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Abstract
Introduction Health needs are issues that face a population or specific groups, which can benefit from healthcare and wider social and environmental changes. They are inextricably linked to health inequalities, which are largely determined by non-health-related factors such as socioeconomic deprivation or belonging to ethnic minority groups. The hospital-accessing paediatric population, with higher rates of morbidity and mortality, are likely to have higher levels of met and unmet health needs related to social determinants, compared with their peers. As the gap in health inequalities widens globally, paediatric health services may now have an increasingly important role to play in identifying and acting on inequalities affecting their patient population. This scoping review aims to collate information on how children’s hospitals assess the health and wider health-related social needs of patients using a health inequalities lens. On a broader level, the review may also reveal themes about healthcare and other health needs of children accessing hospitals globally.
Methods and analysis This scoping review will follow Joanna Briggs Institute guidance. A search strategy will be described to identify published articles from healthcare databases worldwide as well as healthcare-related grey literature. Literature will be examined to identify methods that aim to assess the health and related social needs of hospital-accessing paediatric patients and will exclude literature published before 2010. Two or more reviewers will independently review the results of the searches using the inclusion and exclusion criteria. Study findings will be presented in tabular form detailing the assessments identified.
Ethics and dissemination The review will synthesise information on hospital approaches to understand and assess the health and health-related social needs of children and young people worldwide. The findings will be used to inform guidelines for children’s hospitals in the UK and will be disseminated through national and international professional bodies, conferences and research papers.
- PAEDIATRICS
- Health Equity
- PUBLIC HEALTH
- Hospitals
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Strengths and limitations of this study
The search strategy will comprehensively explore both published and grey literature, using a novel approach used in previous grey literature studies.
The review will consider international literature and use techniques to ‘decolonise’ the search strategy, using purposefully broad search terms as well as exploring grey literature from across the world.
The search will only focus on literature published since 2010, to take into account key events such as the global pandemic and international conflict, which have had effects on many social determinants of health.
The literature search will be limited to English-only texts due to resource constraints.
Introduction
‘Health needs’ are needs that could benefit from changes to healthcare, wider society or the environment. This definition recognises that the social determinants of health, which include housing, deprivation, education and employment, can impact on, and be routes towards improving a person’s health (such as morbidity or life expectancy), as well as traditional ‘healthcare needs’ which include better diagnosis, treatments, rehabilitation pathways etc.1 In particular, there is increasing awareness of the concept of specific health-related social needs, such as food insecurity and housing instability, which can have a direct impact on access to healthcare and also the prevalence and severity of diseases.2
Health needs, the social determinants of health and health-related social needs are inextricably linked with health inequalities, where ‘people in different social circumstances experience avoidable differences in health, well-being and length of life’.3 Variation in health and healthcare needs of individuals may result in, or be a result of, health inequalities in terms of access, experience and ultimately health outcomes within a population, and these may also be considerably shaped by the wider social determinants of health as described above. Differences in outcomes in life expectancy, infant mortality, mental health and non-communicable diseases can be observed between the richest and poorest groups within most European Union countries,4 and there is global evidence of worsening inequalities with regard to access to quality healthcare.5
UK data shows that people living in the most deprived areas of the country have a lower life expectancy and experience worse health outcomes than those living in the least deprived areas.6–8 Children are particularly susceptible to the impacts of health inequalities due to the wider determinants of health.9 In 2021–2022, 29% of children in the UK were deemed to be living in poverty.10 A child’s relative risk of death increases by 10% between each decile of increasing deprivation and this is an association for all categories of cause of death except malignancy.11 A 2015 systematic review indicated a 72% higher prevalence of chronic conditions in socioeconomically disadvantaged children across high-income countries, including psychological disorders, asthma and intellectual disability.12 Childhood obesity rates are considerably higher among Black and Asian children in England, often interlinked with deprivation and low-income households as well as lower physical activity levels.7 On an international scale, evidence suggests that the SARS-CoV-2/COVID-19 pandemic has pushed an estimated 100 million children into multidimensional poverty and that currently half of the world’s children live in countries at extremely high risk of the impacts of climate change, including food scarcity and disease outbreaks.13 Such gaps widen health inequalities, where the poorest children are twice as likely to die than the richest worldwide.14
In the UK, the National Health Service (NHS) (a government-funded, free-at-the-point-of-access, universal medical and healthcare service) has a role to play in reducing health inequalities from a policy and constitutional perspective. The NHS Long Term Plan (2019) outlined that the NHS must play a role by improving upstream prevention of avoidable illness and to meet longstanding unmet health needs of the population.15 The recent ‘Core20PLUS5’ NHS England approach to health inequalities in both adults and children/young people supports the reduction of health inequalities, with a focus on five national priority clinical areas, and on locally identified population groups with specific needs who would benefit from a targeted approach.16
Children and young people (CYP) who access hospital care for a health condition are likely to have a wide range of health needs and related social determinants contributing to their reason for attendance, but also more broadly. Research has found socioeconomic patterns in the way that children access care,17 18 and the Nuffield Trust found that rates for emergency admissions due to asthma were two and a half times higher in school-aged children from the most deprived areas compared with the least deprived.19 It is therefore likely that the population of hospitalised children includes higher numbers of children living in socioeconomic deprivation; however, little work has been done to otherwise describe these populations. Children’s hospitals, and other hospital settings that provide paediatric care, therefore occupy a unique position from which to explore the needs of CYP accessing healthcare services and could intervene to improve inequalities in ways that could inform policy and practice elsewhere.
Health needs assessments (HNAs) are a methodology for systematically assessing the health needs of a population.20 In the UK, HNAs are traditionally performed by local authority public health teams in order to understand and prioritise support where the need is greatest in the local population as a whole.21 To date, there are few examples of this approach undertaken by NHS hospitals to understand the specific population that attends the organisation. However, examples of hospital-initiated HNAs can be found around the world, for example, the Boston Community Health Needs Assessment-Community Health Improvement Plan (CHNA-CHIP) Collaborative. This specifically considers access to healthcare within its population needs, while also working in collaboration with partner institutions such as public health departments, charities, housing and local government offices, with a specific health inequality lens.22 Of note, an amendment to the USA’s Patient Protection and Affordable Care Act in 201323 mandates charitable hospitals to perform a community HNA every 3 years to maintain their tax-exempt status. Hospitals must do this by consulting local communities and organisations to assess and identify key healthcare needs and design strategies to address them.
It is recognised that while the lack of mandate in the UK means NHS organisations are less likely to carry out a formal HNA, such assessments of the hospital-accessing population may have been performed but may come under other hospital activity such as corporate strategy, quality improvement, monitoring and evaluation, or policy work. Therefore, assessments under these headings are unlikely to be published in the traditional manner in peer-reviewed journals or be easily accessible worldwide.
Aim
There is a complex interaction between the health needs and social determinants of health of a local population, and their influence on health inequalities and outcomes, which together are commonly identified within community-based HNAs. The literature suggests that hospitals and related services may serve patients with higher levels of health and health-related social needs than the average population or local community. We therefore aim to explore how this crucial issue is identified and assessed for the populations specifically presenting to hospital services.
This scoping review aims to identify and collate information on how children’s hospitals and hospitals with paediatric services assess or identify the health needs and health-related social needs of paediatric patients aged 0–25 years and their carers, in order to understand how hospitals may tackle inequitable health outcomes in their population.
On a broader level, this in-depth review of hospital-based assessments may reveal recurring themes related to healthcare and other health and health-related social needs of children accessing hospitals globally, and we aim to categorise these findings into broad groups. For example, a recurring theme may be access to transport and therefore access to health services, which may disproportionately impact specific patient groups and their health outcomes. The findings of this review could therefore be used to support the development of toolkits and guidance on targeting health inequalities in children’s hospitals, both nationally and internationally.
Methods and analysis
Scoping reviews are considered a type of review in the ‘broader family of evidence synthesis’, aiming to map the breadth of research in a field or concept irrespective of source and across contexts.24 The authors will follow Joanna Briggs Institute (JBI) methodology for conducting scoping reviews, with the aim of addressing a broader research question than a typical systematic review,25 26 while adhering to gold standard Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) reporting guidelines.27
Due to the nature of the research question, and because hospitals’ work on assessing health needs may not necessarily be published in traditional settings, we will use a strategy that focuses on comprehensive reviews of both published and grey literature. Grey literature can be defined as literature that has not been formally published and can include literature from industry, government and academia, the breadth of which can be a ‘rich source’ of evidence, and which can ultimately reduce publication bias.28 Grey literature may also prove useful with regard to the fast-moving field of health inequalities, particularly in work produced after the start of the COVID-19 pandemic. In addition to this, due to the international relevance of our question and aims, we will attempt to further ‘decolonise’ our review by including additional global databases to search for literature that may be missed through normal channels.29
A preliminary search of PUBMED, MEDLINE Complete, Cochrane Database of Systematic Reviews, JBI Evidence Synthesis and the Open Science Framework was conducted and no current or underway systematic reviews or scoping reviews on the topic were identified.
The scoping review was registered with the Open Science Framework and will be conducted between June and December 2024.
Review questions
Primary question: How do hospitals currently assess the health needs (met and unmet) and wider social determinants of health, affecting CYP aged 0–25 years and their families or carers, who are accessing their services?
Secondary question: Are there specific themes or broad categories of health and health-related social needs of CYP accessing hospital services globally that could be used to inform guidance and policy?
Inclusion and exclusion criteria
This scoping review will consider items published in all countries from 2010 onwards to ensure that highlighted needs and assessments reflect the most recent trends in health inequalities and encompassing major political and global events, including the COVID-19 pandemic.
It will consider both published prospective and retrospective designs, observational and qualitative studies, and systematic reviews, as well as unpublished literature or other documents, text and opinion papers where appropriate. Hospital-related literature that is relevant to the question may include audits, quality improvement projects, guidelines and policies. Publications in English are included only due to limited resources.
The intended subjects are CYP up to the age of 25 (to include countries where systems continue care into adulthood). Settings are hospitals where CYP are cared for, including children’s hospitals, hospitals that provide paediatric services and hospital-delivered services in other settings (eg, ‘satellite’ clinics held in community settings).
A detailed explanation of the inclusion and exclusion criteria is presented in table 1.
Inclusion and exclusion criteria
Search strategy
The aim of this review is to search for any relevant published qualitative and quantitative literature related to the review questions.
An initial limited search of PUBMED and MEDLINE was undertaken to identify key articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles have been used to develop a full search strategy, with the search terms adapted for each information source (see online supplemental appendix I).
Supplemental material
We will explore suitable unpublished grey literature that may have been produced by healthcare-related agencies and organisations, an example protocol of which has been developed by Brennan et al,30 using similar search terms where possible.
The databases to be searched include:
Published literature databases: MEDLINE, CINAHL, PsychInfo, Child Development and Adolescent Studies, SocIndex, PUBMED, SCOPUS, Web of Science.
Grey literature databases, including Healthcare Management Information Consortium Database, policy database Overton.io (international coverage of 182 databases), Trip Pro Medical Database (global database of medical information).
Targeted websites—World Federation of Public Health Associations, American Public Health Association (APHA), WHO and the WHO Health Evidence Network, Office for Health Improvement and Disparities (part of the English Department of Health and Social Care, responsible for improving public health policy), NHS England and other nations’ Public Health Associations (eg, Australia and Canada).
Google search engines by using the anonymous function in web browsers, and reviewing the first 10 pages of Google search results generated from keywords (see online supplemental appendix I). Relevancy ranking will be relied on and results from the first 10 pages will be screened. Specific site searches will also be used for relevant organisations such as APHA, WHO and NHS.
Snowballing by screening the reference list of all included sources of evidence.
The search strategy (online supplemental appendix I) will be used to run the initial search, which will then be adapted for each included database and/or information source, depending on the results of the initial search. The full search strategy will be described in the final review paper.
Source selection
Step one of selection will involve screening the titles and extracting all potentially relevant literature retrieved by the database searches, performed by one reviewer. For each step of the search, a sheet will be created within Excel or appropriate referencing software to record the title, source organisation and URL for the literature identified. Following the search, all identified citations will be collated and duplicates removed.
Following a pilot test, titles and abstracts will then be screened by two or more independent reviewers for assessment against the inclusion criteria of the review, and potentially relevant sources will be retrieved in full.
The full text and reference list of each citation will then be assessed by two or more independent reviewers for assessment against the inclusion criteria for the review. Reasons for exclusion of sources of evidence in full text that do not meet the inclusion criteria will be recorded and reported in the scoping review.
Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer/s. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA-ScR flow diagram.27
Data extraction
Data will be extracted by two or more reviewers from sources included in the scoping review using a data extraction tool developed by the reviewers, based on JBI recommendations (online supplemental appendix II). The data extracted will include details about the source, target population, assessment approach (information about the setting and any methods tools used) and outcomes from the literature. Authors of papers will be contacted to request missing or additional data, where required. As a secondary part of this review, we will record any frequently occurring social determinants or health-related social needs that are being assessed and group these into broad categories (eg, malnutrition and food insecurity, or lack of transport affecting access to healthcare) in order to identify patterns which may be relevant to our recommendations or future research. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper, the details of which will be included in the final review paper.
Supplemental material
Data analysis and presentation
Study findings will be presented in narrative summary and tabular form, detailing assessment locations, specific patient populations, methods used and outcomes as a result of the assessment approach. Where appropriate, themes and broad categories derived from both questions of the review will be accompanied by other illustrative formats (eg, charts or graphs, word clouds, infographics).
Patient and public involvement
This study is a review of the literature where there are no active study participants and forms part of a larger piece of work for a research fellowship which has included engagement with CYP.31 The engagement work has so far concluded that children, young people and carers believe that understanding health inequalities in paediatric hospital settings is an important topic for future research. The results of the final scoping review will be disseminated to the groups that attended the engagement events.
Ethics and dissemination
This study is a synthesis of published and freely available literature and does not involve identifiable information, patients or members of staff; therefore, no ethical review is required. The results of this scoping review will be submitted for publication in a peer-reviewed journal and for presentation at scientific meetings and conferences. The findings could also be used to inform regional and national policies, resulting in a better understanding of, and support for, the population that attends children’s hospitals and hospitals providing paediatric care, both in the UK and abroad.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AH developed the research question and study methods, and led on drafting and editing the final manuscript. RI, JL, LoB and LiB aided in the development of the research question and study methods, contributed to the drafting and editing, and approved the final manuscript. An academic librarian with experience in health research was consulted when developing the search strategy, and to provide additional resources.
Funding This work was funded by the Houghton Dunn Research and Innovation Pump Prime Award fellowship (G80904), hosted by Manchester University NHS Foundation Trust Charity. The views expressed in this paper are those of the authors and not necessarily those of the NHS, or the Department of Health.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.