Despite remarkable technological and biological advances in health care, far less progress has been made in addressing social determinants of health (SDH), which are defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life.” Nursing, with its holistic model of health care, is positioned to be a leader in improving health by linking SDH to outcomes through analysis and action.
SDH includes such factors as socioeconomic status, environment (including air and water quality), food insecurity and food safety, education, employment, social networks, homelessness, and racism. Research has begun to show how SDH affects health outcomes. For example, in 2016 the Dana-Farber/Boston Children's Cancer and Blood Disorders Center reported that children with acute lymphoblastic leukemia who are poor are more likely to suffer earlier relapses than those who are not. Though more study is needed to understand this and other links between SDH and health outcomes, poor families’ lack of resources to pursue care that could delay relapses may be one explanation.
Like poverty, homelessness can both contribute to and result from health problems. The high cost of health care in the United States can create economic difficulties for someone who is ill and lead to homelessness. Homelessness, in turn, because of exposure to contagious conditions, can lead to further illness. Stress, and sometimes overt violence, in the experience of racism is a well-known influence on both mental and physical health.
Environment, too, plays a crucial role in health: a 2015 report from the Edward R. Roybal Institute on Aging at the University of Southern California revealed that people age 50 who live in South Los Angeles have a 5.5-year lower life expectancy than those who live in West Los Angeles. The link between one's neighborhood and one's health reflects multiple inequities in the environment and social contexts of populations.
Many prominent organizations have addressed this issue. The Robert Wood Johnson Foundation, through its Culture of Health initiative, and the Centers for Disease Control and Prevention, through its social determinants of health maps, are leading efforts to better understand the social, environmental, and cultural influences on health. One goal of the Healthy People 2020 campaign is to create social and physical environments to promote good health. In 2016, the National Academies of Sciences published a report on how health professionals can be taught to address SDH.
Nursing has always had a strong focus on SDH. Florence Nightingale emphasized the importance of hygiene, nutrition, social network, and social class. Lillian Wald, the founder of public health nursing, established the Henry Street Settlement, out of which developed the Visiting Nurse Service of New York, which provides health care to the poor. The Code of Ethics for Nurses of the American Nurses Association includes principles of social justice and emphasizes the need to integrate social concerns into nursing and health policy. Nursing can lead in translating SDH awareness into action by taking the following steps:
- Teach SDH content in all clinical courses, with students routinely assessing for SDH in clinical settings and advocating for change to improve SDH.
- Develop interprofessional practice to include representatives of social work, public health, city planning, occupational health, police and fire fighters, and many others who can contribute to addressing SDH.
- Prioritize nursing research on social and biomedical aspects of health to connect SDH to health outcomes and develop nursing interventions that alleviate problematic SDH.
- Collaborate with social and community agencies and institutions to recommend that health policy address harmful SDH.