Nursing has always held health equity as a critical value in many ways. Nurses strive to deliver the best care to all patients, independent of socioeconomic status, gender, race, or other factors.
Health equity arguably gets even more attention than in the past. And that attention also occurs in nursing schools, where nurses are presented with the concept of health equity.
In this article, we examine how various schools teach health equity. But first, let’s define the term.
“Equity should mean that people have the opportunity to get what they need when they need it,” notes Alicea-Planas, associate professor of nursing at Egan and practicing nurse at a community health center in Bridgeport, CT. “That’s something that has historically been lacking for certain communities within our healthcare system.”
Health equity means that “everyone has the ability and opportunity to be healthy and to access healthcare to help them maintain health,” says Latina Brooks, PhD, CNP, FAANP, associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Brooks also directs the MSN and DNP programs at Frances Payne.
Beyond Accessibility
The CDC notes that achieving health equity requires ongoing efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.
Health equity isn’t just about access to healthcare, notes Elaine Foster, PhD, MSN, RN, vice president of nursing, Education Affiliates. It can also relate to whether a diabetic patient, for instance, knows what to get checked. “I think sometimes we’ve put a very narrow description on health equity, and I think if you were to flesh it out, it goes beyond that accessibility,” Foster notes.
“You can even take health equity that next step and say, Do you have an advocate or do you have someone who knows to push the envelope?” says Foster. “We have to be active participants in our healthcare these days to get what we need.”
Besides accessing resources, health equity involves “understanding how to navigate our healthcare system,” says Alicea-Planas. “It is understanding the information that’s being provided to us by healthcare providers and being able to use it for patients to do well on their health and wellness journey.”
Teaching Equity
At various schools, health equity is integrated throughout the course of study. For instance, at Adelphi University College of Nursing and Public Health, Long Island, New York, health equity is threaded throughout the undergraduate and graduate curriculum in various courses, notes Deborah Hunt, PhD, RN, Dr. Betty L. Forest dean and professor. For example, in the school’s community health course, there is a focus on vulnerable and underserved populations. In the childbearing course, Hunt notes, there is a focus on health disparities and maternal and infant mortality.
Foster notes that health equity is threaded into the curriculum at the 21 nursing schools within the Education Affiliates system. Likewise, at Frances Payne Bolton, health equity is integrated into courses. However, Brooks notes that some courses go more in-depth, such as discussing health equity in vulnerable populations.
At Egan, introductory courses talk a lot about health equity and social determinants of health, notes Alicea-Planas, as do clinical courses. “I think a big part of understanding health equity is also understanding social determinants of health,” says Alicea-Planas. “I am super excited that now in the nursing curriculum, we have lots of conversations around those social determinants of health and how they influence people’s ability to attain their highest level of health.”
The Takeaways
One crucial learning that Alicea-Planas hopes students take away is that for students who haven’t been exposed to many people from different backgrounds, it’s essential “to understand how historically our healthcare system has treated certain communities of color. That factors into people’s feelings about how doctors or nurses treat them, influencing their ability to seek care.”
Foster hopes that students learn that no matter what the patient’s background, “Everyone is entitled to good, nonjudgmental care within the healthcare system.” Students must learn “not to impose our beliefs, our judgment on someone. Because until we get rid of that type of judgment, we will never overcome issues with health equity because we’ve got to first check our beliefs and opinions at the door and say I’m going to give the best care possible to these patients.”
When we reflect on nursing, we don’t always consider the concept of justice.
We may think about patients, patient care, medications, interventions, and hospitals, but justice might seem like the purview of lawyers, legislators, activists, human service agencies, and non-profit organizations. However, nursing and justice are more closely related than we think; thus, linking them in our consciousness is an important consideration.
Social Determinants of Health
In some nursing programs, the concept of social determinants of health (SDOH) is taught from the very early stages of student nurses’ education, and the relationship between SDOHs and justice is quite apparent. This CDC definition is as good as any when it comes to clarifying what constitutes an SDOH:
Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems.
Meanwhile, the United Nations’ 17 Sustainable Development Goals (SDGs) offer us another prism through which to view the lives of human beings around the world. The SDGs include broad areas of concern such as good health and well-being, clean water and sanitation, responsible consumption and production, and eradicating poverty and hunger, all of which can be seen as related to justice in the broadest sense.
Regarding the 17 SDGs, the UN asserts that “ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth – all while tackling climate change and working to preserve our oceans and forests.”
The ability of citizens around the world to live healthy, productive lives could not be more crucial, and access to healthcare, education, nutritious food, proper housing, and a clean environment are all aspects of achieving such a life. But what do nurses and nursing have to do with such seemingly disparate yet necessary issues regarding justice and equality for all citizens?
Healthcare Doesn’t Happen in a Vacuum
When a patient attends a medical appointment, their presenting issue might be diabetes, hypertension, or asthma. However, we often miss the point when we simplify health and healthcare down to solely the bare bones of a medical diagnosis. For example, a diabetic patient who doesn’t drive may not live in a food desert since they live within walking distance of a bodega or convenience store. Still, they live in a nutrient desert since they lack access to any appreciable nutrient density and quality food.
A child who lives in a part of the city where lead pipes are an incomprehensible reality (e.g., Flint, Michigan) or factory smoke and toxic waste are prevalent (e.g., any number of poor neighborhoods in American cities) may suffer from learning disabilities, asthma, or even cancer that may have otherwise been preventable but for egregious environmental insults.
Is it just that toxic waste is more likely to be stored in poor neighborhoods than in affluent ones? Is there anything but injustice in that an economically disadvantaged child ingests unclean water and air while their wealthy counterparts across town are spared? Is there any reason racial disparities in healthcare delivery are tolerable in our society?
Patients’ diagnoses and health outcomes can often be directly linked to injustices that are shamefully visited upon certain groups. Nurses and other healthcare professionals are responsible for remaining aware of how multiple factors weigh heavily on the health of myriad communities.
Leveraging Nurse-led Solutions
As the most trusted professionals in the United States year after year, nurses are uniquely positioned to leverage their influence for the good of the whole. Letters to the editor, podcasts, articles, blog posts, social media, and other means can be utilized by nurses to make their voices heard. Nurses can meet with local, state, and national legislators, lobby for bills geared towards many aspects of justice, be it in the realm of healthcare or otherwise.
Organizations like the Alliance of Nurses for Healthy Environments (ANHE) champion causes that are urgent public health matters. For example, on the legislative side, the non-profit and non-partisan Healing Politics “inspire[s], motivate[s], recruit[s], and train[s] nurses and midwives to run for elected office up and down the ballot while building a culture of civic engagement within the professions.”
The intersectionality of justice, nursing, and healthcare is multifaceted, and nurses can choose to be powerful voices within the chorus of those demanding change. Justice comes in many forms, and nurses can decide how they weigh in on issues that directly impact how justice — or the lack thereof — manifests in this country and the broader world around us.
Minority Nurse is thrilled to feature Keith Carlson, “Nurse Keith,” a well-known nurse career coach and podcaster of The Nurse Keith Show as a guest columnist. Check back every other Thursday for Keith’s column.
The role of the health care professional has seen its fair share of evolution throughout history. Shamans and healers in ancient societies paved the way for modern medical professionals, who have a duty to society as a whole that spans well beyond diagnosis and healing. Medical doctors today are expected to exhibit professionalism as well as effectively communicate with patients and colleagues, and conduct plenty of research.
And for optimal patient care, that research isn’t confined to information directly related to the health care industry. Health care professionals must also remain on top of current events, and be aware of the various societal issues that can shape both medicine and public policy, such as immigration. In this regard, health care workers often double as agents of societal change.
As the Hippocratic oath remains a crucial part of modern medicine, ethical considerations are of paramount importance in the health care arena. Whether you’re a primary care provider, registered nurse, anesthesiologist, or another type of health care worker, you’re in a prime position to advocate for immigrant families. You may be unequipped to help immigrant families in a legal or political capacity, but your direct health care efforts may ultimately catalyze societal change.
Medical Care for Immigrant Families
It’s important to note that the needs of immigrant families may differ drastically based on the citizenship status of family members. And the terminology itself doesn’t necessarily tell the entire story: Children who were born in the U.S. but have at least one foreign-born parent are typically identified as children in immigrant families (CIF). As of 2019, an estimated 1 in 4 children in the U.S. can thus be considered CIF, but their social determinants can vary considerably.
For instance, immigrant family members who are legal U.S. citizens can access the same health care benefits afforded to all Americans, including Medicaid and Medicare. Undocumented immigrants, however, are much less likely to have any type of health coverage. These individuals are subsequently more vulnerable to chronic health issues and contagious viruses including COVID-19.
According to the American Medical Association (AMA), approximately 11 million undocumented immigrants are living in the United States. What’s more, “physicians and other health professionals should be aware of how to advocate for these patients, including through self-education, education of trainees, in the exam room, and on Capitol Hill.” A large number of undocumented immigrants tend to avoid seeking medical care, even if it’s urgent, due to fear of deportation or the intervention of government agencies.
Politically speaking, the subject of illegal immigration is a contentious one. Yet it’s crucial to remember that, for many families and individuals, immigrating isn’t exactly a choice. Many immigrants to the U.S. are refugees seeking asylum, or humanitarian protection, from persecution or war in their home countries. Asylum seekers are subject to a lengthy immigration process, and there is a governmental cap on the number of refugees admitted on an annual basis.
The Importance of Immigrant Health Care Workers
As a health care worker, it may behoove you to learn a little bit about the immigrant families that you serve to better address their needs. But you should also look to your colleagues for guidance and inspiration: Plenty of immigrants are gainfully employed in the health care industry. According to the Migration Policy Institute (MPI), about 2.6 million immigrants are employed in various health care fields, including approximately 1.5 million doctors, registered nurses, and pharmacists.
Unfortunately, immigrant health care workers tend to be underappreciated, yet this segment of the workforce is invaluable in the realm of disaster response. In 2021, disaster response is heavily focused on curbing the spread of COVID-19, but the discipline encompasses much more, notably natural disasters like earthquakes, hurricanes, and wildfires. Within disaster response, the humanitarian side of health care is heavily emphasized, as disaster survivors often require social services — to access food and emergency housing, for example — in addition to medical care.
Similarly, immigrant families may have similar psychological and humanitarian needs, even far removed from disaster response scenarios. Health care professionals from immigrant families are well-equipped to address these sorts of needs among their patients, especially if they have personal experience in seeking legal asylum, or securing stable housing and job opportunities.
Looking to the Future: From Telemedicine to Health Care for All
No matter your background, as a health care professional, you’re likely well-versed in the various social determinants that can influence one’s health and well-being. The conditions and places that one is born and raised in, widely known as social determinants of health, overwhelmingly correlate to individual health, as well as that of entire communities.
Even those social determinants that are directly related to economics and education can have a significant impact on individual health, and the COVID-19 pandemic has only exacerbated the situation. In regards to social determinants, the Centers for Disease Control and Prevention (CDC) reports that “for many people in racial and ethnic minority groups, living conditions may contribute to underlying health conditions and make it difficult to follow steps to prevent getting sick with COVID-19 or to seek treatment if they do get sick.”
The good news is that, as a health care provider, you can help bridge the gaps among your minority and immigrant patients, and telemedicine is an ideal starting point. In a world under the threat of a deadly pandemic, telemedicine has become a crucial component of health care. While you can’t treat serious conditions solely via telehealth, the platform is extremely versatile. Telemedicine can streamline patient monitoring as well as the appointment setting process, reducing the need for multiple visits or a lengthy commute to a hospital or clinic. Further, simple tests such as vision exams can be conducted safely and easily using telehealth.
And signs indicate that telemedicine is likely here to stay, post-pandemic, as it can help generate revenue in health care facilities ranging from major research hospitals to local clinics and private practices.
Key Takeaways
Although revenue is certainly relevant in every corner of the health care industry, caring for patients is still the ultimate goal. As a health care professional, you may find that advocating for your patients is just as important as administering quality health care. Determining the individual needs of your patients, whether immigrants or natural-born citizens, can ultimately serve to improve public health overall, and give you greater satisfaction that you’re truly making a difference in the world.
In the spring of 2020, the coronavirus pandemic first gripped the world by the throat and its deadly menace continues to unfurl with renewed ferocity. In the United States, medical and scientific experts issued a series of early recommendations to slow or halt the spread of the virus that causes the disease COVID-19. Such public health measures are clearly warranted. As of this writing, over 285,000 Americans have perished from COVID-19 and the infection numbers are soaring across much of the country. Recommendations to combat the virus spread include handwashing, covering the face when coughing and sneezing, wearing a mask when in public spaces, and social distancing. The most challenging anti-virus measure was the lockdown or stay-at-home orders issued by state and local governments. In many communities, people rushed out to stock up on food, water, and household supplies before they began sheltering in place. The lockdown preparations and implementation clearly highlighted the pervasive and persistent inequalities impacting every aspect of American life that are attributable to social determinants of health (SDH). The World Health Organization defines SDH as “the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” During the current public health crisis one key question for researchers, policymakers, and clinical providers alike to ask is: Which populations in the U.S. are most likely to experience adverse effects from SDH?
As an academic nurse researcher with expertise in health disparities, I closely monitored news about how the spring lockdowns were impacting various population groups. I paid special attention to the dramatically different experiences of white-collar employees, many of whom had the privilege of safely sheltering in place while working from home, and front-line essential workers who had no such option. This later group, often employed in grocery stores, meat-packing plants, bus stations, and other crowded environments, had higher risk of exposure to the coronavirus. Many of these essential workers are people of color and the devastating consequence of this reality was all too predictable. According to the U.S. Centers for Disease Control and Prevention, communities of color have experienced considerably higher rates of infection, severe illness, and death from COVID-19. This population includes approximately 100,000 individuals, largely African American, with sickle cell disease (SCD), an inherited red blood disorder. The major symptom of this disease is persistent, disabling pain, including excruciating episodes known as a pain crisis. SCD is a lifelong illness with a life expectancy of 48 years for women and 42 years for men.
With a primary research focus on pain management disparities experienced by SCD patients, I worry how coronavirus-related stressors are exacerbating the considerable pain already endured by these individuals. My research indicates that systematic stressors such as healthcare injustice—defined as unfair treatment an individual receives from important medical figures such as healthcare providers — predicts increased pain in patients with SCD. They are particularly vulnerable at this time because the coronavirus pandemic can magnify the negative SDH already experienced due to their race and disease trajectory.
I am concerned about how SCD patients are coping with today’s magnified societal stressors, particularly when trying to avoid a stress-related pain crisis that would require hospitalization and potential exposure to the coronavirus. Given the comprised hematologic profile of patients with SCD, which reduces oxygen circulation, these individuals are at elevated risk for both COVID-19 severity and mortality. Statistics from early in the pandemic document this grim reality. A recent study found that between March and May 2020, 178 infected individuals were entered into the SCD-coronavirus disease case registry. Of these, 122 (69%) were hospitalized and 13 (7%) died. (These hospitalization and death rates are much higher than for infected individuals in the general population.) Healthy stress management techniques that decrease emotion-triggered pain crises could greatly improve the well-being of SCD patients and potentially reduce their hospitalizations and deaths. Healthcare professionals can play a key role in encouraging patients to consistently utilize non-drug coping strategies to complement medication regimens for pain management.
Our research team found that patients with SCD who experienced healthcare injustice from nurses reacted to this psychological stressor by isolating themselves. Meanwhile, those who experienced healthcare injustice from doctors reacted by both isolating and pain catastrophizing. These negative coping strategies are associated with poor health outcomes. For example, pain catastrophizing corresponds to lower health-related quality of life for patients with SCD. On a more positive note, patients who experience healthcare justice also cope with prayer and hopeful thinking. These healthy strategies have long been endorsed within African American communities, where deep spiritual beliefs and regular religious practices have helped them deal with the harsh realities of slavery and the systemic racial discrimination and injustice that sadly remains a powerful force in American culture.
Another coping strategy for SCD patients dealing with stress and pain is guided relaxation. This can include deep breathing and counting backwards from 10 to 1 while focusing on a specific spot within an object. This technique has been shown to effectively reduce stress and pain for adults with SCD. Another recent study found that music therapy also reduces pain and improves mood. It is important that these vulnerable patients know there are a number evidence-based drug-free strategies they can utilize during this unprecedented and pressure-filled coronavirus pandemic.
Unfortunately, SCD patients in the United States, like other citizens the world over, cannot individually control the course of the pandemic and the havoc it is wrecking. However, these patients do wield tremendous control over how they choose to cope with coronavirus-related stressors that can intensify their SCD pain. In addition to the non-drug options described above, individuals can explore and try other safe coping strategies to better manage their physical and emotional health challenges. It is vital that patients are proactive on an ongoing basis to reduce their stress and pain and improve their overall well-being as the world awaits better coronavirus treatments and an effective vaccine.
“African American women have the highest incidence and prevalence of hypertension among any ethnic, racial, and gender group in the United States,” explains Taylor, who works at NYU Rory Meyers College of Nursing as the first Vernice D. Ferguson Endowed Chair. “It is important for me to understand not only the genetic or hereditary underpinnings of this health disparity, but also the psychological and/or environment interaction with genomic risks that may influence development of hypertension.”
In her research, Taylor says that she’s focused for the most part on African American women and children. Most of her studies have drawn on two or three generations of African Americans. While the ages of the children studied have often been wide, in her most recent study, she targeted children from head start programs, who ranged in age from 3-5 years old, along with their biological mothers.
“We have had a lot of discoveries in our research and have disseminated our findings in journals ranging from nursing, medical, public health, genomic, and interdisciplinary. Overall, we have found that gene-environment interactions for certain factors such as parenting stress, perceived racism and discrimination, and others significantly influence increases in blood pressure,” says Taylor.
She admits that she wasn’t shocked by the findings: “The findings were not all that surprising as I expected that social determinants of health were significant factors in health outcomes and looking at the combinatorial effects with genetics and epigenetics only further illuminates that magnitude of interaction on health outcomes such as hypertension,” Taylor says.
Although Taylor says that her research is important because of what she did discover, “One important aspect of the research is that we are able to identify genetic risk for chronic diseases such as hypertension in children as young as three prior to them developing the disorder. Early identification of risk provides an opportunity for nurses and other health professionals to intervene to reduce risk of developing hypertension as in previous generations. Interventions based on the research with this population may require focusing on social determinants of health and lifestyle modification in addition to or rather than conventional pharmacological methods.”
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