Abstract
There is currently a shift to the social determinants of health (SDH) framework in public health and the larger health system. The framework demonstrates that larger social systems impact individual socioeconomic position which predicts material, biological, and psychosocial circumstances. The resulting disparity directly impacts health. Disparity can be noted in diabetes and heart disease. Healthy People 2010 and 2020 have raised the issue of disparity at a national level which stimulated research and program and policy development to eliminate SDH. Advanced practice nurses have important roles to play as leaders, researchers, advocates, and care providers in the achievement of this national health goal.
There is increasing recognition that health and disease is not merely the outcome of individual behaviors and choices but are in fact manifestations of systems larger than the individual. From the traditional viewpoint of Western medicine, individuals are solely responsible for their health and should be blamed for their illness (Mitchell, 2012). On the other hand, there those who argue that larger systems are also partly to blame because people have unequal access to the resources, education, and support necessary to maintain health (Mitchell, 2012). The latter view is known as the social determinants of health (SDH). The purpose of this paper is to discuss how social, economic, cultural, and political factors affect health, the impact of health policy on health outcomes, and the role of advance practice nurses in addressing SDH.
Factors that Influence Individual Health
Within an SDH framework, health and illness are influenced by the circumstances a person is born into, lives, works, and ages (Havranek et al., 2015). As illustrated in the Solin and Irwin SDH framework (see Fig. 1), governance, socioeconomic and public policies, culture, and social values help determine a person’s socioeconomic position by virtue of social class, gender, and ethnicity (Davis & Chapa, 2015). For example, laws and policies which favor the wealthy but not the poor, White persons but not ethnic minorities, and men but not women can create disadvantages for certain segments of the population. Furthermore, the dominance of one ethnic group and the minority status of another can result in health and social policies reflecting the cultural perspective of the former and exclusion of the latter. While there may not be laws or policies that explicitly discriminate against groups of people, the lack of such laws and policies that ensure equity would also perpetuate disparity.
One example of public policies determining socioeconomic position by virtue of social class and ethnicity is the public school system. Schools in poor minority communities are disproportionately staffed by low-performing teachers and systems often communicate lower academic expectations (Donald, 2013). These schools also receive the least funding thus limiting students’ access to higher quality education which contributes to an achievement gap. The lack of effective policies that address this gap has made it a lingering social issue. The same can be said of health care. The media has been highlighting the closure of many safety-net hospitals in poor minority communities while new facilities open in wealthier communities (Galewitz, 2015). While there is nothing that prohibits such closures, the lack of policies ensuring that residents of poor communities have equal access to adequate and quality in-patient care contributes to the problem of underserved communities. Further, public health programs that have been implemented broadly but not adapted to suit minority beliefs and values have largely been ineffective in these populations evidenced by poor utilization of services and higher rates of negative health outcomes (Tucker et al., 2011). It illustrates how public policies also shape social position in relation to ethnicity. In terms of public policy and gender, the underrepresentation of women in clinical research has led to an insufficient understanding of gender-based differences in disease, such as the differences in the manifestation of myocardial infarction in men and women, which has led to less effective care in the latter (Kent, Patel & Varela, 2012).
Socioeconomic position based on social class, gender, and ethnicity consequently impacts a person’s educational attainment, which significantly affects future employability, occupation, and income level (Havranek et al., 2015). In this manner, socioeconomic position shapes a person’s material circumstances from birth until death. Material circumstances include the living and work environment, food availability, early childhood care, and health insurance coverage. Socioeconomic position also influences behaviors, biological risks of illness, and psychosocial wellbeing (Davis & Chapa, 2015). These factors account for vulnerability to illness and inequity in health that predisposes disadvantaged groups to earlier onset and greater severity of disease (Williams et al., 2010).
Health inequity can be seen in diabetes and heart disease. By ethnicity, the rate of diabetes in adult American Indians and Alaska natives at 16.3% is almost twice that of Whites which is at 8.7% (Mitchell, 2012). Meanwhile, the rate of diabetes in adult African Americans is 13.2% which is also significantly higher (American Diabetes Association, 2016). African American adults are more likely to develop hypertension compared to Whites and to develop heart failure at an earlier age (Williams et al., 2010). In the hospital setting, women in general are more likely not to receive the same quality of care for cardiovascular disease compared to men because of underestimation or misunderstanding of their risk, signs, and symptoms (Kent, Patel & Varela, 2012). Epidemiological studies of the incidence of poverty and obesity in US counties established a link between these 2 factors with obesity being a risk factor of type 2 diabetes (Levine, 2011).
Material circumstances, behaviors, and psychosocial wellbeing arising from socioeconomic position help explain health disparity in heart disease and diabetes in underserved or vulnerable populations. Historical mistrust of Western medicine is a recognized barrier preventing African Americans and American Indians from utilizing health care early in the disease process (Mitchell, 2012; Plescia & Emmanuel, 2014). Low literacy levels in disadvantaged groups also impact health literacy and the ability to understand and self-manage chronic illness (Plescia & Emmanuel, 2014). Food insecurity arising from employment and income status further limits access to healthy food (Mitchell, 2012). Financial insecurity, high crime rates, and lower levels of social cohesion in poorer neighborhoods can contribute to higher levels of psychological stress (Havranek et al., 2015).
Impact of Policy and the Policy Process
Given the impact of social and public policies in shaping the social determinants of health, policy and the policy process are also necessary in improving health outcomes in underserved or vulnerable populations. The inclusion of the reduction of health disparity as an overarching aim in the Healthy People 2010 elevated the issue into a national public health policy (Davis & Chapa, 2015). However, a decade of focusing mainly on individuals and the biological aspect of disease with only modest results has led to the realization of the need to look beyond the individual. In international policy, the World Health Organization (WHO) had already recognized the impact of SDH leading to the creation of the Commission on Social Determinants of Health (CSDH) in 2005 which advocated for this new framework globally (Sadana & Blas, 2013).
Subsequently, the national goal in the Healthy People 2020 was modified to eliminating health disparity by creating the social and physical environment conducive to good health for everyone (Davis & Chapa, 2015). Health disparity was defined in the document as a specific difference in health associated with socioeconomic and environmental disadvantage based on a broad range of characteristics including ethnicity, religion, age, gender and sexual orientation, social status, mental health, disability, and geographic location (ODPHP, 2016). This goal clearly reflects recognition of the health impact of social determinants and is guided by a national action plan.
The impact was greater awareness, understanding, and use of the SDH framework in improving the health outcomes of disadvantaged groups. Publications focused on how SDH theory could then be applied in public health practice, schools, workplaces, and communities with case studies and other evidence of successful policies and programs in other countries and locally (Public Health Reports, 2013). One example of an SDH program was the Hermosa Vida (Beautiful Life) community-based program implemented in an underserved Arizona city of Hispanic and Navajo residents to tackle childhood obesity (Hardy, Bohan & Trotter, 2013). Rather than targeting obesity and individuals, a coalition between a community health center, a funding agency, and academic institutions conducted research to ascertain the specific social determinants contributing to obesity (Hardy, Bohan & Trotter, 2013). The study revealed that limited access to healthy food, parents lack of time to cook healthier food, and financial limitations prevented children from eating healthier. Partnership with the community led to the identification of strategies to address SDH including afterschool community cooking for school children, increasing local markets for fresh produce, and small business opportunities for those with inadequate income (Hardy, Bohan & Trotter, 2013). The program was positively evaluated by the community. The same approach was employed to address SDH in adult heart disease and diabetes in a North Carolina county.
The policy process assisted and will continue to assist in addressing health disparity through the SDH framework. The Patient Protection and Accountable Care Act (PPACA) expanded health insurance coverage given that insurance was a key determinant of access to health care. In 2010, the (PPACA) also reauthorized the Office of Minority Health which would lead in the development of policies and programs specifically for ethnic or racial minorities (OMH, 2016) and the Office of Women’s Health for gender policies and programs (CDC, 2016). In various states, there are bills in various stages of the policy process addressing different aspects of SDH. In California, for instance, AB 1182 aims to increase the number of health care professionals in underserved communities while in Illinois, HB 5412 aims to include lay community health workers in the health care team (NCSL, 2014). In Iowa and Maryland, there are plans to create health enterprise zones which are communities with socioeconomic and health disparities receiving federal or state funding for programs that address SDH (NCSL, 2014).
The Role of Advanced Practice Nurses
The advanced practice nurse (APN) possesses the knowledge and skills to be able to play an important role in improving health outcomes in vulnerable populations. The APN has the capacity to lead research in exploring SDH in a particular target group and to lead the planning and implementation of programs that address SDH (Davis & Chapa, 2015). At the point of health care delivery, APNs can impact SDH by eliciting related data during health history-taking and to consider these variables in the planning of care (Davis & Chapa, 2015). APNs can make a list of private, public, and community-based resources to which they can refer patients for support (Cox, 2016; Davis & Chapa, 2015).
APNs can also contribute to efforts addressing the larger social, economic, and political determinants of health through advocacy and lobbying (Cox, 2016). They can employ their professional experiences with vulnerable patients to increase awareness of SDH among their peers and the public. They can take part in drafting policies that address SDH, write letters to policymakers, and give testimonies to aid the legislation of policies that will benefit the underserved (Cox, 2016; Davis & Chapa, 2015). Finally, APNs can engage in research and its dissemination to generate evidence that is helpful in designing effective programs eliminating SDH.
Conclusion
There has been a shift in paradigm from an individualistic perspective of health and illness to the SDH framework. The Solin and Irwin model shows how larger social systems impact individual socioeconomic position which predicts material, biological, and psychosocial circumstances which directly impact health. Policies and the policy process now recognize SDH which is driving the implementation of programs to address it. The APN has a leadership, research, advocacy, and care provider role in eliminating SDH.
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