Advertisement
Research Article| Volume 70, ISSUE 1, P10-27, January 2022

Download started.

Ok

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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Nursing Outlook
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. American Academy of Nursing. (2019). Policy priorities 2019-2020. Accessed 9/13/20 from: https://higherlogicdownload.s3.amazonaws.com/AANNET/c8a8da9e-918c-4dae-b0c6-6d630c46007f/UploadedImages/Academy_Federal_Policy_Priorities_Approved_10_30_19.pdf.

        • Aspen Institute Roundtable on Community Change
        Lawrence Keith Sutton Stacey Kubisch Anne Susi Gretchen Fulbright-Anderson Karen Structural Racism and Community Building. The Aspen Institute, Washington, D.C.2004 (Accessed from:)
      2. 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/.

        • 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.
        NAM Perspectives. 2020;
        • 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.
        The Lancet. 2017; 389: 1453-1463https://doi.org/10.1016/S0140-6736(17)30569-X
      3. 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.

        • Bhatt J.
        Your zip code, your health | AHA News.
        American Hospital Association | AHA News, 2018 (Accessed 9/15/20 from: https://www.aha.org/news/insights-and-analysis/2018-05-16your-zip-code-your-health)
        • Bradley E.H.
        • Sipsma H.
        • Taylor L.A.
        American health care paradox—high spending on health care and poor health.
        QJM: An International Journal of Medicine. 2017; : 61-65https://doi.org/10.1093/qjmed/hcw187
        • Braveman P.
        • Arkin E.
        • Orleans T.
        • Proctor D.
        • Plough A.
        What is health equity? And what difference does a definition make?.
        Robert Wood Johnson Foundation, 2017
        • 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.
        American Journal of Public Health. 2016; 106: 1416-1421https://doi.org/10.2105/AJPH.2016.303155
        • Butterfield P.
        Thinking upstream: A 25-year retrospective and conceptual model aimed at reducing health inequities.
        Advances in Nursing Science. 2017; 40: 2-11https://doi.org/10.1097/ANS.0000000000000161
        • Carnes B.A.
        • Staats D.
        • Willcox B.J.
        Impact of climate change on elder health.
        Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2014; 69: 1087-1091https://doi.org/10.1093/gerona/glt159
      4. 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.

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

      6. Centers for Medicare and Medicaid Services. (2019). National health expenditure data. Historical. Accessed 9/22/20 from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.

        • Castrucci B.
        • Auerbach J.
        Meeting individual social needs falls short of addressing social determinants of health.
        Health Affairs Blog. 2019; (Accessed 9/15/20 from:)
        • 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.
        Social Science & Medicine. 2017; 193: 41-50https://doi.org/10.1016/j.socscimed.2017.09.046
      7. County Health Rankings. (2020). 2020 County Health Rankings State Reports. Accessed 9/22/20 from: https://www.countyhealthrankings.org/ Accessed at: August 14, 2020

        • CSDH
        Closing the gap in a generation: health equity through action on the social determinants of health.
        Final Report on the Commission on Social Determinants of Health. World Health Organization, 2008 (Accessed 9/13/20 from: https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf?sequence=1)
        • Dawes D.
        The political determinants of health.
        John Hopkins University Press, 2020
      8. Desmond, M. and Kimbro, R. T., (2015). Eviction's Fallout: Housing, Hardship, and Health, Social Forces, 94,(1),295-324.

        • Drevdhal D.J.
        Cultural shifts: From cultural to structural theorizing in nursing.
        Nursing Research. 2018; 67: 146-160https://doi.org/10.1097/NNR.0000000000000262
        • 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.
        Journal of Social Distress and Homelessness. 2017; 271: 34-43https://doi.org/10.1080/10530789.2018.1441678
        • Ervin N.E.
        • Bickes J.T.
        • Schim S.M.
        Environments of care: a curriculum model for preparing a new generation of nurses.
        Journal of Nursing Education. 2006; 45: 75-80
        • Ervin N.E.
        • Kulbok P.A.
        Advanced public and community health nursing practice: Population assessment, program planning, and evaluation.
        2nd ed. Springer Publishing Company, NY2018
        • Fawcett J.
        The conceptual model of nursology for enhancing equity and quality: population health and health policy.
        in: Moss M. Phillips J. Health equity and nursing: Achieving equity through policy, population health, and interprofessional collaboration. Springer, 2021: 101-117
        • Fawcett J.
        Thoughts about the language of equity for population health.
        Nursing Science Quarterly. 2019; 32: 157-159https://doi.org/10.1177/0894318419826277
        • Fawcett J.
        • Ellenbecker C.H.
        A proposed conceptual model of nursing and population health.
        Nursing Outlook. 2015; 63: 288-298https://doi.org/10.1016/j.outlook.2015.01.009
        • Furlong E.A.
        Agenda setting.
        in: Milstead J.A. Health policy and politics: A nurse's guide. Aspen, 1999: 43-75
        • Gee G.C.
        • Ford C.L.
        Structural racism and health inequities: old issues, new directions.
        Du Bois review: social science research on race. 2011; 8: 115-132https://doi.org/10.1017/S1742058×11000130
        • Hall M.
        • Crowder K.
        • Spring A.
        Neighborhood foreclosures, racial/ethnic transitions, and residential segregation.
        American Sociological Review. 2015; 80: 526-549https://doi.org/10.1177/0003122415581334
        • Hardeman R.R.
        • Medina E.M.
        • Kozhimannil K.B.
        Dismantling structural racism, supporting black lives and achieving health equity: Our role.
        New England Journal of Medicine. 2016; 375: 2113-2115https://doi.org/10.1056/NEJMp1609535
      9. 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.

      10. 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.

      11. 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

        • Hundt B.
        Reflections on nightingale in the year of the nurse.
        American Nurse Journal. 2020; 15 (Accessed 9/15/20 from:): 26-29
      12. Housing First (2019). County health rankings & roadmaps. Accessed 9/22/20 from: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/housing-first.

        • Keyes K.M.
        • Galea S.
        Population health science.
        Oxford University Press, 2016
        • Kindig D.
        • Stoddart G.
        What is population health?.
        American Journal of Public Health. 2003; 93: 380-383https://doi.org/10.2105/AJPH.93.3.380
        • Komro K.A.
        • Livingston M.D.
        • Markowitz S.
        • Wagenaar A.C.
        The effect of an increased minimum wage on infant mortality and birth weight.
        American journal of public health. 2016; 106: 1514-1516https://doi.org/10.2105/AJPH.2016.303268
        • Kuehnert P.L.
        The public health policy advocate: fostering the health of communities.
        Clinical nurse specialist CNS. 1991; 5: 1-10
        • Kuehnert P.L.
        The interactive and organizational model of community-as-client: a model for public health nursing practice.
        Public Health Nursing. 1995; 12: 9-17
        • Kuehnert P.
        Rebel nurses at the crossroads.
        in: Love R. Hanrahan N. Ackerman M.L. Lawlor F.A. Taylor A.R. Toner E. The rebel nurse handbook. Springer, 2021: 141-144
      13. 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/

      14. 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.

      15. 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.

        • Mackenbach J.
        Political determinants of health.
        European Journal of Public Health. 2014; 24: 2https://doi.org/10.1093/eurpub/ckt183
        • Mbilinyi L.
        The Washington state domestic violence housing first program: cohort 2 agencies final evaluation report, september11-september 2014.
        Washington State Coalition Against Domestic Violence. The Bill & Melinda Gates Foundation, 2015
        • McFarland M.R.
        • Wehbe-Alamah H.B.
        The theory of culture care diversity and universality.
        in: McFarland M.R. Wehbe-Alamah H.B. Leininger's culture care diversity and universality: A worldwide nursing theory. 3rd ed. Jones and Bartlett Learning, 2015: 1-34
        • McGill N.
        Education attainment linked to health throughout lifespan: exploring social determinants of health.
        The Nation's Health. APHA publications, 2016
        • McMichael A.J.
        Globalization, climate change, and human health.
        New England Journal of Medicine. 2013; 368: 1335-1343https://doi.org/10.1056/NEJMra1109341
        • Milio N.
        Promoting health through public policy.
        F. A. Davis CO Publishers, 1981
        • Mora C.
        • Dousset B.
        • Caldwell I.
        • Powell F.
        • Geronimo R.
        • Bielecki C.
        • Counsel C.
        • Dietrich B.
        • Johnston E.
        • Louis L.
        • Lucas M.
        • McKenzie M.
        • Shea A.
        • Tseng H.
        • Giambelluca T.
        • Leon L.
        • Hawkins E.
        • Trauernicht C.
        Global risk of deadly heat.
        Nature climate change. 2017; 7: 501-506https://doi.org/10.1038/nclimate3322
        • Nightingale F.
        Notes on nursing: What it is and what it is not (Commemorative ed.).
        Lippincott, 1992 ([Originally published 1859])
      16. 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.

        • 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.
        American Journal of Public Health. 2013; 103: e30-e36https://doi.org/10.2105/AJPH.2013.301628
        • Philipsborn R.P.
        • Chan K.
        Climate change and global child health.
        Pediatrics. 2018; 141e20173774https://doi.org/10.1542/peds.2017-3774
        • Pickett K.E.
        • Wilkinson R.G.
        Income inequality and health: a causal review.
        Social Science and Medicine. 2015; 128: 316-326https://doi.org/10.1016/j.socscimed.2014.12.031
        • Pittman P.
        Activating nursing to address unmet needs in the 21st century.
        Robert Wood Johnson Foundation, 2019
        • Prüss-Üstün A.
        • Wolf J.
        • Corvalán C.
        • Bos R.
        • Neira M.
        Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks.
        World Health Organization, 2016
        • 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.
        MMWR Morbitiy and Mortality Weekly Report. 2017; 66: 921-927https://doi.org/10.15585/mmwr.mm6635a1
        • Remington P.L.
        • Catlin B.B.
        • Gennuso K.P.
        The county health rankings: rationale and methods.
        Population Health Metrics. 2015; 13: 1-12https://doi.org/10.1186/s12963-015-0044-2
        • Rice L.
        • Sara R.
        Debate: updating the determinants of health model in the information age.
        Health Promotion International. 2019; 34: 1241-1249https://doi.org/10.1093/heapro/day064
        • Rothstein R.
        The color of law: a forgotten history of how our government segregated America.
        Liveright Publishing, 2017
      17. Planetary Health Alliance. (2020). Planetary health. Accessed 9/22/20 from: https://www.planetaryhealthalliance.org/planetary-health

        • Saint Arnault D.
        Defining and theorizing about culture: the evolution of the cultural determinants of health-seeking, revised.
        Nursing Research. 2018; 67: 161-168https://doi.org/10.1097/NNR.0000000000000264
        • Serchen J.
        • Doherty R.
        • Atiq O.
        • Hilden D.
        Racism and health in the United States: a policy statement from the American college of physicians.
        Annals of Internal Medicine. 2020; (Accessed from:)https://doi.org/10.7326/m20-4195
        Annals.org
        Date accessed: September 15, 2020
        • 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.
        Journal of Public Health Policy. 2012; 33: 1-15https://doi.org/10.1057/jphp.2011.52
      18. 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.

      19. 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

        • Storfjell J.
        • Winslow B.
        • Saunders J.
        Catalysts for change: Harnessing the power of nurses to build population health in the 21st century.
        Robert Wood Johnson Foundation, 2017 (Accessed from:)
        • 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.
        National Academies Press, 2013
        • Sudduth A.L.
        Policy evaluation.
        (Ed.)in: Milstead J.A. Health policy and politics: A nurse's guide. Aspen, 1999: 219-256
        • Sullivan C.M.
        • Olsen L.
        Common ground, complementary approaches: adapting the Housing First model for domestic violence survivors. 43. Housing and Society, 2016: 182-194https://doi.org/10.1080/08882746.2017.1323305
        • Taylor L.
        Housing and health: an overview of the literature, Health Affairs.
        Health Policy Brief. 2018; https://doi.org/10.1377/hpb20180313.396577
        • The State of the Nation’s Housing
        Joint Center for Housing Studies of Harvard University.
        Harvard University, 2019 (Accessed from:)
        http://www.jchs.harvard.edu/
        Date accessed: September 22, 2020
      20. The Responsible Consumer (2020). Systemic, structural and institutional racism. Accessed 9/22/20 from: https://theresponsibleconsumer.wordpress.com/systemic-implicit-microaggression-racism/.

        • Tsai A.
        Home foreclosure, health, and mental health: a systematic review of individual, aggregate, and contextual associations.
        PLoS One. 2015; 43: 1-21https://doi.org/10.1371/journal.pone.0123182
        • United States Department of Health and Human Services
        Healthy people 2020: Social determinants of health. 2015; (Accessed from:)
        • 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.
        Preventive Medicine. 2018; 112: 97-103https://doi.org/10.1016/j.ypmed.2018.04.009
        • Venes D.
        Taber's cyclopedic medical dictionary.
        22nd ed. F. A. Davis, 2013
        • Wakefield M.K.
        Government response: legislation.
        in: Milstead J.A. Health policy and politics: A nurse's guide. Aspen, 1999: 77-103
        • Wald L.D.
        The House on Henry Street.
        Holt, 1915
        • White K.
        • Haas J.S.
        • Williams D.
        Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation.
        Health Service Research. 2012; 47: 1278-1299https://doi.org/10.1111/j.1475-6773.2012.01410.x
        • 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.
        The Lancet. 2015; 386 (...): 1973-2028https://doi.org/10.1016/S0140-6736(15)60901-1
        • Wilkinson R.G.
        • Pickett K.E.
        Income inequality and population health: a review and explanation of the evidence.
        Social Science and Medicine. 2006; 62: 1768-1784https://doi.org/10.1016/j.socscimed.2005.08.036
        • Wilkinson R.
        • Pickett K.
        The inner level: How more equal societies reduce stress, restore sanity and improve everyone's well-being.
        Penguin Press, 2019
        • Williams D.R.
        • Collins C.C.
        Racial residential segregation: a fundamental cause of racial disparities in health.
        Public Health Reports. 2001; 116: 404-416https://doi.org/10.1093/phr/116.5.404
        • Williams D.R.
        • Mohammed S.A.
        Racism and health I: pathways and scientific evidence.
        American behavioral scientist. 2013; 57: 1152-1173https://doi.org/10.1177/0002764213487340
      21. Woolf S.H. Aron L. U.S. health in international perspective: Shorter lives, poorer health. National Academies Press, 2013
      22. 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.

      23. 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.

      24. 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.

        • Zajacova A.
        • Lawrence E.M.
        The relationship between education and health: reducing disparities through a contextual approach.
        Annual Review Public Health. 2018; 39: 273-289https://doi.org/10.1146/annurev-publhealth-031816-044628