An explanation of the importance and value of taking the SDoH into consideration as a DNP-prepared nurse. Identify the one SDoH Domain you sele
Post the following:
- An explanation of the importance and value of taking the SDoH into consideration as a DNP-prepared nurse.
- Identify the one SDoH Domain you selected and explain why it is particularly important to you.
- An explanation of why and how you intend to shift your thinking and practice related to the SDoH from the patient-level to the organizational, community, and/or larger field of nursing levels. Be specific, provide examples, and cite the three scholarly resources you identified to support your points.
Note: Your posts should be substantial (500 words minimum), supported with scholarly evidence from your research and/or the Learning Resources, and properly cited using APA Style. Personal anecdotes are acceptable as part of a meaningful post but cannot stand alone as the entire post.
Read a selection of your colleagues' posts.
Shaping Nursing Healthcare Policy
A View from the Inside
2022, Pages 91-105
7 - The evolving role of social determinants of health to advance health equity
Author links open overlay panelSandra Davis
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https://doi.org/10.1016/B978-0-323-99993-9.00016-0 Get rights and content
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Abstract
Efforts are steadily increasing to address social determinants of health (SDH) within healthcare delivery systems. Policies and practices in nonhealth sectors impact health and health equity.
Therefore, the crux of health policies and interventions is a clear and accurate understanding of how and why the social determinants differentially impact health, healthcare, and health outcomes. The fundamental drivers of health inequities are the fundamental drivers of social inequities. The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects. Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new. Historical and contemporary policies have created the structures that shape the SDH and have profound and enduring effects on our patients' health, healthcare, and health outcomes. Nurses can lead social change but only with a clear understanding of SDH and its evolving role in advancing health equity.
Keywords
COVID-19
Health equity
SDH frameworks
Social determinants of health
Social needs
Structural racism
Objectives
Upon completion of this chapter, the learner will be able to:
· •
Recognize the meaning and misunderstanding of the social determinants of health (SDH)
· •
Compare and contrast SDH-related terms and concepts
· •
Explore history as groundwork for current approaches to achieving health equity
· •
Describe structural racism as a structural determinant of health and root cause of health inequities
· •
Examine evolving frameworks to address upstream interventions, policy, systems, and structures
· •
Identify nursing's role in informing policy change
Introduction
The disproportionate impact of the COVID-19 pandemic on racialized groups, the murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and others, and the months of worldwide protests over structural racism have ushered in a new national discourse (Bailey et al., 2021; Lavizzo-Mourey et al., 2021). Attention is being shifted to upstream structural drivers of long-standing injustices, policy, and how inequities are codified and reproduced (Lavizzo-Mourey et al., 2021; Yearby & Mohapatra, 2020). The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects (National League for Nursing, 2022). On May 11, 2021, the National Academics of Sciences, Engineering, and Medicine released The Future of Nursing 2020–30: Charting a Path to Achieve Health Equity (National Academies of Sciences, Engineering, and Medicine, 2021) . The report contains an urgent call to action for nurses, over the next decade, to concentrate on the SDH to advance health equity. As the nation's largest healthcare profession , nurses play a vital role in leading change so that every person has an opportunity to live the healthiest life possible ( National Academies of Sciences, Engineering, and Medicine, 2021).
Policies and practices impact health and health equity and efforts are steadily increasing to address SDH in healthcare delivery systems (Ariga & Hinton, 2018; Bailey et al., 2021). Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new ( National Academies of Sciences, Engineering, and Medicine, 2021) .Nurses can lead social change but only if they have a clear understanding of SDH and its important and evolving role in advancing health equity ( National Academies of Sciences, Engineering, and Medicine, 2021) .
The widespread movement for racial justice , along with the stark racial inequities in the impacts of COVID-19, has reinforced the nursing profession's ethical mandate to advocate for racial justice and to help combat the inequities embedded not only in the current healthcare system but across all sectors of society ( National Academies of Sciences, Engineering, and Medicine, 2021, P. 100) . Eliminating persistent, unjust, and avoidable inequities is complex (Braveman, 2006) . It involves social, political, psychosocial, and biological processes that work synergistically and inextricably over the life course, at multiple levels, and through entrenched systems and structures (Braveman et al., 2022) .Despite the inexhaustible efforts of those committed to social justice and social change, eliminating inequities to date has been seemingly unattainable (Yearby, 2020) . There is mounting evidence and an emerging groundswell of thinking that policy change, whether through dismantling existing systems or structures or creating new and innovative policies, is the solution (Braverman, Egerter, et al., 2011; Woolf & Braveman, 2011) .
The same forces that create social inequities also create health inequities and if all policy is health policy, then there is a direct connection between historical and contemporary policy to SDH and its profound and enduring effects on our patients' healthcare, and health outcomes (Bailey et al., 2017; Braveman & Dominquez, 2021; Woolf & Braveman, 2011).
Social determinants of health: the meaning and the misunderstanding
Health inequities, unfair and avoidable differences in health between individuals and groups, result in stark differences in health outcomes for certain communities (Whitehead, 1992). The SDH, commonly taught as the conditions in which people are born, grow, live, work, and age, include factors such as income, education, employment, housing, and neighborhood conditions (Centers for Disease Control and Prevention, 2021). Although it captures many powerful societal factors and societal factors account for up to 80%–90% of health and health outcomes, this definition is incomplete and evasive (Magnan, 2017; Weil, 2021). There is a second part to the definition of SDH that is often omitted, deemed inconsequential, and not discussed (Olayiwola et al., 2020; Weil, 2021).
The World Health Organization (WHO) expands this definition, describing SDH as the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life (World Health Organization, 2022a). This expanded definition adds economic policies, development agendas, cultural and social norms, social policies, and political systems to the SDH construct all of which influence the distribution of money, power, and resources locally, nationally, and globally (World Health Organization, 2022b) .
The WHO's broader definition is critical to recognizing how important historical and contemporary policies, politics, and inequities are to the creation of SDH and health inequity/equity ( Bailey et al., 2017, 2021; Lavizzo-Mourey et al., 2021). It clarifies the forces that gave rise to SDH in the first place, and accounts for how racialized groups are disproportionately burdened by the SDH ( Bailey et al., 2017, 2021; Fleming, 2020; Lavizzo-Mourey et al., 2021). It also lends insight into root causes and conveys the importance of intervening through policy ( Bailey et al., 2017, 2021; Exworthy, 2008; Lavizzo-Mourey et al., 2021). With mounting calls for nurses to lead in advancing health equity, understanding what SDH is not, becomes just as important as understanding what it is ( National Academies of Sciences, Engineering, and Medicine, 2021) .
Social determinants of health and related terms: why clarity matters
Strategies to address SDH are being discussed among the health professions across practice, research, and education (National Academies of Sciences, Engineering, and Medicine, 2016, 2021) . SDH is also being addressed outside healthcare systems by policymakers, health systems administrators, health insurance payors, and across local, state, and federal sectors ( Magnan, 2017) . A clearer understanding of SDH is emerging as multiple stakeholders converge to address concepts related to SDH (Braveman & Gottlieb, 2014; Magnan, 2017) . Clear and standardized definitions are essential to avoid confusion and conflation of terms which is particularly relevant when attempting to forge cross-sector partnerships to collaborate, coordinate, and intervene to resolve SDH issues (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019) .
SDH is not population health
SDH is not the same as population health or public health because SDH is just one factor shaping the health of a population (Alderwick & Gottlieb, 2019). Population health refers to health outcomes of a group of individuals to include the distribution of such outcomes within the group. It is also important to recognize that SDH are often taught as negative factors experienced by only some groups, but SDH may confer health benefits and can affect entire populations not just racialized, marginalized, or excluded groups ( Olayiwola et al., 2020). Public health reflects society's desire and effort to improve the health and well-being of the total population, by relying on the role of the government, the private sector , and the public, and by focusing on the determinants of population health which include SDH (Shi & Kao, 2009) .
SDH and social risk factors: closely connected but not the same
Social risk factors are the adverse social conditions associated with poor health, such as food insecurity and housing instability (Alderwick & Gottlieb, 2019). Implementing housing and food insecurity screening tools are needed to address social risk factors but do not address (a) the upstream systemic and structural determinants of health or root causes and (b) how to keep this from happening (Alderwick & Gottlieb, 2019).
SDH and social needs are two different concepts
Social needs are social conditions that individuals identify as most pressing for them (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). This construct is different from the terms above because social needs depend on individual preferences and priorities, highlighting the importance of patient-centered care and shared decision making (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). An example of social needs would be an individuals in transitional housing who cannot afford to travel for healthy food options that are not available in their neighborhood. They would identify healthy food for their family as a pressing social need. Efforts to link them with a farmers market truck that travels through their community does not address the underlying upstream systemic and structural issues that caused food insecurity in the first place.
It's important to understand the difference between upstream and downstream SDH. Upstream social determinants are the root cause of health and health outcomes while downstream social determinants are factors that are temporarily and spatially close to health and health outcomes but are influenced by upstream factors ( Braverman, Egerter, et al., 2011). Addressing SDH involves advocating for policy change that addresses social risk factors and social needs like food and housing stability (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). The upstream policies decrease the downstream social risk factors and social needs. Policymakers are the ones who can best address upstream SDH (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). However, without political will important policy change does not happen (Dawes, 2020; Lavizzo-Mourey et al., 2021; Ranit, 2019).
Social determinants of health, health disparities, health inequities, and health equity
The concept of health equity encompasses multiple dimensions including health equity, health inequality, health inequity, and health disparity (Yao et al., 2019). Over time, different ethical, philosophical, political, legal, and cultural perspectives have shaped the definitions of these terms and the definitions have evolved and expanded over time (Braveman et al., 2018). All of the terms are based on human rights and social justice principles and although often used interchangeably they have distinctly different meanings (Braveman, Kumanyika, et al., 2011). Clear definitions are important because these terms are commonly used in teaching, practice, research, leadership, and advocacy domains and shape research outcomes, health systems structures, healthcare delivery, and health outcomes ( Braveman et al., 2018).
Health equity means that everyone has a fair and just opportunity to be as healthy as possible and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances ( Braveman et al., 2018).
Health inequalities is a term that is used more internationally and is defined as avoidable and unjust differences in people's health across the population ( Braveman, 2006; Braveman et al., 2018).
Health inequities are the systematic, unnecessary, and avoidable differences in health between groups of people who have different relative positions in social hierarchies based on wealth , structural racism , power, or prestige, all of which can be shaped by policy ( Braveman et al., 2018; Whitehead, 1992).
Health disparities are the avoidable differences in health caused by structural determinants of health that drive SDH and adversely affect racialized, marginalized, or excluded groups. Health disparities include differences in overall health or unequal burden of disease and/or health outcomes between populations that are attributable to social, political, economic, and environmental factors ( Braveman, 2006; Braveman et al., 2018).
The history of social determinants of health
Minimal attention is given to the history of SDH, and history is important because it provides context from within the United States and internationally ( Yao et al., 2019). History illustrates societal concerns and acknowledgment of structural racism as a root cause of inequities; elucidates inconsistencies in evidence and action; and highlights evolving approaches to achieve health equity ( Bailey et al., 2017, 2021; Yao et al., 2019). Moreover, understanding the history of SDH is foundational to truly understanding the persistence of unjust, unnecessary, and avoidable health inequities, underscoring the meaning of the often-heard phrase, it is going to take political will for action on health equity ( Bailey et al., 2017, 2021; Churchwell et al., 2020).
The concept of SDH gained momentum in the United States in 2010 with the release of Healthy People 2020, which built on earlier work out of Europe and Canada. Initially launched in 1979, the Healthy People 10-year reports have focused on health promotion and disease prevention (Breen, 2017; Shi & Kao, 2009). Although the first report did not specifically highlight equity and disparities as important to health, the second report did. Healthy People 2020 was the first report to use social determinants to frame a conceptual understanding of health, and acknowledge that social, economic, and political factors that influence health ( Breen, 2017). Health inequities are not new, they are centuries old. SDH literature dates back over 100 years (Byrd & Clayton, 2000, 2001; Maxmen, 2021).
1800s: landmark SDH works
Chadwick (1842) published a report on the Sanitary Condition of the Laboring Population of Great Britain ( Chadwick, 1842). This report described variations in life expectancy associated with class ( Chadwick, 1842). Recommendations from this report led to the passing of the Public Health Act of 1848 in the United Kingdom (UK) ( Yao et al., 2019). Virchow (1848), reporting on the <a rel='nofollow' target='_blank' href='https://www.s
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