Chapter Three: Social Determinants of Health and Vulnerable Populations

Public and community health nurses are in an ideal position to integrate a holistic understanding of SDOH and recognize the unique health risks to vulnerable populations. Public health nurses assess, identify, and intervene to improve the health and health outcomes of individuals, families, and populations.

Social Determinants of Health

A significant portion of health can be attributed to social and environmental factors, separate from medical care or a person’s individual lifestyle choices. In fact, medical care itself may account for only 10%–20% of an individual’s health outcomes, while approximately 80%-90% of the factors that influence health can be linked with SDOH (Magnan, 2017). Social determinants of health comprise the conditions where people are born, work, live, worship, age, and play that affect an individual’s health, functioning, quality of life outcomes, and risks (Magnan, 2017; U.S. Office of Disease Prevention and Health Promotion [ODPHP], 2022e; Kaiser Family Foundation, 2018).

Social determinants of health can be broadly grouped into five categories: economic stability, educational access and quality, neighborhood and built environment, health access and quality, and social and community context (ODPHP, 2022k). Nurses should recognize that a person’s health consists of a few different factors, and only one of those factors is the individual’s health behaviors. As Figure 3.1 demonstrates, socioeconomic factors and physical environment, both SDOH components, are major factors in a person’s overall health.

Long Description for Figure 3.1

Socio-economic factors include education, job status, family or social support, income and community safety. Health behaviors include tobacco use diet and exercise, alcohol use, sleep habits, and social connectedness. Healthcare includes access to care and quality of care. The physical environment includes air and water quality and housing transit.

Food Insecurity

A household experiences food insecurity when facing recurrent barriers to accessing enough food to live a healthy and active life (Feeding America, 2022). In 2020, there were 38.3 million people living with some level of food insecurity, and 584,000 children were living in households with very low food security (United States Department of Agriculture [USDA], Economic Research Service, 2022). The USDA divides food insecurity into two categories:

1. Low food security: “Reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake.”
2. Very low food security: “Reports of multiple indications of disrupted eating patterns and reduced food intake.”

The type of household a person lives in greatly affects the prevalence of food insecurity. Households with children have higher rates of food insecurity, as also do households that are headed by a single woman, Black non-Hispanic households, and Hispanic households. Some urban and rural neighborhoods have very few full-service supermarkets for residents to frequent. Often, urban neighborhoods have small corner stores with processed food options and limited options for fresh, healthy foods. Additionally, the cost markup for these types of markets tends to be higher than for other grocery stores, effectively limiting the amount of food that local residents can buy. Lack of public transportation also affects a family’s ability to obtain food, particularly for families living in rural areas without access to personal vehicles and without public bus routes.

Food insecurity is linked to negative health outcomes in children and adults, and being hungry or malnourished can lead to decreases in school performance. Helping to reduce hunger by addressing unemployment and providing access to nutrition assistance programs can help families achieve better overall health. Food assistance programs—such as the National School Lunch Program (NSLP), the Women, Infants, and Children (WIC) program, and the Supplemental Nutrition Assistance Program (SNAP)—address barriers to accessing healthy food. Nurses can help by making sure the families they care for know about these programs and help families to get signed up for assistance (ODPHP, 2022d).

Housing

There are complex reasons for housing instability that can include many variables, among them having trouble paying rent, overcrowding, moving frequently, or spending the bulk of household income on housing. If more than 30% of a household’s income is spent on housing, that household is considered to be cost-burdened; if more than 50%, then the householders are considered to be severely cost-burdened (Bailey et al., 2016). A limited rental market with few affordable vacancies may force people with the lowest incomes to rent substandard housing or force individuals to share housing, resulting in overcrowding. When housing costs are more than a household can reasonably afford, it can lead to foreclosures, which cause a loss of money and possessions and can damage the social fabric of neighborhoods.

Multiple forced moves as a result of housing instability have been associated with negative health outcomes in children. For individuals, housing instability can lead to a greater incidence of poor health outcomes, from mental health issues to heightened stress levels, to relationship injury, and to a greater likelihood of infectious disease transmission (ODPHP, 2022f).

Housing deprivation at its most severe leads to people without homes and with health issues: a study of newly unhoused people “in the New York City shelter system found that 6% had diabetes, 17% had hypertension, 17% had asthma, 35% had major depression, and 53% had a substance use disorder—indicating that chronic disease is more common among people who are newly homeless than among the general population” (Schanzer et al., 2007).

Educational Access and High School Graduation Rates

People with higher levels of education are more likely to be healthier and live longer than those with low levels of education. Providing high-quality educational opportunities for children and adolescents, and helping them do well in school, can ultimately also help them achieve better health. A child who struggles with math and reading could potentially be experiencing a learning disability, living in a low-income situation, or facing social discrimination. These children are less likely to graduate from high school, which limits their ability to secure safe, well-paying jobs. Barriers such as poverty can lead to greater health problems, such as heart disease, depression, and diabetes. Some children live in areas where the schools are performing poorly, school resources are limited, and attaining the same level of education as someone in a higher-performing school is outside their control. Additionally, if these children live in poverty, they are more likely to be affected by delayed brain development, making it even harder for them to do well in school. Targeted interventions to support educational access and quality, such as taking preventive mental health measures and improving high school graduation rates, can help children have better health in the long term (ODPHP, 2022b).

Higher levels of education are also linked to a lower risk of early death later in life. Many high school students do not graduate, and graduation rates are lower in some racial/ethnic groups. Students from economically disadvantaged families often have less access to resources, and they tend to live in communities with underperforming schools. These factors may contribute to lower academic achievement and higher dropout rates as compared with students from economically advantaged families. In 2015, the number of young people aged 16 to 24 who did not complete high school or were not enrolled in high school was 4.1 times higher in low-income families compared with high-income families (ODPHP, 2022g). High school graduation is important for many reasons, but primarily because the skills learned help support the attainment of a safe, high-paying job or successful college attendance. The ability to secure stable employment and income helps support conditions where people can achieve better health.

Programs that offer vocational training, alternative schools, social-emotional skills training, and/or counseling can help more students graduate from high school. Research shows that high school graduates have better employment prospects and lifelong earning potential than do nongraduates. For every year of high school a student completes, their lifetime wealth increases by 15%. Overall, high school graduation has the potential to improve population health (ODPHP, 2022g).

Preventive Mental Health in Schools

Anxiety and depression are common among children—even more so in the wake of the recent COVID-19 pandemic, when children were suddenly restricted from engaging in their normal social outlets with teachers and friends. For many children, the lengthy distance-learning periods while schools were physically closed meant that students spent a significant amount of time looking at computer screens without the recess, lunch, physical education, and social breaks that are beneficial to mental health. Children who routinely experience forms of social discrimination—like bullying—are more likely to struggle with math and reading and less likely to graduate from high school or go to college (Community Preventive Services Task Force, 2019). Increasing the proportion of children who receive preventive mental health services in school is a high-priority public health issue. Targeted school-based therapy programs are intended to reduce depression and anxiety in school-aged children and adolescents at increased risk for these conditions. Trained school staff or outside mental health professionals deliver these interventions in individual or group settings that helps students build strategies for problem-solving, emotional regulation, and helpful behavior patterns.

Geospatial Determinants of Health

The places a life is lived—from home to workplace, schools to parks, and town centers to places of worship—all affect the health of individuals and their communities, directly influencing how people experience disease and well-being. Geospatial science, geographic information systems, and cartographic visualization provide important methods and tools that public health scientists use to analyze the critical relationship between health and the places lives are lived.

The Geospatial Research, Analysis, and Services Program, commonly referred to as GRASP, is developing a framework for the specific geospatial determinants of health to (1) define the geospatial drives of health with an emphasis on factors that vary by place; (2) serve as a catalyst to define, promote, and advance the use of place in research and practice across the public health community; and (3) shape the public health curriculum of schools across the United States to advance geospatial analysis, statistics, and technology in the study of public health (Agency for Toxic Substances and Disease Registry, n.d.).

Environmental Conditions

The quality and state of the environment, or environmental conditions, are part of daily life that can affect health and can vary widely among populations and geographic locations. Although many of the conditions people experience in the environment are naturally occurring, the quality of an environment can be affected by historical, economic, and sociopolitical factors detailed in the literature summarized in Healthy People 2030: Environmental Conditions as a social determinant of health (ODPHP, 2022c).

Populations that may be more susceptible to poor environmental conditions and their associated health disparities include communities of color, persons with low incomes, persons who are unhoused, older adults, pregnant women, and children. The rising temperatures and shifting weather patterns around the globe, a result of climate change, are expected to worsen public health challenges, particularly for disadvantaged communities (ODPHP, 2022c). Policies and programs that can have an impact on environmental conditions have been effective in reducing the harmful effects of pollutants. For example, federal laws, such as the Clean Air Act and Safe Drinking Water Act, regulating air and water quality, have successfully reduced the harmful health effects of pollutants (Weinmeyer et al., 2017; Nethery et al., 2021). As environmental conditions continue to evolve, additional innovative and sustainable interventions are needed to address the effects of environmental conditions on health outcomes and disparities.

Health Care Access and Quality

Many people in the United States are unable to obtain the health care services they need, either because they have limited access to care or because the quality of care they are receiving is low. Around 10% of people in the United States do not have health insurance (Berchick et al., n.d.), which makes them less likely to have a primary care provider and to afford the health care services and medications they need. For persons who are uninsured or underinsured, the ability to obtain preventive care services and treatment for chronic illness depends on their finances. Increasing insurance coverage for people in the United States means they can get the necessary health care services. Sometimes people do not get recommended health care services, like cancer screenings, because they do not have a primary care provider. Other times, it is because they live too far away from a health care provider who accepts their type of insurance, offers sliding scale services, or specializes in the care they need.

Differences in quality of care contribute to poor health outcomes just as much as limited access to care does (ODPHP, 2022e). In 2002, the Institute of Medicine reported that racial and ethnic minorities tend to receive a lower quality of care. This is true even when issues such as lack of insurance or limited access to health care are controlled (Brummer et al., 2016). Higher rates of heart disease, cancer, diabetes, obesity, depression, infant mortality, and maternal morbidity are just a few examples of health disparities partially resulting from low-quality care. Interventions to increase access to health care professionals and improve care quality can help more people get and stay healthy (ODPHP, 2022e).

Family Planning

Almost half of the pregnancies in the United States are unintended, and unintended pregnancy is linked to negative outcomes for both individuals who are pregnant and infants (CDC, 2021b). With the overturning of Roe v. Wade and the changing legislation surrounding access to abortion services, a community health focus on family planning is as important as ever. Abortion restrictions disproportionately affect people of color and those with low incomes. According to the CDC, Black women are five times more likely to have an abortion than White women, and Latinx women are two times as likely as White women (CDC, 2022a). Of all people who have abortions, 75% are low income or poor. Reproductive health restrictions also affect women’s earning potential. Studies indicate that an absence of abortion restrictions would translate to between 1.5% and 2.5% increases in the labor force for Black, Hispanic, and Pacific Islander women. This translates to an estimated $13.4 million in increased earnings at the state level for Black women alone (Winny et al., 2021).

Adolescents are at especially high risk for unintended pregnancy. Close to 200,000 babies are born to teen mothers every year in the United States, and this is a reduction in rates from previous years. Abortion restrictions most negatively affect individuals who can become pregnant and teens who already have other negative SDOH working against them.

Data confirm significantly higher pregnancy-related mortality ratios among Black and American Indian/Alaskan Native women compared with other groups. These gaps did not change over time (Figure 3.2).

Long Description for Figure 3.2

The vertical axis measures the pregnancy-related mortality ratio per 100,000 live births with values ranging from 0 to 45. 2007 to 2008: Hispanic, 10. Asian or Pacific Islander: 10. American Indian or Alaskan Native: 25. Black: 35. White, 10. 2009 to 2010: Hispanic, 10. Asian or Pacific Islander: 11. American Indian or Alaskan Native: 30. Black: 40. White, 13. 2011 to 2012: Hispanic, 10. Asian or Pacific Islander: 10. American Indian or Alaskan Native: 35. Black: 45. White, 10. 2013 to 2014: Hispanic, 10. Asian or Pacific Islander: 15. American Indian or Alaskan Native: 30. Black: 40. White, 13. 2015 to 2016: Hispanic, 10. Asian or Pacific Islander: 12. American Indian or Alaskan Native: 30. Black: 40. White, 12. All data are approximate.

Sexually active women who do not want to get pregnant need access to birth control, but many individuals cannot afford effective birth control methods. Interventions such as publicly funded birth control are critical in reducing unintended pregnancies. Linking adolescents to youth-friendly health care services can help prevent pregnancy as well as sexually transmitted infections in this age group. Increasing the use of birth control and family planning services may help, in some situations, to reduce the negative health consequences associated with unintended pregnancy. Unintended pregnancy is linked to outcomes like preterm birth and postpartum depression.

Specific interventions suggested by the CDC include examining the need for contraceptive services among women of reproductive age, developing evidence-based strategies to reduce unmet needs for quality family planning services, and building capacity for health care providers, states, communities, and partners to improve quality family planning services.

Families That Read Together

In 2019, only 55% of children aged 5 and under had a parent or caregiver who read to them at home (ODPHP, 2022h). Studies show that reading to young children improves their language and literacy skills and is linked to better behavior and health. Reading and health go hand in hand throughout life. Children’s behavior improves when they are confident in their reading abilities in school. Readers are encouraged to do their best and receive positive feedback, which sets the foundation for their self-esteem. However, children who struggle with reading might be withdrawn in class and lack self-esteem, and consequently when called on to read they may act out to avoid calling attention to their reading problems. Children might also feel headaches, stomach aches, and fatigue, the physical effects of the anxiety and embarrassment associated with reading struggles.

A further complication is that adults with low literacy skills have 3.5 times the health care costs that literate adults have (Nemours Foundation, 2022). So, it is important to consider methods to help children increase language and reading readiness. These methods include reading with a caregiver for at least 10 minutes a day, having a variety of books accessible in the home, and limiting screen time. Parents and children can share routines, build stronger relationships, and have regular positive interactions through reading out loud. Early intervention programs and national initiatives can help raise awareness about the importance of reading to children, but early and consistent reading in individual social circles is the first step toward healthier outcomes.

Bullying

Bullying of youth is a form of violence and is considered an adverse childhood event. It is a serious problem with serious morbidity and mortality consequences in our communities. Bullying can result in physical injury, social and emotional distress, self-harm, and even death. Youth who bully others are at increased risk for substance misuse, academic problems, and experiencing violence later in adolescence and adulthood. Data from the Youth Risk Behavior Surveillance Survey indicated that almost 20% of students were bullied on school grounds, and 15% had been bullied online (Kann, 2018).

Sexual minority students are at an increased risk of being bullied, especially in conservative or religious districts, where hateful behaviors toward them may often go unchecked by teachers and administrators. Nearly one third of sexual minority (LGBTQIA+) students in grades 9–12 reported that they experienced bullying at school (ODPHP, 2017). High school students who identify as lesbian, gay, or bisexual are almost twice as likely to be bullied as those who identify as heterosexual. Students who are bullied are more likely to have depression, anxiety, and sleep problems—and to drop out of school. As a result of the constant harassment, bullied individuals suffer academically, physically, and emotionally.

School-based programs to reduce violence can help prevent bullying of LGBTQIA+ students. Current bullying prevention efforts include anti-bullying laws and policies at the state, local, and school district levels. Newer efforts toward anti-bullying policies seek to enumerate the specific characteristics of children who are likely to be bullied, among them LGBTQIA+ students, in an effort to create targeted education and campaigns for bullying prevention. Enumerated anti-bullying policies not only define and denounce bullying but also list examples of characteristics that might be the basis of bullying, such as actual (e.g., a student is openly gay) or perceived (e.g., others think that a student is gay) sexual orientation.

Figure 3.3 suggests several protective risk factors and actions nurses can take to help prevent bullying in their communities (CDC, 2021a).

Long Description for Figure 3.3

Promote family environments that support healthy development includes early childhood home visitation and parenting skills and family relationships programs. Providing quality education early in life includes preschool enrichment with family engagement. Strengthen youth’s skills. It includes universal school-based program. Connect youth to caring adults and activities includes mentoring programs and after-school programs. Create protective community environments includes modifying the physical and social environment, reducing exposure to community-level risks and street outreach and community norm change. Intervene to lessen harms and prevent future risk includes treatment to lessen the harms of violence exposures, treatment to prevent problem behavior and further involvement in violence and hospital-community partnerships.