NSG/507 Week 3: Health Equity, sample paper

A Nineteen-Point Gap in Eye Exams: A Health Equity Analysis of Diabetic Retinopathy Screening for Spanish-Speaking Patients and a Plan to Close It

[Student Name]

University of Phoenix

NSG/507: Social Justice and Information Systems for Population Health

Week 3 Assignment

[Instructor Name]

[Date]

The health centers, patients and figures are a composite written for a model paper.

Diabetic retinopathy is a leading cause of preventable blindness in working-age adults, and its early stages cause no symptoms. Annual retinal screening finds it while treatment can still protect vision. When a composite network of five community health centers stratified its diabetes quality data by preferred language for the first time, it found that 58% of English-speaking adults with diabetes had a retinal exam in the past year, compared with 39% of those who preferred Spanish. The two groups had similar ages and similar rates of poorly controlled diabetes. The network had been reporting a single blended rate of 51% for years, and the average had hidden a nineteen-point gap in who was protected from blindness. This paper analyzes that gap as a health equity problem and proposes a plan to close it.

Defining Health Equity

Whitehead (1992) defined inequities in health as differences that are not only unnecessary and avoidable but also unfair and unjust, and she argued that judging whether a difference is unfair requires looking at its causes, particularly whether people had a real choice about the conditions that produced it. Braveman (2006) sharpened the definition for measurement: health disparities are differences in health status, or in the conditions that shape it, between groups with different levels of underlying social advantage, and health equity is the principle of eliminating those disparities. In her framing, disparities are the metric by which progress toward equity is measured.

The two definitions complement each other: Whitehead supplies the moral test, and Braveman supplies a way to measure progress against it. These definitions give the analysis two questions. Is the gap between groups defined by social advantage? And is it avoidable and unjust?

Is the Gap an Inequity?

The groups are defined by language, which in this population tracks social disadvantage closely. Most Spanish-preferring patients in the network are immigrants, many work hourly jobs without paid leave, more than half are uninsured and many have limited health literacy in either language. Language preference is thus a marker of several overlapping disadvantages.

The gap is also avoidable. Retinal screening is a routine service with a clear guideline: the diabetes standards recommend a dilated eye examination or retinal photography at diagnosis of type 2 diabetes and at regular intervals afterward, typically every one to two years depending on findings (American Diabetes Association Professional Practice Committee, 2025). Nothing about the biology of diabetes in Spanish-speaking patients explains lower screening. The difference comes from how the service is delivered. By both definitions, the gap is an inequity.

Tracing the Causes

The nurse practitioner who leads the network's diabetes program reviewed the referral process with staff and interviewed a sample of patients. Retinal exams required a referral to an outside eye clinic 45 minutes away by bus. The clinic's scheduling line and reminder letters were in English only, and the appointment required dilation, which blurs vision for hours and meant missing work. Of Spanish-preferring patients referred in the past year, fewer than half attended. Several patients said they did not understand why an eye exam was needed when they could see well. Some had been charged a fee at the eye clinic that the health center's sliding scale did not cover.

Each cause is structural. None reflects a lack of concern among patients. Language barriers, travel time, lost wages, cost and an unclear explanation of purpose all fall more heavily on the patients the network serves who have the least advantage.

Choosing an Equity-Focused Intervention

An intervention could raise the overall screening rate without narrowing the gap, for example by sending more English reminder letters. The plan therefore favors changes that remove the specific barriers facing Spanish-speaking patients.

The central change is teleretinal screening in primary care. A nonmydriatic retinal camera, which does not require dilation, is placed in each health center. Medical assistants trained to use it take retinal photographs during the regular diabetes visit, and the images are read remotely by eye care specialists, who return results and recommendations within days. Daskivich et al. (2017) evaluated a large teleretinal screening program in the Los Angeles County safety-net system and found that it increased annual screening and sharply reduced waiting times for screening, while reducing the need for in-person specialty eye visits for patients without significant disease. The program was implemented in a population similar to the one this network serves.

Supporting changes address the remaining barriers. Screening is offered in Spanish by bilingual medical assistants, with a short explanation that diabetes can damage the eyes before vision changes. The photograph is included in the visit at no added cost. Patients whose images show retinopathy that needs treatment are referred with the help of a bilingual navigator who schedules the appointment, arranges transportation and follows up.

The Advanced Practice Nurse's Role

The nurse practitioner's role spans the whole effort. She led the stratified data review that revealed the gap, presented the findings to network leadership with the evidence for teleretinal screening, co-wrote the grant that funded the cameras, trained medical assistants on the workflow alongside the vendor and set up the monthly equity report. She also worked with the patient advisory council, whose Spanish-speaking members reviewed the explanation used in the visit and suggested changing the word "screening," which some patients associated with immigration checks, to "eye photo."

Measuring Equity

The primary equity measure is the difference in annual retinal screening rates between Spanish-preferring and English-speaking patients, with a target of closing the gap to five points or fewer within 18 months while raising both rates. The report also tracks the share of patients with abnormal images who complete follow-up with an eye specialist, by language, since screening without follow-up would move the inequity rather than remove it. Results will be stratified by insurance status and health center, so that a gap that narrows in one site but not another can be found.

Limits of the Plan

Teleretinal screening does not replace comprehensive eye care; it detects retinopathy, not every eye disease. Image quality can be poor in patients with cataracts, requiring referral anyway. The plan also addresses language but not every dimension of disadvantage; uninsured patients who need laser treatment or injections may still face costs. These limits argue for tracking outcomes closely and for pairing the program with advocacy for charity care agreements with the eye clinics.

Conclusion

A blended quality rate concealed a nineteen-point gap in diabetic eye screening between Spanish-speaking and English-speaking patients. By the definitions of Whitehead and Braveman, the gap is an inequity: it follows social disadvantage and is avoidable. Its causes are structural, and the plan responds with a structural change, teleretinal screening in primary care delivered in Spanish at no added cost, and with measures that track the gap itself. The advanced practice nurse's role in health equity begins with asking the data a different question and continues until the difference closes.

References

American Diabetes Association Professional Practice Committee. (2025). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes-2025. Diabetes Care, 48(Suppl. 1), S252-S265. https://doi.org/10.2337/dc25-S012

Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167-194. https://doi.org/10.1146/annurev.publhealth.27.021405.102103

Daskivich, L. P., Vasquez, C., Martinez, C., Jr., Tseng, C.-H., & Mangione, C. M. (2017). Implementation and evaluation of a large-scale teleretinal diabetic retinopathy screening program in the Los Angeles County Department of Health Services. JAMA Internal Medicine, 177(5), 642-649. https://doi.org/10.1001/jamainternmed.2017.0204

Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429-445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN