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UNIT II ■ Community Health Across Populations: Public Health Issues
Health Marginalization Disparities in health are often multifactorial and include access to care, income, and marginalization. For example, access to care is an initial assumption for health dispar- ities in maternal health outcomes. Assari and Zare dis- cuss that access to care, along with proximity to care and health-care use, when similar between white and black persons still yielded a considerable disparity. 20 They pos- ited that other factors, such as marginalization of an un- derrepresented group, may be driving health disparities. Discrimination occurs when a marginalized person or group of persons is treated as insignificant or peripheral. In health care, discrimination occurs when patients are not offered care such as pain medications with the same frequency as nonmarginalized patients. It is important for nurses to critically reflect and explore how their conscious and unconscious biases can affect care, how health-care services are offered, frequency of services of- fered, and differences between groups, whether based on race, sex, gender orientation, or another characteristic. Social Determinants of Health The SDOH are the social and environmental conditions in which people are born, live, learn, work, play, worship, and age. 21 The SDOH are organized into five categories: neighborhood and built environment (see Chapter 6), social and community context, economic stability, ed- ucation access and quality, and health-care access and quality (Fig. 7-4). 21 The determinants are not only asso- ciated with risk for communicable and noncommuni- cable disease, but they are also associated with risk for mental health disorders, substance use disorders, injury, and violence. According to the WHO, SDOH account for “the unfair and avoidable differences in health status seen within and between countries.” 22 For all health-care providers, including nurses, un- derstanding SDOH and integrating that knowledge into plans of care results in improved outcomes. When pa- tients come to the hospital for care, it is not always easy to understand the context of their daily lives because nurses are not interacting with them in their home environment. Yet with increasingly short hospital stays, nursing care that incorporates this context in the nursing plan of care and discharge instructions becomes even more impor- tant. Subsequently, communication between the patient and the nurse about their living arrangements is imper- ative. Often, patients go home with complex instruc- tions and a need for medical supplies yet lack the health literacy (see Chapter 2) or the resources to implement
Figure 7-4 Social determinants of health. (Source: Reference [21])
those instructions. This can result in poor outcomes and a return to the hospital. At the tertiary prevention level, addressing this health inequity may include requesting an order for a home health nurse or home health aide on discharge, thus helping vulnerable patients improve their ability to self-manage the disease. On the secondary prevention level, nurses in public health departments are on the front line with screening programs for vulnerable populations at high risk for disease, such as lead poison- ing or sexually transmitted infections. On the primary level, nurses provide education to at-risk populations. As explained in Chapter 2, understanding the SDOH is essential to help identify persons at risk, as well as de- signing an intervention at the individual or community level that considers how the social and environmental conditions in which people live affect their ability to achieve optimal health. During the development of the HP 2030 goals and objectives, an increased emphasis on the SDOH was added to enable stakeholders to identify opportunities to achieve health equity. 23 Neighborhood and Built Environment SDOH related to the neighborhood and built environ- ment focus on where a person lives. 24 This includes their housing, neighborhood, and the physical environment in which they live. Lack of access to potable drinking water within a neighborhood is associated with infectious disease and
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