Be Prepared for the Future of Nursing: Social Determinants of Health and Health Equity

What does the future of nursing look like? And how can nurses carve their own path while serving others? To answer these questions, The National Academy of Sciences, Engineering, and Medicine launched their report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021).

This new report, which commemorated the International Year of the Nurse and the Midwife, acts as the roadmap of where nursing is going. Specifically, it states:

“The decade ahead will demand a stronger, more diversified nursing workforce that is prepared to provide care; promote health and well-being among nurses, individuals, and communities; and address the systemic inequities that have fueled wide and persistent health disparities.” 

Health equity cannot be achieved without nurses; their contribution is central to the delivery of care. At the same time, student nurses have to be aware of this shift in their profession, no matter the nursing specialty. 

The new Future of Nursing report identifies why the role of nurses has to focus on Social Determinants of Health (SDOH) and Health Equity in the next decade.

Osmosis is here to support and prepare you for the future with a focus on diversity, equity, and inclusion (DEI) and SDOH. So you can trust that you're learning the most relevant way.

In this article, our team shares key points from the report on why nurses need to prioritize health equity and how to address SDOH.

First, what is Health Equity?

“Nurses live and work at the intersection of health, education, and communities (...) the world has come to understand the critical importance of health to all aspects of life, particularly the relationship among what are termed social determinants of health (SDOH), health equity, and health outcomes.” 

As the report outlines, “health equity is achieved when everyone has a fair and just opportunity to be as healthy as possible.”

Unfortunately, the pandemic has exacerbated health inequities that mostly affect low-income individuals, people of color, and residents of rural areas.

What are the Social Determinants of Health?

SDOH refer to the conditions in which people live, work, play, learn, age, the “nonmedical factors influencing health, including health-related knowledge, attitudes, beliefs, or behaviors (such as smoking).”

Social determinants of health affect everyone and can be organized in five areas, according to the US Department of Health and Human Services.

In more detail, these factors include:

Economic Stability: 

• Employment
• Food Insecurity
• Housing Instability
• Poverty

Education Early Childhood Education and Development 

• Enrollment in Higher Education
• High School Graduation
• Language and Literacy

Social and Community Context 

• Civic Participation
• Discrimination
• Incarceration
• Social Cohesion

Health and Health Care 

• Access to Health Care
• Access to Primary Care
• Health Literacy

Neighborhood and Built Environment 

• Access to Foods That Support Healthy Eating Patterns
• Crime and Violence
• Environmental Conditions
• Quality of Housing

The report uses the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach to describe the strategies used to improve individual and population health:

1. Upstream Factors

They represent SDOH and affect communities in a large and inequitable way. 

• Examples: low educational status and opportunity, income disparity, discrimination, and social marginalization.
• Nurses engage in upstream factors by informing government policies at the local and federal levels.

2. Midstream Factors

They represent social needs or individual factors that might affect a person’s health. 

• Examples: homelessness, food insecurity, poor access to education, and trauma.
• Nurses focus on preventing disease and meeting social needs by screening for these social risk factors and using data to inform referrals to government and community resources related to each of the identified social needs.

3. Downstream Factors

They refer to the delivery of clinical care and interventions: 

• Disease treatment and chronic disease management.
• Nurses engage in settings where health care is delivered (homes, urgent care clinics, hospitals).

All social determinants intersect (especially gender, race, and class inequity), as our nursing advisor Sharon Goldfarb explains. So SDOH can be seen as:

• 40% Socioeconomic Factors: education, job status, family social support, income, community safety
• 10% Physical Environment
• 30% Health Behaviors: tobacco use, diet and exercise, alcohol use, sexual activity
• 20% Health Care: access to care and quality of care.

Let’s take a look at the main social determinants of health.

Social Determinants of Health and Health Equity

1. Race and Racism

As Sharon points out, “The discussions we’ve been having for a long time about the poor outcomes for communities of color are finally taking place efficiently to end the bias and structural racism that happens in the medical field.”

Structural racism provides advantages to the dominant racial group while oppressing, disadvantaging, or neglecting other racial groups. It can be seen in residential segregation, the criminal justice system, the public education system, and immigration policy.

Segregation is associated with low birth weight and preterm birth, with lower cancer survival rates, and a higher risk of myocardial infarction, as the report outlines.

Cultural racism refers to negative stereotypes and beliefs according to race, which can lead to structural and individual racism and unintentional, unconscious discrimination against others.

Research indicates women of color are less likely to receive an epidural during childbirth, because providers believe in a relationship between race and pain tolerance, for example.

Discrimination refers to microaggressions and treating racial groups differently, with or without intent, which leads to inequitable access to health and resources.

2. Income and Wealth

The socioeconomic status strongly influences predisposition to disease, incidences of illness, increased morbidity and mortality, and even smoking habits.

Children in low-income families usually face educational and social barriers, which limits their social mobility and good health as adults. Also, people with lower income have higher rates of heart disease, stroke, diabetes, hypertension, and are at risk of at least 4 common chronic conditions, according to the report findings.

“There are things in society that predispose Black people to smoke more—there are up to 10x more tobacco ads in Black neighborhoods. So it’s a big thing we have to do: see the life they are living. Part of the nursing role is to always screen for tobacco use and take that opportunity to talk with patients about smoking cessation”, advises Sharon.

3. Access to Health Care

Equitable access is key for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity.”

There is plenty of evidence showing that access to primary care prevents illness and death and is associated with positive health outcomes, which makes it a critical social determinant of health today.

4. Access to Education

According to the report, there’s a strong association between educational attainment and morbidity and mortality. In the US, adults with a lower level of education have higher rates of major circulatory diseases, diabetes, liver diseases, and psychological symptoms like feelings of sadness, hopelessness, and worthlessness.

Lack of access to education is a problem for low-income families, who often live in school districts that lack resources and cannot afford early childhood learning experiences.

5. Housing Instability and Homelessness

People with limited resources and unstable housing are exposed to many physical and mental health issues. Homeless people face higher rates of HIV, alcohol and drug abuse, mental illness, and tuberculosis, to name a few.

Here are the four ways housing instability affects vulnerable people:

• Stability: Not having stable housing can lead to an increased risk of teen pregnancy, early drug use, and depression for young people
• Quality and safety: Poor housing conditions are associated with poor health outcomes, especially asthma.
• Affordability: Low-income families with difficulty in affording rent or utilities are less likely to have a source of medical care and more likely to postpone treatment.
• Neighborhood: having public transportation, grocery stores with fresh foods, and safe parks to exercise is linked to better health outcomes.

6. Food Insecurity

People from low-resource neighborhoods often have limited access to nutritious food options. They’re more likely to live in food deserts - areas with many fast food shops and liquor stores, but a shortage of fresh produce and restaurants that offer healthy choices.

Food insecurity is associated with health problems such as birth defects, anemia, cognitive problems, as well as higher hospitalization rates, poorer general health, asthma, behavioral problems, depression, suicidal ideation, and poor oral health, as the report shows.

Diabetes is one major issue that disproportionality affects communities of color. According to Sharon, the prevalence is 14.7% for American Indians/Alaska Natives; 12,5% for Latinx; 11.7% for non-Hispanic Blacks, 9.2% for non-Hispanic Asians, and only 7.5% for Whites.

“It’s not all genetic, it’s lifestyle and food deserts and stress. So it’s important for nurses to screen people and help them with lifestyle management and medication compliance.”

7. Environment and Climate Change

Environmental hazards, such as air pollution, harmful agricultural chemicals, and poor water quality, are likely to appear in low-income communities and those of color. As a result, these communities are more likely to suffer because of these hazards.

Not only do natural disasters pose huge threats to life, property, and the capacity of health care services in crises, but they affect under-resourced populations more severely.

8. Rurality

Inequities exist particularly at the intersection of geography, race, and ethnicity, and rural citizens face shortages of healthcare providers, many are uninsured, and lack transportation and internet access.

Also, rural areas have higher death rates across the five leading causes of death (heart disease, stroke, cancer, unintentional injury, and chronic lower respiratory disease).

What Future Nurses Need to Prioritize: The Nurses’ Role in Improving Health Equity

As David Williams, MD, co-chair of the Future of Nursing committee, Professor of Public Health, and chair of the Department of Social and Behavioral Sciences at Harvard’s Chan School of Public Health emphasized:

 So as a future nurse, your role will be central in addressing health disparities:

• Nurses are able to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities.
• Nurses can use their interdisciplinary expertise and holistic approach to help develop and advocate for policies and programs that promote health equity.

This can be done by integrating social care into health care through adjustment and assistance (focused on individuals), alignment and advocacy (focused on communities), and awareness (both levels).

1. Addressing Social Needs in Clinical Settings

The provision of clinical care allows nurses to address social needs as part of an essential holistic perspective by:

• Screening for social needs and reviewing results (especially for food insecurity, housing instability, utility needs, transportation, interpersonal violence).
• Making referrals to professionals and social services.
• Creating customized care plans and coordinating care by working with social and community health workers and social services providers.

In order to facilitate these processes, nurses need to learn how to use technology in their practice but also have an education that ensures relevant knowledge and proper communication skills related to social issues.

2. Addressing Social Needs and SDOH in the Community

Public health nurses in particular have extensive knowledge at the community level and can more easily build trust and mutual respect among them. Likewise, home visiting nurses play the same vital role in addressing social needs at individual and family levels.

Public health and community-based nurses can engage with other service providers. Among the roles they will have in addressing health inequity, according to the report:

• Act on the limitations triggered by the inability to afford transportation, food, etc.
• Health promotion and disease prevention and control for families within communities.
• Engage in activities ranging from policy development and coalition building to health teaching and case management.
• Serve people with complex health and social needs, such as the elderly, homeless individuals, teenage mothers, those at risk for a specific disease.
• Use data and knowledge of environmental factors to plan for and respond to public health crises.
• Provide community and health department feedback regarding policies and programs aimed at improving health.
• Implement evidence-based public health programs and develop and manage program budgets.

3. Working Across Disciplines to Meet Multiple Needs

Interventions of nurses working with other sectors address multiple needs of individuals and communities and have a wide impact on health outcomes and health care utilization.

Through partnerships with for-profit and NGOs, community groups, federal programs, hospitals, technology companies, community-based nurses work to address various types of health-related needs, from diabetes management to transportation, to ensure low-income families have access to health care.

In order to succeed, nurses need to be educated in choosing the right multidisciplinary approach to reduce health inequity.

4. Advocating For Policy Change

Nurses can and should promote health equity by getting involved in public policies and decision-making. This can refer to communicating about health disparities and SDOH with the public, policymakers, organizational leaders, focusing on challenges and solutions for addressing health, according to the report.

In short, the modern nursing profession is shifting the focus on programs defined by:

• A holistic approach towards health
• Individual-, family-, and community-centric design
• Relationship-based care
• Ongoing public health approaches to serve underserved populations. 

How can future nurses like you achieve these goals, according to the report: 

1. Support for and the willingness to take on new roles in new settings in the community;
2. Consistency in nurses’ preparation for engaging in strategies to promote health equity by addressing issues that compromise health (geographic disparities, poverty, racism, homelessness, trauma, drug abuse, and behavioral health conditions;
3. More experiential learning and opportunities to work in community settings throughout nursing education to ensure that nurses have competencies to address individuals’ complex needs and help improve the well-being of communities;
4. Nursing education that goes beyond teaching the principles of diversity, equity, and inclusion to provide sustained student engagement in hands-on community and clinical experiences with these issues;
5. Funding to support new models of care and functions that address SDOH, health equity, and population health;
6. Evaluation of models to build the evidence needed to scale programs and the policies and resources necessary to sustain them.

How Osmosis can prepare you for the future of nursing

In NAP's extensive report, the direction for the nursing profession has become clearer than ever: a big focus on diversity, equity, inclusion, and the social aspects of patient care.

These new shifts asked for a relevant, forward-thinking approach to nursing education, as we said before. To accomplish that, our new Nursing Library has been infused with this new philosophy so that student learners can fully prepare for their future.

Osmosis is trusted by leading institutions and offers nursing students powerful studying tools that align with what you'll see in actual practice.

Join millions of learners with a free trial and enjoy a brand new, inclusive way to become the best nurse you can possibly be!