The social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age (World Health Organization [WHO], 2016). These conditions, socioeconomic position, residential location, environmental living conditions, occupational risks and exposures, health risk and health seeking behaviors, along with limited access to medical care, contribute to disparities in health status and health outcomes for certain individuals and groups (Braveman, 2014). Individuals who lack the economic resources to purchase goods and services and reside in neighborhoods with high concentrations of poverty, crime, have limited green space, and lack available neighborhood grocery stores are at risk for adverse health outcomes. The resources needed for health are not just limited to access to medical care but include health promoting physical and social conditions in homes, neighborhoods, and workplaces (Braveman, 2014). Differences in health outcomes are closely connected to the degrees of social disadvantage (Braveman & Gottlieb, 2014). The mere fact that a zip code can determine longevity points to evidence that social factors are powerful influences on health. Simply stated, where you live affects your health and well-being (Greenberg, 2014).
Disparities in health status and health outcomes are rooted in the environmental contexts and conditions in which people live, most often shaped by structural realities such as the distribution of wealth; power; social mores and cultural norms; economic; and political forces (Commission on the Social Determinants of Health [CSDH], 2008 & Heiman & Artiga, 2015). The SDOH and the structures that perpetuate them (structural determinants) must be acknowledged and addressed if we are ever to minimize the disparities seen in disadvantaged populations and achieve equity in health. Health equity is the commitment to eliminate the differences in health and health outcomes. One way to accomplish this is by addressing SDOH (Braveman, 2014).
Health problems begin long before patients seek a healthcare provider. Therefore, it is critical to recognize that interventions outside of the healthcare system that affect everyday life are more likely to impact health status than care rendered within institutions (Heiman & Artiga, 2015; Murray, 2017). The point in case, the United States (U.S.) spent 17.2% of its Gross Domestic Product (GDP) on healthcare while the Organization for Economic Co-operation and Development (OECD) spent an average of 9% (Schneider, Sarnak, Squires, Shah, & Doty, 2017). Despite the higher level of spending, the U.S. ranked last in overall healthcare performance and near last in access, efficiency, equity, and healthcare outcomes when compared with 11 other countries (Bort, 2017; Schneider et al, 2017; The Commonwealth Fund, n.d.).
To improve health for disadvantaged populations requires a broad range of societal sectors that extend beyond the traditional healthcare delivery system to include the social, economic, and environmental factors that influence health (Artiga & Hinton, 2018). A Health in all Policies Approach (HiAP) is an approach that examines how policies related to other aspects of living, such as transportation, minimum wage laws, and zoning for parks and recreation, influence health. A HiAP approach, when applied broadly, could ameliorate or at best buffer the impact of SDOH on the health status of individuals. This OJIN topic about SDOH begins with a discussion of policy and the HiAP approach, and continues to offer discussions related to poverty and childhood; access to care with mobile traveling; food insecurity, and finally, nursing education.
In the first article, “Nurse Advocacy: Adopting a Health in All Policies Approach,” Williams and colleagues advocate to include health in every possible appropriate policy. This multi-sectoral approach could ensure that policymakers realize the relationship between policies developed outside of the healthcare arena, such as housing, education, food security, transportation, and health. Such policies can have a profound effect on the health of those who are disadvantaged or who the authors refer to colloquially as the ‘have-nots.’ The authors postulate that nurses, as the single largest group of healthcare providers, could be powerfully influential as a unified voice when advocating for policies that improve the conditions of disadvantaged populations. The authors highlight several evidence-based strategies, which when legislated and resourced, can improve health for all.
Francis and colleagues describe the long-term health effects of children who are born to families on the lower rungs of the socioeconomic ladder. These children often lack safe places to play, run, grow, and develop. Children near or at federal poverty levels are often exposed to environmental conditions that lead to higher levels of stress. Exposed to persistent and unrelenting stressors, the children often suffer from developmental delays and behavioral issues that lead to a trajectory of chronic illnesses in the adult life. In their article, “Child Poverty, Toxic Stress, and Social Determinants of Health: Screening and Care Coordination,” the authors describe evidence-based strategies that, when implemented, buffer the toxic effects of growing up poor. Through primary prevention, advocacy, research, and outreach, the harmful consequences associated with environmental hazards (such as poor air quality and air pollution, food insecurity, and inadequate housing) were mitigated through innovative, nurse-led models of care. The strategies described within the article can improve the health of the community, have policy implications, and could also be addressed by using a HiAP approach.
The article, “Mobile Traveling Healthcare Teams: An Innovative Delivery System for Underserved Populations,” by Walker and colleagues, describes an innovative model of care, the Juntos for Better Health Program. The program provides access to healthcare services via a team of traveling healthcare providers to the communities where people live, play, work, and age. This collaborative team of interprofessional healthcare providers exemplifies multisector engagement to improve the health of communities that have a disproportionate number of residents who carry the burden of chronic diseases such as diabetes, depression, and obesity.
The article, “Addressing Food Insecurity in Chicago,” describes a specific program developed by nurses who wanted to make a difference by targeting one SDOH. Concerned with the relatively high incidence and prevalence of Americans with varying levels of food insecurity, Grenier and Wynn describe a nurse-led project to address food insecurity in the Chicago metropolitan area, the Rush Surplus Project. The project mission was to collect and distribute surplus food from hospital cafeterias to food insecure families. Over time, the project expanded to include other organizations with the subsequent development of a project guidebook for project replication.
Thornton and Persaud admonish nursing faculty to incorporate SDOH and population health in the curricula of nursing education programs. In their article, “Preparing Today’s Nurses: Social Determinants of Health and Nursing Education,” the authors issue a “call to action” for nurse faculty to equip nursing students with the requisite skills needed to address SDOH and provide clinical opportunities that teach students upstream measures to improve the health of populations. Faculty could structure clinical experiences to provide students with an appreciable understanding of the Culture of Health, the goals set forth by the Robert Wood Johnson Foundation (RWJF) that lead to improved population health, well-being, and equity (Murray, 2017; RWJF, n.d.). The authors encourage actions that could advance diversity within the nursing workforce. Visible diversity is important because healthcare providers who look like the population they serve may improve communication and trust among minority populations through language and cultural concordance. These providers may be more likely to work in resource-poor rural and urban communities where health professions shortages exist, thereby increasing provider services in underserved areas (Williams et al., 2014). This would be a step toward the achievement of equity in health.
The journal editors invite you to share your response to this OJIN topic addressing Social Determinants of Health. Please consider writing a Letter to the Editor or submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Teri A. Murray, PhD, PHNA-BC, RN, FAAN
Dr. Teri Murray is Dean and Professor at Saint Louis University School of Nursing. Dr. Murray is actively involved in workforce development and governmental affairs at state and national levels using regulatory, public, and legislative policy to promote and lead innovation in nursing education and healthcare. Her research and policy interests are focused on the social and structural determinants of health, population health, and the interplay between the social environment and health outcomes.
Artiga, S. & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. KFF Henry J Kaiser Family Foundation, May Issue Brief. Retrieved from https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
Bort, R. (2017, July 14). How bad is U.S. health care? Among high income nations, it’s the worst, study says. Newsweek. Retrieved from https://www.newsweek.com/united-states-health-care-rated-worst-637114
Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Nursing in 3D: Workforce diversity, health disparities, and social determinants of health. Public Health Reports, 2014 Supplement 2(129), 5 – 8.
Braveman, P. & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Nursing in 3D: Workforce diversity, health disparities, and social determinants of health. Public Health Reports, 2014 Supplement 2(129) 19-31.
Commission on the Social Determinants of Health (CSDH). (2008). Closing the gap in a generation. Health equity thru action on the social determinants of health. Geneva: World Health Organization. Retrieved from http://www.who.int/social_determinants/thecommission/finalreport/en/.
Greenberg, M. R. (2014). Healthography. American Journal of Public Health, 104(11), 2022. doi:10.2105/AJPH.2014.302232
Heiman, H.J. & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. The Kaiser Commission on Medicaid and the Uninsured. Washington, DC: The Henry J. Kaiser Family Foundation.
Murray, T. A. (2017). Outside the hospital walls: The social determinants and population health. Journal of Nursing Education, 56(6), 319-320. doi:10.3928/01484834-20170518-01.
Schneider, E.C., Sarnak, O., Squires, D., Shah, A, & Doty, M.M. (2017, July 14). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund. Retrieved from https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and
The Robert Wood Johnson Foundation (RWJF). (n.d.) What is the culture of health? Retrieved from http://www.evidenceforaction.org/what-culture-health
The Commonwealth Fund. (n.d.). International health care system profiles. Retrieved from https://international.commonwealthfund.org/stats/.
Williams, S.D., Hansen, K. Smithey, M., Burnley, J., Koplitz, M., Koyama, K., … Bako’s, A. (2014). Using social determinants of health to link health workforce diversity, care quality and access, and health disparities to achieve health equity in nursing. Nursing in 3D: Workforce Diversity, Health Disparities, and Social Determinants of Health, Public Health Reports, 129(2), 32-36.
World Health Organization (WHO). (2016). Social determinants of health. Retrieved from http://www.who.int/topics/social_determinants/en