Socially and economically disadvantaged populations... are the most affected by public policy and can therefore benefit the most from policies... Socially and economically disadvantaged populations, or colloquially the ‘have-nots’ in our society, are the most affected by public policy and can therefore benefit the most from policies that aim to improve social conditions that impact health (Farrer, Marinetti, Cavaco, & Costongs, 2015). The right public health policies and programs can interrupt the cycle of poverty, disadvantage, and poor health by addressing inadequate social and material resources - often called social determinants of health (SODH). SODH are necessary for better health and longer life. They form the root of the nexus between social injustice, inequalities, poor health, and shorter lives.

Why should nursing as a profession take primary responsibility to advocate for policies to improve social conditions that shape the well-being of poor and disadvantaged populations? Why should nurses concern themselves with conditions of poverty, inequalities, and social justice that reside primarily outside of the healthcare system? Simply, the very foundation of professional nursing is rooted in the fundamental concern for the social, emotional, and physical needs of the poor and disadvantaged in society (Neumann, 2010).

Socially and economically disadvantaged groups are less likely to be in good health, less likely to have access to quality healthcare services, and more likely to die prematurely when compared with socially and economically advantaged (National Center for Health Statistics, 2012; 2016; Singh, Siahpush, Azuine & Williams, 2015; Singh et al., 2017; Woolf et al., 2015). The National Academies of Science, Engineering, and Medicine (NASEM; formerly the Institute of Medicine [IOM]) summarily describe this health disadvantage as ‘Shorter Lives, Poorer Health’ (IOM, 2013).

In almost every society on the globe, the educated, employed, the socially connected, or those who have increased access to material and social resources, experience better health and longer life. In the United States, those who live in poverty, the uninsured, the disabled, and people of color endure most of the health inequities burden (Singh et al., 2017; Woolf et al., 2015). In almost every society on the globe, the educated, employed, the socially connected, or those who have increased access to material and social resources, experience better health and longer life (Lowrey, 2014; Singh et al., 2017; Singh et al., 2015). Furthermore, this health advantage is patterned along a social and economic gradient whereby as one’s status on the social and economic hierarchy increases, health progressively improves (Lowrey, 2014; Singh et al., 2015; 2017; Woolf et al., 2015).

The right policies and appropriate interventions can interrupt the cycle of poverty, disadvantage, and poor health (Aron et al., 2015; Farrer, Marinetti, Cavaco, & Costongs, 2015; Semuels, 2014; 2016). The right policies are those policies that we, as a nation, make as investments to decrease poverty and to prevent precursors of premature disease and death. Evidence-based, effective policies can ensure healthier communities and address the lack of access to social and material resources that form the root of health inequities. Nurses can advocate for the right social policies to promote justice, fairness, and health equity and adequately address SDOH.

Evidence-based, effective policies can ensure healthier communities and address the lack of access to social and material resources that form the root of health inequities. In this article, we discuss nurse advocacy on behalf of SDOH and health equity, particularly on behalf of poor and disadvantaged persons. We discuss components of the right social policies and consider evidence-based policies that have linked improvements in social and economic conditions with increased physical, emotional, and mental health outcomes among poor and disadvantaged social groups.We also highlight select social determinants of health (SDOH) and mitigating policies focus nurses’ social policy advocacy to improve the health of disadvantage populations and reduce health inequities. The conclusion offers resources and strategies to promote nurse engagement in health policy.

Nurse Advocacy to Advance Public Health and Health Equity through Targeted Social Determinants

There is substantial evidence to demonstrate an unequivocal link between social disadvantage and poor health. The World Health Organization (WHO) has defined SDOH as the conditions in which people are born, grow, live, work, and age (WHO, 2012). SDOH are shaped by the distribution of money, power, and resources at global and national levels. These SDOH are mostly responsible for health inequities, or the unfair and avoidable differences in health status seen within and between countries (WHO, 2012). SDOH include a number of factors such as socioeconomic status (SES), employment, housing, food security, transportation, education, as well as social support and the physical environment. There is substantial evidence to demonstrate an unequivocal link between social disadvantage and poor health. In fact, several researchers have reported that as much as 80% of health outcomes are attributable to social determinants (Magnan, 2017; Singh et al., 2015; 2017).

In this respect, SDOH are what Braveman and Gottlieb (2014) defined as “the causes of the causes" of disease, illness and health inequalities. The causes of the causes, or the root cause of disease, illness, and health inequities, have direct implications for nursing as a professional practice discipline. Today, the majority of nursing practice interactions and encounters occur within the context of nurses caring for individuals and their families. Nurses’ face-to-face interactions are ‘downstream,’ as opposed to ‘upstream’ encounters.

The causes of the causes... have direct implications for nursing as a professional practice discipline. There is a now famous allegory in public health that uses a river analogy to make a distinction between downstream versus upstream encounters. As the story goes, you are standing on the bank of a river and a flailing, obviously distressed person passes you. Without thinking, you jump in to grab and drag the person to the shoreline. But, before you can recover, another person comes floating by and you dive in and swim to shore with him/her as well; and then another person and yet another. They are all traumatized, and all need to be rescued and patched up to prevent them from dying. Rescuing people ‘downstream’ on the river is currently a major core function of professional nursing. The allegory continues to suggest that eventually, one exhausted rescuer (i.e., the nurse) pauses to ask, “Who keeps throwing these people into the river”? …and then proceeds ‘upstream’ to find out (Adapted from a story told by Irving Zola, as cited in McKinley, 1986).

Rescuing people ‘downstream’ on the river is currently a major core function of professional nursing. Becoming effective social policy advocates to address SDOH is how nurses navigate upstream, to find out why patients, families, and entire communities end up in the river. Every time a nurse administers a prescription medication for diabetes to a person who could not afford to eat nutritious food or participate in physical activity in a safe, walkable neighborhood—that nurse is engaging in downstream rescues. The social justice perspective argues that the greatest impacts on communities and society-at-large are made upstream by addressing the social and environmental conditions that contribute to a diagnosis of diabetes in the first place.

Gaining expert knowledge on SDOH and speaking boldly on behalf of those who are poor, disadvantaged, and vulnerable is how nurses begin to understand why some individuals, communities, and/or populations are close enough to the river edge to be impacted. Addressing SDOH means creating the social, economic, and environmental conditions in which all people enjoy optimal health and experience physical, mental, and social/emotional well-being, or health equity.

The social justice perspective argues that the greatest impacts on communities and society-at-large are made upstream... Every time a nurse administers a prescription medication for diabetes to a person who could not afford to eat nutritious food or participate in physical activity in a safe, walkable neighborhood that nurse is engaging in a downstream rescue. The social justice perspective argues that the greatest impacts on communities and society-at-large are made upstream, by addressing social and environmental conditions that contribute to a diagnosis of diabetes in the first place (Webb, 2012; World Health Organization, 2013).

The Right Social Policies

Social policies are more impactful on health and health outcomes than genetic endowment, individual behaviors, or access to healthcare services. There is a growing and robust body of evidence that links policy actions in four key social domains with improvements in well-being and reductions in health inequities. These domains are child and youth education and development; fair employment and decent work; social protection; and the living environment. Social policies are more impactful on health and health outcomes than genetic endowment, individual behaviors, or access to healthcare services (Carey & Crammond, 2015; Webb, 2012). Social policies that have the greatest impact on health include early childhood care and youth development; child poverty; inclusive economic investment strategies; and programs to enhance job readiness and promote fair, equitable, and safe work opportunities and conditions. See Table 1 for a select list of SDOH, potentially impactful policies, and opportunities for nurses to advocate on behalf of poor, disadvantaged, and vulnerable populations within these four policy-sensitive areas.

Table 1. Select Social Determinants of Health, Potential Impactful Social Policies and Nurse Advocacy Opportunities

Nurses and Social Policy Advocacy: A Partnership Perspective

...nurses cannot effectively address issues of poverty, disadvantage, and poor health alone. While nurse leaders have sounded the alarm for greater nursing engagement in the social policy arena, nurses cannot effectively address issues of poverty, disadvantage, and poor health alone (Morone, 2017; Mahoney & Jones, 2013; Persaud, 2018). Hospitals and health systems in particular are beginning to apply an inside out approach to identify and address the unmet social needs of those they serve. Thus, nurses are well suited to engage at decision-making and planning tables, and are encouraged to do so. Nurses who participate in these efforts can begin by inquiring about internal and external partnerships available to address issues such as housing instability, food insecurity, and transportation needs. It is important to determine how/if social needs are addressed in the organization’s overall strategic plan. Finally, nurses should question how they individually and collectively can make a substantive contribution to address SDOH.

Many organizations are strengthening internal... and external... partnerships to identify social needs and invest in communities. Many organizations are strengthening internal (e.g., multiple disciplines/departments) and external (e.g., nontraditional partners, community-based organizations) partnerships to identify social needs and invest in communities (Byhoff et al., 2017). A number of screening tools are available to collect data about social needs (Billioux, Verlander, Anthony & Alley, 2017; Morone, 2017; Persaud, 2018). For example, the Centers for Medicare and Medicaid Center for Medicare and Medicaid Innovation created the 10-item tool, Accountable Health Communities (AHC) Health Related Social Needs (HRSN) Screening Tool (Billioux et al., 2017). Providers and healthcare systems can use the AHC HRSN screening tool to assess social needs in five categories: housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety. Individual respondents can answer questions themselves or a parent/caregiver can assist.

Nurses, in concert with other healthcare providers, may incorporate use of a tool such as this into their daily workflow. Patients are prompted to respond to items such as:

• “What is your housing situation today?”
• “Within the past 12 months, the food you bought just did not last and you did not have money to get more”
• “In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?” (Billioux et al., 2017, questions 1, 4, & 6)

The complexity of patient social needs requires strong coordination among a wide array of disciplines and departments.These and other questions may help identify individuals with unmet health-related social needs and facilitate referrals to appropriate resources (Billioux et al., 2017). The American Academy of Nursing (AAN) Expert Panel on Informatics and Technology recommends that nurses, physicians, and other clinicians advocate to ensure that screening for the SDOH becomes standard practice, serving as a foundation to develop individualized plans of care across the continuum of care (Troseth, 2017). The complexity of patient social needs requires strong coordination among a wide array of disciplines and departments.

One exemplar of interprofessional collaboration to support the social needs of patients is from the Rush University Medical Center (RUMC). RUMC is currently pilot testing an interprofessional, team-based, partnership model to assess and address social needs of patients. Providers will use findings from the pilot to inform screening assessments of inpatients. A brief, seven-item tool assesses social needs of patients receiving healthcare in the emergency department and primary care clinics. Nurses screen inpatients for housing; utility and transportation needs; food security; and insurance status. Follow-up interventions require strong collaboration with outside agencies, as well as internal collaboration across multiple departments.

Nurses are an integral part of the screening efforts in this model and collaborate with social workers, case managers, food service personnel, and multiple other non-clinically focused departments. In addition to engaging with multisectoral partners, nurses should also align social policy advocacy efforts with a Health in All Policies (HiAP) approach to address the social and health needs of poor and disadvantaged populations.

Health in All Policies: A Comprehensive Approach

The integration of SDOH into public policies is becoming more established in the policy arena. The integration of SDOH into public policies is becoming more established in the policy arena. This collaborative approach to improve population health is a call to incorporate health considerations into the policy making process. The Health in All Policies (HiAP): Framework for Country Action mandate originated with the WHO (2013) and has since gained momentum in the U.S. and around the world. In the U.S., several state, federal and local governments have started to adopt the HiAP approach in their policies and policy decision-making. The HiAP approach to policy-making integrates SDOH known to influence health (e.g., housing, education, food security, transportation) into public policies. Multisectoral collaboration across sectors and policy areas in government is necessary to ensure success of the HiAP approach.

The HiAP approach to policy-making integrates SDOH known to influence health... into public policies. Multiple sectors, such as housing, transportation, streets and sanitation, and public education, are considering health implications when designing public policy agendas. To illustrate, the City of Chicago created a HiAP Task Force in 2017 as part of Healthy Chicago 2.0, the city’s strategic plan to achieve health equity and foster collaboration across multiple departments and agencies (Chicago Department of Public Health, 2017). On May 18, 2016, the Chicago City Council passed a HiAP resolution to help institutionalize this approach. A detailed overview of the resolution and related action plans is available in their final report (Chicago Department of Public Health, 2017).

Nurse Engagement in Policy

Nurses in all practice settings and specialties are encouraged to assume a leadership role in addressing SDOH. Such engagement complements the rich history of patient and community advocacy inherent in the nursing profession. Table 2 offers tips to enhance effective advocacy engagement and contribution to address SDOH, both at the individual and organizational level.

Table 2. Tips for Effective Health Policy Advocacy for Social Determinants of Health

Nurses interested in developing advocacy and social policy acumen are encouraged to explore resources and opportunities for education through the ANA; the Nurse Internship in Washington Program; the American Association of the Colleges of Nursing; and the National League for Nursing. In addition, the American Hospital Association has tools and resources for hospitals and health systems working to address SDOH. See Table 3 for links to these resources, and Table 4 for a list of practical ways to develop and expand your skills at the policy level.

Table 3. Nursing Association Policy Education and Training Resources

Table 4. Practical Ways to Get Involved with Policy and Advocacy

Advocacy to improve public health through the lens of social determinants is critical for nurses at the individual and collective levels. Policy advocacy and committed resources are essential to address social factors that shape population health. Searching with an upstream approach to identify the causes of the causes of health inequities (Braveman & Gottlieb, 2014) via awareness and screening in all settings is an important strategy. In addition, all nurses can use advocacy as a tool to inform and influence social policies that effectively address SDOH and promote a just and equitable society that encourage health for all. Advocacy to improve public health through the lens of social determinants is critical for nurses at the individual and collective levels.

Authors

Shanita D Williams, PhD, MPH, APRN
Email: Shanita.Williams@hrsa.hhs.gov

Shanita D Williams is deputy division director in the Northeast Health Services Division in the Bureau of Primary Health Care at the Health Resources and Services Administration. She is a social and health policy expert.

Janice M Phillips, PhD, RN, CENP, FAAN
Email: Janice_Phillips@rush.edu

Janice M. Phillips is an associate professor and director of nursing research and health equity at Rush University Medical Center.

Kirk Koyama, MSN, RN, PHN, CNS
Email: Kirk.Koyama@hrsa.hhs.gov

Kirk Koyama is a nurse consultant in the division of nursing and public health at the Health Resources and Services Administration. He oversees a national portfolio of schools of nursing interprofessional collaborative practice investments.