As the first step in an ambitious research agenda to address healthcare racial inequities and hospital infections, Shanina Knighton, PhD, RN, CIC, is starting at ground zero: “hygiene poverty.”
Many people are not aware such conditions exist, but hygiene poverty is a contributor to the disproportionate illness and disease the pandemic all too clearly revealed in poor communities, says Knighton, a leading researcher for the Association for Professionals in Infection Control and Epidemiology (APIC).
“We talk about food poverty, but when you think about hygiene poverty, the concept is not having adequate soap, detergent, toothpaste, disinfection materials,” says Knighton, executive director of the APIC Center for Infection Prevention & Control Research Practice & Innovation. “So I think that is the biggest thing is for us to understand is how do we look at infection prevention and control education and resources through the lens of individuals who may not necessarily be able to afford or have access to common materials that we assume they would have access to.”
The need for education, health literacy, and resources has come to light as the pandemic revealed disparities in healthcare delivery along racial, ethnic, and economic lines.
“As infection preventionists, we are starting to think through solutions on how can we meet people where they are,” she says. “People may not necessarily have access to some of these resources, but we should start to think of infection prevention and control as a part of discharge planning. How do we figure out the resources that they have so they keep themselves clean and safe while in the hospital as well as when they go home?”
As part of her health equity work at APIC, Knighton recently published an editorial on this issue, noting that hygiene poverty is scarcely on the public health radar despite the inequities exposed by the pandemic.
“In fact, government initiatives waive tax for necessities such as food, but not items to maintain adequate personal hygiene and environmental cleanliness,” she wrote.1 “Even prior to COVID-19, hygiene poverty was not overtly defined as a public health issue, less known as an infection prevention and control issue. However, the interactional relationships that exist, such as the consequences of bad personal hygiene, poor living conditions, and work conditions, can lead to infectious diseases and poor health outcomes.”
HAI Reporting Does Not Require Race
In addition to drawing attention to this issue, APIC has formed a Health Inequities and Disparities Taskforce, a formal committee that will explore areas such as possible racial and ethnic disparities in patients who acquire healthcare-associated infections (HAIs), Knighton says. However, the Centers for Disease Control and Prevention’s (CDC) HAI surveillance system currently does not require reporting of ethnicity and race, listing them as optional fields of information. APIC is trying to get the CDC’s National Healthcare Safety Network (NHSN) to add those demographics to the HAI reporting system.
“Our goal is to first and foremost raise the voice that ethnicity and race should be required fields that need to be filled out,” she says. “And then the other piece of it is understanding what are the root causes that go into these racial and ethnic inequities. We can look at individual hospitals and look at the healthcare-associated incidents, but there’s just so much the literature in this area can tell us.”
A major step in this direction has been taken by the Centers for Medicare and Medicaid Services (CMS) in its 10-year action plan issued this year. The top priority in the CMS plan is to expand the collection, reporting, and analysis of standardized data, including metrics that reflect “social determinants of health” (SDOH), which include conditions in the places where people live and work that affect health and quality of life.
“CMS strives to improve our collection and use of comprehensive, interoperable, standardized individual-level demographic and SDOH data, including race, ethnicity, language, gender identity, sex, sexual orientation, [and] disability status,” the plan states.2 “By increasing our understanding of the needs of those we serve, including social risk factors and changes in communities’ needs over time, CMS can leverage quality improvement and other tools to ensure all individuals have access to equitable care and coverage.”
This certainly aligns with APIC’s goals, although it is not clear at this point whether HAIs and the demographics of those infected will be required by CMS. As reported previously in Hospital Infection Control & Prevention, HAIs increased dramatically in the first year of the pandemic but sorting out the racial and ethical implications of that is a challenge.
In addition to the lack of reported data, looking at HAI inequities during the pandemic is complicated by the chaos of an overwhelmed healthcare system.
“Speaking as an infection preventionist, the protocols that were deployed across many different settings were not necessarily reflective of what we typically do,” Knighton says. “We were in an emergency response, essentially, with limited materials, and for example, certain training measures went by the wayside. So it’s very challenging for someone to be able to parse out cleanly that [HAIs reflect racial inequities]. We know the health disparities exist though. COVID-19 showed us that, right? ”
Race Consciousness in Medicine
Knowing that encourages researchers to try to identify and rectify disparities in various fields, and that could be one of the most positive aftermaths of the pandemic.
“It does raise a level of consciousness when we know that outcomes are unfavorable,” Knighton says. “We measure overarching outcomes, but we know that these minority groups are somehow being lost in the numbers, considering that even right now, [race] is not a required reporting field.”
Those going down this research path may face protests and threats by white supremacists, as happened early this year when clinicians at Brigham and Women’s Hospital in Boston were trying to address identified racial disparities in the treatment of cardiac patients.3
“The important thing is that everyone, when they come to a hospital, should be receiving the same level of care — which is the best care,” she says. “[So that], when you walk into a hospital with one condition, you’re not going to leave with a healthcare-associated infection or another unfavorable outcome. We know that there are many factors that exist. We do know that racism is a factor.”
David Ansell, MD, MPH, senior vice president for community health equity at Rush University Medical Center in Chicago, recently published a commentary piece calling for individuals and institutions to speak out against racism and defend those trying to end decades of discrimination in medicine.4
As opposed to the seemingly objective “colorblind” approach — which measures averages and medians of healthcare outcomes — a race-conscious approach breaks down patient outcomes by color and other measures to identify specific populations, he explains. This does not mean, to put it bluntly, that whites receive worse care if Black healthcare is improved.
“The point is that the race-conscious approach can improve care for everybody,” Ansell says. “The reason to name racism as among the root causes of poor health outcomes in the United States is so we can create solutions and mitigate that, just like we would when something goes wrong in a hospital. It’s not to blame. It’s not to judge. It’s just to point out that something is going on. In every state, Black people are more likely than white people to die from a condition a hospital can treat. In every state. To get to understanding of why Black people have higher mortality than whites, we’ve got to consider racism. This is poorly understood by the public, even by CEOs and medical leaders. When you design systems to address the outcomes in those who are historically or systemically most vulnerable, those systems are good for everybody.”
- Knighton SC. Ideal or real: A call to harness infection prevention education and resources through the lens of equity, inclusion and hygiene poverty. Am J Infect Control 2022;50:1077-1078.
- Centers for Medicare and Medicaid Services. CMS Framework for Health Equity 2022-2032. https://www.cms.gov/files/document/cms-framework-health-equity.pdf
- Martin P. Neo-Nazis target anti-racist doctors at Brigham and Women’s Hospital, calling them ‘anti-white.’ WGBH. Published Feb. 2, 2022. https://www.wgbh.org/news/local-news/2022/02/02/neo-nazis-target-anti-racist-doctors-at-brigham-and-womens-hospital-calling-them-anti-white
- Ansell DA, James B, De Maio FG. A call for antiracist action. N Engl J Med 2022;387:e1.
