The Future of Nursing 2020-2030 Charting a Path to Achieve Health Equity (2021) / Chapter Skim
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2 Social Determinants of Health and Health Equity
2 Social Determinants of Health and Health Equity
Pages 31-58
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From page 31... ...
-- Maya Angelou, author, poet, and civil rights activist The United States spends more money on health care than any other highly industrialized country, yet it has the highest poverty rate, the greatest income inequality, and some of the poorest health outcomes of the developed countries. Although access to health care is important, health is driven by many factors outside of medical care, including the neighborhood where one lives, the kind of job one has, one's economic status, one's level of education, and one's access to such things as healthy foods and reliable transportation.
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From page 32... ...
. A concept related to SDOH is social needs -- individual-level nonmedical acute resource needs related to SDOH, such as housing, reliable transportation, and a strong support system at home, that must be met for individuals to achieve good health outcomes and for communities to achieve health equity (NASEM, 2019a; Nau et al., 2019)
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. The nursing community has long focused on the social needs of people and communities, and has worked closely with social workers and community health workers to address individuals' more complex social needs (Foster et al., 2019; Gordon et al., 2020)
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These frameworks help health professionals and others understand and address SDOH to reduce health disparities and improve health equity. Two important frameworks -- the conceptual SDOH framework developed by the World Health Organization's (WHO's)
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Accordingly, Chapter 9 highlights the importance of transforming nursing curriculum and continuing education by integrating SDOH to improve health equity.
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Through midstream efforts, nurses focus on preventing disease and meeting social needs -- for example, in federally qualified health centers or through public health departments -- by screening for such social risk factors as lack of housing and food access and using these data to inform referrals to government and community resources related to the identified social needs. Activities addressing downstream factors include disease treatment and chronic disease management, in which nurses typically engage in settings where health care is delivered, from homes to urgent care clinics to hospitals.
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SOCIAL DETERMINANTS OF HEALTH AND HEALTH EQUITY 37 SOCIAL DETERMINANTS AND SOCIAL NEEDS STRATEGIES TACTICS CT Improving PA Laws, policies, and IM UP STREAM community conditions regulations that create TY and addressing community conditions NI MU adverse social supporting health for all CO M determinants of people health Addressing Include patient screening questions individuals' about social factors like housing PA C T social needs and food access; use data to inform care and provide referrals MIDSTREAM AL IM Social workers, community IDU health workers, and/or community-based DIV organizations providing IN direct support/assistance to meet patients' social needs DOWNSTR EA M Providing Medical and health clinical care care interventions SOURCE: Castrucci and Auerbach, 2019. FIGURE 2-2 Social Determinants of Health and Social Needs Model.
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From page 38... ...
A full un derstanding of intersectionality will allow nurses to take a more holistic approach that considers the intersection of multiple interdependent social determinants that impact the health and well-being of individuals and communities. Race and Racism Racism, a structural inequity that negatively impacts health and health equity, is "an organized social system in which the dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called ‘races' and uses its power to devalue, disempower, and differentially allocate val
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From page 39... ...
Williams and colleagues identify structural racism as the most important way in which racism impacts health. A robust body of evidence on the link between residential segregation and poor health, for example, shows that segregation is associated with outcomes that include low birthweight and preterm birth (Mehra et al., 2017)
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. These experiences of implicit bias, together with a long history of unethical treatment of POC in the health care system, can lead to mistrust and avoidance of the system, thus exacerbating health disparities (Chaturvedi and Gabriel, 2020)
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. This set of risk factors is tied to structural racism, including historical and current residential and educational segregation in the United States.
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. Income correlates highly as well with risk factors for chronic disease and mental health conditions.
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. As health and socioeconomic disadvantages accumulate over a person's lifetime, this pattern of inequity, exacerbated by structural barriers, can persist across generations, preventing intergenerational social mobility (Braveman et al., 2018; Chetty et al., 2014)
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. Wide income and racial/ethnic inequities in insurance coverage therefore have a significant effect on access to health care services, thus influencing health equity.
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. As for life expectancy, in 2017 a White man in the United States with less than a high school education could expect to live 73.5 years, while his counterpart with a graduate degree could expect to live more than 10 years longer.
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The authors also found that food insecurity is more common in households headed by an African American or Hispanic person and households with children (Gundersen and Ziliak, 2015)
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. Compared with metropolitan areas, rural areas have higher death rates across the five leading causes of death nationally (heart disease, stroke, cancer, unintentional injury, and chronic lower respiratory disease)
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. Health Insurance Status Uninsured rural residents face greater difficulty accessing care compared with their urban counterparts because of the limited supply of rural health care personnel who can provide low-cost or charity health care (Newkirk and Damico, 2014)
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Undocumented immigrants are another population in the United States that has been particularly vulnerable to the effects of the virus. An estimated 7.1 million undocumented immigrants lack health insurance, and the Patient Protection and Affordable Care Act excludes undocumented immigrants from eligibility for coverage.
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In the present context, the global COVID-19 pandemic has exacerbated existing health disparities and health care challenges and long-standing ethical issues that threaten the core values of the nursing profession (Laurencin and McClinton, 2020; see Chapter 3)
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The roots of these inequities are shaped by structural determinants, and understanding and acting on those determinants will help nurses play a pivotal role in improving health equity. Improving social conditions upstream and midstream has been found to have positive impacts on health status, and improving those conditions will likely reduce health inequities and improve the health of the U.S.
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2019. Mass incarceration threatens health equity in America.
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2018. Health insurance coverage and access to care for community health center patients: Evidence following the Affordable Care Act.
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2015. Education improves public health and promotes health equity.
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2020. Heart disease and African Americans.
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2017. Communities in ac tion: Pathways to health equity.
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2019. Access to care among Medicaid and uninsured patients in community health centers after the Affordable Care Act.
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From page 58... ...
2020. COVID-19 and African Americans.
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