After studying Module 5: Lecture Materials & Resources, discuss the following: Based on viewing the Johnson & Johnson video, what are your thoughts about health care inequalities

Michael L. Jones, PhD, MBA, RN

The Social Determinants of COVID-19

Abstract: According to the Centers for Disease In a recent CDC Morbidity and Mortality Weekly Control and Prevention ( CDC ), coronavirus disease of Report ( MMMR), cited by McLaughlin ( 2020), it was 2019, also known as COVID- 19, has become a major revealed that African Americans are especially impacted health crisis of our time . Millions of individuals have by COVID – 19 . In a study conducted in New York City , been diagnosed with the disease , and hundreds of death rates among African Americans were 92 . 3 deaths thousands have died of the disease . Although there is per 100 ,000 , compared to 74 . 3 deaths per 100 ,000 for currently no vaccine to address this condition, there Hispanic/Latino Americans , 45 . 2 deaths per 100 ,000 are therapeutic options available to caregivers . Even for Whites , and 34 . 5 deaths for Asian – Americans . so , the most efective defense against COVID- 19, Documentation of the disproportionate impact on African according to the CDC , is prevention, and the primary Americans has been made nationwide and in similar means of preventing COVID- 19 is through addressing studies (" CDC COVID data tracker," 2020). the social determinants of health ( SDOH ). Nurses are at Differences in health between racial groups , also the forefront of addressing SDOH . The purpose ofthis known as health disparities . most often are closely related article is to examine the effects of COVID- 19 and to link to financial and social conditions . The CDC explains , them to SDOH . "The conditions in which people live , work , and play

contribute to our health. These conditions, over time, lead Key Words : Nursing , Community, Public, Prevention, to different levels of health risks , needs , and outcomes Environment , Social Determinants of Health, SDOH , among some people in certain racial and ethnic minority Coronavirus , COVID- 19 groups" (" Health equity considerations …," 2020 ). In

many instances, this is further exacerbated in minority groups compared to Whites. During emergencies in public health, such as with COVID-19, groups such as African

According to the Centers for Disease Control Americans often lack the necessary resources to prepareand Prevention (CDC), coronavirus disease of and survive during a pandemic. Their ability to prepare2019, also known as COVID-19, is a highly for and respond to outbreaks such as COVID-19 is often contagious virus that typically initially affects the compromised by factors include living conditions, work upper respiratory tract. COVID-19 has become a major life, underlying health conditions, and access to care. disease worldwide and has had a devastating impact on Social conditions and the environment are major drivers populations globally. At the time of this article, there in the impact of COVID-19 on ethnic minorities. This are approximately 6.3 million individuals in the United correlation of factors is known as the Social Determinants States who have been diagnosed with COVID-19, and of Health (SDOH). The purpose of this article is to approximately 189,000 deaths related to the disease provide an overview of the SDOH and their relationship ("CDC COVID data tracker," 2020). COVID-19 has to the pandemic of COVID-19 in the United States. been especially detrimental to racial and ethnic minority groups, who bear a disproportionate burden of illness SOCIAL DETERMINANTS OF HEALTH (SDOH) and disease related to the disease ("Health equity According to Healthy People 2020 ("Social considerations…," 2020). determinants of health, 2020), "social determinants

of health are conditions in the environments in which people are born, live, learn, work, plan, worship, and age

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that impact a wide range of health, functioning, and As mentioned earlier, COVID-19 has had a quality-of-life outcomes and risks." Social, economic, disproportionate impact on African Americans. When and physical conditions along with the settings of work, compared to other ethnic and racial groups, African church, school, place of work, and one's neighborhood Americans tend to have a higher percentage of individuals are referred to as "place." Each of these issues work living in poverty; as such, access to adequate health together to have a direct impact on the health outcomes insurance is greatly limited. It follows that an individual's of individuals and communities. When communities are ability to seek testing and treatment related to COVID-19 equipped with the necessary resources, health outcomes is also greatly limited. According to the Centers for are often positive. Affordable housing, safe public Disease Control and Prevention ("Health equity spaces, healthy food availability, access to healthcare considerations…," 2020), African Americans are twice as services, and toxin-free environments are examples likely to not have health insurance. of such resources. Healthy People 2020 identify In addition to not having adequate health insurance, and outline two basic types of determinants: social there is also the issue of individuals who are considered determinants and physical determinants. Examples of the "working poor." These are individuals who make social determinants include access to healthcare, public too much to qualify for government insurance programs safety, social support, literacy, culture, and education. but do not make enough to afford health insurance Physical determinants include the design of housing independently or through their employer. These same and communities, access to communities for individuals individuals tend to work on jobs which do not offer paid living with disabilities, schools, places of work, and the time off. This compels individuals to prioritize their basic level of exposure to toxins within communities (Healthy necessities, such as food, utilities, and healthcare services. People 2020). In many instances, the basic necessities of food and

There are five key attributes of the SDOH. They utilities take priority over healthcare services. include the following: According to the Centers for Disease Control and 1. Economic Stability Prevention ("CDC COVID data tracker," 2020), critical 2. Education workers are at a far greater risk of contracting COVID- 19 3. Social and Community Context 4. Health and Healthcare 5. Neighborhood and Built Environment

Table 1. Key attributes and factors of SDOH

These five key attributes are discussed in detail Attributes Factors below as they relate to COVID- 19 in African American Economic Stability • Employment communities. Please refer to Table 1 for details regarding • Food Insecurity the key attributes and factors of SDOH. • Housing Instability

• Poverty LINKAGES BETWEEN COVID-19 AND SDOH Education • Early Childhood

The following sections discuss each attribute of Education and DevelopmentSDOH and its connection to COVID-19, with the

• Enrollment in Higher objective of understanding the nature of the impact Education of COVID-19 on minority communities. These • High School Graduation communities have been characterized as having less • Language and Literacy than optimal social determinants and are therefore less Social and • Civic Participation conducive to positive health outcomes. Community Context • Discrimination

• Incarceration Economic Stability • Social Cohesion

An individual's or a community's health outcomes Health and • Access to Health Care are greatly impacted by finances and economics. The Healthcare • Access to Primary Care economic attributes of a community have an impact on • Health Literacy whether or not an individual has access to healthcare Neighborhood and • Access to Healthy

Built Environment Foodsservices. In most instances, ethnic minorities are on • Crime and Violencethe lower end of the income spectrum and thus have • Environmentalless than optimal health outcomes. The provision of

Conditionsemployment opportunities, housing, and the reduction • Quality of Housing of poverty is essential to ensuring healthy communities Source: Healthy People 2020 ("Social determinants of health," 2020).

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compared to nonessential workers. African Americans individuals may be reluctant to utilize certain health make up the majority of those individuals categorized as services. critical or essential workers, placing them at a far greater risk of being impacted by COVID-19. This is particularly Social and Community Context relevant to the service industry, comprising retailers, Engagement in civic participation is important for grocery stores, restaurants, other food and service positive health outcomes in communities, according to organizations, and agricultural workers. Compared to Healthy People 2020 ("Social determinants of health," 16% of Whites, approximately 25% of the Hispanic and 2020). Engagement in civic activities within communities African American workforce is employed in the service assists in building trust and solid networks within industry. As mentioned, minorities are dying at a greater communities. Access to networks lead to enhanced use rate when compared to whites ("CDC COVID data of the various resources in communities, such as access tracker," 2020). to healthcare serves, government welfare programs, and

Individuals living in poverty may also have limited support groups. Further, civic participation includes access to personal protective supplies such as face beneficial activities such as volunteering, voting, and masks and hand sanitizer. The Centers for Disease participation in group activities. Control and Prevention ("Health equity considerations," As it relates to COVID-19, individuals who 2020) highlights the importance of the use of personal mistrust the health system, according to the Centers protective supplies to prevent and slow the spread of for Disease Control and Prevention ("Health equity COVID-19. The lack thereof may lead to an increase in considerations…," 2020), tend to have poorer than the incidence of the disease. usual health outcomes. This is especially true of African

Americans living in areas with a history of racial Education segregation and discrimination. An example of such is

When an individual or a community is provided in the rural South. Because these residents mistrust the with a good educational system, their ability to obtain health care system, the likelihood increases that their meaningful employment is enhanced. When an individual health would be greatly compromised. As such, diseases has meaningful employment, their access to health and such like COVID-19, coupled with the presence of health care services is also enhanced. underlying conditions, would have a greater impact on

The issue of health literacy is also a major factor. those communities. According to the Patient Protection and Affordable Care Act of 2010, Title V, ("What is health literacy?" 2020), Health and Healthcare "health literacy is the degree to which an individual Health outcomes, according to Healthy People 2020 has the capacity to obtain, communicate, process, and ("Social determinants of health…" 2020), are more understand basic health information and services to make positive when individuals have access to health and appropriate health decisions." Limited health literacy healthcare services. For example, in most poor and leads to poor health outcomes as individuals lack the underserved communities, Federally Qualified Health ability or knowledge to navigate the health systems or to Centers (FQHC) provide access to care services including put practices in place that lead to good health outcomes. dental, medical, transportation, and social services According to the Centers for Disease Control and that otherwise would not be available According to the Prevention ("CDC COVID data tracker," 2020), Health Resources and Services Administration ("Social COVID-19 has had a disproportionate impact on determinants of health," 2020), FQHCs, also known as individuals with underlying medical conditions, such Community Health Centers (CHCs), often provide the as hypertension, diabetes, and obesity. Inadequate only health care option for many vulnerable populations. health literacy often leads to individuals not having the Vulnerable populations include individuals who face capacity to manage their conditions, thus leading to an barriers to health care for reasons includinp geographical, exacerbation of these conditions and ultimately death. cultural, linguistic, or socioeconomic issues ("Health When individuals do not have sufficient skills to navigate center program…," 2020). For approximately 50 years in the health system or to understanding of a disease such as the United States, CHCs have provided comprehensive COVID-19, these individuals may not seek COVID-19 healthcare services, including medical, dental, pharmacy, testing, thus leading to an unmanaged disease and and transportation. CHCs accept patients with various possibly disease-related mortality. Additionally, there types of insurance; those without health insurance are is the stigma and mistrust of the healthcare system. provided services based upon a sliding fee scale, which

"

One's level of education tends to limit the ability to fully is based upon income levels ("Health center program. .., understand how the health system operates. In such cases, 2020). In many communities of color, access to health

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services is often lacking. As such, health outcomes The CDC points to residential segregation as being are compromised ("Health equity considerations…," one of the most common causes of health disparities 2020). It is important to note that 93% of the CHCs ("Health equity considerations…," 2020). This means in the United States were consistent in meeting or that minorities are shut out from quality housing and exceeding many of the Healthy People 2020 goals in resources needed to achieve parity with the majority 2018 ("Health center program…," 2020). This further group. As a result, the impact of disease such as validates their importance to poor and underserved COVID-19 is even greater. Residential segregation communities. also has an impact on access to healthcare facilities

It has been well established that those persons where prevention and treatment services are offered, with underlying medical conditions are dying thus making disease prevalence higher when compared disproportionately due to COVID-19. When to other areas where residential segregation does not healthcare services such as those offered through exist. Additionally, those individuals living in homes CHCs are not found within a community, access to where several generations are present, have an increased care is greatly compromised. Although there are well likelihood of contracting a disease such as COVID-19. over a thousand CHCs throughout the United States, Ultimately, when space is limited due to the number of there are many communities, especially in rural areas, individuals living within a household, social distancing without access to services that would be found in is more challenging to achive. Minorities are more these clinics for the poor and underserved. In this likely to live in multigenerational homes than their instance, a disease such as COVID-19 can wreak white counterparts. Similarly, this is also true of the high havoc on the citizens of those communities, which has density conditions of incarceration, in which minorities occurred during this global pandemic (CDC COVID are more highly represented (Centers for Disease Control data tracker, 2020). and Prevention, 2020).

Neighborhood and Built Environment SUMMARY This attribute is similar to social and community According to Healthy People 2020, addressing the

context because the interface with the community is many health issues in our society requires us to do so important to ensuring positive health outcomes. It through the lens of where individuals live, work, and also overlaps with the attribute of economic stability play; this is known as the Social Determinants of Health as it has to do with food and housing insecurities. or SDOH ("Social determinants of health…," 2020). This According to Healthy People 2020 ("Social article clearly identified the five key SDOH, and provided determinants of health," 2020), air pollution, water a link between the SDOH and the health outcomes of contamination, and weather extremities (hot or a community, specifically related to COVID-19, which cold), have a direct impact on the health outcomes of has become a global pandemic. Racial and ethnic individuals and communities. As such, communities minorities most often succumb to health issues related to must be built and must be conducive to obtaining the environments in which they live, and individuals in good health outcomes. For example, there must be more densely populations tend to have more significant opportunities for exercising (e.g., walking trails and negative health outcomes. COVID-19 disproportionately biking trails), access to fresh fruits and vegetables, impacts minority communities, specifically African and accessibility to health clinics such as CHCs in American.. As our nation continues to battle this deadly ethnic minority communities. disease, doing so through the lens of the SDOH is key.

According to the Centers for Disease Control and According to the American Nurses Association, Prevention ("Health equity considerations…," 2020), nurses play a key role in every aspect of healthcare. the living conditions of individuals and communities Not only do nurses provide highly skilled quality care are directly related to the number of COVID-19 at the bedside, they are also crucial to the safeguarding cases within that particular community. Individuals of public health ("What is nursing?" 2020). COVID-19 living in densely populated areas are at a greater is certainly a major public health concern. Utilizing the risk of contracting COVID-19 than those living nursing process, nurses are key to making a significant in more sparsely populated areas. Minorities are impact on the COVID-19 pandemic. This may range more likely to live in densely populated areas when from conducting COVID testing, educating communities compared to their White counterparts. This creates a and patients, conducting research, and educating future barrier to social distancing, which has been deemed nurses, in efforts to support the nursing workforce as it one of the most successful preventive activities addresses the many healthcare issues facing our nation, to slow the spread of COVID-19 ("Health equity including COVID-19. considerations…," 2020).

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REFERENCES What is nursing ? ( 2020 ). American Nurses Association . https :// www .

nursingworld.org/practice-policy/workforce/what-is-nursing CDC COVID data tracker . ( 2020 , September 8 ). Centers for Disease

Control and Prevention. http://www.cdc.gov/coronavirus/2019- ncov/cases-updates/cases-in-us.html

Health equity considerations and racial and ethnic minority groups (2020, July 24). Centers for Disease Control and Prevention. http://www.cdc.gov/coronavirus/2019-ncov/need-extra- precautions/racial-ethnic-minorities.html

What is health literacy '? (2019, October 23 ). Centers for Disease Control and Prevention. http://www.cdc.gov/healthliteracy/ learn/index.html

Health center program : Impact and growth. ( 2020 ). Health Resources and Services Administration. http://bphc.hrsa.gov/about/ healthcenterweek.html

Social determinants of health. ( 2020 ). Healthy People 2020 . http :// www.healthypeople.gov/2020/topics-objectives/topic/social- determinants-of-health

McLaughlin , K . ( 2020 , June 25 ). COVID- 19 exposes health inequities . Cancer Today. https://www.cancertodaymag.org/Pages/cancer- talk/COVID-19-Exposes-Health-Inequities.aspx

Michael L . Jones , PhD , MBA , RN, is Assistant Professor of Nursing and Coordinator of the Entry Level Master of Science in Nursing (ELMSN) program at Brenau University. Michael has served in various capacities throughout his 20-year career in health care and nursing, including faculty positions in Nursing and Public Health. Dr. Jones received his formal education at Hampton University and the University of Mississippi Medical Center.

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