Assessment of an individual's social determinants of health (SDOH) is an essential component of holistic patient care. These factors each can contribute to or detract from the health and wellness of individuals, families, and groups (Koh et al., 2011). As such, SDOH can be a major contributor to health disparities. Identifying the influence of these factors on patient outcomes could inform interventions to address the health care needs of various groups and also reduce disparities (Koh et al., 2010). For instance, interventions to increase access to affordable and healthy foods (Congdon, 2019) could help ameliorate the obesity epidemic (Kohn et al., 2014). In another example, addressing factors related to economic stability (Dickman et al., 2017) and available social support (Decker et al., 2018) could yield improved reproductive health outcomes by reducing infant mortality (Reno & Hyder, 2018) and teen pregnancy rates (Fuller et al., 2018).
However, it can be difficult to define the factors that are included in SDOH. The World Health Organization (2019) defines SDOH as “The conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” Although these conditions may differ at each of these geographic levels, the overall goal is the achievement of health equity for all populations and nations. This unifying and over-arching goal cuts across varying definitions and local influences (Lucyk & McLaren, 2017).
In the United States, the guiding principles of Healthy People 2020 include five pillars for SDOH: economic stability, education, social and community context, health and health care, and neighborhood and built environment (Koh et al., 2011; Healthy People 2020). The specific examples for each pillar may vary by region. However, in every area of the country, access to health care is dependent on economic stability. Taking into consideration factors such as employment status, poverty level, or homelessness may shape how individuals characterize their own health status and provide insight into certain practices that are carried out due to necessity, given the surrounding circumstances.
In contrast, other factors may improve health practices. For instance, a higher level of education has been shown to positively impact mortality outcomes and increase the likelihood of healthful behaviors, such as abstaining from smoking and alcohol intake, and participating in regular physical activity (Huijts et al., 2017; Montez et al., 2019). Specifics of the social and community structure (e.g., social cohesion, civic participation, incarceration, or discrimination) impact not only what health and health care resources are available but also whether and how such resources are used in the neighborhood and built environment (Healthy People 2020).
Due largely to their strategic positioning on the frontline of health care, nurses have long since recognized the influence that each pillar of SDOH may have on the overall wellness of individuals and populations. With approximately 2.9 million nurses currently employed in the United States (Thornton & Persaud, 2018), the role of nurses can vary from delivering care in community hospitals or clinics, shaping public policy that may impact the health of individuals and nations, or researching new innovations in care. Each of these roles place nurses in a unique position to improve health outcomes by being prepared to address the health care inequities and disparities that impact society (Thornton & Persaud, 2018). Because of this important role, the integration of SDOH has been recognized as a vital component of nursing education.
The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) support the nursing practices of health promotion and disease and injury prevention as being essential to the health care improvement for individuals and populations. Nursing generalists should be able to identify pertinent SDOH and intervene using appropriate and collaborative primary prevention strategies (American Association of Colleges of Nursing, 2008). Therefore, nursing curricula should be developed to provide students with the necessary skills to accomplish these important tasks. The goal of providing instruction related to SDOH is to improve awareness and allow students to provide appropriate and personalized assessment, planning, and implementation of care. The integration of this information into a curriculum also provides a foundation to enable students to gather resources to address SDOH and improve patient health outcomes. Such a foundation is vital to nursing students, as this knowledge develops a framework for shaping their thinking and gives perspective on the future care they will provide (Koh et al., 2011).
Although many traditional nursing curricula are organized around organ systems, such an approach may not be effective in teaching about SDOH. For example, by focusing on a specific disease state, factors contributing to wellness can be overlooked. In contrast, a concept-based curriculum organizes topics around identified concepts specifically chosen to be helpful for bridging ideas into related themes that may be applied both positively and negatively across situations; this can be a major advantage when teaching about SDOH. The concept-based curriculum also offers several other independent advantages, including better preparing students to become a nurse generalist (Brussow et al., 2019), eliminating content saturation (Giddens & Brady, 2007), and increasing graduation and NCLEX pass rates (Lewis, 2014). Ignatavicius (2019) provides further detail on the concept-based curriculum. Concept-based connections are useful to transfer knowledge in both familiar and unfamiliar situations, which improves clinical judgement as the learner transforms theory into practice (Brussow et al., 2019; Fletcher et al., 2019). Concept-based teaching is grounded in educational theory and improves the student's understanding of SDOH by enabling an effective transfer of didactic knowledge outside of the educational setting (Getha-Eby et al., 2014). Therefore, this type of curriculum is a feasible platform for introducing SDOH topics in nursing education.
In a brief summary of the process for developing a concept-based curriculum, the attributes of that concept first must be selected. These defining features distinguish one concept from another closely related concept. In other words, these are the critical characteristics that make that particular concept unique (Walker & Avant, 2005). For the concept of SDOH, achievement of health equity is the principal attribute. This separates SDOH from the closely interrelated concepts of “health disparities” and “self-management.” The interrelated concepts will share some, but not all, features of each other. For instance, health disparities occur when health equity is not achieved, whereas SDOH are the factors that contribute to the achievement of health equity. After the defining features of the concept are selected, the exemplars of that particular concept should be chosen. The exemplars are not an exhaustive list but rather concrete examples that will apply the attributes of that concept to a more specific situation.
Overall, the coordination of concepts, interrelated concepts, and exemplars have allowed the concept of SDOH to be applied across a host of courses within our baccalaureate curriculum (Table 1). A special emphasis has been placed on always engaging students through active learning strategies, with the goal being to reduce the amount of traditional lecture time. It is important that time is provided to allow students to learn from each other, as they come from diverse backgrounds and may have firsthand experience about how SDOH has impacted their own lives, their families, and their communities, which in turn impacts the care that they provide for their patients. The nature of concept-based curricula lends itself to this kind of team-based learning. Although there is a major advantage for the concept-based curriculum in this area, traditional curricula (whether diploma, associate, or baccalaureate programs) also can apply these team-based learning strategies. The SDOH concept lends itself to placement within many of the core and specialty courses, as this concept affects all patients across the life span.
Suggested Exemplars, Learning Activities, and Descriptions for Incorporating the Concept of SDOH Into Entry-Level Nursing Curricula
The first courses in this program introduce the concept of SDOH in a general way. For instance, in Nursing Concepts I: Foundations of Professional Nursing Care (taught in the first semester), a traditional nutritional assessment is placed within the context of SDOH and would be applicable to either the didactic or the clinical portion of the course. The students are encouraged to think about the basic idea of access to healthy food, which may be impacted by culture, socioeconomic status, and access to transportation. As students progress through the program, their understanding of both the concept and the interrelated concepts grows in complexity.
In the middle of the curriculum, the Pediatric and Adolescent Nursing Concepts specialty course expands on SDOH and the concept of culture to include a group discussion on child-rearing practices. This activity was chosen to allow students to bring forth their own cultural experiences, to discuss such experiences in a professional and respectful way among a diverse group of peers, and then to consider how culture, health promotion, and self-management impact health for all children. This exercise is a higher-level activity than what was taught in Nursing Concepts I, as it assimilates information in a more abstract way. Each course systematically builds on the level of complexity that the previous courses introduced and progressively bridges between didactic and clinical components. Senior students will apply these amorphous ideas to real-life scenarios in the Population Health Nursing Concepts course. The windshield survey investigates how SDOH impact an entire community. Finally, Social, Environmental, and Genomic Determinants of Health is a unique course that specifically integrates and summarizes this information along with genomic characteristics that may also impact health (Table 1).
An understanding of SDOH is imperative for improved nursing practice, regardless of the method used to deliver this content. Thorough assessment, increased empathy, and sensitivity to individual needs can strengthen nurses' ability to yield optimal patient outcomes. In all instances of care, clear communication of SDOH considerations with other members of the health care team will allow community and interdisciplinary resources that provide assistance to be identified. Electronic health record systems should allow and reinforce a regular assessment of such variables and then ensure visibility across disciplines. The appropriate assessment of existing challenges and advantages of SDOH also allows better tailoring of treatment plans to a patient's situation, which results in care that is more effective.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.
- Brussow, J.A., Roberts, K., Scaruto, M., Sommer, S. & Mills, C. (2019). Concept-based curricula: A national study of critical concepts. Nurse Educator, 44(1), 15–19 doi:10.1097/NNE.0000000000000515 [CrossRef]
- Congdon, P. (2019). Obesity and urban environments. International Journal of Environmental Research and Public Health, 16(3). doi:10.3390/ijerph16030464 [CrossRef]
- Decker, M.J., Isquick, S., Tilley, L., Zhi, Q., Gutman, A., Luong, W. & Brindis, C.D. (2018). Neighborhoods matter: A systematic review of neighborhood characteristics and adolescent reproductive health outcomes. Health & Place, 54, 178–190 doi:10.1016/j.healthplace.2018.09.001 [CrossRef]
- Dickman, S.L., Himmelstein, D.U. & Woolhandler, S. (2017). Inequality and the healthcare system in the USA. The Lancet, 389(10077), 1431–1441 doi:10.1016/S0140-6736(17)30398-7 [CrossRef]
- Fletcher, K.A., Hicks, V.L., Johnson, R.H., Laverentz, D.M., Phillips, C.J., Pierce, L.N.B., Wilhoite, D.L. & Gay, J.E. (2019). A concept analysis of conceptual learning: A guide for educators. Journal of Nursing Education, 58(1), 7–15 doi:10.3928/01484834-20190103-03 [CrossRef]
- Fuller, T.R., White, C.P., Chu, J., Dean, D., Clemmons, N., Chaparro, C., Thames, T.L., Henderson, A.B. & King, P. (2018). Social determinants and teen pregnancy prevention: Exploring the role of non-traditional partnerships. Health Promotion Practice, 19(1), 23–30 doi:10.1177/1524839916680797 [CrossRef]
- Getha-Eby, T.J., Beery, T., Xu, Y. & O'Brien, B.A. (2014). Meaningful learning: Theoretical support for concept-based teaching. Journal of Nursing Education, 53(9), 494–500 doi:10.3928/01484834-20140820-04 [CrossRef]
- Giddens, J.F. & Brady, D.P. (2007). Rescuing nursing education from content saturation: The case for a concept-based curriculum. Journal of Nursing Education, 46(2), 65–69 https://www.ncbi.nlm.nih.gov/pubmed/17315564
- Healthy People 2020. (2016). Social determinants of health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
- Huijts, T., Gkiouleka, A., Reibling, N., Thomson, K.H., Eikemo, T.A. & Bambra, C. (2017). Educational inequalities in risky health behaviours in 21 European countries: Findings from the European social survey (2014) special module on the social determinants of health. European Journal of Public Health, 27(suppl_1), 63–72 doi:10.1093/eurpub/ckw220 [CrossRef]
- Ignatavicius, D. (2019). Teaching and learning in a concept-based curriculum. Burlington, MA: Jones & Bartlett Learning.
- Koh, H.K., Oppenheimer, S.C., Massin-Short, S.B., Emmons, K.M., Geller, A.C. & Viswanath, K. (2010). Translating research evidence into practice to reduce health disparities: A social determinants approach. American Journal of Public Health, 100(Suppl 1), S72–S80 doi:10.2105/AJPH.2009.167353 [CrossRef]
- Koh, H.K., Piotrowski, J.J., Kumanyika, S. & Fielding, J.E. (2011). Healthy people: A 2020 vision for the social determinants approach. Health Education & Behavior, 38(6), 551–557 doi:10.1177/1090198111428646 [CrossRef]
- Kohn, M.J., Bell, J.F., Grow, H.M.G. & Chan, G. (2014). Food insecurity, food assistance and weight status in US youth: new evidence from NHANES 2007–08. Pediatric Obesity, 9(2), 155–166 doi:10.1111/j.2047-6310.2012.00143.x [CrossRef]
- Lewis, L.S. (2014). Outcomes of a concept-based curriculum. Teaching and Learning in Nursing, 9(2), 75–79.
- Lucyk, K. & McLaren, L. (2017). Taking stock of the social determinants of health: A scoping review. PLoS One, 12(5), e0177306 doi:10.1371/journal.pone.0177306 [CrossRef]
- Montez, J.K., Zajacova, A., Hayward, M.D., Woolf, S.H., Chapman, D. & Beckfield, J. (2019). Educational disparities in adult mortality across U.S. states: How do they differ, and have they changed since the mid-1980s?Demography, 56(2), 621–644 doi:10.1007/s13524-018-0750-z [CrossRef]
- Reno, R. & Hyder, A. (2018). The evidence base for social determinants of health as risk factors for infant mortality: A systematic scoping review. Journal of Health Care for the Poor and Underserved, 29(4), 1188–1208 doi:10.1353/hpu.2018.0091 [CrossRef]
- Thornton, M. & Persaud, S. (2018). Preparing today's nurses: Social determinants of health and nursing education. OJIN: The Online Journal of Issues in Nursing, 23(3).
- Walker, L.O. & Avant, K.C. (2005). Strategies for theory construction in nursing (4th ed.). Norwalk, CT: Appleton & Lange.
- World Health Organization. (2019). About social determinants of health. https://www.who.int/social_determinants/sdh_definition/en/
Suggested Exemplars, Learning Activities, and Descriptions for Incorporating the Concept of SDOH Into Entry-Level Nursing Curricula
|Course Name||Exemplars||Interrelated Concepts||Learning Activities||Description|
|Nursing Concepts I: Foundations of Professional Nursing Care||Nutrition||Health disparities, health promotion, self-management||Nutritional assessment||Students will complete an evaluation of patients' nutritional status to assess factors that may lead to obesity or malnutrition; there is a focus in this evaluation not only on intake but also on personal/cultural preferences on types of foods based on availability and health-determinant geographical factors|
|Nursing Concepts II: Care for Adult Patients With Acute and Chronic Health Problems||Hypertension||Genomic predisposition, health disparities, health promotion, patient education, perfusion, self-management||Genogram||Students will develop a genogram for a family history of hypertension to assess modifiable and nonmodifiable risk factors contributing to hypertension and their relationship to SDOH|
|Mental Health Nursing Concepts||Intimate partner violence||Communication, family dynamics, health disparities, safety, stress and coping||Case study and group discussion||Students will identify the stages of the cycle of violence and the influence that SDOH have on perpetuating the cycle; using the case study, students will work in groups to identify how SDOH at each stage may impact exposure to violence, increase the risk of mental disorders, and evaluate subsequent physical health issues that reduce quality of life|
|Pediatrics and Adolescent Nursing Concepts||Child-rearing practices||Culture, health promotion, self-management||Group discussion||Students will form groups and discuss how a family's culture and SDOH influence their definition of health and approach to childbirth/child-rearing|
|Reproductive, Childbearing, and Newborn Nursing Care Concepts||Birthrate and infant mortality||Culture, health disparity, health promotion, self-management, informatics and technology||Group presentations||Each group of students will be assigned two specific countries to research (an industrial and an underdeveloped country) and conduct an evaluation of birthrates, infant mortality, and SDOH for each country|
|Population Health Nursing Concepts||Poverty||Diversity, health disparity, health policy, health systems||Windshield survey||Based on an assigned zip code or community, students will conduct a windshield survey; students should identify SDOH, environmental signs of socioeconomic status within a community, and list the positive or negative impact of these factors on health outcomes|
|Social, Environmental, and Genomic Determinants of Health||Health equity||Ethics, health disparity, health policy, health promotion||Roots of health inequity interactive modules and reflection||Students will review selected interactive and free resources available at http://www.rootsofhealthinequity.org/; after review, students will post their reflections on the course discussion board about how this experience will impact their professional nursing practice|