sub-epidermal moisture (SEM) scanner and fluorescence imaging have evidenced their utility across skin tones.^20-23

A key frustration experienced by US wound specialists and providers is being forced to deliver disparate care due to insurance coverage. Instead of recommending treatments based on outcomes and evidence, clinicians are forced to consider insurance coverage and financial ability instead of patient needs. Opposed to evidence-based practice, insurance-based practice occurs when the use of a medically necessary beneficial wound therapy is limited due to insurance.

Conclusion

In conclusion, disparities in wound prevalence and outcomes are due to a constellation of physiologic, biochemical, environmental, and social factors. Future health care priorities should focus on preventing illness through supporting access to structural drivers of health, such as safe housing, food, education, and health care (including mental health care)¹ instead of solely treating the diseases that result from their deficit. While individuals do have the ability to modify what they perceive as stressful and how they respond to it to decrease the negative health outcomes associated with stress,⁴ the profound prevalence of social injustices continues to exert an insurmountable burden among marginalized populations. The health of our patients and ourselves is influenced by so much more than what we can address during an office visit or inpatient stay. This asks the important question, "Where does our role in the facilitation of the health of our patients end?"

References

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20. Okonkwo H et al. A blinded clinical study using a subepidermal moisture biocapacitance device for early detection of pressure injuries. Wound Repair Regen. 2020; 1-11. https://doi.org/10.1111/wrr.12790. Accessed January 21, 2020

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23. Lam Le et al. Diagnostic Accuracy of Point-of-Care Fluorescence Imaging for the Detection of Bacterial Burden in Wounds: Results from the 350-Patient Fluorescence Imaging Assessment and Guidance Trial. Adv Wound Care. 2021; (10)3: 123-136.

About the Author

Laura Swoboda, DNP, APNP, FNP-BC, CWOCN-AP, is a Professor of Translational Science, Nurse Practitioner, and Wound Healing Coordinator at Froedtert & the Medical College of Wisconsin, where they advocate for nurse practitioners and nurse participation in research. They completed their Doctor of Nursing Practice degree at University of Wisconsin Milwaukee (UWM). Dr. Swoboda is a faculty member of the Clinical & Translational Science Institute of Southeast Wisconsin where they serve as principal investigator for quality improvement, evidence based practice, and research projects including the planning, implementation, management, and dissemination of projects in chronic wound care. They further participate in the research process in serving as a peer reviewer for scientific journals. Dr. Swoboda is on the National Pressure Injury Advisory Panel’s Prophylactic Dressing Standards Initiative Task Force, a member of the editorial board for the Wound Care Learning Network and Wound Management and Prevention, and on the board of directors for the WOCNCB and the AAWC.