Social determinants of advanced chronic respiratory interventions: a scoping review

Introduction

Social determinants of health (SDH) refer to the structural, social and economic factors that shape the distribution of health and illness within populations. These include factors such as income, education, occupation, housing and access to healthcare, as well as broader societal factors such as discrimination and poverty [1].

SDH are beyond the control of most individuals and have powerful influences on the experience of healthcare. Low income, unemployment and poor housing and education have been recognised as underlying conditions that negatively influence population health and disease outcomes through multiple risk factors [2]. Advanced chronic respiratory diseases (CRD), such as COPD and interstitial lung disease (ILD) are no exception. People living in lower income and socioeconomically disadvantaged communities are at a higher risk for developing COPD and ILD, which can be attributed to greater exposure to environmental risk factors such as biomass fuel use, smoking tobacco, lack of access to affordable healthcare and limited access to education and information about managing CRD [2]. The World Health Organization (WHO) Commission on SDH acknowledges the racial discrimination endured by indigenous groups globally and their experiences of disadvantaged social positions with health indicators inferior to those of nonindigenous populations [3]. Specific attention to these SDH is crucial to decreasing disparities in the design of affordable, accessible and effective interventions [2]. Alongside improving health outcomes for people with advanced CRD, addressing SDH is also critical for understanding and ensuring the generalisability of clinical trial results to the targeted population. Recognition of SDH can determine selection, participation and adherence of people with advanced CRD from lower socioeconomic backgrounds to inform implementation of interventions.

COPD is the third leading cause of death globally, responsible for 3.23 million deaths in 2019 and the global prevalence is estimated to be 10.3% [4, 5]. Approximately 90% of COPD deaths were in those under 70 years of age living in low- and middle-income countries [5]. People with advanced CRD are often disabled by chronic breathlessness, fatigue and other symptoms, which not only reduce their quality of life but also impact those around them [6]. Social isolation and financial impoverishment are often both risk factors and consequences of chronic disease for both patients and their carers [6]. An increased prevalence of CRD among those from lower socioeconomic status presents a major challenge as disadvantaged populations often face increased barriers to accessing healthcare services and medications for disease management [2].

The treatment of advanced CRD typically involves a combination of different interventions. Pharmacological therapies, such as bronchodilators and antifibrotics, may be delivered in conjunction with rehabilitation [6], and other complex interventions aimed at addressing the various physical, psychological and social factors that contribute to the development and management of the disease [7]. Multidisciplinary services also work with respiratory and palliative care teams to offer patients pulmonary rehabilitation (PR) [8], which is the most evidence-based intervention for improving breathlessness, exercise capacity and health status [9]. Despite achieving comparable clinical outcomes, people living with COPD in the most socioeconomically deprived areas are less likely to complete PR compared to those living in least deprived areas [9]. In New Zealand, those with Māori ethnicity and Pacific Islanders have lower completions rates compared to those with European ancestry [10]. However, it is difficult to measure completion rates in other published cohorts such as the United Kingdom [11] given the lack of reporting of the demographics of people with COPD, as well as the impact of ethno-cultural factors on referrals attendance and completion of PR [12]. Progress in increasing PR uptake and completion has been hindered by the limited reporting of ethnicity and other characteristics associated with health-related disparities such as sexual orientation, sex identity and intersex status [13]. Supporting PR access in diverse communities by recognising the influence of multiple, interacting spheres on health equity is an area that has received very limited attention in data collection [14].

Community-based symptom-directed care such as singing for lung health (SLH) programmes have recently emerged as a novel approach to improve the health-related quality of life of people with advanced CRD through improving capacity to cope with breathlessness [15]. Experienced singing teachers teach breathing and posture techniques in conjunction with group singing activities during the classes, which have been perceived as fun and sociable [15]. Due to the novel nature of the intervention, there has been limited and consideration of SDH contributing to uptake and participation. Multicomponent palliative care interventions (MPCI), which aim to deliver palliative care together with disease-directed care over the last years of life, have also been developed for people with advanced CRD and their carers [6, 7]. However, there remains inconsistent provision of these advanced lung disease clinics and specialist breathlessness services that have been pioneered within palliative care [16]. Reporting on the SDH across complex advance CRD interventions is important for identifying and addressing disparities, as well as ensuring that interventions are culturally appropriate and responsive to the needs of the community. The WHO Commission on SDH developed a conceptual framework for action on the SDH [3]. This study aimed to utilise this framework to assess the extent of reporting and active consideration of SDH across PR, SLH and MPCI interventions for people with advanced CRD.