Practice Tip of the Week | Determining Health: When Health Care Cannot Solve Health Issues

By Maya Peterson, BSN, RN, CCRN

Social determinants of health — the influence of the environment in which a person lives — has a massive impact on a person’s health throughout their lifespan. Healthy People 2030 describes the SDOH as encompassing the environmental conditions where people live their entire lives, including their workplace, neighborhood, house of worship and housing. These environments have an impact on a person’s functioning, quality of life and health as they grow and age.

Healthy People 2030 groups these determinants into five categories: education access and quality, social and community context, health care access and quality, economic stability, and neighborhood and built environment. Within these categories are more specific benefits and detriments, such as food insecurity, structural conflict, social inclusion and non-discrimination, and early childhood development.

Population-level disparities

According to the World Health Organization, the lower one’s socioeconomic position in society, the worse their health. These determinants are present all over the world. A report by WHO Europe stated that people less well off in more affluent countries have a higher illness burden and shorter life expectancies than the rich.

Although health disparities between different socioeconomic classes have been well-known anecdotally for years, the landmark 1981 Whitehall Study by Rose and Marmot shifted the narrative away from simply taking this as a fact and seeking to understand the forces at play. Rose and Marmot studied British Civil Servants at varying levels (professional/executive, administrative, clerical, other) and noted the differences in prevalence of cardiovascular disease could not solely be attributed to any of the modifiable risk factors like smoking, exercise and diet.

Based on studies cited by the National Academy of Medicine, the quality of a person’s health is only impacted by the quality of care received by 10-20 percent. The other 80-90 percent are influenced by the physical environment (10 percent), social and economic factors (40 percent), and health behaviors (30 percent). These figures are not exact and vary based on the source. Nurses may not recognize these additional factors influence care more so than access to and quality of health care. After all, we are taught that our care can make someone better. We are here to fix the problem.

Individual-level difficulties

Think about a time you interacted with someone who needed to make a dietary change to control a health condition — a patient, family member or stranger. You could tell they needed something, but it wasn’t health care. You knew transportation to a grocery store was the number one problem. They couldn’t drive, and there was limited public transportation in the area. They couldn’t afford to live right next to the store, so the next best thing was the convenience store, where carbohydrates are cheap, plentiful and filling.

In this situation, would nutrition counseling help? Would a referral to a dietician really solve the problem?

Similarly, would a new inhaler fix the pollution that triggers a patient with asthma? Does an extensive check-in survey online help someone who cannot access the internet to limit their exposure to COVID-19 for a routine appointment?

As nurses, we engage with patients experiencing these types of challenges every day. The setting, population and location may vary, but the struggle for health in unhealthy circumstances is ubiquitous. Given that most of our time as nurses is spent dealing with the health care aspects of health, we also need to realize that we can and should be an integral part of the solution dealing with the other 80% of what makes someone healthy.

Integrating SDOH into nursing

Nurses should consider the social determinants of health during every interaction with patients. When admitting a patient to the hospital, don’t just ask if they have questions about parking — ask questions pertaining to the additional factors impacting health. For example, ask if they have the ability to get or pay for food.

Use this knowledge to inform your discharge planning and discharge instructions. Having access to medications is a common barrier to consistently taking medications. Even if a patient can obtain their medications, they may not have secure housing or the ability to pick up and pay for their medications. This is a much bigger part of your patient’s story.

Finally make sure your patient knows the best way to access care after they leave. When reviewing instructions on how to schedule a follow up appointment via an online patient portal, ensure they have access to a computer or smart phone and internet or data required to utilize it.

These are just a few examples of how you can be inquisitive to understand the external factors that can affect health outside of health care. There are so many things we as nurses, and as people, can do to help improve the health of those around us, but it starts with us taking the first step and asking the right questions.

Resources

Michael Marmot and the Social Determinants of Health | American Public Health Association

What Makes Us Get Sick? Look Upstream | TED Talks