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Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing

Published:October 08, 2021DOI:https://doi.org/10.1016/j.outlook.2021.08.003

      Highlights

      • Representatives of five expert panels came together to establish conceptual clarity and consensus for what social determinants of health mean for nursing.
      • We define the social determinants of health as having six key dimensions: economic stability, education access and quality (including health literacy), health care access and quality, neighborhood and the built environment, social and community context, and planetary conditions.
      • We provide a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health.
      • We underscore the crucial need to eliminate systematic and structural racism if equity in planetary health-related quality of life is to be attained.
      • Our conceptual framework addresses the particular importance of nursing actions at the individual, family, and population levels to promote health policies that advance health equity, anti-racism, and planetary health-related quality of life.

      Abstract

      Background

      The 2019-2020 American Academy of Nursing (Academy, 2019) policy priorities document states that “they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities”

      Purpose

      This consensus paper seeks to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life.

      Methods

      Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework.

      Findings

      A conceptual framework was developed that describes how the social determinants of health can be addressed through nursing roles and actions at the individual, family, and population levels with a particular focus on the role of health policy. The paper provides a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health.

      Discussion

      Nursing actions can support timely health policy changes that focus on upstream factors in the six key areas of the social determinants of health and thus improve population health. The urgent need to eliminate systematic and structural racism must be central to such policy change if equity in planetary health-related quality of life is to be attained.

      Keywords

      Introduction

      The 2019 to 2020 American Academy of Nursing () policy priorities document states that “they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities”– advancing health equity and championing wellness; promoting innovation and sustainability; and reducing patient, provider, and system burden. As representatives of five Academy expert panels, we acknowledge the importance of this statement, placing social determinants of health in the center of the policy work conducted by the Academy. Nursing practice has always focused on individuals, families, communities, and populations. Recently, the foci have expanded to include the health of our planet.
      The purpose of this consensus paper is to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life.

      Methods

      Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework. After initial discussion via videoconference, the policy examples were developed by small groups of the authors from the various expert panels and then sent to all authors for feedback. Once again, consensus was reached when all authors indicated acceptance of what became the final version of each policy example.

      Background

      The definitions given in this section of our consensus paper provide an overall orientation to the paper content. Additional definitions are given in the conceptual framework section of the paper
      Social determinants of health are the daily conditions in which people are “born, live, learn, work, play, worship, and age” that affect their health and well-being (
      United States Department of Health and Human Services
      ). Social determinants of health encompass structural, system, and social components that cause inequities and are understood to be inclusive of the natural and built environments and incorporate planetary conditions such as extreme weather events and loss of biodiversity that affect human health. Taken together, social determinants are thought to exert a stronger influence on health than individual health behaviors (
      • Remington P.L.
      • Catlin B.B.
      • Gennuso K.P.
      The county health rankings: rationale and methods.
      ).
      Health encompasses wellness, illness, and disease. Well-being refers to “global judgments of life satisfaction and feelings” including the presence of positive emotions and moods and the absence of negative emotions and moods (

      Centers for Disease Control and Prevention. (2018). Well-being concepts. Accessed 9/15/20 from: https://www.cdc.gov/hrqol/wellbeing.htm#three.

      ).
      Planetary health “is the achievement of the highest attainable standard of health, well-being, and equity worldwide through judicious attention to the human systems—political, economic, and social—that shape the future of humanity and the Earth's natural systems that define the safe environmental limits within which humanity can flourish. Put simply, planetary health is the health of human civilization and the state of the natural systems on which it depends” (
      • Whitmee S.
      • Haines A.
      • Beyrer C.
      • Boltz F.
      • Capon A.G.
      • de Souza Dias B.F.
      • Horton R.
      Safeguarding human health in the Anthropocene epoch: report of the rockefeller foundation–lancet commission on planetary health.
      , p. 1978). In addition, planetary health refers to “the human health impacts (including non-communicable diseases, infectious diseases, nutrition, mental health, and civil strife and displacement) of human-caused disruptions of Earth's natural systems” (

      Planetary Health Alliance. (2020). Planetary health. Accessed 9/22/20 from: https://www.planetaryhealthalliance.org/planetary-health

      ). Planetary health affects the wellness, illness, disease, and well-being conditions of all people of Planet Earth and, therefore, attention must be focused on both population and individual levels.
      A population is an aggregate of more than one person residing in a local, state, national, or international geographic region or an aggregate group of people with common characteristics (
      • Fawcett J.
      • Ellenbecker C.H.
      A proposed conceptual model of nursing and population health.
      ;
      • Keyes K.M.
      • Galea S.
      Population health science.
      ).
      Quality of life is a population's “physical, psychological, (mental, emotional,) social, economic, and environmental” well-being (
      • Fawcett J.
      • Ellenbecker C.H.
      A proposed conceptual model of nursing and population health.
      , p. 293). Planetary health-related quality of life is “the measured impact of a person's perception of (their) health and the effect that produces on satisfaction with life and well-being” (
      • Venes D.
      Taber's cyclopedic medical dictionary.
      , p. 1967)
      Equity refers to fair, impartial, or just opportunities for a high level of wellness and other aspects of planetary quality of life. Health equity, which reflects ethical and human rights concerns, refers to a state in which all communities and community members have a fair and just opportunity to experience their best health condition (
      • Braveman P.
      • Arkin E.
      • Orleans T.
      • Proctor D.
      • Plough A.
      What is health equity? And what difference does a definition make?.
      ). Health equity occurs when obstacles to health care are addressed “such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, (high) quality education and housing, safe environments, and health care” (
      • Braveman P.
      • Arkin E.
      • Orleans T.
      • Proctor D.
      • Plough A.
      What is health equity? And what difference does a definition make?.
      , p. 12). Working to achieve health equity requires that effort and resources are focused on those with the greatest needs and least resources in contrast to equality, where effort and resources are equally distributed (
      • Braveman P.
      • Arkin E.
      • Orleans T.
      • Proctor D.
      • Plough A.
      What is health equity? And what difference does a definition make?.
      ;
      • Fawcett J.
      Thoughts about the language of equity for population health.
      ). We contend that equity cannot be achieved at any level (local, national, global) until all forms of structural and systemic racism are eliminated.
      Structural racism is defined as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity. [This form of racism encompasses] dimensions of our history and culture that have allowed privileges associated with ‘whiteness’ and disadvantages associated with (’color’) to endure and adapt over time” (
      Aspen Institute Roundtable on Community Change
      , p. 11).
      Systemic racism “is forms of oppression and privilege that (affect) almost every aspect of our society (including) our laws, institutions, schools, justice system, media, culture, and everyday interactions. This form of racism, although often more harmful than overt racism, is less understood or even recognized by the white . . . majority, who often preserve and perpetuate this racism unconsciously through complicity and complacency. Racial complicity (is) ‘to consciously or unconsciously support, contribute or benefit from racism or racist systems.’ Racism complacency (refers) to ‘support (of) racism and racist systems by not challenging it’” (

      The Responsible Consumer (2020). Systemic, structural and institutional racism. Accessed 9/22/20 from: https://theresponsibleconsumer.wordpress.com/systemic-implicit-microaggression-racism/.

      ).
      Note that “(i)n many ways ‘systemic racism’ and ‘structural racism’ are synonymous. If there is a difference between the terms, it can be said to exist in the fact that a structural racism analysis pays more attention to the historical, cultural and social psychological aspects of our currently racialized society” (

      Aspen Institute. (2016). Racial equity: 11 terms you should know to better understand structural racism. Accessed 9/13/20 from: https://www.aspeninstitute.org/blog-posts/structural-racism-definition/.

      ).

      Conceptual Framework

      Our conceptual framework addresses the social determinants of health directing nursing actions toward health policies supporting upstream and downstream actions, as well as, midstream actions, defined as actions that address individual social needs, that will promote equity in planetary health-related quality of life (
      • Castrucci B.
      • Auerbach J.
      Meeting individual social needs falls short of addressing social determinants of health.
      ). The framework incorporates concepts from the conceptual model of nursology for equity and quality: population health and health policy (
      • Fawcett J.
      The conceptual model of nursology for enhancing equity and quality: population health and health policy.
      ), most of which have been revised for this framework, as well as population-focused nursing (
      • Storfjell J.
      • Winslow B.
      • Saunders J.
      Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
      ).
      The central features of the conceptual framework for our consensus paper are social determinants of health and health equity in planetary health-related quality of life. Our conceptual framework draws from Florence Nightingale's (1992) dictum about the influence of the environment on healing, Lillian
      • Wald L.D.
      The House on Henry Street.
      ideas of who are the clients of nurses, as well as downstream factors, Patricia
      • Butterfield P.
      Thinking upstream: A 25-year retrospective and conceptual model aimed at reducing health inequities.
      model of upstream factors; and
      • Castrucci B.
      • Auerbach J.
      Meeting individual social needs falls short of addressing social determinants of health.
      ideas about upstream, midstream, and downstream factors.
      • Nightingale F.
      Notes on nursing: What it is and what it is not (Commemorative ed.).
      identified several elements of the environment that facilitate healing and recovery; these include ventilation and warming, pure air and water, efficient drainage, personal cleanliness and cleanliness of rooms and walls, elimination of noxious noises, and provision of light. Inasmuch as Nightingale's (1992) ideas about environment remain relevant in the contemporary 21st century (
      • Hundt B.
      Reflections on nightingale in the year of the nurse.
      ), we have extended her ideas about environment to various types of environment that are associated with structural and system components of social determinants of health.
      • Wald L.D.
      The House on Henry Street.
      viewed nurses as working at the intersection of medicine and society. She related health to social, economic, and industrial conditions that affected patients’ lives.
      • Wald L.D.
      The House on Henry Street.
      cared for individuals, families, and communities as clients. She focused on what are now regarded as upstream and downstream nursing interventions. Upstream interventions are those nursing actions “aimed at reducing the magnitude of inequity by recalibrating systems in acting further up etiologic pathways” (
      • Butterfield P.
      Thinking upstream: A 25-year retrospective and conceptual model aimed at reducing health inequities.
      , p. 6). Downstream interventions are those nursing actions aimed at providing care to treat individual's medical and social needs.
      • Butterfield P.
      Thinking upstream: A 25-year retrospective and conceptual model aimed at reducing health inequities.
      Upstream Model for Population Health (BUMP Health) extends
      • Wald L.D.
      The House on Henry Street.
      work by more clearly focusing on upstream nursing interventions in light of an evolving contemporary demographic landscape.
      As can be seen in Figure 1, our conceptual framework includes several concepts— (a) environments (population health concerns, stake holders), (b) individual and population factors (health policies, system, and services; population focused nursing actions), and (c) planetary health related quality of life. Our claim that equity cannot be achieved unless and until structural and systemic racism are eliminated means that elimination of racism is perhaps the most crucial aspect of the entire conceptual framework and, therefore, is reflected in all examples of health policies given in this consensus paper.
      • a.
        Environments are the structural and system components of social determinants of health (
        • Ervin N.E.
        • Bickes J.T.
        • Schim S.M.
        Environments of care: a curriculum model for preparing a new generation of nurses.
        ). The structural and system components are “macro-level forces, such as financial, legal, and governmental systems and policies, which exert an effect on human life” (
        • Drevdhal D.J.
        Cultural shifts: From cultural to structural theorizing in nursing.
        , p. 152). The structural and system determinants distribute power, money, and resources, which drive the conditions of daily life and lead to the potential for health inequities (
        CSDH
        Closing the gap in a generation: health equity through action on the social determinants of health.
        ). Noteworthy is that the cultural environment includes racism which, given the impact of chattel slavery and racial segregation in the United States (
        • Bailey Z.D.
        • Krieger N.
        • Agénor M.
        • Graves J.
        • Linos N.
        • Bassett M.T.
        Structural racism and health inequities in the USA: evidence and interventions.
        ;
        • Williams D.R.
        • Mohammed S.A.
        Racism and health I: pathways and scientific evidence.
        ), requires added attention for health policy as a structural and system determinant of health.
        Also noteworthy is that the cultural environment includes ways of communicating and the extent to which intra- and cross-cultural communications are understood by all persons. Consequently, health literacy is an especially important topic for health policy. Health literacy “occurs when a society provides accurate and clear health information and services that people can easily find, understand, and use to inform their decisions and actions” (

        Healthy People 2030. (2017) Secretary's advisory committee on national health promotion and disease prevention objectives for 2030 report #2: recommendations for developing objectives, setting priorities, identifying data needs, and involving stakeholders for healthy people 2030. Accessed 9/13/20 from: https://www.healthypeople.gov/sites/default/files/Advisory_Committee_Objectives_for_HP2030_Report.pdf.

        , p. 36). The importance of information and communication technology (ICT) that is literacy, linguistically, and language appropriate, needs to be emphasized along with consideration of people's cultural values, beliefs, and norms.
        • Rice L.
        • Sara R.
        Debate: updating the determinants of health model in the information age.
        declared,
        ICT. . . has also changed the very fabric of our cities, neighborhoods, homes and offices, from laptops and mobile phones to wearable technologies. . . . Health communication is a key component in any public health intervention and ICT is central to this (p. 1247).
        Given our focus on health policy and the influence of politics on policy, we added the political environment to our conceptual framework. The types of environments included in our conceptual framework and their definitions are listed in Table 1.
        Table 1Types of Environments and their Definitions
        Cultural EnvironmentThe cultural environment, sometimes known as a worldview, encompasses racial and ethnic life-ways, as well as the life-ways of specific cultural populations. The particular health-related life-ways of a population (
        • McFarland M.R.
        • Wehbe-Alamah H.B.
        The theory of culture care diversity and universality.
        ), include the population's values, beliefs, social organizations, and practices related to health (
        • Drevdhal D.J.
        Cultural shifts: From cultural to structural theorizing in nursing.
        ;
        • Saint Arnault D.
        Defining and theorizing about culture: the evolution of the cultural determinants of health-seeking, revised.
        ).

        Furthermore, the cultural environment represents "an internalized and shared schema or framework that is used by group members as a refracted lens to "see" reality, and in which both the individual and the collective experience the world. The (cultural environment) is created by, exists in, and adapts to the cognitive, emotional, and material resources and constraints of the group's ecologic systems to ensure the survival and well-being of its members, and to provide individual and communal meaning for and in life.” (Singer et. al., 2016, p.242).
        Socioeconomic EnvironmentThe social and financial circumstances of the population, influenced by income, education, occupation, gender, race, and ethnicity. An individual's socioeconomic position is influenced by social stratification and social class (

        World Health Organization. (2010). Conceptual framework for action on the social determinants of health. Socialdeterminants of health discussion paper 2. Debates, policy and practice, case studies. Accessed 9/15/20 from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf?ua=1.

        ), recognizing that structural and systemic racism to a great extent determines social class.
        Physical EnvironmentThe physical surroundings of the population (
        • Kindig D.
        • Stoddart G.
        What is population health?.
        ), including the built environment (e.g., buildings, sidewalks, bike lanes) and the natural environment (e.g., trees, grass, weather) (

        Healthy People 2020. (n.d.). Social determinants of health. U.S. department of health and human services, office of disease prevention and health promotion. Accessed 9/13/20 from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health#two.

        , n.d.). Climate change is a major aspect of the physical environment.
        Political EnvironmentThe political environment represents the socioeconomic and cultural context within which politics, or the process of making and executing collective decisions, takes place (
        • Mackenbach J.
        Political determinants of health.
        ) and are the main drivers of inequities in the United States (
        • Dawes D.
        The political determinants of health.
        ). Political actions represent the forces and systems that shape the conditions of daily life (
        • Dawes D.
        The political determinants of health.
        ).
      • b.
        Individual and population factors are considered the social component of social determinants of health. The individual and population factors included in our conceptual framework and their definitions are listed in Table 2.
        Table 2Individual and Population Factors and their Definitions
        BehaviorLifestyle variables of a an individual or a population (

        Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: population health, experience of care, and per capita cost. IHI innovation series white paper. Cambridge, MA: institute for healthcare improvement. Accessed 9/15/20 from: http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx.

        )
        PhysiologyBiological variables of a an individual or a population (

        Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: population health, experience of care, and per capita cost. IHI innovation series white paper. Cambridge, MA: institute for healthcare improvement. Accessed 9/15/20 from: http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx.

        )
        ResilienceAn individual's or a population's “ability to bounce back or recover from adversity” (
        • Fawcett J.
        • Ellenbecker C.H.
        A proposed conceptual model of nursing and population health.
        , p. 292)
        b-1.A population health concern is a concern about the extent of wellness, illness, or disease of a population that requires attention. Wellness is a “state of mental, (emotional,) and physical balance and fitness” (
        • Venes D.
        Taber's cyclopedic medical dictionary.
        , p. 2501). “Illness (and associated pain, suffering, and distress is subjective and personal” (
        • Venes D.
        Taber's cyclopedic medical dictionary.
        , p. 699). Disease is an “objective and tangible or measurable . . . (condition manifested by) subjective complaints, a specific history, clinical signs and symptoms, and laboratory or radiographic findings” (
        • Venes D.
        Taber's cyclopedic medical dictionary.
        , p. 699). Population health concerns are identified and addressed by communities through organized programs and services as well as public and private policies. Communities, whether defined by affinity, identity, or geography, are where people combine in a variety of ways to attend to their common good.
        Population health has been defined as “health outcomes of a group of individuals, including the distribution of such outcomes within the group. These populations are often geographic populations, such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons”(Kindig & Stoddard, 2003, p. 381) More recently, definitions have incorporated the understanding that social determinants of health shape conditions that influence health and that population health improvement is “a collaborative effort designed to improve the health outcomes of a specific population by addressing upstream factors. Its purpose is to reduce inequities through interventions and policies that influence these upstream factors.” (Storfjell et al., p. 5.). Importantly, a focus on population health does not necessarily imply or require equity.
        b-2.Although population health is a relatively new focus for many health professions, nursing has always understood health and health care within the larger social, emotional, and environmental contexts of peoples’ lives. Indeed, nursing can draw on the long history and conceptual frameworks developed by public health nurses that have centered on populations (

        Bigbee, Jeri & Issel, L. (2012). Conceptual Models for Population-focused Public Health Nursing Interventions and Outcomes: The State of the Art. Public health nursing (Boston, Mass.), 29, 370-9. https://doi.org/10.1111/j.1525-1446.2011.01006.x.

        ) to understand that the social determinants of health and their effect require an expansive definition of nursing practice for the entire profession. It is “the protection, promotion, and optimization of (wellness) and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (2015 ANA Code of Ethics as cited by
        • Pittman P.
        Activating nursing to address unmet needs in the 21st century.
        , p. 27).
        Thus, population health and population health improvement become the responsibility of all nurses and have been labeled population-focused nursing (
        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        ). Population-focused nursing actions are actions performed by nurses directed toward population health concerns and seeking population health improvement. These actions may be delivered by nurses or in collaboration with others, organized through a variety of health and health care organizations and in collaboration with other key community and organizational stakeholders (
        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        ). Population-focused nursing (action) integrates the tenets of public health with clinical care, thus contributing to improving the health of (individuals), communities and populations.” (
        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        , p. 16). Individual and population-focused nursing actions requires that nurses master four core competencies across practice settings and roles: (a) Demonstrating compassion and establishing trust with individuals and community members by utilizing a holistic approach to care that considers the physical, mental, social, and spiritual aspects of people in the context of their environments; (b) Assessing individuals, community members, and community assets as well as needs in the context of their goals while assuring coordination of care across providers and sites of care; (c) Building collaboration within and outside the health professions and health care sector to find solutions; and (d) Advocating effectively for policy and systems solutions to population health concerns (
        • Pittman P.
        Activating nursing to address unmet needs in the 21st century.
        ;
        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        ). The three major categories of actions are given in Table 3, along with definitions.
        Table 3Population-focused Nursing Actions and Definitions
        Individual/Family ServicesNursing actions directed to (a) enhancing the optimal level of the population's collective “growth, integration of experience, and meaningful connection with others, reflecting (population) valued goals and strengths, and resulting in being well and living values” within the context of the culture of the population (
        • Fawcett J.
        • Ellenbecker C.H.
        A proposed conceptual model of nursing and population health.
        , p. 293) and (b) avoiding subjective experiences of an illness and objective and tangible clinical signs and symptoms of a disease (
        • Venes D.
        Taber's cyclopedic medical dictionary.
        )
        Community-level ServicesNursing actions directed toward data collection and analysis for planning, implementation, and evaluation of the community-wide or specific population group(s) evidence-based interventions to address population health concerns (
        • Ervin N.E.
        • Kulbok P.A.
        Advanced public and community health nursing practice: Population assessment, program planning, and evaluation.
        ;
        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        ).
        Community Collaboration and AdvocacyNursing actions, in collaboration with other community stakeholders, directed toward changing policy and systems in order to address population health concerns (
        • Kuehnert P.L.
        The interactive and organizational model of community-as-client: a model for public health nursing practice.
        ;
        • Kuehnert P.
        Rebel nurses at the crossroads.
        )
        b-3.Stakeholders particularly, “(i)ndividuals or organizations that are either directly or indirectly affected by (a health policy or a health concern)”
        • Sudduth A.L.
        Policy evaluation.
        , p. 233), have a variety of roles in health programs, services and policies. Community members who are stakeholders are people and groups who “have a say in what goes on” (
        • Furlong E.A.
        Agenda setting.
        , p. 43), including individuals, families, businesses, worship congregations, other public and private organizations, and elected and appointed policymakers. Communities, in turn, are the building blocks of governmental units, ranging from cities and towns to states, nations and the global community of nations. Stakeholders especially relevant for health policy development related to social determinants of health are listed in Table 4.
        Table 4Examples of Stakeholders for Health Policy Development addressing Social Determinants of Health
        Community MembersIndividuals who share a group or geographic identity and may be members of special interest or other stakeholder groups
        Elected OfficialsPeople holding an elected political office, who make decisions about population health concerns that need to be addressed by health policies by setting policy priorities, determining specific policy agenda, and funding implementation
        Special Interest GroupsCollectives of people addressing a specific population health concern or health policy; “Individuals who have organized themselves around some common interest and who seek to influence (health concerns and) policy. . .They clarify and articulate citizens’ preferences, warn policy-makers of problems with their proposals, and suggest ways to make them more palatable” (
        • Wakefield M.K.
        Government response: legislation.
        , p. 86) Some special interest groups are coalitions or alliances of groups from multiple sectors of a community
        Nurses and other health and social service providersPeople who are engaged in the provision of health and social care and services meant to address population health concerns of a community and its members. Providers may organize as a special interest group.
        Health and Social Service OrganizationsPublic or private entities organized to provide one or more public health, health care or social service to community members
        Policy AdministratorsPeople charged with overseeing implementation of a health policy, including public and private payers and funders
        b-4.Health policy is “The purposeful, general plan of action developed to respond to a concern … or matter in either the public or private sector … that includes authoritative guidelines. This plan directs human behavior toward specific goals” (
        • Sudduth A.L.
        Policy evaluation.
        , pp. 219, 221) When addressing social determinants of health, multiple population health concerns may be addressed by policy in areas outside of the health sector such as transportation, education or economic development (

        World Health Organization. (2013). Framework and statement: consultation on the drafts of the “health in all policies framework for country action” for the conference statement of 8th Global Conference in health promotion. Accessed 9/15/20 from: https://www.who.int/healthpromotion/conferences/8gchp/130509_hiap_framework_for_country_action_draft.pdf?ua=1.

        ). Health policies typically focus on systems and services. Systems refers to the organization of health care agencies, which may be single clinical agencies or large health care systems created by mergers or expansions of discrete clinical agencies. Services encompass what health care systems offer the public, such as nursing and medical care and respiratory, physical, and occupational therapy.
      • c.
        Population health-related quality of life is extended to planetary health-related quality of life in our conceptual framework. Quality of life is considered the results of individual- and population-focused nursing actions. More specifically, quality of life is a population's “physical, psychological, [mental, emotional,] social, economic, and environmental” well-being (Fulton, Miller, & Otte, 2012, as cited in
        • Fawcett J.
        • Ellenbecker C.H.
        A proposed conceptual model of nursing and population health.
        , p. 293). Our constant concern as nurses is equity in population health-related quality of life for all people of Planet Earth. The elements of health-related quality of life for the populations of our planet are listed with their definitions in Table 5.
        Table 5Elements of Planetary Health Related Quality of Life and their Definitions
        Well-beingA population's condition of overall wellness; “the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning-being” including physical, economic, social, emotional, and psychological well-being, development and activity, life satisfaction, and engaging activities and work (

        Centers for Disease Control and Prevention. (2018). Well-being concepts. Accessed 9/15/20 from: https://www.cdc.gov/hrqol/wellbeing.htm#three.

        ).
        Disease BurdenIncidence and/or prevalence of major chronic health conditions in a population (

        Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: population health, experience of care, and per capita cost. IHI innovation series white paper. Cambridge, MA: institute for healthcare improvement. Accessed 9/15/20 from: http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx.

        ); “the total effect of a disease” on a population (
        • Venes D.
        Taber's cyclopedic medical dictionary.
        , p. 699), including extent of disability
        Functional Status“A population's optimal level of performing usual activities of daily living” (
        • Fawcett J.
        • Ellenbecker C.H.
        A proposed conceptual model of nursing and population health.
        , p. 293)
        Life ExpectancyA population's overall “expected years of remaining life at any age” (

        Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: population health, experience of care, and per capita cost. IHI innovation series white paper. Cambridge, MA: institute for healthcare improvement. Accessed 9/15/20 from: http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx.

        , p 13)
        Mortality“Years of potential life lost” for a population (

        Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: population health, experience of care, and per capita cost. IHI innovation series white paper. Cambridge, MA: institute for healthcare improvement. Accessed 9/15/20 from: http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx.

        , p. 4)
      Figure 1
      Figure 1Conceptual framework to guide policy development

      Relational Propositions of the Conceptual Framework

      Our conceptual framework proposes that the relations of planetary health-related quality of life. individual and population factors, and environments are overarching societal contexts in which population health concerns arise. These population health concerns are articulated by stakeholders who, in turn, are the catalyst for population-focused nursing actions. These population-focused nursing actions occur at multiple levels (upstream, midstream, downstream) in a variety of settings (such as clinical and community) with a variety of persons and groups (individuals, families, communities) and shape health policies. Over time, the actions and interactions depicted by the cycle (see Figure 1) change the societal contexts.
      Specific relational propositions are:
      • Population health concerns, stakeholders, population focused nursing actions, and health policies are interrelated and cyclical.
      • The cyclical interrelations of population health concerns, stakeholders, population focused nursing actions, and health policies are influenced by individual and population factors and environments.
      • The influences of individual and population factors and environments on the cyclical interrelations of population health concerns, stakeholders, population focused nursing actions, and health policies affect planetary health-related quality of life.

      Conceptual Framework Supports a Focus on Health Policy

      The Academy utilizes the expertise and collective power of its members to improve individual and population health, and ultimately, planetary health, through influencing U.S. national health policy. To this end, we seek to emphasize the conceptual framework's identification of health policy as a focus of population-focused nursing actions.
      Accordingly, our conceptual framework leads us to offer examples of policies that address key areas of social determinants of health, specifically those identified by

      Healthy People 2030. (2020) U.S. department of health and human services, office of disease prevention and health promotion. Accessed 9/13/20 from: https://health.gov/healthypeople/objectives-and-data/social-determinants-health

      (n.d.)—economic stability, education access and quality (including health literacy), health care access and quality, neighborhood and the built environment, and social and community context. We added a sixth key area, planetary conditions, to highlight the important relationships between the natural world and human health. The key areas, their definitions, and associated issues are listed in Table 6, along with linkages to relevant elements of environments, which is one of the concepts of our conceptual framework. Of note is that each key area reflects multiple population health concerns that are addressed by population-focused nursing actions, taking individual and population factors and stakeholders into account, and recognizing that an underlying requirement is the elimination of systemic and structural racism.
      Table 6Six Key Areas of the Social Determinants of Health, their Definitions, Associated Issues for Translation to Health Policies, and Relevant Elements of Environments
      Economic Stability

      Socioeconomic environment

      Political environment
      An individual's ability to access resources to fulfill basic needs.

      Associated issues include food security, stable and safe housing, and adequate income.
      Education Access and Quality

      Socioeconomic environment

      Cultural environment

      Political environment
      From a life course perspective, both length and quality of education structure occupation and income (

      World Health Organization. (2010). Conceptual framework for action on the social determinants of health. Socialdeterminants of health discussion paper 2. Debates, policy and practice, case studies. Accessed 9/15/20 from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf?ua=1.

      ).

      Associated issues include early childhood education and development, kindergarten through 12th grade, high school graduation, enrollment in higher education, language, literacy, and lifelong learning including workforce development.
      Health Care Access and Quality

      Cultural environment

      Socioeconomic environment

      Political environment
      Health care includes the financing of and access to health delivery systems, which directly address differences in exposure and vulnerability and lead intersectoral action in the health sector (

      World Health Organization. (2010). Conceptual framework for action on the social determinants of health. Socialdeterminants of health discussion paper 2. Debates, policy and practice, case studies. Accessed 9/15/20 from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf?ua=1.

      ).

      Associated issues include access to high-quality health care, including primary care (; Millman, 1993), and to relevant health information, as well as building health literacy (Nutbeam, 2008).
      Neighborhood and the Built Environment

      Physical environment

      Cultural environment

      Political environment
      Neighborhoods are geographic areas where individuals reside. The built environment (place) includes human-made structures such as buildings and parks (
      • Chambers T.
      • Pearson A.L.
      • Kawachi I.
      • Rzotkiewicz Z.
      • Stanley J.
      • Smith M.
      • Signal L.
      Kids in space: measuring children's residential neighborhoods and other destinations using activity space GPS and wearable camera data.
      ).

      Associated issues include access to foods that support healthy eating patterns and food security, decrease in crime and violence, improvement in environmental conditions, and improvement in the quality of housing. Other associated issues include provision of safe transportation, reliable and safe energy sources, and elimination of air pollution.
      Social and Community Context

      Political environment

      Cultural environment
      Social context, “which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions” (

      World Health Organization. (2010). Conceptual framework for action on the social determinants of health. Socialdeterminants of health discussion paper 2. Debates, policy and practice, case studies. Accessed 9/15/20 from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf?ua=1.

      , p. 5).

      One associated issue is systemic and structural racism, which “is an organized system premised on the categorization and ranking of social groups into races and devalues, disempowers, and differentially allocates desirable societal opportunities and resources to racial groups regarded as inferior” (
      • Williams D.R.
      • Mohammed S.A.
      Racism and health I: pathways and scientific evidence.
      , p.1153). Other associated issues include civic participation, discrimination, incarceration, exposure to trauma, and social cohesion.
      Planetary Conditions

      Physical environment

      Political environment
      The human health impacts of climate change that directly result in destruction of our natural world (e.g., hurricanes, wildfires, spillover infection diseases) due to human-caused disasters and disruptions of Earth's natural systems (Planetary Health Alliance, n.d.).

      Associated issues include climate change, biodiversity loss, and resource (food, water, quality air) depletion.
      • Castrucci B.
      • Auerbach J.
      Meeting individual social needs falls short of addressing social determinants of health.
      practical and policy-oriented framework deconstructs social determinants of health, making them actionable at several levels (Figure 2). However, without concurrently addressing all determinants of health through changes in policies, including their focus on systems and services, health improvement efforts will not succeed at the planetary level. As Castrucci and Auerbach explained:
      Figure 2
      Figure 2Social determinants & social needs: Moving Beyond Midstream. SOURCE:
      • Castrucci B.
      • Auerbach J.
      Meeting individual social needs falls short of addressing social determinants of health.
      . Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/
      This isn't about picking one approach over another – we need social and economic interventions at . . . (planetary, community, family,) and individual levels. We often discuss health using the metaphor of a stream, with upstream factors bringing downstream effects. Social needs interventions create a middle stream. They are further upstream than medical interventions, but not yet far enough. Social needs are the downstream manifestations of the impact of (all) . . . determinants of health. . . Improvements in (the planet's) health can be achieved only when we have the commitment to move even further upstream to change the (planetary) conditions that make people sick.
      Once a population health concern is identified, nurses and other stakeholders conduct a root cause analysis to identify which social determinant key areas the concern is related to so to identify evidence-based policy interventions that would address it. As illustrated in Figure 3, the planning analysis also identifies the level of intervention—upstream, midstream, or downstream—and the policy target, such as a private entity such as a health care system or some level of government. Nurses and other stakeholders can then engage in developing the strategies and tactics needed to pursue the desired health policies (
      • Milio N.
      Promoting health through public policy.
      ;
      • Kuehnert P.L.
      The public health policy advocate: fostering the health of communities.
      ;
      • Ervin N.E.
      • Kulbok P.A.
      Advanced public and community health nursing practice: Population assessment, program planning, and evaluation.
      ), as illustrated in Figure 4.
      Figure 3
      Figure 3Planning tool for Social Determinant of Health (SDOH) policy action.
      Figure 4
      Figure 4Pathways to policy change. PACS, Political action coalitoins. Adapted from: Kuehnert, P. L. (1991). Milio, N. (1981).

      Examples of Health Policies

      The conceptual framework presented in this paper was particularly useful as a guide to the articulation of examples of the collective policy recommendations from the members of the Academy expert panels who contributed to the paper. It is important to note that the conceptual framework was not developed with the intention of it serving as a guide for practice but instead provides a guide for development of health policies that address planetary conditions within the contexts of structural and systematic racism, and promotion of equity in matters of individual, population, and planetary health.
      Inasmuch as nurses have a social justice orientation and holistic view of wellness, illness, and disease, we are perfectly positioned to act on the structural, system, and social components of social determinants of health in our effort to achieve equity in planetary health-related quality of life through health policies that take into account elimination of systemic and structural racism. Our examples of six health policies illustrate how we can utilize our understanding of the social determinants of health as articulated in our conceptual framework. These social determinants are one way to “celebrate (nursing's) role in transforming health care throughout (Planet Earth), serving as a bridge for patients, families, and communities when and where they need it most” (
      • Hundt B.
      Reflections on nightingale in the year of the nurse.
      , p 29). As will be seen in these examples, the key areas of social determinants are interrelated

      Economic Stability

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Economic StabilityUpstreamCongressGuaranteed minimum incomeWorking with coalitions to support legislation
      Income inequality is inextricably related to most, if not all, of the social determinants of health. Income and the key area of education are highly correlated in that one's education, to a great extent, determines one's access to jobs and, thus, lifetime income (
      • Stroud C.
      • Mainero T.
      • Olson S.
      Families Board on Children, Youth, Institute of Medicine, & National Research Council
      Improving the health, safety, and well-being of young adults: Workshop summary.
      ). Structural racism is paramount in driving income inequality in the U.S. Access to all levels of high-quality education is strongly related to the color of one's skin and family income (
      • Rothstein R.
      The color of law: a forgotten history of how our government segregated America.
      ).
      • Siddiqi A.
      • Kawachi I.
      • Berkman L.
      • Hertzman C.
      • Subramanian S.V.
      Education determines a nation's health, but what determines educational outcomes? A cross-national comparative analysis.
      reported that income inequality had a large and damaging effect on literacy among students in their study. Income typically determines where one lives, which is related to length of life and access to resources; zip code is a major indicator of social determinants of health (
      • Bhatt J.
      Your zip code, your health | AHA News.
      ). Income inequality affects all people worldwide resulting in shorter life spans, lower quality of life, and greater expenditures for attempts to correct the problems caused by the inequality (
      • Wilkinson R.
      • Pickett K.
      The inner level: How more equal societies reduce stress, restore sanity and improve everyone's well-being.
      ). Increased minimum wages have been associated with many positive health outcomes, including decreased infant mortality rates, decreased heart disease death rates, and increased infant birth weight (e.g.,
      • Komro K.A.
      • Livingston M.D.
      • Markowitz S.
      • Wagenaar A.C.
      The effect of an increased minimum wage on infant mortality and birth weight.
      ;
      • Van Dyke M.E.
      • Komro K.A.
      • Shah M.P.
      • Livingston M.D.
      • Kramer M.R.
      State-level minimum wage and heart disease death rates in the United States, 1980–2015: a novel application of marginal structural modeling.
      ). Nurses can be at the forefront of establishing coalitions that develop and/advocate for policies that guarantee minimum income that would increase economic stability and decrease income inequality.

      Education Access and Quality

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Education Access and Quality

      UpstreamLocal/State/National

      Expand local/state/national funding to ensure access to full-time nurses in all schools to keep students well so they can learn, thrive, and graduate (National Association of School Nurses, 2020)School nurses help students stay in school through preventive health services, mitigation of health risks, and linkages to educational, social, and economic resources
      Equitable access to high quality education is crucially important to ensure that all students achieve happiness, safety, and well-being. As noted in the previous section, education is related to the key area of economic stability. In addition, long-established links between the level of education and the key area of health care access and quality have been reported (

      Healthy People 2020. (n.d.). Social determinants of health. U.S. department of health and human services, office of disease prevention and health promotion. Accessed 9/13/20 from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health#two.

      ;
      • Rasberry C.N.
      • Tiu G.F.
      • Kann L.
      • McManus T.
      • Michael S.L.
      • Merlo C.L.
      • Lee S.
      • Bohm M.
      • Annor F.
      • Ethier K.A.
      Health-related behaviors and academic achievement among high school students - United States, 2015.
      ). Yet, structural racism continues to have a substantial effect on intergenerational transmission disparities in educational attainment (
      • Gee G.C.
      • Ford C.L.
      Structural racism and health inequities: old issues, new directions.
      ;
      • Serchen J.
      • Doherty R.
      • Atiq O.
      • Hilden D.
      Racism and health in the United States: a policy statement from the American college of physicians.
      ;
      • Zajacova A.
      • Lawrence E.M.
      The relationship between education and health: reducing disparities through a contextual approach.
      ). For example, in marginalized communities, education is a reproducer of inequality in education access and quality through systematic differences in school resources, quality of instruction, peer influences, and teacher expectations (
      • Zajacova A.
      • Lawrence E.M.
      The relationship between education and health: reducing disparities through a contextual approach.
      ).
      Founded in early childhood education models that integrate health and education, school health nurses can holistically address students through health services and education that empowers healthy lifestyles, builds health literacy and establishes community-engaged partnerships (

      County Health Rankings. (2020). 2020 County Health Rankings State Reports. Accessed 9/22/20 from: https://www.countyhealthrankings.org/ Accessed at: August 14, 2020

      ). Funding for nurses in all schools nationwide, with appropriations to meet the high health needs of lower socioeconomic areas is a policy that promotes equitable health resources for all schools. An upstream, systems-level change is urgently needed to strengthen the integration of school health services, education and health literacy, which is a major goal of health education (
      • Auld M.E.
      • Allen M.P.
      • Hampton C.
      • Montes J.H.
      • Sherry C.
      • Mickalide A.D.
      • Logan R.A.
      • Alvarado-Little W.
      • Parson K.
      Health literacy and health education in schools: collaboration for action.
      ;

      Centers for Disease Control and Prevention. (2020). Characteristics of an effective health education curriculum. Accessed 9/22/20 from: https://www.cdc.gov/healthyschools/sher/characteristics/index.htm.

      ; Nutbeam, 2008). Providing access to full-time nurses in all schools institutionalizes multiple touchpoints to facilitate physical, social, and mental health and well-being, as well as supporting positive interactions with individuals, families, and communities. Nurses are at the frontline of health and education who can advocate for making education accessible to all at an early age and across the lifespan and emphasize the need to eliminate structural racism in all educational settings and education-related policies.

      Health care Access and Quality

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Health care Access and QualityUpstreamElected officials

      Policy administrators
      Support standardization of full practice authority for nurse practitioners across the nation

      https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/nurse-practitioner-scope-of-practice
      Formulate policies and advocate for policy change at state and institutional levels
      Health care access and quality are operationalized in the ability of nurses to practice within the context of the full scope of their knowledge and skills, which has a substantial impact on all other key areas. Americans have poorer health outcomes, including higher maternal and infant mortality rates, shorter life expectancies, and increased prevalence of chronic conditions than international peers (
      • Bradley E.H.
      • Sipsma H.
      • Taylor L.A.
      American health care paradox—high spending on health care and poor health.
      ;

      Squires, D., & Anderson, C. (2015). U.S. health care from a global perspective. Spending, use of services, prices, and health in 13 countries. Accessed 9/15/20 from: https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective

      ). These comparatively worse health outcomes are most apparent among socioeconomically disadvantaged groups (
      ), as evidenced by the persistent inequities in health insurance coverage, access to and utilization of health care services, prevalence of chronic physical and mental health conditions, and disproportionately higher mortality rates experienced by Black Americans, Latinx [Hispanic] Americans, Asian Americans, Native Hawaiian or other Pacific Islander Americans, and Indigenous [American Indians or Alaska Natives] people (

      Kaiser Family Foundation. (2019). Health and health care in the U.S. by race and ethnicity. Accessed 9/22/20 from: https://www.kff.org/infographic/health-and-health-care-in-the-u-s-by-race-and-ethnicity/

      ). The potential of the nation's health system to mediate the differences in exposures, differences in vulnerability, and differences in the consequences of illness for people's health and their social and economic circumstances, depends on access to and utilization of that system (

      World Health Organization. (2010). Conceptual framework for action on the social determinants of health. Socialdeterminants of health discussion paper 2. Debates, policy and practice, case studies. Accessed 9/15/20 from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf?ua=1.

      ).
      The National Academies of Science, Engineering, and Medicine defines access to health care as “the timely use of personal health services to achieve the best health outcomes” that requires three steps: gaining entry to the health system usually via insurance coverage, having a usual source of care such as a primary care provider, and being geographically available (Milliman, 1993, p. 4). Overwhelming evidence reveals that nurse practitioners provide high quality health care and achieve outcomes comparable to physicians . However, restrictions on the scope-of-practice for nurse practitioners has a negative impact on access to care and utilization of health care services and contributes to population health disparities across the country. Yet, research indicates that expanding scope of practice is associated with increases in the care intensity of Medicaid patients without increasing the cost of the care provided (

      Norful, A. A., Swords, K., Marichal, M., Cho, H., & Poghosyan, L. (2019). Nurse practitioner-physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care. Health care management review, 44(3), 235-245. https://doi.org/10.1097/HMR.0000000000000161.

      ) and full practice authority is estimated to achieve aggregate annual Medicare cost savings of $44.5 billion at the national level. State scope of practice laws that support full practice authority maximize the availability of this advanced practice workforce resulting in increased access to care, reduced cost of care, improved quality of care and reduced health disparities for many populations, especially racial and ethnic minority populations (

      Xue, Y., Kannan, V., Greener, E., Smith, J.A., Brasch, J., Johnson, B.A., & Spetz, J. (2018). Full Scope-of-Practice Regulation Is Associated With Higher Supply of Nurse Practitioners in Rural and Primary Care Health Professional Shortage Counties. Journal of Nursing Regulation, 8(4),5-13.

      ), all of which contributes substantially to reduction or elimination of systematic and structural racism. Consequently, nurses must participate in policy development and advocate with relevant stakeholders for appropriate scope of practice laws.

      Neighborhood and Built Environment

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Neighbor-hood and Built EnvironmentDownstream

      Midstream

      Upstream
      Local/State/NationalHousing First: An approach that averts housing insecurity and homelessness by providing rapid access to permanent housing and support as an initial step for stabilization, recovery, and establishing well-being ().Health Provider: Engages in direct provision of care and case management

      Advocate: Supports initiatives that undergird the philosophy of, and financial backing for Housing First as a model approach for housing stability

      Researcher: Investigates the specific dimensions of this housing approach and disseminates findings regarding improved health and housing outcomes related to Housing First
      Structural racism influences exposure to the key area, neighborhood and built environment. Several distinct yet interdependent pathways connect and intersect housing and health: affordability, safety and quality, and neighborhood conditions/opportunities (Hernandez & Swope, 2018;
      • Taylor L.
      Housing and health: an overview of the literature, Health Affairs.
      ). Millions of American families spend a disproportionate amount of their income on housing, foregoing other essentials, such as food and health services (
      The State of the Nation’s Housing
      Joint Center for Housing Studies of Harvard University.
      ). The inability to secure affordable housing can cascade into circumstances leading to evictions, foreclosures, and homelessness often with dire health related consequences (

      Desmond, M. and Kimbro, R. T., (2015). Eviction's Fallout: Housing, Hardship, and Health, Social Forces, 94,(1),295-324.

      ;
      • Hall M.
      • Crowder K.
      • Spring A.
      Neighborhood foreclosures, racial/ethnic transitions, and residential segregation.
      ;
      • Tsai A.
      Home foreclosure, health, and mental health: a systematic review of individual, aggregate, and contextual associations.
      ). Moreover, individuals and families with low incomes may have no other choice than to live in substandard housing that exposes them to health and safety risks.
      Neighborhoods include structural and social attributes and conditions affecting access to health-promoting and health sustaining resources and may also include undesirable amenities that may adversely influence health behaviors and health outcomes (

      Healthy People 2030. (2020) U.S. department of health and human services, office of disease prevention and health promotion. Accessed 9/13/20 from: https://health.gov/healthypeople/objectives-and-data/social-determinants-health

      ;
      • Taylor L.
      Housing and health: an overview of the literature, Health Affairs.
      ). The extent to which housing and neighborhoods are physically separated from the mainstream allows for inequities to proliferate. Racial residential segregation involving concentrated poverty, sparse job opportunities, limited educational advancement opportunities, limited transportation, and lack of proximal health care facilities, widens health inequities (
      • Williams D.R.
      • Collins C.C.
      Racial residential segregation: a fundamental cause of racial disparities in health.
      ;
      • White K.
      • Haas J.S.
      • Williams D.
      Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation.
      ). Consideration of the multifaceted integration of health and housing is essential for addressing health equity. This connection is particularly cogent for those within our communities who suffer from chronic mental illness, persistent substance abuse, disabilities, and are survivors of intimate partner violence. Housing First has been demonstrated to reduce homelessness, increase housing stability, and reduce hospitalizations for these populations (
      • Driscoll D.L.
      • Johnston J.
      • Chapman C.
      • Hedwig T.
      • Shimer S.
      • Barker R.
      Changes in the health status of newly housed chronically homeless: the Alaska Housing First program evaluation.
      ;

      National Alliance to End Homelessness. (2016). Fact Sheet: Housing First. Accessed 9/22/20 from: https://endhomelessness.org/wp-content/uploads/2016/04/housing-first-fact-sheet.pdf.

      ;
      • Mbilinyi L.
      The Washington state domestic violence housing first program: cohort 2 agencies final evaluation report, september11-september 2014.
      ;
      • Palepu A.
      • Patterson M.L.
      • Moniruzzama A.
      • Frankish C.J.
      • Somer J.
      Housing First improves residential stability in homeless adults with concurrent substance dependence and mental disorders.
      ;
      • Sullivan C.M.
      • Olsen L.
      ). Nurses can and should advocate for the Housing First model.

      Social and Community Context

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Social and Community ContextUpstreamNationalEquitable access to health care through support of ACA and Medicaid expansionAdvocacy, stakeholder engagement, coalition building, and cross- sector partnerships
      Social and community context is directly related to all other key areas. Racism is a system of structuring opportunity, advantage, and value based on phenotype that advantages one group unfairly over another (
      • Hardeman R.R.
      • Medina E.M.
      • Kozhimannil K.B.
      Dismantling structural racism, supporting black lives and achieving health equity: Our role.
      ). Racism emerged from early settler colonial times when Black and Indigenous individuals were believed inferior based on phenotypic characteristics that were cited as justification for oppression and privilege (

      Aspen Institute. (2016). Racial equity: 11 terms you should know to better understand structural racism. Accessed 9/13/20 from: https://www.aspeninstitute.org/blog-posts/structural-racism-definition/.

      ;
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: evidence and interventions.
      ). Structural racism is deeply embedded in the social, economic, and political systems in the United States whereby public policies, institutional practices, cultural representations, and other customs and practices work in various reinforcing ways to perpetuate inequities based on race (

      Aspen Institute. (2016). Racial equity: 11 terms you should know to better understand structural racism. Accessed 9/13/20 from: https://www.aspeninstitute.org/blog-posts/structural-racism-definition/.

      ). Structural racism resides in the historical and cultural aspects of society that advantage racially white persons, disadvantage black and brown racialized populations, and these advantages and disadvantages were codified in ways that perpetuate inequities, including health inequities, among persons of color (
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: evidence and interventions.
      ;
      • Hardeman R.R.
      • Medina E.M.
      • Kozhimannil K.B.
      Dismantling structural racism, supporting black lives and achieving health equity: Our role.
      ;

      Aspen Institute. (2016). Racial equity: 11 terms you should know to better understand structural racism. Accessed 9/13/20 from: https://www.aspeninstitute.org/blog-posts/structural-racism-definition/.

      ). These systemic inequities in health referred to as “structural determinants” or the “political determinants of health” involve the systematic processes of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce one another to shape opportunities that advance health equity or create, perpetuate, and exacerbate health inequities (
      • Dawes D.
      The political determinants of health.
      , p. 146). A focus on structural racism is necessary to advance health equity and improve the health of racialized black and brown populations. The Patient Protection and Affordable Care Act (ACA) and Medicaid expansion in those states adopting it, have been shown to reduce racial/ethnic disparities in coverage for health care among Black and Latinx people (
      • Buchmueller T.C.
      • Levinson Z.M.
      • Levy H.G.
      • Wolfe B.L.
      Effect of the affordable care act on racial and ethnic disparities in health insurance coverage.
      ). According to Christen

      Linke Young, C. (2020) There are clear, race-based inequalities in health insurance and health outcomes. USC-Brookings Schaeffer on Health Policy. Accessed from: https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/02/19/there-are-clear-race-based-inequalities-in-health-insurance-and-health-outcomes/. Accessed at: September 11, 2020.

      , with implementation of the ACA core provisions in 2014, insurance coverage rose across all racial and ethnic groups, especially among Back and Latinx people. However, in the 14 states that have not expanded Medicaid, people of color are far more likely to be uninsured. This highlights the need to expand Medicaid nationally and to move toward universal health coverage if we truly want to eliminate systemic racism in access to health care insurance coverage. Therefore, nurses must raise our collective voices individually and through professional organizations, including the Academy, to insist that the ACA remains in effect and that all states expand access to Medicaid.

      Planetary Conditions

      Tabled 1
      Social DeterminantLevel of InterventionPolicy TargetExample PolicyPopulation-focused Nursing Role(s)
      Planetary ConditionsUpstreamNationalAlign national efforts with leading scientific bodies to reduce greenhouse gas emissions by 45% by 2030 in all organizations, businesses, and governmental entities.Nurses provide information, education, background, and advocacy to work with elected officials, NGOs and leaders, specifically related to climate change and health and to health care practice, with a focus on BIPOC and other under-represented communities.
      Planetary conditions are related to other key areas, especially neighborhood and built environment, social and community context, and economic stability. climate change is intertwined with racism. Poor countries and poor communities within affluent communities are disproportionately affected by the effects of climate change. People in countries most affected by climate change and the consequential violence that ensues, try to escape the situation only to be marginalized and relegated to poor, crowded, unhealthy communities in their new home. The warming planet harms health directly (heat, fires, and storms), indirectly (infectious disease spread, air pollution, mental health) and civilly (migration, unrest, violence) (
      • McMichael A.J.
      Globalization, climate change, and human health.
      ). Black, Indigenous, and People of Color (BIPOC), and those living in poverty are most affected by the sequelae of climate change. Furthermore, children bear 88% of poor health outcomes from climate change (
      • Philipsborn R.P.
      • Chan K.
      Climate change and global child health.
      ), and warming will have profound consequences on the health of older adults (
      • Carnes B.A.
      • Staats D.
      • Willcox B.J.
      Impact of climate change on elder health.
      ). Human health depends on our ability to reduce the harms caused by these human-caused damages to our planetary balance. Although many people worldwide are working to reduce planetary climate change, many nurses’ voices have not been heard. However, as health and well-being advocates across populations and ages, nurses’ perspectives of environment are crucial to informing policy.

      Conclusion

      We have presented a conceptual framework that guides nurse-led development and implementation of health policies to improve population health. Specifically, we address six key areas of Social Determinants of Health which we have linked to the environment concepts of our conceptual framework—economic stability, education access and quality, health care access and quality, neighborhood and built environment, social and community context, and planetary conditions. Examples of a timely and socially significant health policy that focuses on upstream factors and identifies the distinctive population-focused nursing actions are given for each key area to illustrate how the framework can be operationalized. Our work underscores the crucial need to eliminate systematic and structural racism if equity in planetary health-related quality of life is to be attained.

      Author Contribution

      Paul Kuehnert - Conceptualization, Methodology, Writing - original draft, Writing - review & editing; Jacqueline Fawcett- Conceptualization, Methodology, Writing - original draft, Writing - review & editing; Kelli DePriest- Conceptualization, Methodology, Writing - original draft, Writing - review & editing; Peggy Chinn- Conceptualization, Writing - original draft, Writing - review & editing; Lakeshia Cousin- Conceptualization, Writing - original draft, Writing - review & editing; Naomi Ervin-Conceptualization, Writing - original draft, Writing - review & editing; Jane Flanagan- Conceptualization, Writing - original draft, Writing - review & editing; Eileen Fry-Bowers-Conceptualization, Writing - original draft, Writing - review & editing; Cheryl Killion- Conceptualization, Writing - original draft, Writing - review & editing; Sally Maliski- Conceptualization, Writing - original draft, Writing - review & editing; Erin D. Maughan- Conceptualization, Writing - original draft, Writing - review & editing; Cathy Meade- Conceptualization, Writing - original draft, Writing - review & editing; Teri Murray-Conceptualization, Writing - original draft, Writing - review & editing; Beth Schenk- Conceptualization, Writing - original draft, Writing - review & editing; Roberta Waite- Conceptualization, Writing - original draft, Writing - review & editing.

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