ETHICS AND THE DNP-PREPARED NURSE

Abstract 

Abstract: Determinants of health (DOH) are key predictors of health, wellness, morbidity, and mortality. The more familiar  social DOH are not the only DOH. By themselves, the social DOH do not adequately explain how individuals and populations achieve and maintain  health equity or  inequity. Other DOH also exert political, economic, and institutional forces at all levels of the socioecological systems in which humans interact with their environment.

According to the American Nurses Association, the  Nursing Code of Ethics is a "non-negotiable moral standard for the profession" (Fowler, 2015a, p. viii). Provision 9 of the  Code of Ethics states that social justice is of primary concern for social ethics (p. 159) and that professional nurses are obligated to advocate for and integrate principles of social justice into nursing practice and health policy (p. 151).

In search of conceptual explanations for these phenomena, and to locate health equity/inequity within a wide array of upstream DOH, a comprehensive review of the interdisciplinary professional literature and conceptual analysis were conducted. A new conceptual framework that acknowledges nursing's collective responsibility for ethical action for transformative change was developed. The framework addresses both "further upstream" antioppression efforts and "farther downstream" efforts to remediate the impacts of health inequity.

The purpose of this Policy Watch column was to introduce a new "Expanded Conceptual Framework for Ethical Action by Nurses on the 'Further Upstream and Farther Downstream' Determinants of Health Equity" (Fornili, 2022).

INTRODUCTION

The World Health Organization ( WHO, 2022a ) defines  health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (para. 2). Note the similarities between this definition of health and the Substance Abuse and Mental Health Services Administration working definition of recovery, the primary goal of behavioral health care (for mental health and/or substance use disorders).  Recovery is not merely abstinence from substance use but rather "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential" ( Substance Abuse and Mental Health Services Administration, 2012 , p. 3). According to the American Nurses Association (ANA), health is a specific social need and  nursing was created to address that need. The ANA refers to this relationship between the nursing profession and society as  nursing's social contract; it explains expectations about what society and governments expect from nursing and what nursing should expect from them ( Fowler, 2015b , p. xi).

Determinants of health (DOH), including  determinants of substance use and recovery, refer to a wide range of factors that influence health status. Sometimes, the determinants are described using an  upstream,  downstream metaphor, with the determinants referred to as upstream causal factors, and good or poor health being the resulting downstream outcomes. Numerous determinants are responsible for health outcomes (National Academies of Sciences, Engineering, and Medicine [ NASEM], 2017 , p. 2). Many people are familiar with the term  social determinants of health (SDOH). The SDOH are defined as "the conditions in the environments in which people live, learn, work, play, worship and age that affect a wide arrange of health, functioning, and quality-of-life outcomes and risks" (p. xxiv). The SDOH include education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment, and transportation (p. xxiv).

Although the SDOH are key predictors of health, wellness, morbidity, and mortality, by themselves, they do not adequately explain how individuals and populations achieve and maintain health equity or health inequity. Other DOH also exert  oppressive political, economic, and institutional forces at all levels of the socioecological systems ( Bronfenbrenner, 1977 ) in which humans interact with each other and their environment ( Hofrichter, 2003 ;  McGibbon, 2021a, 2021b ;  Schoon & Krumwiede, 2022 ).  Systematic oppression and  structural power are "further upstream" antecedents of the structural societal and social determinants.

Health equity refers to the absence of avoidable, preventable, or remediable differences in health among groups of people ( Dawes, 2020 , p. 19;  WHO, 2021 )-the state in which the unjust burdens of disease and the just benefits of good health are equitably distributed ( NASEM, 2017 , p. 1). As  equity is closely related to "what is considered fair and just,"  inequity exists when differences in health determinants and outcomes are "systematic, unfair and avoidable" ( Penman-Aguilar et al., 2016 , p. S35). Health inequities are "systemic political obstacles" that are "baked into our systems" by discriminatory standards, practices, and beliefs ( Dawes, 2020 , p. 19).

Critical theory illustrates the often-hidden processes by which dominant power structures create inequities and maintain oppressive forms of injustice ( Chinn & Kramer, 2015 , p. 247).  Critical consciousness involves  awareness of and action against forces that limit or promote opportunities for certain groups ( Freire, 2000 ;  Jemal, 2018 ). It is "a philosophical, theoretical, and practice-based framework that has been identified as an  antidote to oppression" ( Jemal, 2018 , p. 1, italics added). Jemal presented a new construct called  transformative consciousness, composed of three domains for each level of the socio-ecosystem (awareness, behavioral response, and consequences); its aim is to help to move people in the direction of  actions to overcome and dismantle oppression.

Ethics refers to a pattern of knowing related to matters of moral and ethical significance, which is expressed in practice as moral and ethical comportment ( Chinn & Kramer, 2015 , p. 248). Reflection on these analyses improves  emancipatory knowing, that is, the understanding of the factors that create unfair and unjust social and societal conditions. Nurses strive for emancipatory knowing, because it involves understanding not only the factors that create unfair and unjust social and societal conditions but also  actions needed to change conditions in society that create inequities (p. 248). The ANA's  Nursing Code of Ethics is a "non-negotiable moral standard for the profession" that encompasses nursing's ethical values, obligations, ideals, and commitments ( Fowler, 2015a , pp. viii-ix). Provision 9 of the  Code of Ethics says that social justice is a primary concern of social ethics (p. 159), and professional nurses are  obligated to integrate principles of social justice into nursing and health policy (p. 151).

Conceptual analyses help to explain the attributes of various phenomena and the nature of how related factors affect them ( Chinn & Kramer, 2015 ). In search of conceptual explanations for these phenomena, and to locate health equity/inequity within a wide array of upstream DOH, a comprehensive review of the interdisciplinary professional literature and conceptual analysis were conducted, and a new conceptual framework was developed. One aim was to articulate obligations and expectations for nurses to ameliorate  DOH inequity and promote  DOH equity, as described within the context of the nursing code of ethics and the social contract that guides our profession. A secondary aim was to provide a guide for future research and scholarship regarding nursing interventions to impact these determinants.

The purpose of this Policy Watch column was to introduce a new "Expanded Conceptual Framework for Ethical Action by Nurses on the 'Further Upstream and Farther Downstream' Determinants of Health Equity" (Fornili, 2022). The  Framework acknowledges nursing's collective responsibility for ethical action for transformative change, including both "further upstream" antioppression efforts and "farther downstream" efforts to remediate the impacts of health inequity.

BACKGROUND

Healthy People 2030 is the fifth iteration of the Healthy People initiative since it was originally introduced in 1979. The top three overarching goals for Healthy People 2030 are to attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death; to eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all; and to create social, physical, and economic environments that promote attaining the full potential for health and well-being for all. Key foundational principles that guide the initiative are that the health and well-being of  all people and communities are essential to a thriving, equitable society and that efforts to promote health and prevent diseases encompass physical, mental, and social health dimensions ( U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion, n.d.-a ). The  2030 Agenda for Sustainable Development was developed in a global partnership and adopted by all United Nations Member States in 2015. This global initiative contains a shared blueprint for achieving 17 Sustainable Development Goals designed to improve health and education, reduce inequality, and spur economic growth ( United Nations Department of Economic and Social Affairs, n.d. ). Addressing the SDOH is key to successful achievement of the objectives for these national and global initiatives.

Dr. John McKinlay is credited with coining the classic " upstream factors" metaphor in relation to SDOH during a 1974 conference presentation where he was invited to speak about "broad social structural factors influencing the onset of heart disease and/or at-risk behavior" ( McKinlay, 2019 , p. 1). He originally published an article about these factors for the American Heart Association in  Applying Behavioral Science to Cardiovascular Risk ( McKinlay, 1975 ). However, the 1975 article remains difficult to find, so it was reprinted in 2019 as an  Occasional Classics by the Interdisciplinary Association for Population Health Science, with permission of the American Heart Association ( McKinlay, 2019 ). Dr. McKinlay described " upstream factors" as "where the real problems lie" (p. 1) and cautioned attendees about the "short-term nature and ultimate futility" of " downstream endeavors," which only treat the condition (p. 1). He defined "manufacturers of illness" as public or private entities that generate poor health and urged social scientists to pay attention to the "political economy of illness" (p. 1). He described "manufacturers of illness" that control and operate important segments of our social system "in such a way that people inevitably fail" (p. 5). He claimed that these individuals are next "blamed for not approximating the artificially contrived norm and are treated as if responsibility for their state lay entirely with them" (p. 5). He concluded that once "certain individuals and groups have 'failed', we establish at a point downstream, a substructure of services[horizontal ellipsis][the] very system which had a primary role in manufacturing the problems and need for these services in the first place" (p. 5).

Castrucci and Auerbach (2019) have presented an upstream, midstream, and downstream model. Their model views "downstream" as the  point of service for medical interventions and  screening for individual social needs as "midstream" services performed by social workers and community-based organizations. These authors pointed out that individual-level strategies can "convey a false sense of progress" (para 6) because they are often limited to a small segment of the population in a "frayed social safety net" (para 1). Those patients with the worst health and the greatest heath care costs, although not among the "sickest and most expensive," are basically ignored (para 7). Castrucci and Auerbach noted that mitigation of the acute social and economic needs of individual patients is important but inefficient. They called for "upstream tactics" to address the SDOH (laws, policies, and regulations conducive of health that produce community-level impact), as opposed to "downstream" medical interventions.

Some researchers have pointed out that an interest in the SDOH can produce a heightened interest in  individual health behaviors and the narrowly defined biomedical approaches to them, which may result in an overemphasis on  individual choice and  personal responsibility ( Short & Mollborn, 2015 , p. 2). This may make individuals more susceptible to bias, stigma, and stereotypes (p. 4). Accordingly, Short and Mollborn called for shifting from an "individual attribution approach" (p. 7) to an expanded approach that examines the complex interplay of biopsychosocial determinants (p. 1) and context-dependent societal structures, inequalities, and ideologies (p. 7).

Elizabeth McGibbon, RN, PhD, is an internationally recognized nurse and critical health scholar with extensive academic and public policy experience. She referred to the  synergies of social, ecological, and structural determinants as " wicked problems" because they are "particularly complex, persistent, and hard-to-resolve" and "nested" (co-occurring and related) problems that defy linear approaches and straightforward solutions ( McGibbon, 2021b , p. 38). She called for naming and analyzing the  root causes of health and planetary health injustices, using the  belling the cat metaphor from Aesop's fables ( McGibbon, 2021a , p. 11). In this fable, if the sly and treacherous cat is the common enemy of the mouse community, then a bell on a ribbon around the neck of the cat would at least signal the mice of the cat's approach so they could avoid becoming its victims. The fable acknowledges what an extremely difficult task it would be for a mouse to " bell the cat" (i.e., tie the bell on the cat's neck).  McGibbon (2021b) believes "belling the cat" is necessary for reframing vulnerable and at-risk populations as "people and planet  under threat" (italics added), because of social, economic, political, and cultural systems or "pathogens that threaten health" (p. 11).

The term  social murder was originally coined by Friedrich Engels in the mid-1800s. Victims of social murder are the poor and working-class people (the proletariat) whose living and working conditions deprive them of the necessities of life and cause them to meet early and unnatural deaths ( Engels, 1845/2009 ). Engels accused powerful ruling authorities and the bourgeoisie of being criminally guilty of social murder, because they held power, were responsible for their unjust and squalid conditions, and were aware of their effects, yet they did nothing to change them ( Medvedyuk et al., 2021, p. 1).

According to Engels:

When one individual inflicts bodily injury upon another such that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder. But when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live-forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence-knows that these thousands of victims must perish, and yet permits these conditions to remain, its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission. But murder it remains[horizontal ellipsis]society knows how injurious such conditions are to the health and the life of the workers, and yet does nothing to improve these conditions. That it knows the consequences of its deeds; that its act is, therefore, not mere manslaughter, but murder[horizontal ellipsis]the bourgeoisie reads these things every day in the newspapers and takes no further trouble in the matter. But it cannot complain if[horizontal ellipsis]I broadly accuse it of social murder. Let the ruling class see to it that these frightful conditions are ameliorated, or let it surrender the administration of the common interests to the labouring-class. (Engels, "The Condition of the Working Class in England," 1845/2009)

Recently, there has been a resurgence of the use of this term ( Govender et al., 2022 ;  Medvedyuk et al., 2021).  McGibbon (2021b)  described systemic risks from social pathogens and their impacts on people and planet as "modern day social murder" (p. 27). A member of parliament in London accused those responsible for the political decisions that lead to the deaths of 80+ people in the tragic Grenfell Tower fire as being guilty of social murder ( Guardian, 2017 ). It has also been used to describe cuts in social security benefits for working-aged people in Britain's "age of austerity" and governmental mishandling of the COVID-19 pandemic ( Govender et al., 2022 ;  Grover, 2019 ).

According to  Govender et al. (2022) , social murder "is driven by the capitalist economic system with its inevitable exploitative social relations" and it results from "problematic public policy without explicit reference to capitalist exploitation" (p. 63). The same authors suggested that the preferred option for building a movement to change the economic system responsible for killing massive numbers of people is to "shift power and influence from those who profit from these structures and processes" ( Medvedyuk et al., 2021, p. 11). Medvedyuk et al. also justified the use of strong, emotion-laden language like "social murder" to describe capitalist-created social inequalities, because it can increase the likelihood of evoking public reactions and class-oriented mobilization (p. 11).

THE "FURTHER UPSTREAM AND FARTHER DOWNSTREAM" FRAMEWORK

Chinn and Kramer (2015) define a  conceptual framework as a "logical grouping of related concepts or theories that is usually created as "complex mental formulation[s] of experience" (p. 159) and the term  concept as "a complex mental formulation of experience[horizontal ellipsis]perceptions of the world[horizontal ellipsis]that can be symbolically shared and verified by others with sensory evidence" (p. 160). Conceptual models are symbolic representations of experiences in the form of words and pictorial or graphic diagrams (p. 160). Conceptual definitions enhance semantic clarity (i.e., articulate clear conceptual meaning) and aid in the identification of operational (measurable) definitions or empiric indicators (p. 201).

As this is the first launch of the "Expanded Conceptual Framework for Ethical Action by Nurses on the 'Further Upstream and Farther Downstream' Determinants of Health Equity" (i.e., the Framework), only conceptual definitions are provided throughout this article (i.e., no operational definitions are specified at this time, although some may be available in the reference citations provided). More robust analyses and discourse are reserved for later discussion.

Recommended practices for measurement to advance health equity include assessing differences in health and its determinants that are associated with social position; assessing social and structural determinants, with consideration of multiple levels of measurement; and providing rationale and implications for methodological choices ( Penman-Aguilar et al., 2016 , pp. S35-S36). In recognition of the concept of  intersectionality, Penman-Aguilar and colleagues also recommended monitoring progress toward health equity by social position, assessing within-group heterogeneity, and simultaneously accounting for health conditions according to multiple forms of social status (p. S39).

One might question whether " further" upstream and " farther" downstream are grammatically correct or whether they can or should be used interchangeably. According to  Merriam-Webster's (2022)  online dictionary, historically, both terms have been used interchangeably when relating to literal or figurative distance, but "further" is preferred when used as an adjective meaning "additional." For the purposes of this Framework, "further upstream" is intended to mean "even more upstream" antecedent factors than the SDOH, and "farther downstream" is intended to mean some distance farther away or "beyond."

In this Framework, the starting point for the model's use of the upstream/downstream metaphor is the "midstream" position (see  Figure 1 , "You Are Here"). The DOH and health equity/inequity, including the SDOH, are in the "midstream" position. The "fundamental" determinants (systemic oppression and structural power) are depicted "further upstream," at the "Headwaters."

Health equity and inequity (consequences) are "downstream" from (in the causal pathway of) the determinants. In addition, "downstream" is the point where the nurse must engage in  critical reflection to acknowledge the existence of health inequity, to attain transformative consciousness about why inequity exists and how inequitable conditions can be prevented and remediated.

Simply acknowledging the existence of health inequities as well as understanding  why they exist and  how inequitable conditions can be improved is insufficient. Once an assumption is made about whether the nurse has achieved critical/transformative consciousness about health inequity, the nurse must then further go even "farther downstream" to both express an "intention" to change inequitable conditions  and to make a "decision to respond." In this Framework, "farther downstream" represents the  decisions nurses must make and the  actions nurses must take "beyond" what they may see as their usual, customary, and comfortable roles (see  Figure 1 ).

Explaining the Framework (Key Conceptual Definitions)

Further Upstream: Systemic Oppression and Structural Power

In the second edition of  Oppression: A Social Determinant of Health, Dr. Elizabeth McGibbon (editor) and other contributors describe how  systemic oppression deepens disadvantage, heightens privilege, and creates and sustains intergenerational health damage. According to  McGibbon (2021a) ,  oppression is "discrimination backed up by systemic or structural  power" (p. 21) and  structural power "is at the heart of oppression" (p. 12).

"Oppression embeds itself in everyday life through a cyclic process involving biased information, stereotyping, prejudice and discrimination" ( McGibbon, 2021a , p. 16). Multiple types of oppression work together ( intersect) to produce injustice ( Felluga, 2015, p. 173). The "cycle of oppression" is a complex process involving domination, power, and systemic discrimination, which are interconnected, synergistic, and backed up by systemic or structural power and policy-driven power relations (p. 16). Genocide, policy-created poverty, dangerous work environments, privatization, globalism, and "numerous actions and inactions" are the "interconnected mechanisms of oppression" that create and maintain systems of dominance (p. 12). Thus, the oppressor gains political, economic, or other power and advantage over others ( Bryant, 2021 , p. 157).

Oppression can be a  state (or outcome), a  condition, or a  process ( Bryant, 2021 ;  Prilletensky & Gonick, 1996).

* The  state (or outcome) of oppression occurs "when access to resources has been consistently denied" ( Bryant, 2021 , p. 156;  Watts & Abdul-Adil, 1994 ).

* The  condition of oppression is "a state of domination in which those who are oppressed endure deprivation, discrimination, and exploitation" ( Bryant, 2021 , p. 156;  Prilletensky & Gonick, 1996).

* The  process of oppression refers to "institutionalized collective and individualized forms of behavior by which one group exerts domination and control over another, especially for racialized populations in terms of living conditions and employment ( Bryant, 2021 , p. 157).

Key concepts related to oppression (in alphabetical order) are defined as follows:

*  Bias: personal and sometimes unreasoned judgment ( Merriam-Webster, 2022 )

*  Deprivation: the state of being kept from possessing, enjoying, or using something; the state of being deprived ( Merriam-Webster, 2022 )

*  Discrimination: individual or collective actions or inactions, based in prejudice, which are created, sustained, or redeployed by policy-driven power or ruling relations and structural power ( McGibbon, 2021a , p. 16)

*  Domination: supremacy or preeminence over another; exercise of ruling power; governing or controlling influence ( Merriam-Webster, 2022 )

*  Exploitation: the action of treating someone unfairly to benefit from their work; using a situation to gain unfair advantage ( Lexico-Oxford, 2022)

*  Prejudice: biased way of thinking and understanding based in stereotypes; embedded in and reinforced by policy-driven oppressive power relations, ruling relations, and structural power ( McGibbon, 2021a , p. 16)

*  Stereotype: exaggerated, oversimplified, fixed images, often negative, that can be held by persons, groups, or policy governance systems ( McGibbon, 2021a , p. 16)

*  Systemic: part of or embedded in the system itself; what relates to or affects an entire system; as opposed to "systematic," which describes something that is done according to a system or method ( Merriam-Webster, 2022 )

Power can be defined as the possession of control, authority, or influence over others ( Merriam-Webster, 2022 ). Robert Reich, in his book  The System: Who Rigged It, How We Fix It, takes this definition even further.  Reich (2020)  defines power as "the ability to direct or influence the behavior of others. On a larger scale, power is the capacity to set the public agenda" (p. 9). The "Matrix of Domination" (MoD) has been described in critical race theory and black feminist theory to describe multiple structures that work together to oppress or exploit identity groups ( Felluga, 2015, p. 173). The MoD includes four interrelated  domains of power; each domain appears across different forms of oppression, regardless of the intersections involved, and each serves a specific purpose (p. 173).

The four MoD domains of power are the following:

*  Structural: Organization of power at the macro level of social organization; reproduction of subordination over time, via "legal systems, labor markets, schools, the housing industry, banking, insurance, the news media, and other social institutions" ( Felluga, 2015, p. 173)

*  Disciplinary: Management of oppression and power relations, through social policies primarily managed through bureaucracies ( Felluga, 2015, p. 173)

*  Hegemonic: Justification of oppression ( Felluga, 2015, p. 173), through social, cultural, ideological, or economic influences exerted by a dominant group ( Merriam-Webster, 2022 )

*  Interpersonal: Power that functions through the everyday actions of individual people; systematic, routinized, recurrent, day-to-day practices of how people treat one another ( Felluga, 2015, p. 173)

Midstream: Structural Societal and Social Determinants

Various systems constantly exert both negative and positive interactive forces on individuals and groups. Health is impacted by the characteristics of these individuals and groups as well as their constant interactions with each other and their environment ( Kilanowski, 2017 ). Therefore, complex, nonlinear, multilevel, multisectoral approaches are required to address the complex, ever-changing needs of individuals, families, communities, and diverse populations ( Schoon & Krumwiede, 2022 ).

Recent scholarship indicates that although the SDOH framework can be useful for addressing various social conditions that affect health outcomes and inequalities, this approach fails to identify the specific  mechanisms through which social conditions, such as "entrenched power structures," adversely affect health ( Flynn, 2021 , p. 1). Some distinguish between the  social DOH (the more concrete factors related to inequality, the "causes of the causes" of disease) and the  societal determinants, which are macro-societal factors that  shape the SDOH ( Birn et al., 2017 , p. 287;  Flynn, 2021 , p. 1).

Bronfenbrenner (1977) described a nested socioecological systems model (SESM), often depicted in diagrams showing concentric circles, sometimes referred to as the "socioecological onion." Bronfenbrenner's SESM involves four nested systems, including the

*  microsystem (the center position, the immediate settings where the individual directly engages in activities and social roles, p. 514);

*  mesosystem ("a system of microsystems" [p. 514], in which there are interrelations among the individual's various microsystems-their family, school, church, peer groups, etc.);

*  exosystem (an extension of the mesosystem, the specific structures that "impinge on or encompass the settings in which that person is found" [p. 515], including institutions; local, state, and national governments; work settings; mass media; and informal social networks); and

*  macrosystem ("overarching institutional patterns of the culture or subculture, such as the economic, social, educational, legal and political systems,  of which the micro-, meso-, and exosystems are the concrete manifestations" [p. 515, italics added]).

In the new "Further Upstream and Farther Downstream" Framework, there are three major types of DOH, including the structural determinants, the structural "isms," and the SDOH, collectively referred to as  structural societal and social determinants. These are found in the midstream portion of the model (see  Figure 1 ), because they are downstream from the  fundamental determinants (systemic oppression and structural power) yet upstream from (in the causal pathway to) health equity and inequity.

The Framework classified the DOH using Bronfenbrenner's SESM. Accordingly, the "structural determinants" are  macrosystems level determinants, and the "structural 'isms'" and the SDOH can be  microsystem, mesosystem, and/or exosystem manifestations of them, depending on their context (how they overlap with each other and interact with each other). All three types of DOH and their subcomponent concepts overlap with or interact with each other in numerous uncountable ways. Therefore, they are depicted in the Framework as being encircled by and bound together within the larger concept of  intersectionality.

Intersectionality helps to explain how  intersecting power relationships influence social relations and individual experiences as well as why the problems discussed herein are so complex ( Collins & Bilge, 2020 ;  Lopez & Gadsden, 2016 ). According to Collins and Bilge, race, class, gender, and other power relations are not "discrete and mutually exclusive" but rather as "interrelated and mutually shaping" constructs that "build on each other and work together" and "affect all aspects of the social world" (p. 2). As  Delgado and Stefancic (2017)  describe intersectionality in their book about critical race theory, "No person has a single, easily stated, unitary identity! Everyone has potentially conflicting, overlapping identities, loyalties, and alliances" (pp. 10-11). For example, one person can be both Black and female, straight or gay, rich or poor.

Structural DOH

McGibbon (2021a) describes the  structural DOH as "the economic, social and cultural structures of society, including their temporal and spatial impacts on health" (p. 5). If structural DOH lead to inequities, these  structural inequities can be defined as the "systematic disadvantage of one social group compared to other groups with whom they coexist that are deeply bedded in the fabric of society" ( NASEM, 2017 , p. 102). The following structural determinants are provided as examples, but there are likely others.

*  Cultural determinants:  Verbunt et al. (2021) examined cultural DOH among Aboriginal and Torres Strait Islander people in Australia. They identified four factors that have positive impacts on the health of indigenous populations. These included family/community, country and place, cultural identity, and self-determination. Connections across generations and participation in community activities and events (sports, art-based cultural expression) were found to be beneficial. Verbunt et al. concluded that the cultural DOH can  positively impact the health of indigenous populations. Note the relationships between  cultural DOH and  social DOH (family, community).

*  Commercial determinants:  Kickbush et al. (2016)  define the commercial DOH as "strategies and approaches used by the private sector to promote products and choices that are detrimental to health" (p. e895). Three major concepts for the commercial DOH include  unhealthy commodities (e.g., tobacco, prescription opioids, sugar-sweetened beverages),  profit-driven diseases (e.g., lung cancer, opioid dependence, obesity), and  corporate practices harmful to health (corporate drivers including growth demand, the expanding outreach of corporations, and the internationalization of trade and capital). Kickbush et al. related the commercial DOH to Bronfenbrenner's SESM, relating key health behaviors, individualization, and choice at the micro level. The global risk society, the global consumer society, and the political economy of globalization were described as the macro-level concepts. These authors noted that  corporate influence is exerted through four channels:  marketing to enhance the desirability and acceptability of unhealth commodities,  lobbying to impede policy barriers,  corporate social responsibility strategies that "deflect attention and whitewash tarnished reputations," and  extensive supply chains, which amplify global company influence. Note the interdependent relationships between the commercial, political, and global DOH. The corporate DOH phenomenon, as described here by Kickbush et al., perfectly explains Purdue Pharma's corporate influence in the OxyContin-related prescription opioid overdose epidemic.

*  Ecological determinants (or "ecodeterminants"): These refer to the Earth's systems (atmosphere, geosphere, hydrosphere, and biosphere) and human dominance over the global environment. They impact SDOH and health equity/inequity related to pollution, ecotoxicity, resource and ozone layer depletion, ocean acidification, desertification, deforestation, species extinction, and so forth ( McGibbon, 2021b , p. 35). Note that these determinants correlate or overlap with (intersect with) the geographic or spatial DOH as well as the global DOH.

*  Geographic/spatial determinants: These determinants refer to the geographic or spatial contexts of oppression that impact SDOH and health equity/inequity related to conditions like lack of geographic access to goods and services or persistent location of toxic waste in racialized communities. They include concepts like green spaces, urban versus rural or remote, deforestation, and so forth ( McGibbon, 2021b , pp. 32-33). Note that these determinants correlate or overlap with (intersect with) the ecological and global DOH.

*  Global determinants:  Flynn (2021)  argued that the theory of global capitalism can explain "deeper societal factors that shape the more proximate social determinants" (p. 1) of global health and inequities, largely because of exploitative class relationships inherent in capitalism, colonialism, and imperialism. The theory's key concepts include transnational corporations, financialization, consumerism, transnational social classes, and the transnational state (political institutions). According to Flynn, improved understanding of the "endless drive for profits, exploitive class relations, and the commodification of nature and public goods" (p. 7) provides opportunities for scholars, practitioners, and activists to address issues that can achieve equitable improvements in health.

*  Political determinants:  Dawes (2020)  argues that the political DOH (PDOH) are "even further upstream," the "overarching influence" on all the determinants (p. 44). Dawes defines the PDOH as a "systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance equity or exacerbate health inequities" (p. 44) through "legalized discrimination" (p. 46). The PDOH consist of three major concepts-voting, government, and policy-which exacerbate inequities by affecting structures, processes, and outputs (determinants) responsible for inequity (p. 45). Of these three component concepts,  voting may be the most important upstream determinant because it installs policy makers who drive the agenda at the macro level (p. 51). Whether a state votes "blue" (Democratic) or "red" (Republican) correlates to differences in financial health and access to goods and services. Eight of 10 states most dependent on federal funds are "red states" that generally receive more federal funds than they pay in taxes. Seven of nine "blue states" have higher incomes and pay more taxes, but citizens in those states are less dependent on the government because their residents need less support ( Gordon, 2022 ).

Structural "Isms"

The  structural "isms" are known to be strong DOH ( McGibbon, 2021b ).  Carter et al. (2020)  have defined "the isms" as "any form of conscious or unconscious discrimination, prejudice, or stigmatization against a group or population of people (2020, p. 2). The "isms" include but are not limited to those listed on  Table 1 .

The more immediate effects of being the target of an ism can include "hurt feelings, closely associated with agony, suffering and anguish" ( Carter et al., 2020 , p. 2). These can lead to other emotions like anger, disappointment, mistrust, and "a desire for social acceptance while avoiding social interactions" (p. 2). Note that each of the "isms" can be associated with adverse outcomes and traumas, and each can be defined conceptually, but for the purpose of this column, only the conceptualization of  racism is provided as an example (see  Table 2 ).

Social Determinants of Health

The SDOH are defined as "non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life[horizontal ellipsis]" ( WHO, 2022b , para. 1). Most sources are in agreement that there are nine SDOH, including

* physical environment,

* public safety,

* social environment,

* transportation,

* education,

* employment,

* health systems and services,

* housing, and

* income and wealth ( NASEM, 2017 , p. 48).

According to Healthy People 2030 ( U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion, n.d.-b ). The SDOH can be grouped into five domains, including

* economic stability

* education access and quality

* health care access and quality

* neighborhood and built environment, and

* social and community context.

Causal Pathways in Which the Structural DOH Lead to Health Inequity

Numerous social, environmental, economic, and structural factors influence the inequitable distribution of the burdens of poor health and the benefits of well-being ( NASEM, 2017 ). There are two main "clusters of root causes of inequity" that NASEM described as the "terrain on which  structural inequities produce  health inequities" (p. 100). These include mechanisms that "organize the distribution of power and resources differentially across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identity," and the unequal allocation of power and resources, "the more fundamental root cause of inequity" (p. 99).

It is  traumatizing and  stressful to be the target of discrimination, prejudice, and stigmatization. In this Framework, experiencing more stress is associated with health inequity, and experiencing less stress is associated with health equity.

*  Trauma exposure has been linked to numerous adverse health outcomes ( Carter et al., 2020 ) and can predict alcohol and drug use ( Dyar et al., 2020 ;  Zapolski et al., 2021 ).  Chronic stress greatly increases the likelihood of adverse medical outcomes, including clinical depression, upper respiratory infections, allergic or autoimmune condition flare-ups, and accelerated progression of chronic diseases ( Miller et al., 2007 ).

*  Stress is defined as responses to noxious demands upon the body, which are expressed as physiological changes and overactivation of the body's normal hormonal stress or emotional systems ( Hennessy & Levine, 1979 ;  Selye, 1936 ; in  Koob, 2009 ). High levels of stress hormones disrupt and change neurological, endocrine, immune, metabolic, and genetic functioning.  Toxic stress involves relentless, prolonged activation of the stress response systems and disruption of brain architecture and other organ systems, which increase the risk for stress-related diseases and cognitive impairments that can persist across the lifespan ( Bhushan et al., 2020 ).

*  Stigma is defined as a "mark separating individuals from one another based on a socially conferred judgment that some persons or groups are tainted and 'less than'" ( Pescosolido et al., 2008 , p. 431). Effects of stigma include anxiety and depression, increased stress, decreased quality of life, interference with recovery, loss of legal rights, discrimination in medical care, and shortened life span (p. 433). Eventually, people endorse the stereotypes, internalize the stigma, and develop a low self-worth ( Richter et al., 2019 , p. 93). The Framework portrays this as "internalized oppression" (see  Figure 1 , midstream).

Taking the Northern Route (the "High Road"): Ethical Nursing Actions for Transformative Change

Antioppression is defined as "a theoretical approach and practice that equips individuals with skills to tackle complicated public health issues and systems of oppression" and brings about systemic change ( Aqil et al., 2021 , p. 345;  Lavallee, 2014 ). The point where the nurse decides whether to respond is one of the most important concepts in the model. Responding affirmatively ("yes," to take "action" for transformative, systemic change) or negatively ("no," for "inaction" and "moral bystanding") is important at two levels.

The first level is where the nurse has decided whether to make efforts to  remediate the effects of health inequity (i.e.,  farther downstream action or inaction to assist people with homelessness, wealth inequality, substance use problems, poor health, etc.). Many nurses already work comfortably at this level to make changes as a part of their day-to-day nursing practice.

At the second level, nurses can either take the "Northern Route" (the high road) at the top of the figure ( for further upstream action) or the "Southern Route" (the low road) near the bottom of the figure ( for further upstream inaction). This second level can be more difficult and less comfortable for some nurses, depending on whether they have decided to cycle back to the headwaters to address systemic oppression and structural power.

When nurses take the "Southern Route" (the low road), they may have knowingly or unknowingly chosen  inaction over potential opportunities for action. They may have knowingly or unknowingly chosen the  status quo. Nurses in the  moral bystander role ( McGibbon & Lukeman, 2019 ) can either knowingly or unknowingly be depriving themselves of opportunities to reduce morbidity and mortality and to interrupt multigenerational cycles of poverty and deprivation. It is understandable that many nurses may not know how to or may not yet feel comfortable working to dismantle oppression and power. Disrupting the status quo takes bravery, grit, and additional effort. Thus, many nurses find it easier and more comfortable to maintain the status quo.

If nurses  knowingly choose inaction over action, oppression over antioppression, or power over disruption of power, they may fail to fully adhere to the moral and ethical standards for professional nursing practice. Sadly, these nurses could be guilty of failing to prevent  social murder, at least for some individuals and some communities that are unlucky enough to suffer disproportionately from the unjust, unfair, and unhealthy conditions responsible for health inequity.

In January 2022, Americans ranked nurses the most honest and ethical professionals for the 20th year in a row ( ANA, 2022 ;  Saad, 2022 ). This is solid evidence that the public understands the normative ethics of nurses. They know that nurses have a good "moral compass"; understand right from wrong, as well as good versus evil; and can be trusted to "do what we ought to do" ( Fowler, 2015a , p. 176).

The "Northern Route" (the high road) involves a moral imperative for ethical nursing practice. It reflects nursing's primary commitment for the patient (extended to mean primary commitment for  society, i.e., "the common good"). It shows a higher level of professionalism, in accordance with nursing's sacred contract with society (or rather a sacred  covenant with society).

A future Policy Watch column will be devoted to further fleshing out the "Further Upstream, Farther Downstream" Framework. Collectively, nurses can learn to and become empowered to navigate the high road to engage in antioppressive efforts to disrupt structural power that ultimately reduce health inequity.

REFERENCES

American Nurses Association. (2022).  Amid a persistent pandemic and longstanding staffing crisis, Americans range nurses the most honest and ethical professionals[Press release].  https://www.nursingworld.org/news/news-releases/2021/amid-a-persistent-pandemic-and-longstanding-staffing-crisis-americans-rank-nurses-the-most-honest-and-ethical-professionals/ [Context Link]

Aqil A., Malik M., Jacques K., Lee K., Parker L., Kennedy C., Mooney G., German D. (2021). Engaging in anti-oppressive public health teaching: Challenges and recommendations.  Pedagogy in Health Promotion, 7(4), 344-353.  [Context Link]

Bailey Z., Krieger N., Agenor M., Graves J., Linos N., Bassett M. (2017). Structural racism and health inequities in the USA: Evidence and interventions.  The Lancet, 389, 1453-1463.  Bibliographic Links

Bhushan D., Kotz K., McCall J., Wirtz S., Gilgoff R., Dube S., Powers C., Olson-Morgan J., Galeste M., Patterson K., Harris L., Mills A., Bethell C., Burke Harris N.Office of the California Surgeon General. (2020). Roadmap for resilience: The California Surgeon General's report on adverse childhood experiences, toxic stress, and health. Office of the California Surgeon General. .  https://osg.ca.gov/wp-content/uploads/sites/266/2020/12/Roadmap-For-Resilience_CA-Surgeon-Generals-Report-on-ACEs-Toxic-Stress-and-Health_12092020.pdf [Context Link]

Birn A., Pillay Y., Holtz T. (2017).  Textbook of global health. Oxford University Press.  [Context Link]

Bonnett A. (2000).  Anti-racism. Routledge.

Braveman P., Arkin E., Proctor D., Kauh T., Holm N. (2022). Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling.  Health Affairs, 41(2), 171-178. 

Bronfenbrenner U. (1977). Toward an experimental ecology of human development.  American Psychologist, 32(7), 513-531.  [Context Link]

Bryant T. (2021). Redistributive politics and public policy. In McGibbon E. A. (Ed.),  Oppression: A social determinant of health(2nd ed., pp. 156-174). Fernwood Publishing.  [Context Link]

Butler A., Elliot T., Stopard N. (2003). Living up to the standards we set: A critical account of the development of anti-racist standards.  Social Work Education, 22(3), 271-283. 

Carter K., Crewe M., Joyner A. Mc Clain, Sheperis C., Townsell S. (2020). Educating health professions educators to address the "isms.".  NAM Perspectives, 2020, 1-5.  [Context Link]

Castrucci B., Auerbach J. (2019, January 16). Meeting individual social needs falls short of addressing social determinants of health.  Health Affairs.  https://www.healthaffairs.org/do/10.1377/forefront.20190115.234942/ [Context Link]

Chinn P., Kramer M. (2015).  Knowledge development in nursing: Theory and process(9th ed.). Elsevier Mosby.  [Context Link]

Collins P., Bilge S. (2020).  Intersectionality(2nd ed.). Polity Press.  [Context Link]

Comas-Diaz L., Hall G., Neville H. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue.  American Psychologist, 74(1), 1-5. 

Corneau S., Stergiopoulis V. (2012). More than being against it: Anti-racism and anti-oppression in mental health services.  Transcultural Psychiatry, 49(2), 261-282. 

Dawes D. (2020).  The political determinants of health. Johns Hopkins University Press.  [Context Link]

Dei G. (2005). Unmasking racism: A challenge for anti-racist educators in the 21st century. In Karumanchery L. (Ed.),  Engaging equity: New perspectives on anti-racist education(pp. 135-148). Detselig Enterprises, Ltd.

Delgado R., Stefancic J. (2017).  Critical race theory: An introduction(3rd ed.). New York University Press.  [Context Link]

Dovidio J., Pearson A., Penner L. (2019). Aversive racism, implicit bias, and microaggressions. In Torino G., Rivera D. (Eds.),  Microaggression theory: Influence and implications(pp. 16-31). John Wiley & Sons.

Dyar C., Sarno E., Newcomb M., Whitton S. (2020). Longitudinal associations between minority stress, internalizing symptoms, and substance use among sexual and gender minority individuals assigned female at birth.  Journal of Consulting & Clinical Psychology, 88(5), 389-401.  http://dx.doi.org/10.1037/ccp0000487 [Context Link]

Engels F. (1845/2009).  The condition of the working class in England. Penguin Classics.  https://www.marxists.org/archive/marx/works/1845/condition-working-class/ch07.htm [Context Link]

Felluga D. (2015).  Critical theory: The key concepts. Routledge.  [Context Link]

Flynn M. B. (2021). Global capitalism as a societal determinant of health: A conceptual framework.  Social Science and Medicine, 268, 1-8.  [Context Link]

Fowler M. (2015a).  Guide to the code of ethics for nursing with interpretive statements: Development, interpretation and application(2nd ed.). American Nurses Association.  [Context Link]

Fowler M. (2015b).  Guide to nursing's social policy statement: Understanding the profession from social contract to social covenant. American Nurses Association.  [Context Link]

Freire P. (2000).  Pedagogy of the oppressed(30th anniversary ed.). Continuum (Original work published 1970).  [Context Link]

Gordon D. (2022).  Return on statehood: How much value every state gets from the federal government. Moneygeek.  https://www.moneygeek.com/living/states-most-reliant-federal-government/ [Context Link]

Govender P., Medvedyuk S., Raphael D. (2022). Mainstream news media's engagement with Friedrich Engle's concept of social murder.  Communication, Capitalism, & Critique (tripleC), 20(1), 60-81.  [Context Link]

Grover C. (2019). Violent proletarianization, social murder, the reserve army of labor and social security 'austerity' in Britain.  Critical Social Policy, 39(3), 335-355.  [Context Link]

Guardian. (2017).  John McDonnell says Grenfell Tower disaster was 'social murder'.  https://www.theguardian.com/uk-news/2017/jul/16/john-mcdonnell-says-grenfell-tower-disaster-was-social-murder [Context Link]

Hardeman R., Homan P., Chantarat C., Davis B., Brown T. (2022). Improving the measurement of structural racism to achieve antiracist health policy.  Health Affairs, 41(2), 179-185. 

Hennessy J., Levine S. (1979). Stress, arousal, and the pituitary-adrenal system: A psychoendocrine hypothesis. In Sprague J., Epstein A. (Eds.),  Progress in psychobiology and physiological psychology(8th ed., pp. 133-178). Academic Press.  [Context Link]

Hofrichter R. (2003). The politics of health inequities. In Hofrichter R. (Ed.),  Health and social justice: Politics, ideology, and inequity in the distribution of disease(pp. 1-56). Jossey-Bass.  [Context Link]

Jemal A. (2018). Transformative consciousness of health inequities: Oppression is a virus and critical consciousness is the antidote.  Journal of Human Rights and Social Work, 3(4), 202-215.  [Context Link]

Kickbusch I., Allen L., Franz C. (2016). The commercial determinants of health.  The Lancet, 4(12), e895-e896.  [Context Link]

Kilanowski J. (2017). Breadth of the socio-ecological model.  Journal of Agromedicine, 22(5), 295-297.  Bibliographic Links [Context Link]

Koob G. (2009). Brain stress systems in the amygdala and addiction.  Brain Research, 1293, 61-75.  Bibliographic Links [Context Link]

Lavallee L. (2014). Anti-oppression research. In Coghlan D., Brydon-Miller M. (Eds.),  The SAGE encyclopedia of action research(pp. 41-44). Sage.  [Context Link]

Lexico-Oxford. (2022).  English dictionary.  https://www.lexico.com/ [Context Link]

Lopez N., Gadsden V. (2016). Health inequities, social determinants, and intersectionality.  National Academy of Medicine Perspectives, 6, 1-15.  https://doi.org/10.31478/201612a [Context Link]

McGibbon E., Lukeman S. (2019). Critical social justice: The moral imperative for critical perspectives in nursing.  The Canadian Journal of Critical Nursing Discourse, 1(1), 3-12.  [Context Link]

McGibbon E. A. (2021a).  Oppression: A social determinant of health. In McGibbon E. A. (Ed.),  Oppression: A social determinant of health(2nd ed., pp. 4-21). Fernwood Publishing.  [Context Link]

McGibbon E. A. (2021b). People and planet under threat: Social, ecological, and structural determinants of health. In McGibbon E. A. (Ed.),  Oppression: A social determinant of health(2nd ed., pp. 25-43). Fernwood Publishing.  [Context Link]

McKinlay J. B. (1975). A case for refocusing upstream-The political economy of illness. In Enelow A. J., Henderson J. B. (Eds.),  Applying behavioral science to cardiovascular risk(pp. 7-17). American Heart Association.  [Context Link]

McKinlay J. B. (2019). A case for refocusing upstream-The political economy of illness.  IAPHS Occasional Classics, 1, 1-10.  https://iaphs.org/wp-content/uploads/2019/11/IAPHS-McKinlay-Article.pdf

Medvedyuk S., Govender P., Raphael D. (2021). The reemergence of Engels' concept of social murder in response to growing social and health inequalities.  Social Science & Medicine, 289, 114377.  [Context Link]

Merriam-Webster. (2022).  Online dictionary.  https://www.merriam-webster.com/ [Context Link]

Miller G., Chen E., Zhou E. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans.  Psychological Bulletin, 133(1), 25-45.  Bibliographic Links [Context Link]

National Academies of Sciences, Engineering, and Medicine. (2017).  Communities in action: Pathways to health equity. National Academies Press.  [Context Link]

National Commission to Address Racism in Nursing. (2021).  Defining racism.  https://www.nursingworld.org/~49f737/globalassets/practiceandpolicy/workforce/commission-to-address-racism/final-defining-racism-june-2021.pdf

Penman-Aguilar A., Talih M., Huang D., Moonesinghe R., Bouye K., Beckles G. (2016). Measurement of health disparities, health inequities, and social determinants of health to support the advancement of health equity.  Journal of Public Health Management and Practice, 22, S33-S42.  [Context Link]

Pescosolido B., Martin J., Lang A., Olafsdottir S. (2008). Rethinking theoretical approaches to stigma: A framework integrating normative influences on stigma (FINIS).  Social Science & Medicine, 67, 431-440.  [Context Link]

Prilletensky I., Gonick L. (1996). Politics change, oppression remains: On the psychology and politics of oppression.  Political Psychology, 17(1), 127-148.  [Context Link]

Reich R. (2020).  The system: Who rigged it, how we fix it. Vintage Books Penguin Random House.  [Context Link]

Richter L., Vuolo L., Salmassi M. (2019). Stigma and addiction treatment. In Avery J. D., Avery J. J. (Eds.),  The stigma of addiction: An essential guide(pp. 93-130). Springer.  [Context Link]

Saad L. (2022).  Military brass, judges among professions at new image lows. Gallop.  https://news.gallup.com/poll/388649/military-brass-judges-among-professions-new-image-lows.aspx [Context Link]

Schoon P. M., Krumwiede K. (2022). A holistic health determinants model for public health nursing education and practice.  Public Health Nursing. 1-8.  [Context Link]

Selye H. (1936). A syndrome produced by diverse nocuous agents.  Nature, 138, 32.  [Context Link]

Short S., Mollborn S. (2015). Social determinants and health behaviors: Conceptual frames and empirical advances.  Current Opinion in Psychology, 5, 78-84.  [Context Link]

Substance Abuse and Mental Health Services Administration. (2012). SAMHSA's working definition of recovery.  https://store.samhsa.gov/sites/default/files/d7/priv/pep12-recdef.pdf [Context Link]

Torino G., Rivera D., Capodilupo C., Nadal K., Sue D. (2019). Everything you wanted to know about microaggressions but didn't get a chance to ask. In Torino G., Rivera D. (Eds.),  Microaggression theory: Influence and implications(pp. 1-15). John Wiley & Sons.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.-a).  Healthy People 2030 framework.  https://health.gov/healthypeople/about/healthy-people-2030-framework [Context Link]

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.-b).  Social determinants of health.  https://health.gov/healthypeople/priority-areas/social-determinants-health [Context Link]

United Nations Department of Economic and Social Affairs. (n.d.).  Sustainable development: Do you know all 17 SDGs? https://sdgs.un.org/goals#goals [Context Link]

Verbunt E., Luke J., Paradies Y., Bamblett M., Salamone C., Jones A., Kelaher M. (2021). Cultural determinants of health for Aboriginal and Torres Strait Islander people-A narrative overview of reviews.  International Journal for Equity in Health, 20(1), 181.  [Context Link]

Watts R. J., Abdule-Adil J. (1994). Psychological aspects of oppression and socio-political development: Building young warriors. Newby R., Manley T. (Eds.),  The Poverty of Inclusion, Innovation and Interventions: The dilemma of the African-American underclass. Rutgers University Press.  [Context Link]

Williams M., Metzger Leins, C., DeLapp C. (2018). Assessing racial trauma within a DSM-5 framework: The UConn racial/ethnic stress and trauma survey.  Practice Innovations, 3(4), 242-260. 

World Health Organization. (2021). Health equity and its determinants: It's time to build a fairer, healthier world for everyone, everywhere.  https://cdn.who.int/media/docs/default-source/world-health-day-2021/health-equity-and-its-determinants.pdf?sfvrsn=6c36f0a5_1&download=true [Context Link]

World Health Organization. (2022a). Health and well-being.  https://www.who.int/health-topics/social-determinants-of-healthhttps://www.who.int/data/gho/data/major-themes/health-and-well-being [Context Link]

World Health Organization. (2022b). Social determinants of health.  https://www.who.int/health-topics/social-determinants-of-health#tab=tab_3 [Context Link]

Zapolski T., Rowe A., Clifton R., Khazvand S., Crichlow Q., Faidley M. (2021). Examining the unique and additive effect of trauma and racial microaggressions on substance use risk among Black young adults.  Cultural Diversity & Ethnic Minority Psychology. 1-13. Advance online publication.  [Context Link]

Keywords: Determinants of Health; Health Equity; Health Inequity; Nursing Code of Ethics; Nursing's Social Policy; Oppression; Social Murder; Upstream Determinants of Health

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