Provide a brief synopsis of the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
Provide a brief synopsis of the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
Chapter1: Taking Risks And Making Profits Within The Dynamic Business Environment
Section: Chapter Questions
Problem 1CE
Related questions
Question
Provide a brief synopsis of the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
![IN PRACTICE
women's health
Moving Toward Health Equity by
Addressing Social Determinants of Health
Breanna Lathrop
ABSTRACT: Social determinants of health-the conditions in which people bom, grow, work, live, and age that affect health and
quality of life are strongly associated with disparities in health status and life expectancy. Nurses require a comprehensive
understanding of social determinants and their associations with health outcomes to provide patient centered care. Nurses can be leaders
and change agents in advancing health equity by screening for social determinants that affect women and by
nd by engaging in cross-sector
collaboration to build partnerships outside the health care system to address complex social needs. Nurses can also use their experience
and knowledge to advocate for system-level change, which is required to address the upstream factors influencing the health of women.
dol: 10.1016/j.mwh.2019.11.003
Accepted November 2019
KEYWORDS: health disparities, health equity. expectancy, quality of life, social determinants of health, socioeconomic status
J
"essica was homeless and sleeping outside when she
first started coming to the clinic for management of
returned to the clinic having determined that she was pregnant.
Jessica had run away from a dysfunctional and abusive family
as an adolescent and had spent the last several years on the
street. Her boyfriend, also a runaway youth with anger
management issues and ADHD, came with her to her first
36 © 2020 AWHONN; dok 10.1016/).wh.2019.11.003
Health Equity and Social Determinants of Health
However, social determinants of health further complicate
health care delivery in that their impact is not isolated to those
at the bottom of the socioeconomic ladder. It is not only the very
poor or homeless who experience an increased risk of poor
health outcomes. Rather, determinants operate on a gradient
with each step up in social status, increasing the chances of
better health and longer life (Marmot, Rose, Shipley, &
Hamilton, 1978). For example, simply becoming employed
does not equate to good health. Jobs with high demand and
little control of work environment are associated with poorer
health outcomes (Hämmig & Bauer, 2013). Such jobs breed
frustration, stress, and burnout with little chance for upward
mobility. Nurses and other clinicians cannot assume that an
employed woman with health insurance is not experiencing
chronic stress as a result of an unhealthy work environment,
Care that does not consider social determinants falls short
of being patient centered and outcomes focused in a time when
zip code can be a better predictor of life expectancy than ge-
netic code. Virginia Commonwealth University's Center on
Society and Health (2016) life expectancy mapping project
found life expectancy gaps of up to 19 years between zip codes
within the same urban area. From a 5-year life expectancy gap in
Denver to 13 years in Atlanta and 19 in Philadelphia, health
inequity is a national problem. At the neighborhood level, this
difference is even more staggering, with a life expectancy gap of
more than 30 years between neighborhoods in the same U.S.
city (Ducharme & Wolfson, 2019; NYU Langone Health, 2019).
Improved access to quality health care alone cannot solve this
problem. This creates a challenge for nurses and other health
care professionals in that addressing determinants, such as
inadequate housing, food insecurity, poverty, and unemploy-
ment, falls outside the scope of traditional health care in-
terventions. However, mounting evidence shows that social
determinants are a driving force behind health outcomes and
health inequities.
Implications for Nursing Practice
Nurses regularly address the consequences of social de
terminants of health, whether readmitting a woman who did
not have adequate shelter at discharge, teaching a woman
with diabetes who lives in a food desert about dietary man-
agement, or providing prenatal care to a woman whose preg-
nancy is complicated by transportation barriers and unhealthy
behaviors.
For many nurses, the influence of social determinants of
health on health status may be more overwhelming than
surprising. The issue is not whether social determinants of
health matter but how to go about addressing them. Nurses,
along with other health care professionals, are already over-
burdened. With staffing shortages, growing rates of burnout,
and increased pressure to provide patient-centered care and
decrease readmissions, there does not seem to be space for
new interventions or programs. However, emergency de
prenatal appointment. They had no financial resources, no
family connections, no knowledge of the Medicaid system, and
no housing. During her prenatal care, clinic staff and health
care providers helped her obtain Medicaid benefits and referred
her to a youth counseling program that provided case
management and housing. By the time she gave birth, Jessica
and her boyfriend were living together in a rented room of a
house through a voucher program.
nwhjournal.org
people whose conditions have likely been caused in part by
their environment and stress level. Discharges are delayed
when housing, social support, and food and medication ac
cess are not available to make a safe transition home. Moving
upstream in approach, although difficult, is the only means of
stemming growing pressure on the health care system to
eliminate persistent health disparities.
Health equity is the "attainment of the highest level of health
for all people" and occurs when everyone has the opportunity to
live a healthy life (USDHHS, 2014, para. 5). Social
determinants of health stand in direct opposition to the
achievement of health equity in the United States. Social
conditions such as poverty and inadequate housing are caused
by multiple factors, many of which lie outside of a person's
control. Inequities in social determinants largely stem from
structural racism and historical discrimination against
marginalized populations (American Public Health Association,
2018). Structural racism describes the normalization and
legitimization of a system in which policies, procedures, and
cultural representations favor white people at the expense of
people of color (Lawrence & Keleher, 2004; The Aspen
Institute, n.d.). As outlined in Healthy People 2020 (USDHHS,
2014), achieving health equity requires "societal efforts to
address avoidable inequities, historical and contemporary
injustices, and the elimination of health and health care
disparities* (para. 5). This reality cannot be achieved through
the health care system alone but requires the active
engagement and advocacy of all health care professionals.
Whether working with women to
promote a healthy pregnancy or
manage chronic conditions such as
hypertension or heart disease,
nurses need an understanding of the
social determinants contributing to
woman'a hoolth and illu
CLINICAL IMPLICATIONS
Social determinants of health the conditions in which people
are bom, grow, play, work, live, and age that affect health and
quality of life are a driving force behind health disparities.
The chronic stress caused by social determinants such as
poverty, racism, inadequate housing, unemployment, and food
insecurity d
y damages body systems and is linked to chronic
disease and premature aging.
Implementing social determinants screening enables nurses to
link women to needed resources and assists in program and
intervention planning.
Addressing social determinants requires cross sector collaboration
in which partnerships extend beyond the health care system.
Nurses can have the greatest impact on social determinants of
health by using their experience and knowledge to advocate for
the system-level and policy changes required to create health
equity.
for Women, Infants,
After the birth of a healthy, term infant, the family returned to
the clinic. The newbor's Medicaid had not been processed, and
the couple did not know how to apply for benefits provided by the
Special Supplemental Nutrition Prong but did not own a
and Children. Jessica was s breastfeeding
pump, had only one bottle, and was struggling to keep up her
milk supply. She and her boyfriend had no source of income to
buy diapers or clothes. Their
love for their child was evident,
but they were struggling as
young new parents who had
never witnessed a healthy
family environment. The
newbom was not gaining
weight, and Jessica was
struggling with depression.
Clinic staff focused an increasing amount of time on the family's
social condition. With the exception of Jessica's bipolar disor-
der, the family's health problems fell largely outside of the scope
of traditional health care. They needed infant supplies, parenting
education, Medicaid, economic resources, food, safe housing,
and social support. These social needs stemmed from systemic
issues of poverty, family violence, the affordable housing crisis,
and historical issues with mental health parity. Postpartum visits
and well-child checkups that did not address these underlying
issues would do little to improve the health of this family.
Social Determinants of Health
Jessica's experience illustrates the limitations of the health
care system when social determinants such as socioeconomic
status, food access, and housing are not considered in the plan
Breanna Lathrop, DNP, MPH, FNP-BC, Chief Operating Officer, Good
Samaritan Health Center. Atlanta, GA. The author reports no conflicts of
interest or relevant financial relationships. Address correspondence to:
Breanna@goodsamatlanta.org.
February 2020
The chronic stress resulting from.
factors such as poverty and other
social determinants accelerates the
onset of chronic disease and aging
Given that inequities often stem from racism and discrim-
ination, nurses desiring to promote health equity must be
willing to examine their personal biases. Everyone has blases,
and although some may be explicit stereotypes, blas is often
implicit. Implicit bias describes subconscious attitudes and
stereotypes that affect understanding and actions (The Joint
Commission, 2016). Implicit bias is particularly conceming in
the health care setting because it can result in lower-quality
care and perpetuate health disparities. Authors of one sys-
tematic review found that most health care providers have low
to moderate levels of implicit blas with negative attitudes to
ward people of color (Hall et al., 2015). In a meta-analysis of
42 articles, FitzGerald and Hurst (2017) found that health
care providers, including nurses, manifest implicit biases
similar to the general population around issues of race/
ethnicity, gender, socioeconomic status, mental illness, drug
use, and social circumstances. The same social determinants
that correlate to poor health and lower life expectancy also
make people more vulnerable in health care settings. Fortu-
nately, nurses willing to recognize their implicit blases can
take steps to prevent disparities in treatment. The develop
ment of certain interpersonal skills can limit the impact of
implicit bias. Skills such as empathy, perspective taking.
emotional regulation, and partnership building with patients
have had positive effects on patient experience and outcomes
(van Ryn et al., 2011). Nurses committed to the ongoing
process of examining their implicit blases and recognizing the
influence of social determinants on the women they care for
are positioned to be change agents in developing and imple-
menting new approaches for health equity.
A New Approach
For nurses seeking action steps toward achieving health eq-
uity and addressing the health effects of social determinants
of health, it is their lived experience, health knowledge, and
The Accountable Health
Communities Health-
Related Social Needs
Screening Tool
Social Needs Screening
Toolkit
of care. Social determinants of health are the conditions in
which people are born, grow, play, work, live, and age that affect
health and quality of life and are shaped by the distribution of
money, power, and resources (U.S. Department of Health and
Human Services [USDHHS], 2018; World Health Organization,
2018). Although health care no doubt can have a positive in-
fluence on health, its influence is limited. Whether working with
women to promote a healthy pregnancy or manage chronic
conditions such as hypertension or heart disease, nurses need
an understanding of the social determinants contributing to
women's health and illness.
Determining how social factors affect the body on a physi-
ologic level is complex, but emerging research shows a strong
and persistent relationship between socioeconomic factors
and health (Braveman & Gottlieb, 2014). The human body was
designed to manage episodic stress protective mecha-
nisms that return the body to allostasis after extreme physical
or emotional stress. Poverty, unsafe living conditions, food
insecurity, oppression, abuse, racism, and other determinants
create chronic stress. In these situations, the body's mecha
nisms become maladaptive, resulting in damage to the body's
functioning systems (Steptoe & Marmot, 2002). Chronic stress
leads to changes in autoimmune, endocrine, and neurologic
systems and has been linked to health conditions such as
hypertension and preterm birth (Steptoe & Marmot, 2002;
Wadhwa, Entringer, Buss, &
Lu, 2011). It is not simply that
social determinants of health
make some individuals more
likely to get sick than others;
rather, social determinants
have a direct influence on
disease (Braveman & Gottlieb,
2014).
TABLE 1 SCREENING TOOLS FOR SOCIAL DETERMINANTS OF HEALTH
Tool
Organization
National Association for Community
Health Centers
PRAPARE: Protocol for
Responding to and
Assessing Patient Assets,
Risks, and Experiences
Social Needs Screening Tool
Health Leads
Lathrop
Another example of the association between social de
terminants and poor health is premature aging. The weathering
hypothesis, first proposed in 1992 by Arline Geronimus as a way
of explaining the early adulthood decline in health experienced
by African American women, states that differences in early
onset of chronic disease are a result of differences in exposure
to stress and access to coping resources (Geronimus, 1992;
Geronimus et al., 2015). The chronic stress resulting from
factors such as poverty and other social determinants acceler
ates the onset of chronic disease and aging. At the biological
level, this can be tested through the measurement of telomere
length. Telomeres are the protective end caps of chromosomes
that prevent cell death and DNA degradation (Shammas, 2011).
Factors that accelerate their shortening can lead to premature
death. Geronimus et al. (2015) found that telomere length was
influenced by poverty, education, safety stress, negative social
interaction, neighborhood satisfaction, hopelessness, and
obesity across all racial/ethnic groups included in the study.
Because social determinants are linked to chronic disease
burden and premature aging, addressing them is of critical
importance to the health care system.
American Academy of Family
Physicians
Center for Medicare and Medicaid
Services
Nursing for Women's Health
strength in patient advocacy that are needed, within the
health care system and beyond. Nurses can start in their own
clinics and health systems while fostering the societal change
required to address upstream factors.
Lathrop
Screening for Social Determinants of Health
An initial step toward addressing social determinants of
health involves knowing and understanding the factors that
are most affecting specific patient populations. Screening
women for the presence of social determinants of health al-
lows health care providers and leaders health systems to
better understand the needs of their patients and create an
environment in which women better understand the influence
of their environment on their health. Nurses working in clinics.
or health systems currently not screening for social de
terminants of health can start by advocating for the imple-
mentation of a screening system. Several validated screening
tools exist (see Table 1).
PRAPARE: Protocol for Responding to and Assessing Pa-
tient Assets, Risks, and Experiences, developed by the
National Association of Community Health Centers (2016),
consists of 21 questions assessing social determinants of
health. PRAPARE aligns with Healthy People 2020 initiatives
around social determinants and emphasizes measures that
are actionable (National Association of Community Health
Centers, 2019). Core measures assessed include race/
ethnicity, language, housing status, education, employment,
transportation, and social integration, among others. The tool
can be downloaded for free in paper form and several tem-
plates for electronic health records (EHRS) are also available.
The American Academy of Family Physicians (AAFP; 2019)
produces long and short versions of the Social Needs
Screening Tool as part of its EveryONE Project, which aims to
advance health equity through family medicine by addressing
social determinants of health and promoting diversity. The
37
Website
http://www.nachc.org/research-and-data/
prapare/about-the-prapare-assessment-tool
https://www.aafp.org/dam/AAFP/documents/
patient care/everyone_project/physician-long.pdf
https://innovation.cms.gov/Files/worksheets/
ahcm-screeningtool.pdf
https://healthleadsusa.org/resources/the-
health-leads-screening-toolkit](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2Fac3be618-b645-4bd8-855b-808ff3fc18d4%2F5ac1af0a-c688-46fa-8412-a2cf4bd978d1%2Fk3tcxzp_processed.png&w=3840&q=75)
Transcribed Image Text:IN PRACTICE
women's health
Moving Toward Health Equity by
Addressing Social Determinants of Health
Breanna Lathrop
ABSTRACT: Social determinants of health-the conditions in which people bom, grow, work, live, and age that affect health and
quality of life are strongly associated with disparities in health status and life expectancy. Nurses require a comprehensive
understanding of social determinants and their associations with health outcomes to provide patient centered care. Nurses can be leaders
and change agents in advancing health equity by screening for social determinants that affect women and by
nd by engaging in cross-sector
collaboration to build partnerships outside the health care system to address complex social needs. Nurses can also use their experience
and knowledge to advocate for system-level change, which is required to address the upstream factors influencing the health of women.
dol: 10.1016/j.mwh.2019.11.003
Accepted November 2019
KEYWORDS: health disparities, health equity. expectancy, quality of life, social determinants of health, socioeconomic status
J
"essica was homeless and sleeping outside when she
first started coming to the clinic for management of
returned to the clinic having determined that she was pregnant.
Jessica had run away from a dysfunctional and abusive family
as an adolescent and had spent the last several years on the
street. Her boyfriend, also a runaway youth with anger
management issues and ADHD, came with her to her first
36 © 2020 AWHONN; dok 10.1016/).wh.2019.11.003
Health Equity and Social Determinants of Health
However, social determinants of health further complicate
health care delivery in that their impact is not isolated to those
at the bottom of the socioeconomic ladder. It is not only the very
poor or homeless who experience an increased risk of poor
health outcomes. Rather, determinants operate on a gradient
with each step up in social status, increasing the chances of
better health and longer life (Marmot, Rose, Shipley, &
Hamilton, 1978). For example, simply becoming employed
does not equate to good health. Jobs with high demand and
little control of work environment are associated with poorer
health outcomes (Hämmig & Bauer, 2013). Such jobs breed
frustration, stress, and burnout with little chance for upward
mobility. Nurses and other clinicians cannot assume that an
employed woman with health insurance is not experiencing
chronic stress as a result of an unhealthy work environment,
Care that does not consider social determinants falls short
of being patient centered and outcomes focused in a time when
zip code can be a better predictor of life expectancy than ge-
netic code. Virginia Commonwealth University's Center on
Society and Health (2016) life expectancy mapping project
found life expectancy gaps of up to 19 years between zip codes
within the same urban area. From a 5-year life expectancy gap in
Denver to 13 years in Atlanta and 19 in Philadelphia, health
inequity is a national problem. At the neighborhood level, this
difference is even more staggering, with a life expectancy gap of
more than 30 years between neighborhoods in the same U.S.
city (Ducharme & Wolfson, 2019; NYU Langone Health, 2019).
Improved access to quality health care alone cannot solve this
problem. This creates a challenge for nurses and other health
care professionals in that addressing determinants, such as
inadequate housing, food insecurity, poverty, and unemploy-
ment, falls outside the scope of traditional health care in-
terventions. However, mounting evidence shows that social
determinants are a driving force behind health outcomes and
health inequities.
Implications for Nursing Practice
Nurses regularly address the consequences of social de
terminants of health, whether readmitting a woman who did
not have adequate shelter at discharge, teaching a woman
with diabetes who lives in a food desert about dietary man-
agement, or providing prenatal care to a woman whose preg-
nancy is complicated by transportation barriers and unhealthy
behaviors.
For many nurses, the influence of social determinants of
health on health status may be more overwhelming than
surprising. The issue is not whether social determinants of
health matter but how to go about addressing them. Nurses,
along with other health care professionals, are already over-
burdened. With staffing shortages, growing rates of burnout,
and increased pressure to provide patient-centered care and
decrease readmissions, there does not seem to be space for
new interventions or programs. However, emergency de
prenatal appointment. They had no financial resources, no
family connections, no knowledge of the Medicaid system, and
no housing. During her prenatal care, clinic staff and health
care providers helped her obtain Medicaid benefits and referred
her to a youth counseling program that provided case
management and housing. By the time she gave birth, Jessica
and her boyfriend were living together in a rented room of a
house through a voucher program.
nwhjournal.org
people whose conditions have likely been caused in part by
their environment and stress level. Discharges are delayed
when housing, social support, and food and medication ac
cess are not available to make a safe transition home. Moving
upstream in approach, although difficult, is the only means of
stemming growing pressure on the health care system to
eliminate persistent health disparities.
Health equity is the "attainment of the highest level of health
for all people" and occurs when everyone has the opportunity to
live a healthy life (USDHHS, 2014, para. 5). Social
determinants of health stand in direct opposition to the
achievement of health equity in the United States. Social
conditions such as poverty and inadequate housing are caused
by multiple factors, many of which lie outside of a person's
control. Inequities in social determinants largely stem from
structural racism and historical discrimination against
marginalized populations (American Public Health Association,
2018). Structural racism describes the normalization and
legitimization of a system in which policies, procedures, and
cultural representations favor white people at the expense of
people of color (Lawrence & Keleher, 2004; The Aspen
Institute, n.d.). As outlined in Healthy People 2020 (USDHHS,
2014), achieving health equity requires "societal efforts to
address avoidable inequities, historical and contemporary
injustices, and the elimination of health and health care
disparities* (para. 5). This reality cannot be achieved through
the health care system alone but requires the active
engagement and advocacy of all health care professionals.
Whether working with women to
promote a healthy pregnancy or
manage chronic conditions such as
hypertension or heart disease,
nurses need an understanding of the
social determinants contributing to
woman'a hoolth and illu
CLINICAL IMPLICATIONS
Social determinants of health the conditions in which people
are bom, grow, play, work, live, and age that affect health and
quality of life are a driving force behind health disparities.
The chronic stress caused by social determinants such as
poverty, racism, inadequate housing, unemployment, and food
insecurity d
y damages body systems and is linked to chronic
disease and premature aging.
Implementing social determinants screening enables nurses to
link women to needed resources and assists in program and
intervention planning.
Addressing social determinants requires cross sector collaboration
in which partnerships extend beyond the health care system.
Nurses can have the greatest impact on social determinants of
health by using their experience and knowledge to advocate for
the system-level and policy changes required to create health
equity.
for Women, Infants,
After the birth of a healthy, term infant, the family returned to
the clinic. The newbor's Medicaid had not been processed, and
the couple did not know how to apply for benefits provided by the
Special Supplemental Nutrition Prong but did not own a
and Children. Jessica was s breastfeeding
pump, had only one bottle, and was struggling to keep up her
milk supply. She and her boyfriend had no source of income to
buy diapers or clothes. Their
love for their child was evident,
but they were struggling as
young new parents who had
never witnessed a healthy
family environment. The
newbom was not gaining
weight, and Jessica was
struggling with depression.
Clinic staff focused an increasing amount of time on the family's
social condition. With the exception of Jessica's bipolar disor-
der, the family's health problems fell largely outside of the scope
of traditional health care. They needed infant supplies, parenting
education, Medicaid, economic resources, food, safe housing,
and social support. These social needs stemmed from systemic
issues of poverty, family violence, the affordable housing crisis,
and historical issues with mental health parity. Postpartum visits
and well-child checkups that did not address these underlying
issues would do little to improve the health of this family.
Social Determinants of Health
Jessica's experience illustrates the limitations of the health
care system when social determinants such as socioeconomic
status, food access, and housing are not considered in the plan
Breanna Lathrop, DNP, MPH, FNP-BC, Chief Operating Officer, Good
Samaritan Health Center. Atlanta, GA. The author reports no conflicts of
interest or relevant financial relationships. Address correspondence to:
Breanna@goodsamatlanta.org.
February 2020
The chronic stress resulting from.
factors such as poverty and other
social determinants accelerates the
onset of chronic disease and aging
Given that inequities often stem from racism and discrim-
ination, nurses desiring to promote health equity must be
willing to examine their personal biases. Everyone has blases,
and although some may be explicit stereotypes, blas is often
implicit. Implicit bias describes subconscious attitudes and
stereotypes that affect understanding and actions (The Joint
Commission, 2016). Implicit bias is particularly conceming in
the health care setting because it can result in lower-quality
care and perpetuate health disparities. Authors of one sys-
tematic review found that most health care providers have low
to moderate levels of implicit blas with negative attitudes to
ward people of color (Hall et al., 2015). In a meta-analysis of
42 articles, FitzGerald and Hurst (2017) found that health
care providers, including nurses, manifest implicit biases
similar to the general population around issues of race/
ethnicity, gender, socioeconomic status, mental illness, drug
use, and social circumstances. The same social determinants
that correlate to poor health and lower life expectancy also
make people more vulnerable in health care settings. Fortu-
nately, nurses willing to recognize their implicit blases can
take steps to prevent disparities in treatment. The develop
ment of certain interpersonal skills can limit the impact of
implicit bias. Skills such as empathy, perspective taking.
emotional regulation, and partnership building with patients
have had positive effects on patient experience and outcomes
(van Ryn et al., 2011). Nurses committed to the ongoing
process of examining their implicit blases and recognizing the
influence of social determinants on the women they care for
are positioned to be change agents in developing and imple-
menting new approaches for health equity.
A New Approach
For nurses seeking action steps toward achieving health eq-
uity and addressing the health effects of social determinants
of health, it is their lived experience, health knowledge, and
The Accountable Health
Communities Health-
Related Social Needs
Screening Tool
Social Needs Screening
Toolkit
of care. Social determinants of health are the conditions in
which people are born, grow, play, work, live, and age that affect
health and quality of life and are shaped by the distribution of
money, power, and resources (U.S. Department of Health and
Human Services [USDHHS], 2018; World Health Organization,
2018). Although health care no doubt can have a positive in-
fluence on health, its influence is limited. Whether working with
women to promote a healthy pregnancy or manage chronic
conditions such as hypertension or heart disease, nurses need
an understanding of the social determinants contributing to
women's health and illness.
Determining how social factors affect the body on a physi-
ologic level is complex, but emerging research shows a strong
and persistent relationship between socioeconomic factors
and health (Braveman & Gottlieb, 2014). The human body was
designed to manage episodic stress protective mecha-
nisms that return the body to allostasis after extreme physical
or emotional stress. Poverty, unsafe living conditions, food
insecurity, oppression, abuse, racism, and other determinants
create chronic stress. In these situations, the body's mecha
nisms become maladaptive, resulting in damage to the body's
functioning systems (Steptoe & Marmot, 2002). Chronic stress
leads to changes in autoimmune, endocrine, and neurologic
systems and has been linked to health conditions such as
hypertension and preterm birth (Steptoe & Marmot, 2002;
Wadhwa, Entringer, Buss, &
Lu, 2011). It is not simply that
social determinants of health
make some individuals more
likely to get sick than others;
rather, social determinants
have a direct influence on
disease (Braveman & Gottlieb,
2014).
TABLE 1 SCREENING TOOLS FOR SOCIAL DETERMINANTS OF HEALTH
Tool
Organization
National Association for Community
Health Centers
PRAPARE: Protocol for
Responding to and
Assessing Patient Assets,
Risks, and Experiences
Social Needs Screening Tool
Health Leads
Lathrop
Another example of the association between social de
terminants and poor health is premature aging. The weathering
hypothesis, first proposed in 1992 by Arline Geronimus as a way
of explaining the early adulthood decline in health experienced
by African American women, states that differences in early
onset of chronic disease are a result of differences in exposure
to stress and access to coping resources (Geronimus, 1992;
Geronimus et al., 2015). The chronic stress resulting from
factors such as poverty and other social determinants acceler
ates the onset of chronic disease and aging. At the biological
level, this can be tested through the measurement of telomere
length. Telomeres are the protective end caps of chromosomes
that prevent cell death and DNA degradation (Shammas, 2011).
Factors that accelerate their shortening can lead to premature
death. Geronimus et al. (2015) found that telomere length was
influenced by poverty, education, safety stress, negative social
interaction, neighborhood satisfaction, hopelessness, and
obesity across all racial/ethnic groups included in the study.
Because social determinants are linked to chronic disease
burden and premature aging, addressing them is of critical
importance to the health care system.
American Academy of Family
Physicians
Center for Medicare and Medicaid
Services
Nursing for Women's Health
strength in patient advocacy that are needed, within the
health care system and beyond. Nurses can start in their own
clinics and health systems while fostering the societal change
required to address upstream factors.
Lathrop
Screening for Social Determinants of Health
An initial step toward addressing social determinants of
health involves knowing and understanding the factors that
are most affecting specific patient populations. Screening
women for the presence of social determinants of health al-
lows health care providers and leaders health systems to
better understand the needs of their patients and create an
environment in which women better understand the influence
of their environment on their health. Nurses working in clinics.
or health systems currently not screening for social de
terminants of health can start by advocating for the imple-
mentation of a screening system. Several validated screening
tools exist (see Table 1).
PRAPARE: Protocol for Responding to and Assessing Pa-
tient Assets, Risks, and Experiences, developed by the
National Association of Community Health Centers (2016),
consists of 21 questions assessing social determinants of
health. PRAPARE aligns with Healthy People 2020 initiatives
around social determinants and emphasizes measures that
are actionable (National Association of Community Health
Centers, 2019). Core measures assessed include race/
ethnicity, language, housing status, education, employment,
transportation, and social integration, among others. The tool
can be downloaded for free in paper form and several tem-
plates for electronic health records (EHRS) are also available.
The American Academy of Family Physicians (AAFP; 2019)
produces long and short versions of the Social Needs
Screening Tool as part of its EveryONE Project, which aims to
advance health equity through family medicine by addressing
social determinants of health and promoting diversity. The
37
Website
http://www.nachc.org/research-and-data/
prapare/about-the-prapare-assessment-tool
https://www.aafp.org/dam/AAFP/documents/
patient care/everyone_project/physician-long.pdf
https://innovation.cms.gov/Files/worksheets/
ahcm-screeningtool.pdf
https://healthleadsusa.org/resources/the-
health-leads-screening-toolkit
![Health Equity and Social Determinants of Health
Sometimes the most influence nurses
can have on social determinants of
health is not in their work as nurses
but in their actions as community
citizens
long form consists of 15 questions addressing housing, food,
employment, finances, education, child care, transportation,
utilities, and personal safety (AAFP, 2018a). The short version
includes 11 questions addressing housing, food, trans-
portation, utilities, and personal safety (AAFP, 2018b). Both
forms, along with action plan templates, are available on the
project's website.
The Centers for Medicare and Medicaid Services (n.d.)
produces The Accountable Health Communities Health-
Related Social Needs Screening Tool. This 10-question
screening tool identifies needs in the areas of housing
instability, food insecurity, transportation problems, utility
help, and interpersonal safety. Supplemental questions are
also available.
OLUNTEER
Health Leads (2018) offers a Social Needs Screening
Toolkit to assist practices and health systems in designing a
screening tool. Interested practices can download a how-to
guide from their website.
Regardless of the tool used, screening for social de
terminants of health has several benefits. First and foremost,
40 Volume 24 Issue 1
Health Equity and Social Determinants of Health
BOX 2 EXAMPLES OF ACTIONS TO ADDRESS
SOCIAL DETERMINANTS OF HEALTH
Addressing the Individual Social Needs of Women
• A nurse provides a woman with a list of local food
assistance locations and the nearest Special
Supplemental Nutrition Program for Women,
Infants, and Children (WIC) office upon discharge
postpartum.
• A nurse practitioner or midwife refers a woman to a
local social worker with a Continuum of Care
organization and helps complete paperwork to
facilitate qualification for permanent supportive
housing.
A nurse administrator writes grant to provide
public transport ride cards to any prenatal care
patient who reports missing appointments because
of lack of transportation.
Participation in Health Care System Change
• A nurse collaborates with an interdisciplinary team
implement universal screening for social
determinants of health in the hospital system.
to
• A nurse joins a national nursing organization and
testifies at a state senate hearing about the
effects of proposed Medicaid budget cuts on the
women receiving care in his/her clinic.
A nurse practitioner or midwife joins a local task
force aimed at creating strategies for increasing
access to mental health care in a rural community.
Advocacy Around Upstream Structural Factors
A team of nursing educators redesigns their
institution's nursing curriculum to include
information about social determinants of health
and implicit bias during each semester.
• A nurse-researcher develops a program in which
parents receive information about language
nutrition and an age-appropriate book at each well-
child check-up and educates the nursing staff on
how to talk to parents about language nutrition.
• A nurse runs for office to develop and vote on
policies that promote health equity.
social services can refer people for services and receive
confirmation that the referral was successful (Amdt, 2019).
This trend moves from a resource list approach to a model in
which organizations collaborate and share information.
Nurses and health systems can work with EHR vendors or use
third-party software programs to improve the efficiency and
effectiveness of referralls outside of the health system.
Nurses are most effective in cross-sectional collaboration
when they are knowledgeable about the
e programs available to
women presenting with social needs. National programs
designed to assist individuals in need of health and social
42 Volume 24 Issue 1
tools allow health care
providers to identify which
social determinants most
influence women's health
and to link them to
needed resources and
support systems. This ex-
ercise also helps women
understand how their so-
cial conditions affect their
health and creates oppor
tunities for discussions.
Screening tools also pro-
vide population data that
can be used to inform the
growth and programmatic
development of health
systems. Staff and clini-
cians at health systems.
and clinics can develop
initiatives, patient in
centives, and partnerships
to address the social
needs most commonly re-
ported by women. Staff at
nonprofit clinics can use
these data to inform grant applications and obtain grant
funding, which can increase the sustainability of programs
that address social determinants of health.
Cross-Sector Collaboration
When considering social needs such as food insecurity.
housing instability, lack of transportation, and unemployment,
it becomes clear that the health care system is not equipped
to address all social determinants affecting women's health.
Medical care can reduce only approximately 10% of premature
deaths in the United States (Schroeder, 2007). Strategies to
alleviate social determinants and eliminate disparities in
premature death rely on coordinated and effective cross-
sector collaboration.
Nurses continue to be at the forefront of interdisciplinary
care. Interdisciplinary or multidisciplinary care describes
different health care staff working together to improve pa
tient care
work involving nurses, technicians, aides, physicians, and
other health care professionals is associated with improved
patient outcomes and decreased adverse events (Epstein,
2014). The skills nurses have developed regarding
communication and collaboration within the health care
sector must now be applied to building teams that extend
beyond the traditional health care system. Addressing social
determinants requires team members from multiple sectors,
such as social work, housing, business enterprise, the
philanthropic community, education, employers, religious
institutions, and government. Building common language,
doi: 10.1016/j.2019.11.003
services are highlighted in Box 1. Having a basic under-
standing of eligibility for these programs and how to direct
women to these services allows nurses to link women to
support beyond their immediate scope of care. However,
nurses do not need to be in leadership positions or have
expansive knowledge of the social safety net to address so-
cial determinants at the health systems level. Nurses can
identify team members and community liaisons with expertise
in areas such as housing, transportation, legal assistance,
food assistance, and addiction services.
Cross-sectional collaboration might begin with a
nurse creating or using a referral system to key social
service providers. Nurses can identify gaps between
women's social needs and services offered within the
health system and then forge partnerships to meet these
needs. Nurses can also urge hospital administrators to
invest in technology to advance referral coordination and
effectiveness. Nurses advocating for improved patient out-
comes need to push health care systems beyond traditional
boundaries and set a new standard for collaboration.
Advocacy Outside the Health Care Center
Outside of professional responsibilities, nurses are commu
nity members. They are parents, renters, homeowners, voters,
shoppers, local leaders, and members of social organiza
tions, religious congregations, and neighborhoods. Some-
times the most influence nurses can have on social
determinants of health is not in their work as nurses but in
citizens.
their actions community de
terminants of health and eliminating health disparities re
quires systemic change around poverty, housing, food
access, transportation, financial literacy, and education,
among others. Furthermore, achieving health equity requires
the dismantling of oppressive systems shaped by discrimi-
nation and racism. Providing for the social needs of in-
dividuals is essential, life-saving work but falls short for
addressing social determinants. As Castrucci and Auerbach
(2019) articulate, individual interventions "mitigate the acute
social and economic challenges of individual patients, but
they do so without implementing long-term fixes" (para. 7).
Nurses are ideally positioned to bring issues regarding
the health implications of policy and social conditions to
the forefront. Using their experience of how social
terminants affect health and how interventions have been
successful in improving the health of individuals, nurses
can educate those outside the health care system. Nurses
can use their stories and health care knowledge to
advocate for community-level interventions and Health in All
Policies. Based on the understanding that social de-
terminants are shaped by decisions made primarily outside
of the health care sector, Health in All Policies is an
approach to public policy that considers the health implica-
tions of decisions (Rudolph, Caplan, Ben-Moshe, & Dillon,
2013). It involves collective decision making in which deci
sion makers consider health, equity, and sustainability in
dot: 10.1016/j.2019.11.009
BOX 1 EXAMPLES OF PUBLIC ASSISTANCE PROGRAMS
Medicaid
Emergency Medicaid
Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC)
State Children's Health Insurance Program
Supplemental Nutrition Assistance Program (SNAP)
Continuum of Care
Temporary Assistance for Needy Families
General Assistance
communication systems, and resource sharing among sec
tors is critical in creating a culture of health that transcends
the health care system.
are
Equipped with information about the social needs of
their patient population, nurses can lead health systems
and provider teams toward cross-sector collaboration.
Innovative and effective models of this type of collaboration
e plentiful. The assertive community treatment approach
originated from the health care system to address the
needs of patients experiencing mental health illness. The
model involves health care providers meeting patients in
community settings and integrating multiple services to
address housing, finances, rehabilitation, a d other needs
in addition to mental health care (Bond & Drake, 2015). In
response to frequent emergency department use, Pathways
Housing First initiated a strategy in which people are
housed immediately and the support systems they need
to maintain housing are built around them (Padgett,
Henwood, & Tsemberis, 2016). Clinics and health care
February 2020
evaluating policy options (Rudolph et al., 2013). Regardless
of their position, place of employment, or interaction with
the care of women, all nurse have the ability to influence
their communities and public policy, which is essential to
address the social determinants influencing the health of
women.
Taking Action
Because social determinants of health act on a gradient
strategies to address them can be conceptualized similarly.
There is no singular approach to achieving health equity.
Nurses providing direct care can start by identifying and
addressing, through partnerships and referrals, the social
needs of patients. Next, nurses can advocate for and lead
structural changes within the larger scope of the health sys-
tem. This might include changing hospital policies to promote
equitable health outcomes or joining a national advocacy or
ganization to influence health policy. Finally, nurses can
confront the structural causes of inequity. This confrontation
can start with understanding personal implicit bias and
drawing attention to the operation of structural racism within
communities. This action might also include advocacy for
policy change in areas outside of the health field such as
housing subsidies or transportation. Examples of activities at
each level of advocacy are provided in Box 2.
Conclusion
At a time of high health care spending, increasing health care
costs, and persistent disparities in health status, the United
States is in need of new strategies to improve the nation's
health. The impact of social determinants on health and life
expectancy mandates that solutions to health disparities
occur within the health care system and outside of it. Nurses
have several key opportunities to advance a health equity
agenda. First, they can facilitate understanding in their health
care systems about the social needs of women and how to
ensure that these needs are addressed, thus mitigating the
negative effects of social determinants
health status.
Next, nurses can develop and promote community-level in-
terventions and systemwide changes to better address social
determinants of health. Last, nurse can advocate for the so-
cietal and policy changes needed to create a nation in which
health equity is a reality. NWH
Check for updates
References
American Association of Family Physicians. (2018a). Social Needs
Screening Tool (Physician Long Version). Retrieved from https://www
aafp.org/dam/AAFP/documents/patient care/everyone_project/
physician-long.pdf
American Association of Family Physicians. (2018b). Social Needs
Screening Tool (Physician Short Version). Retrieved from https://www.
February 2020
Lathrop
State and federal program that provides health coverage for
some low-income individuals, families with children,
pregnant women, the elderly, and people with disabilities.
Eligibility varies by state.
Health coverage provided retroactively for certain people
who have experienced a medical emergency, including
those not eligible for Medicaid due to immigration status.
women
Medicaid is often used to cover the birth costs
of uninsured women.
Emergency
Provides supplemental food, formula, and nutrition
education for pregnant and postpartum women, infants,
and children up to age 5 years.
State and federal program expanding health coverage to
children who do not qualify for Medicaid but cannot afford
private insurance.
Also known as food stamps, this program provides a
monthly supplement for purchasing nutritious food for low-
income people.
Federal program providing funding to nonprofit
organizations to help people experiencing homelessness
obtain transitional and permanent housing.
Monthly cash assistance program for families with children
younger than 18 years of age.
State or local programs that provide financial assistance to
very poor individuals who do not have minor children.
Currently, 26 states have General Assistance programs.
systems are also well positioned to address food insecu-
rity. Food prescription programs and partnerships with
farmers markets and local farms offer affordable produce.
Partnerships built out of a mutual desire to help people
achieve health by addressing social needs allow health
systems to move upstream in their approach to improved
health outcomes.
Collaboration
with sectors outside of the traditional health
system is also aided through coordinated referral processes
and information sharing Software prochas Unite Us
(2019), Healthily (2019), NowPow ), and
nd Aunt Bertha
(2019) help clinicians connect patients to community re-
sources to address social needs. Although EHR vendors are
increasingly able to collect and report social determinants
data for providers, the use of referral products is still new
(USDHHS Assistant Secretary for Planning and Evaluation,
2018). EHR vendors and developers of software tools are
under increasing pressure to close the loop by creating a two-
way communication system in which health systems and
Nursing for Women's Health 41
Lathrop
aafp.org/dam/AAFP/documents/patient care/everyone_project/
physician short.pdf
American Association of Family Physicians. (2019). The EveryONE Project
Toolkit. Retrieved from https://www.aafp.org/patient-care/social-
determinants-of-health/everyone-project/eop-tools.html
American Public Health Association. (2018). Creating the healthiest
nation: Advancing health equity. Retrieved from https://www.apha
org/-/media/files/pdf/factsheets/advancing_health_equity.ashx?
la=en&hash=9144021FDA33B4E7E02447CB28CA3F9D48E5EF18
Amdt, R. (2019). Tending to social determinants of health with software.
Modern Healthcare. Retrieved from https://www.modemhealthcare.
com/article/20190126/TRANSFORMATION03/190129973/tending
to-social-determinants-of-health-with-software
Aunt Bertha. (2019). Aunt Bertha. Retrieved from https://www.
auntbertha.com
Bond, G., & Drake, R. (2015). The critical ingredients of assertive
community treatment. World Psychiatry, 14(2), 240-242. https://
doi.org/10.1002/wps.20234
Braveman, P., & Gottlieb, L. (2014). The social determinants of health
It's time to consider the causes of the causes. Public Health Reports
129(Suppl 2), 19-31, https://doi.org/10.1177/
003335491412915206
Castrucci, B., & Auerbach, J. (2019, January 16). Meeting individual
social needs falls short of addressing social determinants of health
[Web log post]. Retrieved from https://www.healthaffairs.org/do/
10.1377/hblog20190115.234942/full
Centers for Medicare and Medicaid Services. (n.d.). The Accountable
Health Communities Health-Related Social Needs Screening Tool
Retrieved from https://innovation.oms.gov/Files/worksheets/ahom
screeningtool.pdf
Duchamme, J
J., & Wolfson, E. (2019, une four ZIP code might
determine how long you live-And
217). Your 2
difference could be decades
Time. Retrieved from https://time.com/5608268/zip-code-health
Epstein, N. (2014). Mutidisciplinary in-hospital teams improve patient
outcomes: A review. Surgical Neonatal International, 5(Suppl. 7).
$295-5303. https://doi.org/10.4103/21527806.139612
FitzGerald, C., & Hurst, S. (2017). Implicit blas in healthcare
professionals: A systematic review. BMC Medical Ethics, 18, 19.
https://doi.org/10.1186/s12910-017-01798
Geronimus, A. (1992). The weathering hypothesis and the health of
African American women and infants: Evidence and speculations.
Ethnicity and Disease, 2(3), 207-221.
Geronimus, A., Pearson, J., Linnenbringer, E., Schulz, A., Reyes, A., Epel,
E..... Blackbum, E. (2015), Race/ethnicity, poverty, urban stressors
and telomere length in a Detroit community-based sample. Joumal
Health and Social Behavior, 56(2), 199-224,https://doi.org/
10.1177/0022146515582100
he
Hall, W., Champman, M., Lee, K., Merino, Y., Thomas, T., Payne, B.,
Coyne-Beasley, R. (2015). Implicit racial/ethnic blas among
health
care professionals and its influence on health care outcomes: A
systematic review. American Journal of Public Health, 105(12), e60-
e76. https://doi.org/10.2105/AJPH.2015.302903
Hämmig, O., & Bauer, G. F. (2013). The social gradient in work and
health: A cross-sectional study exploring the relationship between
working conditions and health inequities. BMC Public Health, 13,
1170. https://doi.org/10.1186/1471-2458-13-1170
Health Leads. (2018). The Health Needs Screening Toolkit. Retrieved from
https://healthleadsusa.org/resources/the-health-leads-screening
toolkit/
Healthify, (2019). Healthify. Retrieved from https://www.healthify.us
Lawrence, K., & Keleher, T. (2004). Chronic disparity: strong and
pervasive evidence of racial inequities. Poverty outcomes. Structural
racism. Paper presented at Race and Public Por
Policy Conference. Paper
Nursing for Women's Health 43](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2Fac3be618-b645-4bd8-855b-808ff3fc18d4%2F5ac1af0a-c688-46fa-8412-a2cf4bd978d1%2F7yz4f6_processed.png&w=3840&q=75)
Transcribed Image Text:Health Equity and Social Determinants of Health
Sometimes the most influence nurses
can have on social determinants of
health is not in their work as nurses
but in their actions as community
citizens
long form consists of 15 questions addressing housing, food,
employment, finances, education, child care, transportation,
utilities, and personal safety (AAFP, 2018a). The short version
includes 11 questions addressing housing, food, trans-
portation, utilities, and personal safety (AAFP, 2018b). Both
forms, along with action plan templates, are available on the
project's website.
The Centers for Medicare and Medicaid Services (n.d.)
produces The Accountable Health Communities Health-
Related Social Needs Screening Tool. This 10-question
screening tool identifies needs in the areas of housing
instability, food insecurity, transportation problems, utility
help, and interpersonal safety. Supplemental questions are
also available.
OLUNTEER
Health Leads (2018) offers a Social Needs Screening
Toolkit to assist practices and health systems in designing a
screening tool. Interested practices can download a how-to
guide from their website.
Regardless of the tool used, screening for social de
terminants of health has several benefits. First and foremost,
40 Volume 24 Issue 1
Health Equity and Social Determinants of Health
BOX 2 EXAMPLES OF ACTIONS TO ADDRESS
SOCIAL DETERMINANTS OF HEALTH
Addressing the Individual Social Needs of Women
• A nurse provides a woman with a list of local food
assistance locations and the nearest Special
Supplemental Nutrition Program for Women,
Infants, and Children (WIC) office upon discharge
postpartum.
• A nurse practitioner or midwife refers a woman to a
local social worker with a Continuum of Care
organization and helps complete paperwork to
facilitate qualification for permanent supportive
housing.
A nurse administrator writes grant to provide
public transport ride cards to any prenatal care
patient who reports missing appointments because
of lack of transportation.
Participation in Health Care System Change
• A nurse collaborates with an interdisciplinary team
implement universal screening for social
determinants of health in the hospital system.
to
• A nurse joins a national nursing organization and
testifies at a state senate hearing about the
effects of proposed Medicaid budget cuts on the
women receiving care in his/her clinic.
A nurse practitioner or midwife joins a local task
force aimed at creating strategies for increasing
access to mental health care in a rural community.
Advocacy Around Upstream Structural Factors
A team of nursing educators redesigns their
institution's nursing curriculum to include
information about social determinants of health
and implicit bias during each semester.
• A nurse-researcher develops a program in which
parents receive information about language
nutrition and an age-appropriate book at each well-
child check-up and educates the nursing staff on
how to talk to parents about language nutrition.
• A nurse runs for office to develop and vote on
policies that promote health equity.
social services can refer people for services and receive
confirmation that the referral was successful (Amdt, 2019).
This trend moves from a resource list approach to a model in
which organizations collaborate and share information.
Nurses and health systems can work with EHR vendors or use
third-party software programs to improve the efficiency and
effectiveness of referralls outside of the health system.
Nurses are most effective in cross-sectional collaboration
when they are knowledgeable about the
e programs available to
women presenting with social needs. National programs
designed to assist individuals in need of health and social
42 Volume 24 Issue 1
tools allow health care
providers to identify which
social determinants most
influence women's health
and to link them to
needed resources and
support systems. This ex-
ercise also helps women
understand how their so-
cial conditions affect their
health and creates oppor
tunities for discussions.
Screening tools also pro-
vide population data that
can be used to inform the
growth and programmatic
development of health
systems. Staff and clini-
cians at health systems.
and clinics can develop
initiatives, patient in
centives, and partnerships
to address the social
needs most commonly re-
ported by women. Staff at
nonprofit clinics can use
these data to inform grant applications and obtain grant
funding, which can increase the sustainability of programs
that address social determinants of health.
Cross-Sector Collaboration
When considering social needs such as food insecurity.
housing instability, lack of transportation, and unemployment,
it becomes clear that the health care system is not equipped
to address all social determinants affecting women's health.
Medical care can reduce only approximately 10% of premature
deaths in the United States (Schroeder, 2007). Strategies to
alleviate social determinants and eliminate disparities in
premature death rely on coordinated and effective cross-
sector collaboration.
Nurses continue to be at the forefront of interdisciplinary
care. Interdisciplinary or multidisciplinary care describes
different health care staff working together to improve pa
tient care
work involving nurses, technicians, aides, physicians, and
other health care professionals is associated with improved
patient outcomes and decreased adverse events (Epstein,
2014). The skills nurses have developed regarding
communication and collaboration within the health care
sector must now be applied to building teams that extend
beyond the traditional health care system. Addressing social
determinants requires team members from multiple sectors,
such as social work, housing, business enterprise, the
philanthropic community, education, employers, religious
institutions, and government. Building common language,
doi: 10.1016/j.2019.11.003
services are highlighted in Box 1. Having a basic under-
standing of eligibility for these programs and how to direct
women to these services allows nurses to link women to
support beyond their immediate scope of care. However,
nurses do not need to be in leadership positions or have
expansive knowledge of the social safety net to address so-
cial determinants at the health systems level. Nurses can
identify team members and community liaisons with expertise
in areas such as housing, transportation, legal assistance,
food assistance, and addiction services.
Cross-sectional collaboration might begin with a
nurse creating or using a referral system to key social
service providers. Nurses can identify gaps between
women's social needs and services offered within the
health system and then forge partnerships to meet these
needs. Nurses can also urge hospital administrators to
invest in technology to advance referral coordination and
effectiveness. Nurses advocating for improved patient out-
comes need to push health care systems beyond traditional
boundaries and set a new standard for collaboration.
Advocacy Outside the Health Care Center
Outside of professional responsibilities, nurses are commu
nity members. They are parents, renters, homeowners, voters,
shoppers, local leaders, and members of social organiza
tions, religious congregations, and neighborhoods. Some-
times the most influence nurses can have on social
determinants of health is not in their work as nurses but in
citizens.
their actions community de
terminants of health and eliminating health disparities re
quires systemic change around poverty, housing, food
access, transportation, financial literacy, and education,
among others. Furthermore, achieving health equity requires
the dismantling of oppressive systems shaped by discrimi-
nation and racism. Providing for the social needs of in-
dividuals is essential, life-saving work but falls short for
addressing social determinants. As Castrucci and Auerbach
(2019) articulate, individual interventions "mitigate the acute
social and economic challenges of individual patients, but
they do so without implementing long-term fixes" (para. 7).
Nurses are ideally positioned to bring issues regarding
the health implications of policy and social conditions to
the forefront. Using their experience of how social
terminants affect health and how interventions have been
successful in improving the health of individuals, nurses
can educate those outside the health care system. Nurses
can use their stories and health care knowledge to
advocate for community-level interventions and Health in All
Policies. Based on the understanding that social de-
terminants are shaped by decisions made primarily outside
of the health care sector, Health in All Policies is an
approach to public policy that considers the health implica-
tions of decisions (Rudolph, Caplan, Ben-Moshe, & Dillon,
2013). It involves collective decision making in which deci
sion makers consider health, equity, and sustainability in
dot: 10.1016/j.2019.11.009
BOX 1 EXAMPLES OF PUBLIC ASSISTANCE PROGRAMS
Medicaid
Emergency Medicaid
Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC)
State Children's Health Insurance Program
Supplemental Nutrition Assistance Program (SNAP)
Continuum of Care
Temporary Assistance for Needy Families
General Assistance
communication systems, and resource sharing among sec
tors is critical in creating a culture of health that transcends
the health care system.
are
Equipped with information about the social needs of
their patient population, nurses can lead health systems
and provider teams toward cross-sector collaboration.
Innovative and effective models of this type of collaboration
e plentiful. The assertive community treatment approach
originated from the health care system to address the
needs of patients experiencing mental health illness. The
model involves health care providers meeting patients in
community settings and integrating multiple services to
address housing, finances, rehabilitation, a d other needs
in addition to mental health care (Bond & Drake, 2015). In
response to frequent emergency department use, Pathways
Housing First initiated a strategy in which people are
housed immediately and the support systems they need
to maintain housing are built around them (Padgett,
Henwood, & Tsemberis, 2016). Clinics and health care
February 2020
evaluating policy options (Rudolph et al., 2013). Regardless
of their position, place of employment, or interaction with
the care of women, all nurse have the ability to influence
their communities and public policy, which is essential to
address the social determinants influencing the health of
women.
Taking Action
Because social determinants of health act on a gradient
strategies to address them can be conceptualized similarly.
There is no singular approach to achieving health equity.
Nurses providing direct care can start by identifying and
addressing, through partnerships and referrals, the social
needs of patients. Next, nurses can advocate for and lead
structural changes within the larger scope of the health sys-
tem. This might include changing hospital policies to promote
equitable health outcomes or joining a national advocacy or
ganization to influence health policy. Finally, nurses can
confront the structural causes of inequity. This confrontation
can start with understanding personal implicit bias and
drawing attention to the operation of structural racism within
communities. This action might also include advocacy for
policy change in areas outside of the health field such as
housing subsidies or transportation. Examples of activities at
each level of advocacy are provided in Box 2.
Conclusion
At a time of high health care spending, increasing health care
costs, and persistent disparities in health status, the United
States is in need of new strategies to improve the nation's
health. The impact of social determinants on health and life
expectancy mandates that solutions to health disparities
occur within the health care system and outside of it. Nurses
have several key opportunities to advance a health equity
agenda. First, they can facilitate understanding in their health
care systems about the social needs of women and how to
ensure that these needs are addressed, thus mitigating the
negative effects of social determinants
health status.
Next, nurses can develop and promote community-level in-
terventions and systemwide changes to better address social
determinants of health. Last, nurse can advocate for the so-
cietal and policy changes needed to create a nation in which
health equity is a reality. NWH
Check for updates
References
American Association of Family Physicians. (2018a). Social Needs
Screening Tool (Physician Long Version). Retrieved from https://www
aafp.org/dam/AAFP/documents/patient care/everyone_project/
physician-long.pdf
American Association of Family Physicians. (2018b). Social Needs
Screening Tool (Physician Short Version). Retrieved from https://www.
February 2020
Lathrop
State and federal program that provides health coverage for
some low-income individuals, families with children,
pregnant women, the elderly, and people with disabilities.
Eligibility varies by state.
Health coverage provided retroactively for certain people
who have experienced a medical emergency, including
those not eligible for Medicaid due to immigration status.
women
Medicaid is often used to cover the birth costs
of uninsured women.
Emergency
Provides supplemental food, formula, and nutrition
education for pregnant and postpartum women, infants,
and children up to age 5 years.
State and federal program expanding health coverage to
children who do not qualify for Medicaid but cannot afford
private insurance.
Also known as food stamps, this program provides a
monthly supplement for purchasing nutritious food for low-
income people.
Federal program providing funding to nonprofit
organizations to help people experiencing homelessness
obtain transitional and permanent housing.
Monthly cash assistance program for families with children
younger than 18 years of age.
State or local programs that provide financial assistance to
very poor individuals who do not have minor children.
Currently, 26 states have General Assistance programs.
systems are also well positioned to address food insecu-
rity. Food prescription programs and partnerships with
farmers markets and local farms offer affordable produce.
Partnerships built out of a mutual desire to help people
achieve health by addressing social needs allow health
systems to move upstream in their approach to improved
health outcomes.
Collaboration
with sectors outside of the traditional health
system is also aided through coordinated referral processes
and information sharing Software prochas Unite Us
(2019), Healthily (2019), NowPow ), and
nd Aunt Bertha
(2019) help clinicians connect patients to community re-
sources to address social needs. Although EHR vendors are
increasingly able to collect and report social determinants
data for providers, the use of referral products is still new
(USDHHS Assistant Secretary for Planning and Evaluation,
2018). EHR vendors and developers of software tools are
under increasing pressure to close the loop by creating a two-
way communication system in which health systems and
Nursing for Women's Health 41
Lathrop
aafp.org/dam/AAFP/documents/patient care/everyone_project/
physician short.pdf
American Association of Family Physicians. (2019). The EveryONE Project
Toolkit. Retrieved from https://www.aafp.org/patient-care/social-
determinants-of-health/everyone-project/eop-tools.html
American Public Health Association. (2018). Creating the healthiest
nation: Advancing health equity. Retrieved from https://www.apha
org/-/media/files/pdf/factsheets/advancing_health_equity.ashx?
la=en&hash=9144021FDA33B4E7E02447CB28CA3F9D48E5EF18
Amdt, R. (2019). Tending to social determinants of health with software.
Modern Healthcare. Retrieved from https://www.modemhealthcare.
com/article/20190126/TRANSFORMATION03/190129973/tending
to-social-determinants-of-health-with-software
Aunt Bertha. (2019). Aunt Bertha. Retrieved from https://www.
auntbertha.com
Bond, G., & Drake, R. (2015). The critical ingredients of assertive
community treatment. World Psychiatry, 14(2), 240-242. https://
doi.org/10.1002/wps.20234
Braveman, P., & Gottlieb, L. (2014). The social determinants of health
It's time to consider the causes of the causes. Public Health Reports
129(Suppl 2), 19-31, https://doi.org/10.1177/
003335491412915206
Castrucci, B., & Auerbach, J. (2019, January 16). Meeting individual
social needs falls short of addressing social determinants of health
[Web log post]. Retrieved from https://www.healthaffairs.org/do/
10.1377/hblog20190115.234942/full
Centers for Medicare and Medicaid Services. (n.d.). The Accountable
Health Communities Health-Related Social Needs Screening Tool
Retrieved from https://innovation.oms.gov/Files/worksheets/ahom
screeningtool.pdf
Duchamme, J
J., & Wolfson, E. (2019, une four ZIP code might
determine how long you live-And
217). Your 2
difference could be decades
Time. Retrieved from https://time.com/5608268/zip-code-health
Epstein, N. (2014). Mutidisciplinary in-hospital teams improve patient
outcomes: A review. Surgical Neonatal International, 5(Suppl. 7).
$295-5303. https://doi.org/10.4103/21527806.139612
FitzGerald, C., & Hurst, S. (2017). Implicit blas in healthcare
professionals: A systematic review. BMC Medical Ethics, 18, 19.
https://doi.org/10.1186/s12910-017-01798
Geronimus, A. (1992). The weathering hypothesis and the health of
African American women and infants: Evidence and speculations.
Ethnicity and Disease, 2(3), 207-221.
Geronimus, A., Pearson, J., Linnenbringer, E., Schulz, A., Reyes, A., Epel,
E..... Blackbum, E. (2015), Race/ethnicity, poverty, urban stressors
and telomere length in a Detroit community-based sample. Joumal
Health and Social Behavior, 56(2), 199-224,https://doi.org/
10.1177/0022146515582100
he
Hall, W., Champman, M., Lee, K., Merino, Y., Thomas, T., Payne, B.,
Coyne-Beasley, R. (2015). Implicit racial/ethnic blas among
health
care professionals and its influence on health care outcomes: A
systematic review. American Journal of Public Health, 105(12), e60-
e76. https://doi.org/10.2105/AJPH.2015.302903
Hämmig, O., & Bauer, G. F. (2013). The social gradient in work and
health: A cross-sectional study exploring the relationship between
working conditions and health inequities. BMC Public Health, 13,
1170. https://doi.org/10.1186/1471-2458-13-1170
Health Leads. (2018). The Health Needs Screening Toolkit. Retrieved from
https://healthleadsusa.org/resources/the-health-leads-screening
toolkit/
Healthify, (2019). Healthify. Retrieved from https://www.healthify.us
Lawrence, K., & Keleher, T. (2004). Chronic disparity: strong and
pervasive evidence of racial inequities. Poverty outcomes. Structural
racism. Paper presented at Race and Public Por
Policy Conference. Paper
Nursing for Women's Health 43
Expert Solution
This question has been solved!
Explore an expertly crafted, step-by-step solution for a thorough understanding of key concepts.
Step by step
Solved in 3 steps
Recommended textbooks for you
Understanding Business
Management
ISBN:
9781259929434
Author:
William Nickels
Publisher:
McGraw-Hill Education
Management (14th Edition)
Management
ISBN:
9780134527604
Author:
Stephen P. Robbins, Mary A. Coulter
Publisher:
PEARSON
Spreadsheet Modeling & Decision Analysis: A Pract…
Management
ISBN:
9781305947412
Author:
Cliff Ragsdale
Publisher:
Cengage Learning
Understanding Business
Management
ISBN:
9781259929434
Author:
William Nickels
Publisher:
McGraw-Hill Education
Management (14th Edition)
Management
ISBN:
9780134527604
Author:
Stephen P. Robbins, Mary A. Coulter
Publisher:
PEARSON
Spreadsheet Modeling & Decision Analysis: A Pract…
Management
ISBN:
9781305947412
Author:
Cliff Ragsdale
Publisher:
Cengage Learning
Management Information Systems: Managing The Digi…
Management
ISBN:
9780135191798
Author:
Kenneth C. Laudon, Jane P. Laudon
Publisher:
PEARSON
Business Essentials (12th Edition) (What's New in…
Management
ISBN:
9780134728391
Author:
Ronald J. Ebert, Ricky W. Griffin
Publisher:
PEARSON
Fundamentals of Management (10th Edition)
Management
ISBN:
9780134237473
Author:
Stephen P. Robbins, Mary A. Coulter, David A. De Cenzo
Publisher:
PEARSON