Social Determinants of Health (SDOH) are non-medical factors that influence health. Public health nursing has organically included these, but due to various reasons, nursing has lost its focus on SDOH. The reintegrated of SDOH into nursing can be achieved through education programs, using a systematic approach and intentional efforts. This will equip nurses with a better understanding of the meaningful impact of social determinants on health.
Social Determinants of Health (SDOH) are the conditions and environments in which people live, and include various non-medical factors that influence health outcomes. Nursing has long recognized the link between the social determinants of one’s lived experience and their health. With strong roots in public health, nursing has demonstrated the value of services delivered in homes and neighborhoods where people live, work, play, and worship.
Lillian Wald, the pioneer of public health nursing in the United States in the early 20th century, coined the term “public health nurse.” Nurses, according to Wald, should not merely take care of sick people, but also address social and economic problems. Her holistic nursing approach addressed social determinants of health in her efforts to improve patients’ health and treat root causes of poor health.
Today, however, the number of public health nurses in the US is strikingly low given the total number of four million nurses. Furthermore, social determinants have not been traditionally part of required coursework for nursing, and as a result, many nurses have limited awareness of how factors such as racial discrimination, violence, poverty, and trauma can intersect, compound, and influence health.
Nursing employment trends also contribute to the loss of the profession’s lens on the importance of SDOH in predicting the overall health of patients. The majority of new nursing graduates today are employed by hospital systems and in this setting, they have little-to-no time to focus on the social context of patients’ lives. Decreasing hospital length-of-stay also limits the interaction of nurses with patients, and there are few opportunities to follow up in the community. Even nurses working in ambulatory settings are often in specialty clinics where the emphasis is on managing the disease process.
In an effort to respond to the unfortunate distancing of SDOH from nursing, an emphasis on educating faculty and students to better respond to the social determinants that affect health outcomes among patients has emerged. This includes understanding the ways in which SDOH can strengthen health as well as the societal barriers that have been shown to result in poorer health outcomes.
With leading nursing organizations all mandating that SDOH be integrated into nursing courses, a ground-breaking textbook titled Integrating a Social Determinants of Health Framework into Nursing Education is a key comprehensive resource on how this can be undertaken in practice.
It describes and illustrates the systematic approach to integrating SDOH throughout all courses in the Emory School of Nursing.
An overarching Four-Pillar Framework of SDOH guided this approach. As shown in the figure, the four pillars of social determinants—Social, Cultural, Environmental, and Policy—are interwoven and effect each other, depicting the real-life experiences of individuals in their health trajectory.
The Emory School of Nursing furthermore developed a training module for faculty with SDOH conceptualizations, frequently cited frameworks, and embedding SDOH into clinical and didactic courses. Faculty also mapped out SDOH in the curriculum for the purpose of identifying strengths, gaps, and any redundancies in course content. And finally, a system for the evaluation of SDOH content provided critical feedback that was useful in assessing progress and areas the required improvement.
While these efforts have been challenging and labor-intensive, overall, the value of SDOH is embraced and there is a commitment to sustaining this focus. Ultimately, graduates will have new and enhanced skills to apply this knowledge in the care of their patients, contributing to their health and well-being.
Dr. Jill B. Hamilton, PhD, MPRL, RN, FAAN
Jill Hamilton, is Professor, tenured, and Senior Faculty Fellow of SDOH & Health Disparities at the Nell Hodgson Woodruff School of Nursing and Affiliate Professor at Candler School of Theology at Emory University in Atlanta, Georgia. Dr. Hamilton’s research interests include social determinants of health, health disparities, and the mental health promoting strategies used among older African American their families in response to life-threatening illness. She has developed culturally-relevant measures of social support and spirituality and has conducted research to examine ways in which these social determinants influence health outcomes. Dr. Hamilton is published on topics related to culture, social support, religiosity, spirituality, and quality of life among African Americans with life-threatening illness.
Linda A. McCauley, began her appointment as Dean of Nell Hodgson Woodruff School of Nursing (NHWSN) in 2009. She has since developed and executed a comprehensive strategic plan to position NHWSN at the forefront of nursing research, education, and policy. Under Dean McCauley’s leadership, the school has risen from its No. 26 ranking in 2011 to its current position as No. 1 in US News and World Report’s “Best Graduate Nursing Schools” guide.
Dr. McCauley own research—for which she has been consistently funded for over two decades—lies at the intersection of nursing and environmental and occupational health sciences.