Policy advocacy and committed resources are essential to address social factors that shape population health. In this article, we discuss nurse advocacy to advance public health and health equity through targeted social determinants, 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. With a partnership perspective, select social determinants of health (SDOH) and mitigating policies focus nurses' social policy advocacy to improve the health of disadvantaged populations and reduce health inequities. We suggest nurses engage in multisectoral partnerships and adopt a Health in All Policies (HiAP) approach to address social and health needs of concern. The conclusion offers resources and strategies to promote nurse engagement in health policy.
Key Words: Nurse advocacy, social policy, public policy, vulnerable populations, social determinants of health, social disadvantage, economic disadvantage, social justice, health equity, social gradient, multisectoral partnerships, poverty, root cause, population health
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
Evidenced-based Programs/ Policies
Nurse Advocacy Opportunities
Child and Youth Education and Development
Early Childhood Education (ECE)
Critical period in a child’s development of personality, cognition, language, and behavior
Establishes a solid and broad foundation for lifelong learning and well-being
Children with low SES backgrounds experience increased physical, social, emotional, language, cognitive and behavioral delays
Delayed ECE is linked to depression, attention deficits, and poor academic achievement in later school years
Maternal, Infant and Child Home Visiting Programs
Early Childhood Development Programs
Early Childhood Education (pre-school/pre-K) Programs
Childcare assistance programs
Partner with ECE professionals to support ECE funding/ programs
Support universal access to quality and affordable childcare education/ services
Support high-quality free ECE for low- and middle-income families
Support publicly funded center-based programs for children 3-5 years of age
(Kirkpatrick, McIntyre, & Potestio, 2010; Osypuk, Joshi, Geronimo, & Acevedo-Garcia, 2014; Wicks-Lim & Arno, 2017)
Condition in which a child lacks basic resources such as food, clothing, and shelter that may inhibit social, emotional, language, cognitive, and behavioral development
Children experience poverty as an environment that is damaging to their mental, physical, emotional, and spiritual development
The majority of poverty-stricken children are born to poor parent(s)
The major cause of child poverty is adult poverty fueled by low education attainment, unemployment, housing instability, and food insecurity and single parent/caregiver households
Childhood poverty produces negative impacts on education, nutrition/health, psychological, and behavioral/social outcomes that persists into adulthood and subsequent generations
Programs to increase parent/caregiver education attainment /employment opportunities
Policies to supplement parental/caregiver household income (e.g., Federal Earned Income Tax Credits)
Educational development opportunities for parent/caregivers
Fair housing opportunities
Universal child health benefits/insurance
Support policies/programs to address adult/child poverty
Support programs that expand economic opportunities for disadvantaged/ rural girls
Influence policy dialogue on poverty reduction to include children’s experience of poverty, in addition to the associated negative economic and social impacts
Process that prepares a young person to meet the challenges of adolescence and adulthood and achieve his or her full potential
Activities and experiences that help youth develop social, ethical, emotional, physical, and cognitive competencies
Programs demonstrate a positive effect on youth school achievement, motivation and social behavior, especially for boys
Educational development opportunities for youth
School-based centers for disadvantaged young people
Community-based mentoring programs (e.g., Big Brothers Big Sisters of America; 4-H Clubs)
Rehabilitative and violence prevention programs
Support efforts of other youth, adults, communities, government agencies, and schools to provide opportunities for youth to enhance their interests, skills, and abilities
Support policies and legislation that advance youth development
Inject ideas and information about youth development into communications with lawmakers
Become an expert on the dynamic challenges in the youth development policy field
Fair Employment and Decent Work
Affords the wage earner and their family the most basic costs of living without need for government support or poverty programs
Policies that provide additional income can be effective in improving health
Statutory minimum wages
Fair Labor Standards Act (FLSA) Program
Support federal, state, and local minimum wage campaigns
An assurance that an individual will keep his or her job without the risk of becoming unemployed
Continuity in employment
Job security offers greater economic security and increased ability to accumulate wealth, enabling individuals to obtain healthcare when needed, to provide themselves and their families with more nutritious foods, and to live in safer and healthier homes and neighborhoods with supermarkets, parks and places to exercise—all of which can promote good health by making it easier to adopt and maintain healthy behaviors
Job/skills development & training
Family and Medical Leave Act (FMLA)
Paid parental leave
Support policies and programs that increase education and job training opportunities
Support policies that maintain employment security after the birth or adoption of a child or other major life event
Safe Working Conditions
Workplace free of known health and safety hazards to reduce the risk of accidental injury, death, or disease
Lower-paying jobs are associated with more occupational hazards, including environmental and chemical exposures (e.g., pesticides, asbestos) and poor working conditions (e.g., shift work with few breaks, potentially harmful tools) that put them at higher risk of injury and fatality
Workplace safety laws (e.g., Occupational Safety and Health Act [OSHA])
State Worker’s Compensation Programs
Support labor laws that ensure employers enforce safety standards for employees
Highest degree of education an individual has completed
A powerful and valid predictor of SES, long-term health and well-being, and quality of life
Plays a significant role to shape employment opportunities and increasing social and personal resources
Increased educational attainment leads to better employment opportunities and higher income, which are linked with better health
Supplemental funding for public education
State need grant programs
Higher Education Affordability programs such as (e.g., College Bound Scholarships)
College and career readiness programs
Recruitment and retention of adult students
Work-based learning programs
Support educational attainment policies such as Student Achievement Councils
Promote workforce training and employment services
Support Title 1 of the Workforce Investment Act
Support legislation addressing entrepreneurship education at the K-12 level
(Aron, 2015; Marr, Huang, Sherman, & DeBot, 2015; Osypuk et al., 2014; Webb, 2012; Wicks-Lim & Arno, 2017)
The unequal distribution of income and opportunity between advantaged and disadvantaged groups in society
Inequalities in income/wealth, education, nutrition, and healthcare access contribute to health inequities
Earned income tax credits
Child tax credits
Minimum wage laws
Universal health benefits/expanded health insurance
Support family income supplementation programs and policies
A person's standing or importance in relation to other people within a society
The relative rank that an individual holds, with attendant rights, duties, and lifestyle, in a social hierarchy based upon honor or prestige
Social status is linked to health outcomes; as social status increases, health and health outcomes improve
Support maternal, child, and youth development policies and programs
Support education and job training policies and programs
Affordable/ Safe Housing
(Acevedo-Garcia et al., 2004; Bambra, 2010; Ludwig et al., 2011)
Affordable dwelling is one that a household can obtain for 30 percent or less of its income. A dwelling is considered "affordable" for low-income families if it costs less than 24 percent of the area median income
Strong association between better housing conditions and better overall health, less substance abuse, less neighborhood disorder, less violence exposure, higher rates of employment, and lower rates of public assistance.
Housing Choice Voucher Program
Tenant-based rental assistance programs
Support the Fair Housing Act and policies to eliminate redlining
Support increased funding for tenant-based rental assistance programs
(Gundersen & Ziliak, 2015; Kirkpatrick et al., 2010; Webb, 2012)
The availability and adequate access at all times to sufficient, safe, nutritious food to maintain a healthy and active life
When all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life
Food insecurity in children can lead to developmental impairments and long term consequences such as weakened physical, intellectual and emotional development
Food insecurity also related to obesity for people living in neighborhoods where nutritious food are unavailable or unaffordable
School nutrition programs (e.g., National School Breakfast/Lunch Programs)
Federal nutrition programs (e.g. Supplemental Nutrition Assistance Program; Women, Infant and Child Program; Child and Adult Care Food Program)
Public-private partnerships with local farmer’s markets
Community garden initiatives
Advocate for school subsidies to support free/reduced price breakfast and lunches for school-age children
Start/support a local community garden
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
American Nurses Association
Nurse Internship in Washington
American Association of Colleges of Nursing
National League for Nursing
The American Hospital Association
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.
Shanita D Williams, PhD, MPH, APRN
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
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
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.
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