THE SOCIAL DETERMINANTS OF HEALTH
jaydenson
discmater2ShapingNursingHealthcarePolicy.docx
Shaping Nursing Healthcare Policy
A View from the Inside
2022, Pages 91-105
7 - The evolving role of social determinants of health to advance health equity
Author links open overlay panelSandra Davis
Show more
Add to Mendeley
Share
Cite
https://doi.org/10.1016/B978-0-323-99993-9.00016-0 Get rights and content
Complimentary access
Abstract
Efforts are steadily increasing to address social determinants of health (SDH) within healthcare delivery systems. Policies and practices in nonhealth sectors impact health and health equity.
Therefore, the crux of health policies and interventions is a clear and accurate understanding of how and why the social determinants differentially impact health, healthcare, and health outcomes. The fundamental drivers of health inequities are the fundamental drivers of social inequities. The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects. Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new. Historical and contemporary policies have created the structures that shape the SDH and have profound and enduring effects on our patients' health, healthcare, and health outcomes. Nurses can lead social change but only with a clear understanding of SDH and its evolving role in advancing health equity.
Keywords
COVID-19
Health equity
SDH frameworks
Social determinants of health
Social needs
Structural racism
Objectives
Upon completion of this chapter, the learner will be able to:
· •
Recognize the meaning and misunderstanding of the social determinants of health (SDH)
· •
Compare and contrast SDH-related terms and concepts
· •
Explore history as groundwork for current approaches to achieving health equity
· •
Describe structural racism as a structural determinant of health and root cause of health inequities
· •
Examine evolving frameworks to address upstream interventions, policy, systems, and structures
· •
Identify nursing's role in informing policy change
Introduction
The disproportionate impact of the COVID-19 pandemic on racialized groups, the murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and others, and the months of worldwide protests over structural racism have ushered in a new national discourse (Bailey et al., 2021; Lavizzo-Mourey et al., 2021). Attention is being shifted to upstream structural drivers of long-standing injustices, policy, and how inequities are codified and reproduced (Lavizzo-Mourey et al., 2021; Yearby & Mohapatra, 2020). The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects (National League for Nursing, 2022). On May 11, 2021, the National Academics of Sciences, Engineering, and Medicine released The Future of Nursing 2020–30: Charting a Path to Achieve Health Equity (National Academies of Sciences, Engineering, and Medicine, 2021) . The report contains an urgent call to action for nurses, over the next decade, to concentrate on the SDH to advance health equity. As the nation's largest healthcare profession , nurses play a vital role in leading change so that every person has an opportunity to live the healthiest life possible ( National Academies of Sciences, Engineering, and Medicine, 2021).
Policies and practices impact health and health equity and efforts are steadily increasing to address SDH in healthcare delivery systems (Ariga & Hinton, 2018; Bailey et al., 2021). Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new ( National Academies of Sciences, Engineering, and Medicine, 2021) .Nurses can lead social change but only if they have a clear understanding of SDH and its important and evolving role in advancing health equity ( National Academies of Sciences, Engineering, and Medicine, 2021) .
The widespread movement for racial justice , along with the stark racial inequities in the impacts of COVID-19, has reinforced the nursing profession's ethical mandate to advocate for racial justice and to help combat the inequities embedded not only in the current healthcare system but across all sectors of society ( National Academies of Sciences, Engineering, and Medicine, 2021, P. 100) . Eliminating persistent, unjust, and avoidable inequities is complex (Braveman, 2006) . It involves social, political, psychosocial, and biological processes that work synergistically and inextricably over the life course, at multiple levels, and through entrenched systems and structures (Braveman et al., 2022) .Despite the inexhaustible efforts of those committed to social justice and social change, eliminating inequities to date has been seemingly unattainable (Yearby, 2020) . There is mounting evidence and an emerging groundswell of thinking that policy change, whether through dismantling existing systems or structures or creating new and innovative policies, is the solution (Braverman, Egerter, et al., 2011; Woolf & Braveman, 2011) .
The same forces that create social inequities also create health inequities and if all policy is health policy, then there is a direct connection between historical and contemporary policy to SDH and its profound and enduring effects on our patients' healthcare, and health outcomes (Bailey et al., 2017; Braveman & Dominquez, 2021; Woolf & Braveman, 2011).
Social determinants of health: the meaning and the misunderstanding
Health inequities, unfair and avoidable differences in health between individuals and groups, result in stark differences in health outcomes for certain communities (Whitehead, 1992). The SDH, commonly taught as the conditions in which people are born, grow, live, work, and age, include factors such as income, education, employment, housing, and neighborhood conditions (Centers for Disease Control and Prevention, 2021). Although it captures many powerful societal factors and societal factors account for up to 80%–90% of health and health outcomes, this definition is incomplete and evasive (Magnan, 2017; Weil, 2021). There is a second part to the definition of SDH that is often omitted, deemed inconsequential, and not discussed (Olayiwola et al., 2020; Weil, 2021).
The World Health Organization (WHO) expands this definition, describing SDH as the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life (World Health Organization, 2022a). This expanded definition adds economic policies, development agendas, cultural and social norms, social policies, and political systems to the SDH construct all of which influence the distribution of money, power, and resources locally, nationally, and globally (World Health Organization, 2022b) .
The WHO's broader definition is critical to recognizing how important historical and contemporary policies, politics, and inequities are to the creation of SDH and health inequity/equity ( Bailey et al., 2017, 2021; Lavizzo-Mourey et al., 2021). It clarifies the forces that gave rise to SDH in the first place, and accounts for how racialized groups are disproportionately burdened by the SDH ( Bailey et al., 2017, 2021; Fleming, 2020; Lavizzo-Mourey et al., 2021). It also lends insight into root causes and conveys the importance of intervening through policy ( Bailey et al., 2017, 2021; Exworthy, 2008; Lavizzo-Mourey et al., 2021). With mounting calls for nurses to lead in advancing health equity, understanding what SDH is not, becomes just as important as understanding what it is ( National Academies of Sciences, Engineering, and Medicine, 2021) .
Social determinants of health and related terms: why clarity matters
Strategies to address SDH are being discussed among the health professions across practice, research, and education (National Academies of Sciences, Engineering, and Medicine, 2016, 2021) . SDH is also being addressed outside healthcare systems by policymakers, health systems administrators, health insurance payors, and across local, state, and federal sectors ( Magnan, 2017) . A clearer understanding of SDH is emerging as multiple stakeholders converge to address concepts related to SDH (Braveman & Gottlieb, 2014; Magnan, 2017) . Clear and standardized definitions are essential to avoid confusion and conflation of terms which is particularly relevant when attempting to forge cross-sector partnerships to collaborate, coordinate, and intervene to resolve SDH issues (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019) .
SDH is not population health
SDH is not the same as population health or public health because SDH is just one factor shaping the health of a population (Alderwick & Gottlieb, 2019). Population health refers to health outcomes of a group of individuals to include the distribution of such outcomes within the group. It is also important to recognize that SDH are often taught as negative factors experienced by only some groups, but SDH may confer health benefits and can affect entire populations not just racialized, marginalized, or excluded groups ( Olayiwola et al., 2020). Public health reflects society's desire and effort to improve the health and well-being of the total population, by relying on the role of the government, the private sector , and the public, and by focusing on the determinants of population health which include SDH (Shi & Kao, 2009) .
SDH and social risk factors: closely connected but not the same
Social risk factors are the adverse social conditions associated with poor health, such as food insecurity and housing instability (Alderwick & Gottlieb, 2019). Implementing housing and food insecurity screening tools are needed to address social risk factors but do not address (a) the upstream systemic and structural determinants of health or root causes and (b) how to keep this from happening (Alderwick & Gottlieb, 2019).
SDH and social needs are two different concepts
Social needs are social conditions that individuals identify as most pressing for them (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). This construct is different from the terms above because social needs depend on individual preferences and priorities, highlighting the importance of patient-centered care and shared decision making (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). An example of social needs would be an individuals in transitional housing who cannot afford to travel for healthy food options that are not available in their neighborhood. They would identify healthy food for their family as a pressing social need. Efforts to link them with a farmers market truck that travels through their community does not address the underlying upstream systemic and structural issues that caused food insecurity in the first place.
It's important to understand the difference between upstream and downstream SDH. Upstream social determinants are the root cause of health and health outcomes while downstream social determinants are factors that are temporarily and spatially close to health and health outcomes but are influenced by upstream factors ( Braverman, Egerter, et al., 2011). Addressing SDH involves advocating for policy change that addresses social risk factors and social needs like food and housing stability (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). The upstream policies decrease the downstream social risk factors and social needs. Policymakers are the ones who can best address upstream SDH (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). However, without political will important policy change does not happen (Dawes, 2020; Lavizzo-Mourey et al., 2021; Ranit, 2019).
Social determinants of health, health disparities, health inequities, and health equity
The concept of health equity encompasses multiple dimensions including health equity, health inequality, health inequity, and health disparity (Yao et al., 2019). Over time, different ethical, philosophical, political, legal, and cultural perspectives have shaped the definitions of these terms and the definitions have evolved and expanded over time (Braveman et al., 2018). All of the terms are based on human rights and social justice principles and although often used interchangeably they have distinctly different meanings (Braveman, Kumanyika, et al., 2011). Clear definitions are important because these terms are commonly used in teaching, practice, research, leadership, and advocacy domains and shape research outcomes, health systems structures, healthcare delivery, and health outcomes ( Braveman et al., 2018).
Health equity means that everyone has a fair and just opportunity to be as healthy as possible and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances ( Braveman et al., 2018).
Health inequalities is a term that is used more internationally and is defined as avoidable and unjust differences in people's health across the population ( Braveman, 2006; Braveman et al., 2018).
Health inequities are the systematic, unnecessary, and avoidable differences in health between groups of people who have different relative positions in social hierarchies based on wealth , structural racism , power, or prestige, all of which can be shaped by policy ( Braveman et al., 2018; Whitehead, 1992).
Health disparities are the avoidable differences in health caused by structural determinants of health that drive SDH and adversely affect racialized, marginalized, or excluded groups. Health disparities include differences in overall health or unequal burden of disease and/or health outcomes between populations that are attributable to social, political, economic, and environmental factors ( Braveman, 2006; Braveman et al., 2018).
The history of social determinants of health
Minimal attention is given to the history of SDH, and history is important because it provides context from within the United States and internationally ( Yao et al., 2019). History illustrates societal concerns and acknowledgment of structural racism as a root cause of inequities; elucidates inconsistencies in evidence and action; and highlights evolving approaches to achieve health equity ( Bailey et al., 2017, 2021; Yao et al., 2019). Moreover, understanding the history of SDH is foundational to truly understanding the persistence of unjust, unnecessary, and avoidable health inequities, underscoring the meaning of the often-heard phrase, it is going to take political will for action on health equity ( Bailey et al., 2017, 2021; Churchwell et al., 2020).
The concept of SDH gained momentum in the United States in 2010 with the release of Healthy People 2020, which built on earlier work out of Europe and Canada. Initially launched in 1979, the Healthy People 10-year reports have focused on health promotion and disease prevention (Breen, 2017; Shi & Kao, 2009). Although the first report did not specifically highlight equity and disparities as important to health, the second report did. Healthy People 2020 was the first report to use social determinants to frame a conceptual understanding of health, and acknowledge that social, economic, and political factors that influence health ( Breen, 2017). Health inequities are not new, they are centuries old. SDH literature dates back over 100 years (Byrd & Clayton, 2000, 2001; Maxmen, 2021).
1800s: landmark SDH works
Chadwick (1842) published a report on the Sanitary Condition of the Laboring Population of Great Britain ( Chadwick, 1842). This report described variations in life expectancy associated with class ( Chadwick, 1842). Recommendations from this report led to the passing of the Public Health Act of 1848 in the United Kingdom (UK) ( Yao et al., 2019). Virchow (1848), reporting on the Typhus Epidemic in Upper Siesia, emphasized the role of social and environmental factors , documented social inequality as a cause of ill-health, and characterized medicine as a social science ( Virchow, 1848). It is important to note that in 1899 W. E. B. Du Bois identified both social and structural determinants of health in his book The Philadelphia Negro: A Social Study (Du Bois, 1899). Du Bois documented that health disparities of Blacks compared to Whites in the United States were a result of social conditions and not inherent racial traits ( Du Bois, 1899). Further, the social problems experienced by Blacks were rooted in Whites' enforcement of racial discrimination and provision of unequal opportunity ( Du Bois, 1899).
1900s: notable SDH contributions
The Constitution of the World Health Organization, 1946 (World Health Organization, 2022c), defined health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The preamble declared that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition ( World Health Organization, 2022a). Later in the 1900s, the Whitehall Studies of British civil servants in the mid-1900s investigated SDH and showed an inverse social gradient in mortality from a wide range of diseases (Marmot et al., 1991).
2000s: evolving SDH works
The work of Professor Sir Michael G. Marmot on social determinants of health and health inequities laid the groundwork for establishing the WHO Commission on Social Determinants of Health to support countries in addressing social factors leading to health inequities ( World Health Organization, 2022b). A major focus of the Commission was to turn SDH knowledge into political action (Marmot, 2005). Most recently a growing body of literature is focusing on structural determinants of health ( Bailey et al., 2017, 2021; Braveman et al., 2022; Churchwell et al., 2020; Yearby, 2020). Bailey et al. (2017)published a paper documenting evidence and interventions for structural racism as a root cause of health inequities. Lavizzo-Mourey et al. (2021) and Shah (2021) emphasized that achieving health equity will require dismantling structural racism through upstream policy intervention and political will.
History as a determinant of health
While historical accounts of SDH have traditionally begun with works published in the 1800s, there is now growing acknowledgment that social, economic, and political influences started with the inception of this nation. To this day, they negatively impact the health and well-being of Blacks and other racialized groups1 ( Bailey et al., 2017, 2021; Braveman & Dominquez, 2021; Byrd & Clayton, 2000, 2001; Churchwell et al., 2020).
Healthy People, now in its fifth decade, has made progress in reducing morbidity and mortality and improving health and well-being across the United States but these improvements have not been realized equitably across racialized groups ( Churchwell et al., 2020). Blacks continue to experience higher cardiovascular disease and stroke mortality rates regardless of socioeconomic position , so higher income and access do not appear to protect Black people from the impact of structural racism and its health effects ( Churchwell et al., 2020). Blacks with a college degree are more likely than Whites to experience unemployment and have lower wealth at every level of income ( Churchwell et al., 2020). Health profession's students are taught that infant mortality is more than twice as high in Black than White infants, but faculty often fail to underscore that racism is a toxic prenatal stress for Black mothers at every income and educational level (Krieger et al., 2014).
Structural racism
Structural racism refers to the laws, policies, institutional practices, and entrenched norms that undergird all our systems ( Bailey et al., 2017). It includes the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice ( Bailey et al., 2017), all of which reinforce discriminatory beliefs, values, and distribution of resources ( Bailey et al., 2017). Although systemic racism and structural racism are very similar and often used interchangeably, there are important differences in the terms ( Bailey et al., 2017). Systemic racism is how discriminatory actions against racialized groups show up in political, legal, economic, healthcare, school, and criminal justice systems, and what structures reinforce or perpetuate racial group inequity ( Braverman et al., 2022). Structural racism takes systemic racism and layers on the historical, cultural, and social constructs beginning with the enslavement and genocide of Blacks and Indigenous people in the United States ( Bailey et al., 2017, 2021).
Race and racism in America
Understanding race and racism in America is foundational to any discourse on health equity ( Bailey et al., 2017, 2021; Braveman & Dominquez, 2021). Yet, many educators, healthcare professionals, policymakers, elected officials, and others responsible for responding to the national discourse on the disparate health outcomes in COVID-19 and racial injustice in America remain resistant to identify structural racism as a root cause of racial health inequities ( Bailey et al., 2017).
Race is a social construct that emerged in the 1600s with the trans-Atlantic slave trade and over the centuries, European settlers sought to maintain an economy with the labor of enslaved African people and their descendants while attempting to uphold the universal rights of man ( Bailey et al., 2017; Braveman & Dominquez, 2021; Byrd & Clayton, 2000; Byrd & Clayton, 2001; Yudell et al., 2016). To reconcile this contradiction legal categories were created on the premise that Blacks were innately different, less than human, and therefore subordinate to whites because they were intellectually, and morally, inferior ( Bailey et al., 2017; Braveman & Dominquez, 2021; Byrd & Clayton, 2000, 2001). Throughout the 17th and 18th centuries scientific racism or pseudoscientific experiments, writings, and teachings reinforced the myth of white superiority and the converse myth of Black inferiority ( Byrd & Clayton, 2000, 2001). These false narrativescontributed to the structural racism in the United States and have resulted in implicit and explicit biases, discrimination, abuse, and neglect of Black patients by generations of healthcare providers ( Byrd & Clayton, 2000, 2001; Reynolds, 2020).
Inequities in the United States include stark and persistent gaps between Blacks and Whites that began over 400 years ago with chattel slavery and Jim Crow law and are ongoing, maintained by policies and practices such as redlining and racial segregation, mass incarceration and police violence, and unequal medical care ( Bailey et al., 2017, 2021). These discriminatory policies and practices share three distinguishing factors (1) they affect multiple overlapping systems, (2) they rely on false racial assumptions and stereotypes, and (3) the harms are historically grounded ( Bailey et al., 2021). In order to dismantle discriminatory/racist ideas and policies, it is critical to first learn how and why they were created and then teach learners about them using important historical context ( Churchwell et al., 2020; Jones, 2018).
Jones (2016) proposed that the attainment of health equity is an ongoing process of assurance that requires three things: (1) valuing all individuals and populations equally, (2) recognizing and rectifying historical injustices, and (3) providing resources according to need ( Jones, 2016).
Nurses have a professional and ethical obligation to dismantle systems that have been structurally designed to harm ( National Academies of Sciences, Engineering, and Medicine, 2021) . They must be taught to recognize SDH and encouraged to find their voice to call out policies and structures that contribute to SDH and acknowledge that structural racism is the root cause of health inequities. Nonmaleficence, or do no harm , is the first of the ethical principles for nurses (American Nurse Association, n.d.; National Academies of Sciences, Engineering, and Medicine, 2021) .
Evolving SDH frameworks
A complete and accurate understanding of the causes, impacts, and extent of racial health inequities is a prerequisite to intervening and evaluating on SDH ( Braverman, Egerter, et al., 2011; Braveman, Kumanyika, et al., 2011; Lavizzo-Mourey et al., 2021) .Several SDH frameworks have been developed to help health professionals, community agencies, researchers, and policymakers organize the multileveled and inextricably complex connections involved in addressing health inequity solutions ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). Over the past decade Accountable Care Organizations (ACO), value-based payment programs, and Community Based Organizations (CBO) collaborated to reduce cost and improve quality ( Artiga & Hinton, 2018). As a result, several SDH frameworks have been created to promote health equity ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022).
SDH frameworks are evidence-based models designed to help healthcare professionals, community agencies, researchers, academics, and policymakers understand, address, and evaluate the complex, intersecting, and multiple social, economic, and environmental factors that affect health and health outcomes ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). Several SDH frameworks have been created, applying specific perspectives to an array of contexts including assessing and improving population health, community well-being, rural health, health professions education, reducing health inequities, education and collaboration, and workforce development ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). As our understanding of SDH expands, the frameworks are evolving, but by and large these frameworks are derived from socioecological models or the World Health Organization (WHO) SDOH framework ( Rural Health Information Hub (RHIhub), 2022).
Socioecological models of SDH
A socioecological model broadly conceptualizes health and focuses on multiple interactions between the individual, the group/community, and the physical, social, and political environments that affect health ( Rural Health Information Hub (RHIhub), 2022).
The Dahlgren Whitehead Model developed in 1991 is a widely used socioecological model used to illustrate how economic, environmental, and social factors determine health with individuals placed at the center (Dahlgren & Whitehead, 2021). In a recent paper commemorating the 30-year anniversary of their model, the authors admit a flawed assumption of the model is that lifestyles of different socioeconomic groups are freely chosen when in fact they are structurally determined ( Dahlgren & Whitehead, 2021).
The WHO conceptual social determinant of health framework
The WHO SDOH Framework depicts how social, economic, and political factors such as income, education, occupation, gender, race, and ethnicity impact a person's socioeconomic position which then plays a role in determining health outcomes (Solar & Irwin, 2010). These factors can influence a person's ability to lead a healthy life, impacting things such as quality of housing, opportunities in the built environment that encourage physical activity , and access to healthcare services ( National Academies of Sciences, Engineering, and Medicine, 2021; Solar & Irwin, 2010). In this framework, SDH are categorized into two broad types that work together to impact health and well-being. These determinants are structural determinants, which include socioeconomic and political contexts, class, gender, ethnicity and racism, and intermediary determinants, which include the living and working conditions of people ( Solar & Irwin, 2010).
The social determinants of health and social needs model of Castrucci and Auerbach
The Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) elucidates upstream, midstream and downstream strategies to address SDH ( Castrucci & Auerbach, 2019). The downstream strategies are individual-level interventions that include disease treatent and chronic disease management. The midstream strategies address social needs including housing conditions , employment, and food security ( Castrucci & Auerbach, 2019). While downstream and midstream strategies impact individuals, upstream stretegies impact communities ( Castrucci & Auerbach, 2019; National Academies of Sciences, Engineering, and Medicine, 2021). Upstream interventions influence root causes or sociostructural factors such as policies, economics, discrimination, and racism ( Castrucci & Auerbach, 2019; National Academies of Sciences, Engineering, and Medicine, 2021).
Yearby's revised SDOH framework
Yearby's revised SDOH framework ( Yearby, 2020) is a multilayered model that includes structural racism and law, constructs that have been omitted from other models ( Yearby, 2020). Yearby's model addressed the connection between structural discrimination, law, systems, and racial health disparities and inequities ( Yearby, 2020). Yearby posits that structural racism is the way our systems are structured to advantage Whites and disadvantage racialized groups in the five key areas of the SDH ( Yearby, 2020). Yearby's model also underscores the mounting attention being given to political determinants of health ( Dawes, 2020; Ranit, 2019).
Putting it all together: nurses role in informing policy change
Public health in the United States does not have a broad mandate that addresses the SDH ( Shi & Kao, 2009). Countries vested in improving population health are likely to direct their public health efforts at addressing the SDH ( Shi & Kao, 2009). On the other hand, countries with a narrow public policy goal of treating individuals' illness are likely to direct their public health efforts at meeting immediate social needs and targeting risk factors ( Shi & Kao, 2009).
The United States does not have a national health insurance program run by the government and financed through general taxes ( Shi & Kao, 2009). While the US Department of Health and Human Services (DHHS) and Centers for Disease Control and Prevention (CDC) provide guidance and major funding to state (and sometimes local) health departments, the authority for the health of the public constitutionally resides with state governments ( Shi & Kao, 2009). State health departments craft policy and entrust the operational component to local health departments ( Shi & Kao, 2009). Although DHHS and CDC are two federal lead agencies expected to provide guidance to state and local health departments, local entities carry out essential public health services . In the United States many other agencies such as the Department of Agriculture, the Food and Drug Administration (FDA), the US Department of Labor, the Department of Energy, the Environmental Protection Agency (EPA), and the Department of Transportation are involved, all of which share a widespread agreement on the overall mission of public health. When it comes to intervention, however, there is no consensus as to what constitutes necessary public health services and coordination among and within agencies providing public health services ( Shi & Kao, 2009). No single US entity has overall authority and/or responsibility for creating, maintaining, and overseeing the nation's public health infrastructure. Policymakers across jurisdictions and levels of government do not share a vision of what public health should accomplish and who should be held accountable ( Shi & Kao, 2009).
In the United States, work to address SDH has taken place only in recent years marked notably through the Healthy People 2010, 2020, and 2030 initiatives, which acknowledge that upstream social and economic forces are involved in shaping population health and that a broader policy agenda is needed to successfully improve population health ( Ranit, 2019; Shah, 2021).
With a robust advocacy action center and a strong public policy agenda, the NLN is a leader in making an impact on public policy decisions at the national level. The NLN's objective in the public policy arena is to shape and influence those policies that affect nursing education, workforce, access, and diversity ( National League for Nursing (NLN), 2022).
The NLN's Taking Aim initiative, launched in 2020, is transforming nursing education to address the impact of structural racism and societal inequities ( National League for Nursing (NLN), 2022). The Taking Aim objectives include addressing the impact of structural racism on SDH to enable nurses to become better informed, to create a forum for nurse educators to openly dialogue about bias and racism in nursing education and healthcare, and to offer strategies for classroom and clinical instruction to prepare nurses to encounter and defuse structural racism in clinical practice ( National League for Nursing (NLN), 2022).
The NLN/Walden University College of Nursing Institute for Social Determinants of Health and Social Change was introduced in 2021 ( National League for Nursing (NLN), 2022). This innovative partnership was created to develop leaders and cultivate leadership competencies to integrate a full and complete understanding of SDH and weave social change into nursing curricula and programs. The Institute's SDH and Social Change Leadership Academy is novel to nursing education and will start in 2022. Ten selected nurse educators and interprofessional colleagues with a strong commitment to addressing the SDH and social change will engage in a year-long academy to develop as leaders to transform SDH and social change and engage in research and other scholarly activities with broad dissemination ( National League for Nursing (NLN), 2022).
Leading the future could be ours with a collective commitment to pedagogy, education, and accreditation standards that ensure knowledge of history and political participation for social change. Through education, practice, leadership, and policy the NLN is leading the way in focusing on the SDH to advance health equity.
References
1. Alderwick and Gottlieb, 2019
H. Alderwick, L.M. Gottlieb
Meanings and misunderstandings: A social determinants of health lexicon for health care systems
The Milbank Quarterly, 97 (2) (2019), pp. 407-419, 10.1111/1468-0009.12390
View at publisher View in Scopus Google Scholar
2. American Nurses Association
American Nurses Association (n.d.). Ethics and human Rights. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/.
S. Artiga, E. Hinton
Beyond health care: The role of social determinants in promoting health and health equity
Kaiser Family Foundation (May 10, 2018)
Z.D. Bailey, N. Krieger, M. Agénor, J. Graves, N. Linos, M.T. Bassett
Structural racism and health inequities in the USA: Evidence and interventions
Lancet, 389 (10077) (2017), pp. 1453-1463, 10.1016/S0140-6736(17)30569-X
View PDF View article View in Scopus Google Scholar
Z.D. Bailey, J.M. Feldman, M.T. Bassett
How structural racism works-racist policies as a root cause of U.S. racial health inequities
New England Journal of Medicine, 384 (8) (2021), pp. 768-773, 10.1056/NEJMms2025396
View at publisher View in Scopus Google Scholar
6. Braveman and Dominquez, 2021
P. Braveman, T.P. Dominquez
Abandon “race.” Focus on racism
Frontiers in Public Health, 9 (2021), pp. 1-9, 10.3389/fpubh.2021.689462
View at publisher Google Scholar
7. Braveman and Gottlieb, 2014
P. Braveman, L. Gottlieb
The social determinants of health; It's time to consider the causes of the causes
Public Health Records, 129 (Suppl. 2) (2014), pp. 19-31, 10.1177/00333549141291S206
P. Braveman, S. Egerter, D.R. Williams
The social determinants of health: Coming of age
Annual Review of Public Health, 32 (2011), pp. 381-398, 10.1146/annurev-publhealth-031210-101218
View at publisher View in Scopus Google Scholar
P.A. Braveman, S. Kumanyika, J. Fielding, T. Laveist, L.N. Borrell, R.Manderscheid
Health disparities and health equity: The issue is justice
American Journal of Public Health, 101 (Suppl. 1) (2011), pp. S149-S155, 10.2105/AJPH.2010.300062
View at publisher View in Scopus Google Scholar
P. Braveman, E. Arkin, T. Orleans, D. Proctor, J. Acker, A. Plough
What is health equity?
Behavioral Science and Policy, 4 (1) (2018), pp. 1-14, 10.1353/bsp.2018.0000
View at publisher View in Scopus Google Scholar
P. Braveman, E. Arkin, D. Proctor, T. Kauh, N. Holm
Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling
Health Affairs, 2 (2022), pp. 171-178, 10.1377/hlthaff.2021.01394
12. Braveman, 2006
P. Braveman
Health disparities and health equity: Concepts and measurement
Annual Review of Public Health, 27 (2006), pp. 167-194, 10.1146/annurev.publhealth.27.021405.102103
View at publisher View in Scopus Google Scholar
13. Breen, 2017
N. Breen
For the first time, healthy people initiative focuses on social determinants of health
National Institute on Minority Health and Health Disparities (April 20, 2017)
W. Byrd, L. Clayton
An American health dilemma: The medical history of African Americans and the problem of race: Beginnings to 1900, Vol. 1, Routledge (2000)
W.M. Byrd, L.A. Clayton
Race, medicine, and health care in the United States: A historical survey
Journal of the National Medical Association, 93 (3) (2001), pp. 11S-33S
16. Castrucci & Auerbach, 2019
B. Castrucci, J. Auerbach
Meeting individual social needs falls short of addressing social determinants of health
Health Affairs Blog (2019), 10.1377/hblog20190115.234942
View at publisher Google Scholar
17. Centers for Disease Control and Prevention, 2021
Centers for Disease Control and Prevention (CDC)
Social determinants of health: Know what affects health
U.S. Department of Health and Human Services (2021)
https://www.cdc.gov/socialdeterminants/index.htm
18. Chadwick, 1842
E. Chadwick
Report from the poor law Commissioners on an Inquiry into the sanitary Conditions of the laboring Population of Great Britain
(1842)
Retrieved on 2/27/2022 from
https://www.gutenberg.org/files/65090/65090-h/65090-h.htm
A. Chepaitis, C. Kordomenos, A. Bernacet
Social determinants of health: Language nuance matters
RTI International (April 16, 2021)
https://www.rti.org/insights/key-concepts-in-social-determinants-of-health
K. Churchwell, M.S.V. Elkind, A.P. Carson, E.K. Change, W. Lawrence, A.Mills, T.M. Odom, F. Rodriquez, E. Sanchez, A.Z. Sharrief, M. Sims, O. Williams
Call to action: Structural Racism as a fundamental driver of health disparities. A presidential advisory from the American Heart Association
Circulation, 142 (2020), pp. e454-e468, 10.1161/CIR.0000000000000936
View at publisher Google Scholar
21. Dahlgren and Whitehead, 2021
G. Dahlgren, M. Whitehead
The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows
Public Health, 199 (2021), pp. 20-24, 10.1016/j.puhe.2021.08.009
View PDF View article View in Scopus Google Scholar
22. Dawes, 2020
D. Dawes
The political determinants of health
Johns Hopkins University Press (2020)
23. Du Bois, 1899
W.E.B. Du Bois
The Philadelphia Negro: A social study
The University of Pennsylvania Press (1899)
24. Exworthy, 2008
M. Exworthy
Policy to tackle the social determinants of health: Using conceptual models to understand policy process
Health Policy and Planning, 23 (2008), pp. 318-327, 10.1093/heapol/czn022
25. Fleming, 2020
P.J. Fleming
The importance of teaching history of inequities in public health programs
Pedagoy in Health Promotion, 6 (4) (2020), pp. 253-256, 10.1177/2373379920915228
View at publisher View in Scopus Google Scholar
K. Green, M. Zook
When talking about social determinants of health, precision matters
Health Affairs (October 29, 2019)
https://www.healthaffairs.org/do/10.1377/forefront.20191025.776011/
27. Jones, 2016
C.P. Jones
How racism makes people sick: A conversation with camara phyllis Jones, MD, MPH, PhD
Kaiser Permanente Institute for Health Policy (August 2, 2016)
28. Jones, 2018
C.P. Jones
Toward the science and practice of anti-racism: Launching a national campaign against racism
Ethnicity and Disease, 28 (Suppl. 1) (2018), pp. 231-234
View at publisher Crossref View in Scopus Google Scholar
N. Krieger, J.T. Chen, B.A. Coull, J. Beckfield, M.V. Kiang, P.D. Waterman
Jim Crow and premature mortality among the US Black and White population, 1960–2009: An age period-cohort analysis
Epidemiology, 25 (4) (2014), pp. 494-504
30. Lavizzo-Mourey et al., 2021
R.J. Lavizzo-Mourey, R.E. Besser, D.R. Williams
Understanding and mitigating health inequities -Past, current, and future directions
New England Journal of Medicine, 384 (18) (2021), pp. 1681-1684, 10.1056/NEJMp2008628
View at publisher View in Scopus Google Scholar
31. Magnan, 2017
S. Magnan
Social determinants of health 101 for health care: Five plus five
National academy of medicine (NAM) perspectives. Discussion paper, National Academy of Medicine, Washington, DC (2017), 10.31478/201710c
View at publisher Google Scholar
M.G. Marmot, S. Stansfeld, C. Patel, F. North, J. Head, I. White, E. Brunner, A.Feeney, M.G. Marmot, G.D. Smith
Health inequalities among British civil servants: The Whitehall II study
The Lancet, 337 (8754) (1991), pp. 1387-1393, 10.1016/0140-6736(91)93068-k
View PDF View article View in Scopus Google Scholar
33. Marmot, 2005
M. Marmot
Social determinants of health inequities
The Lancet, 364 (9464) (2005), pp. 1099-1104, 10.1016/S0140-6736(05)71146-6
View PDF View article View in Scopus Google Scholar
34. Maxmen, 2021
A. Maxmen
Inequality's deadly toll. Nature
https://www.nature.com/immersive/d41586-021-00943-x/index.html (April 28, 2021)
35. National Academies of Sciences and Engineering and Medicine, 2021
National Academies of Sciences, Engineering, and Medicine
The future of nursing 2020–2030: Charting a path to achieve health equity
The National Academies Press, Washington, DC (2021), 10.17226/25982
View at publisher Google Scholar
36. National Academies of Sciences Engineering and Medicine, 2016
National Academies of Sciences Engineering and Medicine
A framework for educating health professionals to address the social determinants of health
National Academies Press, Washington, DC (2016), 10.17226/21923
View at publisher Google Scholar
37. National League for Nursing, 2022
National League for Nursing (NLN)
Welcome to the new
(2022)
38. Office of Disease Prevention and Health Promotion (ODPHP), 2022
Office of Disease Prevention and Health Promotion (ODPHP)
Healthy people 2020. Social determinants of health
(2022)
J.N. Olayiwola, J.J. Joseph, A.R. Glover, H.L. Paz, D.M. Gray II
Making anti-racism a core value in academic medicine
Health Affairs (August 25, 2020)
40. Ranit, 2019
M. Ranit
The social determinants of health? It's time to focus on the political determinants of health!
Medical Care, Special Commentary, 00 (00) (2019), pp. 1-3, 10.1097/MLR.0000000000001131
View at publisher Google Scholar
41. Reynolds, 2020
P.P. Reynolds
UVA and the history of race: Eugenics, the racial integrity act, health disparities
University of Virginia (January 9, 2020)
42. Rural Health Information Hub, 2020
Rural Health Information Hub (RHIhub)
Frameworks to address social determinants of health
(2020)
https://www.ruralhealthinfo.org/toolkits/sdoh/1/frameworks
43. Shah, 2021
H. Shah
Addressing the social determinants of health upstream
Loma Linda University Health. Institute for Health Policy and Leadership (June 3, 2021)
https://ihpl.llu.edu/blog/addressing-social-determinants-health-upstream
L. Shi, S. Kao
Public health, social determinants of health, and public policy
Journal of Medical Sciences, 29 (2) (2009), pp. 43-59
O. Solar, A.A. Irwin
Conceptual framework for action on the social determinants of health
WHO, Geneva, Switzerland (2010)
(Social determinants of health discussion paper 2 (policy and practice)
https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
46. Virchow, 1848
R.C. Virchow
Report on the Typhus epidemic in upper silesia
American Journal of Public Health, 96 (12) (1848), pp. 2102-2105
(2006), Excerpted from Virchow RC. Archiv für pathologische Anatomie und Physiologie und für klinische Medicin. Vol 2. Berlin, Germany: George Reimer; 1848;143–332
47. Weil, 2021
A. Weil
The social determinants of death
Health Affairs (June 3, 2021)
https://www.healthaffairs.org/do/10.1377/forefront.20200603.831955/
48. Whitehead, 1992
M. Whitehead
The concepts and principles of equity and health
International Journal of Health Services, 22 (3) (1992), pp. 429-445
https://www.jstor.org/stable/45131055
S.H. Woolf, P. Braveman
Where health disparities begin: The role of social and economic determinants and why current policies may make matters worse
Health Affairs, 30 (10) (2011), pp. 1852-1859, 10.1377/hlthaff.2011.0685
View at publisher View in Scopus Google Scholar
50. World Health Organization, 2022a
World Health Organization (WHO)
Social determinants of health
(2022)
https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
51. World Health Organization, 2022b
World Health Organization (WHO)
Taking action on the social determinants of health
(2022)
https://www.who.int/westernpacific/activities/taking-action-on-the-social-determinants-of-health
52. World Health Organization, 2022c
World Health Organization (WHO)
Constitution of the World health organization, 1946
(2022)
53. Yao et al., 2019
Q. Yao, L. Xin, F. Luo, L. Yang, C. Liu, J. Sun
The historical roots and seminal research on health equity: A referenced publication year spectroscopy (RPYS) analysis
International Journal for Equity in Health, 18 (152) (2019), pp. 1-15, 10.1186/s12939-019-1058-3
54. Yearby and Mohapatra, 2020
R. Yearby, S. Mohapatra
Law, structural racism, and the COVID-19 Pandemic
Journal of Law and the Biosciences, 7 (1) (2020), pp. 1-20, 10.1093/jlb/lsaa036
55. Yearby, 2020
R. Yearby
Structural racism and health disparities: Reconfiguring the social determinants of health framework to include the root cause
Journal of Law, Medicine, and Ethics, 48 (2020), pp. 518-526, 10.1177/1073110520958876
M. Yudell, D. Robert, R. DeSalle, S. Tishkoff
Taking race out of human genetics
Science, 351 (6273) (2016), pp. 564-565
Crossref View in Scopus Google Scholar
Cited by (4)
2024, Nursing Outlook
Citation Excerpt :
While nursing has long recognized the importance of social conditions on health, a four-dimensional upstream perspect
