2
Social Determinants of Health
Andrew Scanlon and Courtney Reinisch
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Culture Population Health
Health Disparities
LEARNING OUTCOMES
1. Identify the social determinants of health. 6. Describe the role of nursing in promoting health equity.
2. Describe the factors that contribute to health disparities and 7. Examine ways that your cultural background may influence
health equity. nursing care.
3. Define cultural competence and its related terminology. 8. Describe strategies for successfully communicating with a
4. Explain how culture and ethnicity may affect a person’s person who speaks a language that you do not understand.
health.
5. Apply strategies for integrating social determinants of
health in the nursing process.
KEY TERMS
acculturation health status
cultural competence place
culture race
ethnicity racism
ethnocentrism social determinants of health
folk healers stereotyping
health disparities values
health equity
This chapter discusses social determinants of health (SDH), health nonmedical factors that (1) influence the health of persons and
disparities, and culture. The SDH serve as the foundation for how groups and (2) explain why some people have poorer health
we express our culture. Understanding the SDH is needed to pro- than others.1 The SDH can be broken down into 5 groups.
vide patient-centered care. Health is a cultural concept because These are neighborhood, economic stability, education, health
culture frames and shapes our experiences. Cultural beliefs influ- care access, and community context (Fig. 2.1). Where people
ence health promotion practices and attitudes about seeking are born, grow up, live, work, and age helps to determine their
health care. Social and cultural factors influence equity in health health status, behaviors, and care.
care. Health disparities are differences in the incidence, preva- Health status is a holistic concept that is more than the
lence, mortality rate, and burden of diseases that exist among spe- presence or absence of disease. It encompasses life expec-
cific population groups. An inability to address the SDH results in tancy and self-assessment of health. Many measures make
health disparities and negatively impacts well-being. up the concept of health status. For a person, this means
the sum of their current health problems plus their coping
resources (e.g., family, financial resources). For a commu-
SOCIAL DETERMINANTS OF HEALTH nity, health status is the combination of health measures for
Why are there differences in people’s health status? How do all people living in the community. Community health mea-
these differences occur? The social determinants of health are sures include birth and death rates, life expectancy, access
19
,20 SECTION 1 Concepts in Nursing Practice
Social determinants of health
Economic Community
Neighborhood Education Health care
stability context
Employment Housing Literacy Social Health coverage
integration
Income Transportation Language HCP
Support systems availability
Expenses Safety Early childhood
education Community
Debt Recreation Linguistic and
engagement
Vocational cultural
Medical bills Walkability training Discrimination competency
Support Zip code/ Higher Stress Quality of care
geography education
Food
Health outcomes
Mortality, morbidity, life expectancy, health status, functional limitations
Fig. 2.1 Social determinants of health.
to care, and morbidity and mortality rates related to disease About 20% of Americans live in nonurban or rural areas.2
and injury. Differences in access to health care services between rural and
Factors in a person’s social and physical environment, includ- urban settings can create geographic health disparities. People
ing personal relationships, workplace, housing, transportation, in rural areas may need to travel long distances to receive health
and neighborhood violence, contribute to health status.1 For care.2 This can result in inadequate or less-frequent access to
example, the risk of youth homicide is much higher in neigh- health care services. Some parts of the rural United States are
borhoods with gang activity and high crime rates. The physical “medically underserved” because of low numbers of HCPs.
environment in which one lives, works, and plays may expose a People in rural areas have higher rates of obesity and chronic
person to such risks as environmental hazards (workplace inju- disease. They are more likely to have cancer, heart disease,
ries), toxic agents (chemical spills, industrial pollution), unsafe diabetes, depression, and injury-related deaths than people in
traffic patterns (lack of sidewalks), or absence of fresh, healthy urban areas. In rural Appalachia, the rates of lung, colon, cervi-
food choices. cal, and colorectal cancer are higher than average. Rural popu-
A person’s behavior is influenced by their environment, edu- lations tend to be older than urban populations. The impact of
cation, and economic status. Behaviors such as tobacco and social and physical environment on health choices can be illus-
drug use are strongly linked to many health conditions (e.g., trated by the problem of intimate partner violence in rural com-
lung cancer, liver disease). A person’s biologic makeup, such as munities.3 The decision to seek help is affected by geographic
genetics and family history of disease (e.g., heart disease), can isolation, traditional gender roles, patriarchal attitudes, fear of
increase the risk for specific diseases. lack of confidentiality, and economic factors that exist in some
Access to health care contributes to a person’s health. small rural communities.
Although government initiatives strive to reduce the number Living in urban centers may predispose a person to other
of uninsured Americans, millions still are uninsured and have health disparities. People in high crime areas may not visit
limited access to care. This affects both individual and commu- HCPs. High rates of chronic health problems and premature
nity health. deaths occur in neighborhoods with social inequalities. These
include high poverty rates, high crime rates, and residential
Neighborhood segregation.
Place refers to the geographic and environmental location Among the most obvious health behaviors affected by place
where a person is born, grows, lives, works, and ages. Your are physical activity and nutrition. Safe, walkable neighbor-
neighborhood affects the use of health services, health status, hoods with playgrounds promote physical activity. Source and
and health behaviors. price of healthy foods affect diet intake and weight. Social sup-
Housing is a basic need. It protects us from environmental port positively affects coping with illness. Social networks are
harm. Housing can contribute to poor health outcomes. Unsafe more likely in communities where neighbors interact and rely
or poor-quality housing is associated with exposure to lead, on one another.
indoor air pollution, and asthma triggers (dust, mold, rodents).
Overcrowded living conditions can contribute to the spread of Economic Stability
infectious disease. Living close to environmental hazards can The main nonmedical factor affecting health is socioeconomic
affect pregnancy outcomes. It increases the risk of cancer and status. Socioeconomic status is related to wealth, education, and
neurologic problems. occupation. Those living in poverty cannot afford healthy food,
, CHAPTER 2 Social Determinants of Health 21
35% of the population but only 24% of the nation’s nurses.4
Biased behaviors against nurses of diverse cultural and ethnic
backgrounds by patients and health care professionals may con-
tribute to their underrepresentation.
Cultural differences affect how well patients think they can
communicate with their HCP. In the United States, minority
patients are more likely to have difficulty understanding and
communicating with their HCP. Communication issues include
not understanding the HCP, feeling that they are not listened to,
and having questions but not asking them.
Education
Where you live influences your access to quality education.
Some communities have better schools than others. People with
higher levels of education tend to be healthier. Adults without a
Fig. 2.2 Interprofessional team working together in a multicultural high school diploma or equivalent are 3 times more likely to die
health care environment. (© Thinkstock/Stockbyte/Thinkstock.)
before age 65 than those with a college degree.
Health literacy is defined as the degree to which a person
health care, and safe housing. People of lower income report has the capacity to obtain, process, and understand basic health
worse health and die at a younger age. Hazardous work envi- information and services needed to make appropriate health
ronments and high-risk occupations increase health risk and decisions. This includes the ability to (1) read, understand, and
contribute to higher rates of illness, injury, and death. analyze information; (2) understand instructions; (3) weigh
risks and benefits; and (4) make decisions and act. Low health
Health Care literacy is related to more hospitalizations, greater use of emer-
Many people do not have access to quality health care. Health gency department care, decreased use of cancer screening and
care coverage is a key factor that contributes to health dispari- influenza vaccine, decreased ability to use medications cor-
ties. People who are underinsured, have no insurance, or lack rectly, and higher mortality rates among older adults.
financial resources to pay for treatment of diseases may forgo Patients need to be able to self-manage conditions such as
health care visits, screenings, and treatments. Patients who lack diabetes and asthma. Patients with diabetes may not be able to
the knowledge and/or access to apply for government aid pro- maintain adequate blood glucose levels if they cannot read or
grams (e.g., Medicaid) are also at risk. understand the numbers on the home glucose monitoring sys-
The health care system may contribute to health disparities. tem. The inability to read and understand medication labels can
For example, a clinic located in an area with a large population result in taking medications at the wrong time or in the wrong
of non–English-speaking immigrants that does not provide dose. See Chapter 4 for more about health literacy.
interpreters or educational materials and financial forms in
languages other than English may limit these families’ ability to Community
understand how to access health care. Our sense of connection with family, friends, coworkers, and
Discrimination and bias based on a patient’s race, ethnicity, community members affects our health and well-being. Positive
gender, age, body size, sexual orientation, or ability to pay are relationships can improve health. Persons who are bullied may
likely to result in less aggressive or negative treatment practices. not get the support they need. Nurses can help people get social
Discrimination can result in the delay of a diagnosis due to assump- support in the community to reduce health disparities.
tions made about the patient. Sometimes discrimination is hard to
recognize, especially when it occurs at the institutional level.
An HCP’s discriminatory behavior may not be clear to
HEALTH DISPARITIES AND HEALTH EQUITY
the patient or yourself. It may be difficult to confront. Even In the United States, health disparities occur because of social,
well-intentioned HCPs who try to eliminate bias in their care economic, or environmental disadvantages. They can affect
can show their prior beliefs or prejudices through nonverbal population groups based on gender, age, ethnicity, socioeco-
communication. Many policies are in place to eliminate dis- nomic status, education, location, sexual orientation, or dis-
crimination, but it still exists. ability status (Box 2.1).5 Health equity is achieved when every
Poorer health outcomes for minorities are linked to the person has the opportunity to attain their health potential, and
shortage of culturally and ethnically diverse HCPs, who are no one is disadvantaged (Box 2.2).
underrepresented in the health professions. A diversity gap
exists between the ethnic composition of the health care team Factors and Conditions Leading to Health
and the overall population in the United States (Fig. 2.2). For Disparities
example, the diversity of nurses in the United States is increas- Many factors and conditions can lead to the development of
ing but still lags that of the overall population. Blacks, Hispanic/ health disparities (Table 2.1). Awareness of these factors will
Latino Americans, and Native Americans make up more than help you to provide optimal care for your patients.
Social Determinants of Health
Andrew Scanlon and Courtney Reinisch
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Culture Population Health
Health Disparities
LEARNING OUTCOMES
1. Identify the social determinants of health. 6. Describe the role of nursing in promoting health equity.
2. Describe the factors that contribute to health disparities and 7. Examine ways that your cultural background may influence
health equity. nursing care.
3. Define cultural competence and its related terminology. 8. Describe strategies for successfully communicating with a
4. Explain how culture and ethnicity may affect a person’s person who speaks a language that you do not understand.
health.
5. Apply strategies for integrating social determinants of
health in the nursing process.
KEY TERMS
acculturation health status
cultural competence place
culture race
ethnicity racism
ethnocentrism social determinants of health
folk healers stereotyping
health disparities values
health equity
This chapter discusses social determinants of health (SDH), health nonmedical factors that (1) influence the health of persons and
disparities, and culture. The SDH serve as the foundation for how groups and (2) explain why some people have poorer health
we express our culture. Understanding the SDH is needed to pro- than others.1 The SDH can be broken down into 5 groups.
vide patient-centered care. Health is a cultural concept because These are neighborhood, economic stability, education, health
culture frames and shapes our experiences. Cultural beliefs influ- care access, and community context (Fig. 2.1). Where people
ence health promotion practices and attitudes about seeking are born, grow up, live, work, and age helps to determine their
health care. Social and cultural factors influence equity in health health status, behaviors, and care.
care. Health disparities are differences in the incidence, preva- Health status is a holistic concept that is more than the
lence, mortality rate, and burden of diseases that exist among spe- presence or absence of disease. It encompasses life expec-
cific population groups. An inability to address the SDH results in tancy and self-assessment of health. Many measures make
health disparities and negatively impacts well-being. up the concept of health status. For a person, this means
the sum of their current health problems plus their coping
resources (e.g., family, financial resources). For a commu-
SOCIAL DETERMINANTS OF HEALTH nity, health status is the combination of health measures for
Why are there differences in people’s health status? How do all people living in the community. Community health mea-
these differences occur? The social determinants of health are sures include birth and death rates, life expectancy, access
19
,20 SECTION 1 Concepts in Nursing Practice
Social determinants of health
Economic Community
Neighborhood Education Health care
stability context
Employment Housing Literacy Social Health coverage
integration
Income Transportation Language HCP
Support systems availability
Expenses Safety Early childhood
education Community
Debt Recreation Linguistic and
engagement
Vocational cultural
Medical bills Walkability training Discrimination competency
Support Zip code/ Higher Stress Quality of care
geography education
Food
Health outcomes
Mortality, morbidity, life expectancy, health status, functional limitations
Fig. 2.1 Social determinants of health.
to care, and morbidity and mortality rates related to disease About 20% of Americans live in nonurban or rural areas.2
and injury. Differences in access to health care services between rural and
Factors in a person’s social and physical environment, includ- urban settings can create geographic health disparities. People
ing personal relationships, workplace, housing, transportation, in rural areas may need to travel long distances to receive health
and neighborhood violence, contribute to health status.1 For care.2 This can result in inadequate or less-frequent access to
example, the risk of youth homicide is much higher in neigh- health care services. Some parts of the rural United States are
borhoods with gang activity and high crime rates. The physical “medically underserved” because of low numbers of HCPs.
environment in which one lives, works, and plays may expose a People in rural areas have higher rates of obesity and chronic
person to such risks as environmental hazards (workplace inju- disease. They are more likely to have cancer, heart disease,
ries), toxic agents (chemical spills, industrial pollution), unsafe diabetes, depression, and injury-related deaths than people in
traffic patterns (lack of sidewalks), or absence of fresh, healthy urban areas. In rural Appalachia, the rates of lung, colon, cervi-
food choices. cal, and colorectal cancer are higher than average. Rural popu-
A person’s behavior is influenced by their environment, edu- lations tend to be older than urban populations. The impact of
cation, and economic status. Behaviors such as tobacco and social and physical environment on health choices can be illus-
drug use are strongly linked to many health conditions (e.g., trated by the problem of intimate partner violence in rural com-
lung cancer, liver disease). A person’s biologic makeup, such as munities.3 The decision to seek help is affected by geographic
genetics and family history of disease (e.g., heart disease), can isolation, traditional gender roles, patriarchal attitudes, fear of
increase the risk for specific diseases. lack of confidentiality, and economic factors that exist in some
Access to health care contributes to a person’s health. small rural communities.
Although government initiatives strive to reduce the number Living in urban centers may predispose a person to other
of uninsured Americans, millions still are uninsured and have health disparities. People in high crime areas may not visit
limited access to care. This affects both individual and commu- HCPs. High rates of chronic health problems and premature
nity health. deaths occur in neighborhoods with social inequalities. These
include high poverty rates, high crime rates, and residential
Neighborhood segregation.
Place refers to the geographic and environmental location Among the most obvious health behaviors affected by place
where a person is born, grows, lives, works, and ages. Your are physical activity and nutrition. Safe, walkable neighbor-
neighborhood affects the use of health services, health status, hoods with playgrounds promote physical activity. Source and
and health behaviors. price of healthy foods affect diet intake and weight. Social sup-
Housing is a basic need. It protects us from environmental port positively affects coping with illness. Social networks are
harm. Housing can contribute to poor health outcomes. Unsafe more likely in communities where neighbors interact and rely
or poor-quality housing is associated with exposure to lead, on one another.
indoor air pollution, and asthma triggers (dust, mold, rodents).
Overcrowded living conditions can contribute to the spread of Economic Stability
infectious disease. Living close to environmental hazards can The main nonmedical factor affecting health is socioeconomic
affect pregnancy outcomes. It increases the risk of cancer and status. Socioeconomic status is related to wealth, education, and
neurologic problems. occupation. Those living in poverty cannot afford healthy food,
, CHAPTER 2 Social Determinants of Health 21
35% of the population but only 24% of the nation’s nurses.4
Biased behaviors against nurses of diverse cultural and ethnic
backgrounds by patients and health care professionals may con-
tribute to their underrepresentation.
Cultural differences affect how well patients think they can
communicate with their HCP. In the United States, minority
patients are more likely to have difficulty understanding and
communicating with their HCP. Communication issues include
not understanding the HCP, feeling that they are not listened to,
and having questions but not asking them.
Education
Where you live influences your access to quality education.
Some communities have better schools than others. People with
higher levels of education tend to be healthier. Adults without a
Fig. 2.2 Interprofessional team working together in a multicultural high school diploma or equivalent are 3 times more likely to die
health care environment. (© Thinkstock/Stockbyte/Thinkstock.)
before age 65 than those with a college degree.
Health literacy is defined as the degree to which a person
health care, and safe housing. People of lower income report has the capacity to obtain, process, and understand basic health
worse health and die at a younger age. Hazardous work envi- information and services needed to make appropriate health
ronments and high-risk occupations increase health risk and decisions. This includes the ability to (1) read, understand, and
contribute to higher rates of illness, injury, and death. analyze information; (2) understand instructions; (3) weigh
risks and benefits; and (4) make decisions and act. Low health
Health Care literacy is related to more hospitalizations, greater use of emer-
Many people do not have access to quality health care. Health gency department care, decreased use of cancer screening and
care coverage is a key factor that contributes to health dispari- influenza vaccine, decreased ability to use medications cor-
ties. People who are underinsured, have no insurance, or lack rectly, and higher mortality rates among older adults.
financial resources to pay for treatment of diseases may forgo Patients need to be able to self-manage conditions such as
health care visits, screenings, and treatments. Patients who lack diabetes and asthma. Patients with diabetes may not be able to
the knowledge and/or access to apply for government aid pro- maintain adequate blood glucose levels if they cannot read or
grams (e.g., Medicaid) are also at risk. understand the numbers on the home glucose monitoring sys-
The health care system may contribute to health disparities. tem. The inability to read and understand medication labels can
For example, a clinic located in an area with a large population result in taking medications at the wrong time or in the wrong
of non–English-speaking immigrants that does not provide dose. See Chapter 4 for more about health literacy.
interpreters or educational materials and financial forms in
languages other than English may limit these families’ ability to Community
understand how to access health care. Our sense of connection with family, friends, coworkers, and
Discrimination and bias based on a patient’s race, ethnicity, community members affects our health and well-being. Positive
gender, age, body size, sexual orientation, or ability to pay are relationships can improve health. Persons who are bullied may
likely to result in less aggressive or negative treatment practices. not get the support they need. Nurses can help people get social
Discrimination can result in the delay of a diagnosis due to assump- support in the community to reduce health disparities.
tions made about the patient. Sometimes discrimination is hard to
recognize, especially when it occurs at the institutional level.
An HCP’s discriminatory behavior may not be clear to
HEALTH DISPARITIES AND HEALTH EQUITY
the patient or yourself. It may be difficult to confront. Even In the United States, health disparities occur because of social,
well-intentioned HCPs who try to eliminate bias in their care economic, or environmental disadvantages. They can affect
can show their prior beliefs or prejudices through nonverbal population groups based on gender, age, ethnicity, socioeco-
communication. Many policies are in place to eliminate dis- nomic status, education, location, sexual orientation, or dis-
crimination, but it still exists. ability status (Box 2.1).5 Health equity is achieved when every
Poorer health outcomes for minorities are linked to the person has the opportunity to attain their health potential, and
shortage of culturally and ethnically diverse HCPs, who are no one is disadvantaged (Box 2.2).
underrepresented in the health professions. A diversity gap
exists between the ethnic composition of the health care team Factors and Conditions Leading to Health
and the overall population in the United States (Fig. 2.2). For Disparities
example, the diversity of nurses in the United States is increas- Many factors and conditions can lead to the development of
ing but still lags that of the overall population. Blacks, Hispanic/ health disparities (Table 2.1). Awareness of these factors will
Latino Americans, and Native Americans make up more than help you to provide optimal care for your patients.
