Exploring Social Determinants of Health

Good morning, everyone. I am so pleased to welcome you all to NINR's directors lecture on social determinants of health. Before we get started. I'd like to remind everyone that today's lecture will be recorded and made available through our website, ninr.nih.gov Today's event is the first in a series of webinars that we are hosting to provide an in-depth look at each of the research lenses in our 2022 - 2026 strategic plan, which we launched in May of this year. So I am excited to tell you a little bit about it. But first a couple of housekeeping notes. Next slide, please. So before we get started I would like to remind you that today's lecture will be recorded. As I said, and made available on our website. Closed captions are available, and it may be enabled at the bottom of your screen. So at NINR we are committed to leaving nursing science to solve pressing health challenges and inform practice and policy, optimizing health and advancing health equity into the future. Our mission statement reflects our belief that nursing research is the key to unlocking the power and potential of nursing. And our strategic plan describes how we want to leverage the strengths and unique knowledge and perspectives inherit to the discipline of nursing, to the benefit of all people. Next slide. The plan includes 5 research lenses. that we think will help push nursing science forward to innovate, think bigger, and greatly increase our impact. When we say lens, we're describing a perspective through which we examine a health challenge the lenses and the strategic plan are health equity, social determinants of health, population and community health, prevention and health promotion, and systems and models of care. Next slide. Today's webinar we'll focus on the social determinants of health research lens. This lens recognizes that nursing research is needed, that identifies and develops interventions delivered at the right place and the right time to target social determinants of health building on NINR's ongoing investment in this area. Research through this lens aims to discover creative solutions powerful enough to address upstream and midstream causes of health. Next slide, please. So through this webinar series we aim to help nursing researchers better understand and apply NINR's research lenses to their own work. We have 3 learning objectives for the series. First we want to provide a forum for discussion on how nursing research can help address our nation's most pressing help challenges. Second, we want to provide examples that illustrate the possibilities for scientific inquiries through NINR's research lenses. And third, we want to discuss practice and policy implications of nursing research through each of the NINR. Lenses. You can use the Q&A module to ask questions at any time during the webinar. We'll hold questions, though, until the end, and try to get in as many as possible. We're pleased to be offering continuing education credits for today's webinar. Stay with us at the end for more information, and the QR Code to scan for to obtain your credits. Next slide, please. So I am delighted that we have 2 distinguished speakers with us today to talk more about research through the social determinants of health lens, and implications for practice and policy. Our first speaker is Dr. Vincent Guilamo-Ramos, Dean and Distinguished Professor at the Duke University School of Nursing and Vice Chancellor of Nursing Affairs at Duke University He is also the founding director of the Center for Latino, Adolescent and Family Health, a Duke University. Dr. Guilamo-Ramos is a nurse practitioner, duly licensed and primary care and psychiatric mental health nursing, widely regarded as an expert scholar and leader, in adolescent and young, adult, sexual and reproductive health promotion and the social determinants of health. Dr. Guilamo-Ramos' research has been funded for 2 decades by the National Institutes of Health and various other Federal agencies. His research focuses on the role of families and promoting adolescent and young adult health among Latinos and then other underserved populations, with a special focus on mitigating the mechanisms through its social determinants shape, help outcomes and inequities. Our second speaker is Dr. Brian Castrucci, President and Chief Executive Officer of the de Beaumont Foundation. Dr. Castrucci has built the de Beaumont Foundation into a leading voice in health in philanthropy and public health practice. He is an award-winning epidemiologist with 10 years of experience, working with health departments of Philadelphia, Texas, and Georgia and brings a unique perspective to the philanthropic sector that allows him to shape and implement visionary and practical in the initiatives and partnerships, and bring together research and practice to improve public health. So doctors Guilamo-Ramos and Dr. Castrucci, welcome. We're so pleased that you could join us today, and with that Dr. Guilamo-Ramos, I will turn things over to you to get started. Thank you. Thank you very much, Dr. Zenk. It's quite an honor to be here with everyone, including my fellow panelist, Dr. Castucci. I'm gonna share my slides and i'm gonna try to get across a number of important ideas in a fairly short amount of time. And so hopefully, I can. do a good job at this. But yeah, you guys will let me know. So my talk today's entitled Future Directions in Nursing Science: A Call to Action for Mitigating the Social Determinants of Health. and I think that if I'm successful, there are actually two things that I'm hoping to do first and foremost really stimulate a discussion around some of the ways that the nursing profession that neuroscientists can really think about the new strategic plan which I personally think is terrific and some potential scientific areas that are sort of really opportunities for us to advance health equity, and then in a more personal way I'm hoping to really highlight what I see as a important moment in time, where we, as a profession as nurses, should be thinking about building on what we've done and all of the terrific work that has occurred in the nursing profession. But it in my view it's a call to action and if I'm successful. I hope that I'll be able to communicate that comments There are a couple of things that I'm planning in my presentation. You can see on the slide I'm gonna spend a very short amount of time just talking about the current dynamic context that we're in in terms of healthcare delivery, but with a particular emphasis on health equity I'm going to very quickly review all of the terrific research that has happened on social determinants of health, but with a particular lens towards what does that research mean? And what are the principles? and perhaps potential strategies that we can adopt moving forward that in my view represent a paradigm shift. And then I'm going to hopefully apply that to an actual example that I'm. currently working on now as part of the RADx-UP initiative. So undoubtedly there have been major large-scale, transformative events that have impacted our country, particularly over the last couple of years. But they've actually been going on for quite some time and some of these things represent new challenges like the Covid-19 pandemic. but our number of them represent more ongoing chronic issues that we face us a nation and you can see here, I'm just going to illustrate a couple that certainly we're experiencing demographic shifts. We're grappling with climate change issues of migration structural racism widening inequality. There's been lots of talk about inflation and many of us have experienced sort of how our dollar is being stretched to actually meet many of our needs. The growing substance use and mental health epidemic in the country. These are all things that we're facing and they have important implications. For how we think about health, equity, and how social determinants play an important role. And so here there are 3 relational forms that I think are worth mentioning. Again very quickly. The first is what I started with and mentioned just a second ago, that there have been new large scale events that represent challenges that have resulted in new inequity, and probably the most sort of pronounced example is the Covid-19 pandemic. and you can see here, for example, that Covid-19 results in immortality. Differentials between vaccinated and unvaccinated individuals. But what also is true that some of these large-scale transformative events, that we're facing right now they actually expose chronic inequities, things that have been happening in our country, and for that matter, across the globe for a very, very long time and and what's being depicted in that second relational form is that the Covid-19 epidemic had a disproportionate impact on communities of color. And again, we know that those communities have historically been the places where many inequities have had the largest impact. There's also been this interesting relationship that I'll call that third relational form where the 3 is on the right hand side of the slide a synergistic relationship. And here there are sort of challenges, that we've had for example, sort of use of substances, and in this example I'm particularly referring to opioids, and there have been record increases in overdose steps during the Covid-19 pandemic. And so again, the idea is that there have been direct new challenges. There has been awareness of historical challenges, inequities, and there has been some synergistic or amplification of more than one particular health inequity. In preparation for today, I and my research team, we worked on sort of reviewing the literature and I'm, smiling, because as a professor, this is sort of my natural place that I return, and you can see here that in PubMed. We did a search of using the term social determinants of health. And what you can see is that roughly 16,600 or 16,700 articles were identified. And really what we're striking to me is that the first paper that I could find was back in 1961 so again, SDOH not being necessarily a new concept. To us, as you know, nurses, but also to others outside of the nursing profession. But what was really striking was that in 2010 to now there was a rapid escalation, scholarship and research that was specifically identifying social determinants of health. And so part of what I'm going to present in my subsequent slides from 2010 to now, what does that research suggest? What does it really? Sort of provide in terms of thinking about where we should go? Looking forward. I think it's important to mention and for this audience no surprise, and really a review. But social determinants of health account for 80 to 90% of modifiable contributors to health outcomes. They are huge, they are important, and they are certainly some place where the nursing and other health professions need to focus. I'm happy to just report been there has been much attention to social determinants across many national organizations. I think the most pronounced is probably the Future of Nursing report, but certainly equally exciting have been the ANA, The American Academy of Nurses. I think Dr. Zenk referenced the National Institute of Nursing Research, the terrific strategic plan. This is the time for nursing to really think through social determinants of health. I think what's also true is despite all the successes that we've had in nursing, and again, this is not a new concept for us in our profession, but we're building and thinking about how we can amplify our efforts. The truth is that more than half of Americans already have a chronic disease, and the proportion with 2 or more chronic diseases is increasing. Since 2014 U.S. life expectancy has stagnated or declined, and more than half of U.S. adults delayed or skipped care due to cost last year. And these are just some very high level examples that illustrate, despite our increased attention, that really achieving health equity is something that has not come to fruition. What's also interesting in preparation for today was reading a recent article that was published in Deloitte insights, and you could see here that without progress in chronic conditions the cost of health inequities is projected to triple by 2040. And so right now, the cost of inequities today is about 320 billion dollars. But if we project out to 2040, you can see the cost of inequities being a one trillion, and this one trillion number actually speaks to the actual cost of the inequity. And so not the total cost of care, but the money that we will spend because we have not addressed. Sort of the communities with greatest need, and the ways in which those chronic conditions are inevitable. And they represent really preventable health outcomes. This slide is saying something that I feel very proud to convey, and I also realize that most of us are aware of this. But the nursing workforce, we are central to a achieving health equity. We are central to thinking about a paradigm shift that we are seeing, to doing the nursing, research and practice and changes in our academic programs, and how we truly train nurses to really help our country to achieve health equity. I want to spend some time talking about what I've called the paradigm shift, and to do that I'm gonna focus on some of that literature and kind of highlight a couple of things. But right before I do that, I think it's important to recognize that we are at a really terrific point. One example is that HHS and Healthy People 2030. There is an overarching framework. That focuses on SDOH, and you can see on the right hand side some of the areas that are being targeted. And I think what's exciting about this is that it certainly is moving, and stoh increasingly into the way we think about health in our country. But what's also true is that I when I've looked at the literature over that 10 year period from 2010 to now that sort of 10 to 12 year period a couple of things jump out. So one I think there's been a conceptual evolution initially I think there was sort of very little recognition of social determinants. There was just simply health outcomes. But over time, and thinking through the onset of social determinants. starting with that 1961 paper, there was a recognition that social determinants shape health outcomes. But what was missing was an understanding of what those mechanisms are. What later emerged was a sense that the health outcomes represent a health disparity, and that a health disparity is often tied to systematic kind of disparities. And there was this notion of vulnerability. The literature started to reflect vulnerable individuals, vulnerable communities, vulnerable populations. I think, what later evolved was this third relational form, where we have a disparity that now is referenced as a health inequity, and what that health inequity refers to is this notion of there being social injustice and there are processes that are unfair that are actually contributing to the disparity which is now being viewed as an inequity. And I also started to see notions that vulnerability was being unpacked, and that rather than being vulnerable individuals or families or communities, or populations, there was a sense that there were drivers that were impacting vulnerability, and so more in that in a little bit. So here there's been an awful lot of work in the social determinant space, and in many ways I'm going to do a disservice to that work because of time. But what I do want to get across is there a number of landmark, conceptual and empirical research studies, that actually have identified across all of that work that was depicted from 2010 to 2022, 8 principles. And you can see them reflected on the slide, and I'm very briefly gonna cover each. And so the first is principle number one, that there are underlining causes beyond individuals that are driving health and equities. And so here we have distal factors or exposures that influence individual risk. They're also protective factors, and that these exposures and risk factors shape disease and health outcomes. The second principle is that contact matters and here it's not enough to say that it's solely a function of an individual. But this landmark framework, it really characterizes what was referred to as the structural production of health inequities. And so here, risk is largely seen as being exogenous outside of the individual, and there's recognition that there are four dimensions. The physical environment, the social environment, the economic environment, and policy. And I know that Dr. Castrucci is going to talk about policy later. But I think here the risk is not solely a function of the individual, but it also is reflected in the environment. And so here's a really important way of characterizing two communities, Community A and Community B And if you think about those four dimensions of risk on the bottom, physical, social, economic, and policy think about them in relation to the sharks that are swimming in those pools, those sharks represent those four dimensions and Community B is certainly much riskier than Community A. But any of us could swim in either Community A or Community B. But our outcome would be you know different depending upon the community that we're in. It's also important to recognize that context is not deterministic. And so contextual disadvantage doesn't mean that every single person in that context will have the same a negative outcome. Assuming that that context is one that is not that is a negative one that is not supporting one health. And so there's recognition that there are sort of multiple levels. There's a micro level, a meso level and a macro level, and that those three levels that they interact in ways that they can reinforce risk or they can actually weaken the effects of negative influences, or at the opposite, strengthen the effects of positive health, promoting influences. This is a great example. In this example you have two swimmers, Swimmer A and Swimmer B You can see that in this case both communities, Community A and B have the same number of sharks. The same prevalence. But what is different is that in community a there's a lifeguard and there's medical care. There are nurses, there's a healthcare system also the individual's behavior in community a Swimmer A is actually different. They stay on the shallow side of the pool, and therefore the outcome is different. Despite the fact that there is the same prevalence of sharks and the context is the same between Community A and B below. In Community B, you can see there is no lifeguard. There is no medical care. There are no nurses, there is no public health workforce and that the behavior may be different in this case Swimmer B is actually swimming on the deeper side of the pool. And what's happening there there's greater likelihood of coming into contact with the shark, and there for having a bite Principal Number 4 is that SDOH influences health across our lifetime. There's a life course perspective, and so you can see here the early life exposure. You know, impacts what happens later on. There is an important spatial, temporal component, and that the life course framework suggests that the social, the economic, the psychological, and environmental influences that they accumulate over the course of our life, and they affect our behavior. They affect our mental health and our physical health. Biological embedding, very, very important work, a lot of this work being reflected in some of the research. Actually a lot of the research that is being undertaken and has been undertaken in nursing. And so SDOH operates through biological embedding. Biological embedding is a process by which the social conditions they initiate and they sustain biological changes that have short and long term effects on physical health and well-being. And so social conditions, they alter biological processes, the epigenetic, the neuros developmental, the immune, the engineer, the microbiome. They are stable and long-term, and they can alter biological processes that impact our health and well-being our learning or behavior over the life course. The social can be, and is the biological it's not simply that the social is the social. There's also Principal 6 which is that SDOH operates intergenerationally, and there are 3 basic relational forms from parents, parents to child. Multi-generationally within a household so in this case there's a family living in a household, and in that family there are multiple generations, and that particular social determinant, let's say, income inequalities affecting that entire family inter sort of across the generation in that household. And then the transgenerational relationship where it's not solely from parent. It's a child which is cross-generational, but there's actually multiple generations that consecutively experience that particular social determinant. And then have the negative health outcome. There's also a principle that is focused on clustering and synergistic effects. And here the impacts of social determinants of health cluster and they could interact synergistically. And so you can see here that a syndemic is defined. This 2 or more clustered epidemics that interact in ways that they can reinforce one another. There can be biological synergism a really really good example is sort of inflammation that's due to STIs, and how that facilitates the transmission or acquisition of HIV or there can be a socio-contexual synergism which really the increased risk of a given outcome. For example, sexual HIV acquisition among a particular population. Individuals who use substances can be due to sexual behavior. The main point here is that SDOH may operate through both biological and socio-contexual synergisms. There's also the echosocial framework and here, what's being expressed that social injustices, including structural racism, shaped the impact of social determinants of health. And here your social positioning, who you are you're a Latino gay man with a disability that intersectional identity impacts social processes that they can result in health inequities and again, any of the sort of biological or social exemplars are related to this eco set social framework that that way in which that process is shaping the health and equity is either through the biological embedding or through the social process. So how do we pull all this together? So this is a framework that I've been working on with a group here at the Duke University School of nursing, and one of the things that I'm trying to or we are trying to convey is that each of the principles is reflected in this heuristic, and the idea is to take a particular health inequity in a particular context and sort of map it back. It's an interesting way to kind of organize what an intervention might look like. How does that inequity relate to exposure? So really pushing away ideas of vulnerability. But how does it relate to behavioral or social exposure? How does it relate to susceptibility, which is really a biological concept that notions of resilience, despite all of the university? How can individuals, families, communities, thrive? Is there a science of resilience? How do we think about things at multiple levels, at the micro Meso and Macro? And how do we consider them in context? The family contacts and A and across the life course? So i'm gonna give an applied example and then i'm gonna wrap up, and hopefully i've been successful at conveying some importance. And so one of the products that i'm currently working on is our ct. Along with another investigator, Holly Hagan. So both Holly and I are both nurses. We service multiple pis on this randomized clinical trial, and it's part of the radics up initiative, which is a national large jail effort to really respond to the Kovat 19 pandemic in our country. We developed a nurse lead model of care that was designed to mitigate a specific health inequity. Covid 19 testing and vaccine uptake in the South Bronx, which at the time was experiencing really devastating diagnosis, hospitalizations, and depths. And we compared our nurse data model to the standard of care which is what was happening in the Department of Health. And you You know the actual healthcare system in the South Bronx. What you can see here is what I just shared, that the highest rates of COVID-19 hospitalizations in depth of any New York City borough is in the Bronx, and this happens to be the community that I was born and raised in it, spent most of my life. So it had really personal and also a professional meaning. and you can see that the Bronx has more covid 19 depths than 99% of other counties in the United States. And so truthfully. There was a huge inequity that was occurring was geographically concentrated, and the Bronx is a New York city borough that is heavily concentrated with Latinos and African Americans, and our project is taking place in public housing. Meet Miguel. Miguel is a nurse like many of us on this Webinar today, and Miguel is involved in the implementation, and also the the evaluation of a multi-level nursing intervention that is tied to these notions of nurse, that miles of care that are specifically designed to address social determinants of health but within the context of a particular health and equity. Covid 19 I don't have enough time to kind of review all the components of the nurse that'll nurse that model of care. But what I will say is that each of those pieces of the puzzle that you see on the lower right, the of the slide really speak to some of the thinking that is currently going on in my research groups thinking and also beyond here at the school of nursing here at Duke as important pieces of how nursing can advance social determinants of health. Each of the principles was applied to the intervention and reflects what we did in the Ncfp project, and I'm gonna give a couple of examples now, and share what that means. Taking it from a conceptual to an actual application. So the locus of care is in the home. We moved the testing the monitoring of the the families with Covid, the care, coordination, regarding chronic disease, and also all the testing of vaccine uptake directly to the families and so it's delivered by bilingual and bicultural nurse, community health worker, intervention teams. That partner with families there's an individualized household infection control plan that does not focus on the individual, but focuses on the contacts. The household, the family, and how that family is potentially at risk, and how risk can be mitigated. There's an explicit focus on resilience. and how that family can overcome some of the challenges that are identified in the family based mitigation risk assessment. And then also there are wraparound services that are provided by the community health workers because of all the secondary sequela that are tied to covid. But also things that were preexisting the particular community. We were working in the South Bronx Mod Haven, one of the most economically disadvantaged communities in the United States, and certainly in New York City. Their health and social, educational and vocational supports that are offered across the life course. Multi-generationally in that family's home and in the community. Health workers are wrapping those services and linking those families to additional services in their community. There's enhancement of of covid 19 immunity through offering of the vaccine and the vaccine being delivered directly to families in their home There's a theory based intervention that actually shapes, their vaccine decision making both the core dose and also boosters. There's what I've mentioned previously the family-based prevention of mitigation. So it's not about individual behavior but about families thinking through how they can collectively build mutual aid, and how they can help one another, and those in their community to prevent Covid from mentoring their household. I've mentioned some of the care coordination from the community health workers. But here the nurses are involved in coordination of comorbidities outside of the Covid context, because many of the services to during you know, the period when we were locked down folks could not access routine healthcare. And so our nurses and community health workers were providing care management in the home, and there's also a collaborative sort of approach that is, about families, community health workers and nurses and rather than focusing on building trust. The team focuses on how we, as a team, can convey trustworthiness. I wish I had more time to relate each of these components back to the principles, the circles that you see on the slide. They map back to the principles that were highlighted in the literature review. And then what I'm trying to suggest is that NCFP really is a an applied example of many of the concepts and ideas that I've laid out in the previous sections of my talk, a couple of pictures to show the community health workers. The nurses and the families in action. I think this makes me smile because it's my home community, and it's also me with others. Nurses and community health workers and families working to solve a real health issues in our communities. And I guess what I want to leave folks with is first and foremost, I think that the NINR strategic plan is a wonderful call to action for nurse. That SDOH and health equity research this is our time this is the time to move away from beyond simply characterizing inequities. But to truly think about how we can mitigate, how we can prevent. What are those mechanisms? Is there a science of resilient? How do people thrive despite the adversity that we face? And how can we develop a disseminate multi-level nursing, lead interventions that are collaborative, that pull on the principles that are depicted in the SDOH literature? Thank you very much. Special thanks to my team. I'm gonna turn it over to you, Dr. Castrucci. Thank you. Thank you so much, Dr. Guilamo-Ramos. That was just a terrific talk, and very quick talk. So appreciate you fitting in so much very helpful information in a short period of time. Certainly an important aspect of the new strategic plan is ensuring that nursing research informs both practice and policy. So I can think of no one better position to discuss the policy implications of social determinants of health, and our next speaker, Dr. Castrucci the floor is yours. Oh, thank you! Dr. Zenk. That was, that was awesome, that was a great presentation by Vince and I'm super happy to be here day so let me just start out I'm not a nurse, but both of my parents were nurses, so I feel, like, you know, growing up with nursing journals in the bathroom. Give me some credibility to to talk a little bit about this. This is my information I'm happy to have folks tweet this I nurse Twitter is very strong, and we should be having this conversation, not just today, but throughout throughout the year, throughout the decade. This is a conversation that keep going. So feel free to follow me I'll follow you back at Brian C. Castrucci In all transparency, I need 36 more people to get to 10,000, so help me out there in nurse community. when you think about where we are in in healthcare I think we're kind of stuck. when you think of futurists, futurist is say that we're going to have more change in the next 20 years, than we've had in the past 100. But I don't know that that's going to be true in healthcare. I think we are often stuck in an individual focus in an individual lens, and we're not really addressing the things that are making us sick. We have a an expansive and expensive healthcare infrastructure. But, it is not bugs and bacteria that are driving our health. Those things that are in our community. It's policy it's environment and the healthcare structure that we have now it's not working. It absolutely is not delivering, given what we are paying. And so in thinking about what I wanted to share with you all today is how do we get to a future not of nursing research or public health or medicine, but how do we get to a future of health, of better health? And when you think about the future, you you conceive of a future right, this is what it's going to be, and then you act. And so, as you act, you make the future right, so if someone tells you all of a sudden, Bitcoin, which I don't really even understand what that is. But if someone tells you that Bitcoin is going to be the future, you start buying Bitcoin. So your act just the the prognostication of Bitcoin got you to act in a way that created that future. So for for the 900 or so nurse leaders and researchers on this call, I want to talk to you about these kind of 8 mega shifts, things that you can do to actually help change the future of health And so I, I just wanna go through these and and share some of my thinking on these mega shifts, and how we, how we can actually get there. And so kind of the first is is this: Social needs and social determinants are different. The the link between community and personal health is indelible, and medicine is not enough. And I think we know these things. But this is how I think of healthcare right now. We are. We are asking clinical medicine to use bigger and more buckets to bail the ship, right, instead of really dealing with our issue with this is social determinant of health. Now, while I am not a nurse, I have probably unfortunately had a lot of interaction with nurses. In February I had a heart attack, and I feel great. It was like the best thing that ever happened to me do why it's the best thing ever happened to me, because I can afford Corvette, level healthcare because I didn't have to be asked the questions about hey? Do you have a 108 hours of leave for the cardiac rehab for the next 12 weeks? I didn't have to worry about what jobs I had, I have one job. It gave me a lot of paid sick leave. I didn't have to worry about that, because in right now you know, we all know this a car that drives a lot smoother than a Chevy. A Corvette's a better ride, it's more luxurious, and that in a capitalist automotive market makes sense to me. But right now we are building a healthcare system where health is a luxury item. Where, if you can afford that Corvette, you're gonna get great care, because those social determinants have already been taken care of by your community. But in communities where, where there are challenges in the community like I love Vince aside with the with the sharks, my job, I want to kill those sharks. I don't want to just stay in the shallow end of the pool. I want to figure out how we off those sharks, and how we off them in an equitable way. And and this, if you take nothing else from this from this whole talk that i'm gonna give, please take this and and call people on this every day. Here is a difference between social determinant and social needs. If someone says, look I'm addressing the social determinant in my hospital, I have a food bank for my patient. Just look at them dead in the eye and say you don't know what a social determinant is that's a social need. Social needs help us still work through an individual lens. I can mitigate my patient's housing needs, but that does nothing for the housing needs of the community. We need to understand that the only way to really get to social determinants is to think through a policy lens. A community lens. So this is something I call the Health Investment Opportunity Framework. We have given a really poor dichotomy of upstream downstream. It's not binary. Right that's a problem. We said, okay, go upstream, and so someone takes one step upstream, and they're like, look I did it. No, it's many steps upstream so in our lowest. If you look in the two different colors, it's individual lens versus community lens, in that individual lens you can be downstream which is the community. And then you I'm sorry the individual is the the healthcare, the clinical environment. Then midstream midstream is that non medical social needs? And then we could even get to individual level policy individual upstream, where we talk about something like the earned income tax credit, which is still something I get as an individual, and I have to actually get, but there's a community accrual there, but it's still the individual lens. Then let's talk about community food banks, meals on wheels, that is community level, but it's very downstream. It still requires a lot of individual action. It is not sustainable. It only lasts as long as we can pay for it. And then you look at things like community midstream that's where, where Kaiser Permanente is doing impact, investing to build housing. But ultimately that keeps decisions about housing in the hands of the private sector. We need to get to community upstream. We need evidence based in our policies. We need research on policies like rental inspection, and complete streets, that when you are in Box 6 you are addressing the social determinants of health. But if one I do only helps one patient at a time that social need. Don't let people get away with confusing them. Changing the health narrative or changing the narrative to health and building partnerships. Someone asked in the Q&A, whether social determinants of help was the right word. I don't care what the word is I don't care if any. We don't even have to agree the 900 of us on this call. What we think this word needs to be is irrelevant. Because we know the concept. Those that we are trying to influence, elected business leaders, other people in other sectors. We need a word and a language that resonates with them. We need to rebuild trust by having better communication. Communication research should be something nurses are leading we need more communication research. That's the way we're going to build partnerships. We cannot do this alone. You know let's be honest, public health got it but handed to it throughout the pandemic. It's partly because we didn't have the credibility with the schools, and the business leaders to do some of the actions that we wanted to do and we need these partnerships. Now something that we've done just as some reference we have this this tool kit called PHRASES. It, public health reaching across sectors, and yes, for those who do. You have never been to schools of public health. We have a whole class in acronym, where we have to go through the class, and everything has to be an acronym. So PHRASES stands for public health reaching across sectors. It is the communications toolkit for the chief health strategist. And later this month our book, talking health will be released and that's really talking about how we talk about health, so that people understand that you know. I often say to folks when you look at the former President, you remember his campaign? What did he want to do to Hillary? And whether you're a Democrat or a Republican? You remember, he wanted to lock her up? We talk about how we say, well, health is 3 hours later, that's what health is. 3 words versus 3 hours we need better communication. Policy is the prescription for better health there's nothing more important than that, No matter what we're doing, all of our policies are just trying to control the flow of disease, we need to shut off the spigot. Throughout the pandemic, we said things like, if you are sick you should stay home from work. Well, i'm not staying home from work if it means my kids don't eat. If it means I lose my house. I need paid sick leave, we're one of 2 nations that don't have a national paid sick leave standard, us in South Korea, the only 2 industrialized nations without without a paid sick leave standard. And then, if you, if you are if you're sick you should isolate into one room of your home. But what if my home only has one room, our policies actually can change the environment, I always tell I'll tell a very quick story of you playing Monopoly with my son, and I told him one day you know you always lose. You should be the boat instead of the car. Well, he played as the boat, and he still lost. We enacted a set of policies, rule changes where if I go around "Go" I get 200, but he gets 300. If I landed a property, I pay all the rent. He plays half the rent. If you want the outcome of the game to change, you must change the rules that govern that game. That's what policy can do for us. I encourage you to check out cityhealth.org. City Health is a partnership between de Beaumont and Kaiser. We have policies that are evidence-based, and we rate the 75 largest cities in the country previously. The 40 largest cities in the country as to the quality of each of those policies, and whether they have them and an overall level because policy is what's going to change the way that we are healthy it's policy takes care of the sharks. That's what we need we need, policy to intervene at that level. Data. I gotta mention data here because data are the original sin. If you are talking about how health, equity and you think data somehow deliver you. You know, high quality information. It may do that, but data are biased. Health, equity, and disparities start with how you collect the data. Who's at the table when you define the the actual instrument. All of our Covid messaging was done with a sample of 1,200 Americans, and it left out any number of nuanced communities and different perspectives. Data are something we have to think about and we have to develop political will to actually mobilize the data that exists. Let's not forget that we sent a robot to Mars to engage in robot tourism. It got out it took pictures. it send pictures back. That was pretty awesome. We sent a robot to Mars to take pictures. I got bunch of kids in my community who are hitting the ER routinely with asthma and they're in different schools, and they're in different pediatricians offices, on different insurance and seeing different hospitals, and I can't find out that those four kids all live in the same apartment building. I can't find that out. That's because of political, but I can sure as heck put a robot on Mars to take pictures. How are our priorities? Where our priority to making those kids healthy? Is it sending robots to mars? And then held equity cuts all of it. Hopefully you've seen the new updated 10 essential services of public health. It centers health equity. It's in our data, it's in our policies. We have to be very thought when you look at health, policy, and equity, why was it so easy to take smoking out of public housing developments, but not so easy to get smoking out of casinos. What do you think that had something to do with power and equity? So we have to think about equity, not saying the word. We work on health equity. We need to have an operationalization of what that means. Where are we actually doing? And and we need to make sure that our researchers are diverse and I'm sure you know, NINR is thinking about this. How do we diversify our PI? The universities that get our money? How do we make sure that they are paid, get extra points in their application? When you were paying community members to bring their expertise, not just putting them on some sort of panel where they are unpaid and are giving volunteer services. Pay people for the expertise that they bring. And remember that when we talked about Covid, Covid was the match. But we in this country provided a whole lot of kindling, that's why we have not fared as well as so many other nations, because we have been stacking for centuries. These sticks in Covid lit that match. Love you to check out Healing Through Policy. This is something that we worked on with the American Public Health Association the National Collaborative for Health Equity, and these are policies that advance racial healing because you can't you you know, if you have a fish tank you can't just deal with the fish and every so often you have to change the water and clean the tank. Policy does that. There are policies that cities now that they've all made great declarations. CDC made a great declaration racism of public health crisis, but short of that going on a t-shirt, they've done very little else. Policy can advance racial healing in our nation I wish you know I'm like Captain America on this stuff. I could do this all day, but hopefully we've left some time for question. You all nurse leaders. nurse researchers it's on you to help us get to these mega shift in our thinking and in our action. Thanks, everybody, for for giving me some time today. This is really enjoyable. Thank you. Thank you so much. Dr. Castrucci. That was excellent. and thank you both for the really inspiring talks. Really really appreciated it. So let's start with questions and we will get to as many as we can. So the first one let's start with is for you Dr. Guilamo-Ramos. Currently healthcare research is often focused on measuring outcomes at the individual level. This can result in ascribing blame to the individual for poor health rather than the meso and macro factors. So how can we incorporate measures that influence of nurse fled interventions at those higher levels? So they'd love to hear you talk about measurement of nurse community health work for trustworthiness was this conceived as a way to measure efficacy of the intervention at the level outside of the individual. So hopefully I did okay, conveying the question. So I think that was a great question, and thank you. Dr. Zenk and the individual that asked that question. So I completely agree. My short answer would be to say that we do need to measurement that's not solely at the individual level. But that is going to necessitate that conceptually that we're thinking through. What is it that we're actually trying to measure and how do we best align that conceptual sort of understanding to measurement at the appropriate unit of analysis? And so if that's a family or that's an institution or if that's in a community, that we then have measures that are precise, allow us to understand how some factor that is exogenous in that visual is actually shaping a health outcome. But I would argue that we still need to understand also how individuals are perceiving and experiencing that exogenous factor, and that both of those things are true and will allow us to better understand the phenomena. So this is for you, Dr. Castrucci. There are so many factors and interventions being used. How do you know which of these is making a difference? So this is never going to be bench science, right? I get that question from my board at times, like, how do you know that policy works? Well, you know what we have to do is the research on the policy. Like, no one says to you, you know well, let's see there's Lipitor work for you. We should do a study for you. No, we we do the pharmaceutical trials. We know the medication works, and then we apply it. And so I think what we have to do in a community setting where understanding like. Listen in my next life i'm coming back as a bench scientist. I'm going to mix ooze A with powder B. And I'm gonna look this what happened. But what I know is that when I do an intervention in my community, I had McDonald's open 5 sites right? So I never can control for everything. But we need is the good research on the policy. We need evidence-based policy to show the work, and then we need to apply it. And and maybe it's gonna work differently in some communities than others like. Listen. Some people have drug reactions, some drugs aren't as effective for some as others. But but we still take the medication and policy is that medication for our community. Yeah, right again. You don't run a trial every time your doc gives you a prescription. We shouldn't have to run a trial every time that we're doing a policy, and so that's I understand, and I'm an epi, I love evaluation. But this is a community context, and evaluation becomes challenging because there are so many confounders happening at the same time. Thank you. So let me transition back to you, Vince. So you you talked about by biological factors and embedding. So that concept. So for nursing researchers who are currently focused on basic science or the biological underpinnings of health, how can they start to incorporate at some aspects of social determinants of health into their research if they haven't done that to date. How could they get started? That's a terrific question, and I think what I like about that question so much, Dr. Zenk is that it really speaks to one of the areas that has been a historical long term competency and nursing, and it allows us as a profession to kind of build on what we've done and so I'm thinking about areas like symptoms science and other sort of more biologically based sort of research programs. I would say that, recognizing that those symptoms are occurring in our broader context, and I think nursing has done that, and that it's important, then, to illustrate how those biological processes are related to social phenomena. So one thing that we might consider is that while we're doing that sort of basic work on sort of pathophysiology and sort of what's happening in a very biological sense, are there more social kinds of measurements that can then be correlated or related to those processes. So we start to see some of those relationships, and as we make changes we have experimental manipulations on social processes. Do we see changes biologically? I mean to me that would be one example of exciting work that would help advance our contribution. So we might have chance for one more question so i'm gonna ask you both to respond. Starting with you, Brian. So what are your recommendations? For nursing and public health to collaborate and address the leading causes of pregnancy associated with deaths in the United States, due to homicide, suicide, and drug overdose? Do you mind commenting on that first Brian? We've known this is again. This is not an issue of needing more science. This is an issue of political will. We run maternal death reviews forever on the public outside with nurses and clinicians, and it's not the fact that we don't know why people are dying, but we lack the political will to change the system. such that it prevents these deaths. I mean implementation science is something you know, NINR should should be engaging in, you know. Someone asked in the questions, how do we change policy? In City Health we've changed 50, some odd policies in just a couple of years. This is the implementation science of it. We impacted 36 million people. So we have to ensure that there's access to health care. We have to ensure, you know, again, we can do a whole lot of research and out. Listen might be really clear on this let's stop all the research on housing. Let's stop all the research on hunger. We know how to, we know what to do about people who are homeless. You get them a house. we know what to do about people who are hungry. You give them food. But not just today. You have to build systems that sustain and address people's hunger. We know in the EMR all the places there are food insecurity, don't build a food bank. Don't build a food bank, build a grocery store. And that's the hospital putting up cheap cash, you know. Cash with a low interest rate and that's the city council not having taxes on that grocery store because they're serving a public good. This is what we have to do is to change our thinking, it's not research. None of us are researchers. Okay? No, we have 813 people. None of you are researchers. You don't run, Dr. Zenk, you don't run the National Institute of Nursing Research. You run the "National Institute of Nursing Change," the "National Institute of Nursing Impact." That's what we have to do. Research is a tool to get us there, but embody the change, know where you're going. That's what we need to do. So really distinctly I guess what I would say, I'll pick up on where Dr. Castrucci left off, I think, first and foremost, doctors think I would say that as a nurses, we need to fully embrace, that I think many of us do but I would like us all to do this, that we are in the largest segment of the health and public health workforce, and that we have a contribution to nursing science, to practice, and to education; that we should fully step into what is rightfully ours, and be able to really lead in terms of shaping the agenda around achieving health equity. I also would say that we have conceptual models, our science, our interventions, our policy recommendations. The kinds of clinical care that we provide, there's value in the nursing perspective and I think that it's time to kind of operationalize that and to hold it up as really helping to achieve what we collectively want to do and then I would say, you know, lastly, I do believe that there is lots of room for additional research, but that research will bend itself to addressing real problems in the community, in families, in contexts, and that will be responsive to what I see being the focus of the terrific NINR strategic plan, the challenges that are facing our society today and in the future. And so thank you very much for that. Thank you both. I wish we had more time. but those were great closing remarks. So, unfortunately we will need to close. So as a reminder, though to our participants continuing education, credits are available. So please scan the QR code on this slide for a link to a short survey in order to receive your certificate. A webinar evaluations and continuing education certificates are provided by the Foundation of Advanced Education and the Sciences. This organization was created by the NIH to facilitate a collegial environment and provide educational opportunities to the scientific community. So you can visit their website to learn more about their workshop and course offerings. So we would like to thank FAES for supporting our mission and this lecture series. Next slide, please. So thank you again so much to today's speakers, Dr. Guilamo-Ramos and Dr. Castrucci. We are so grateful to you for sharing your knowledge and expertise with us. We'll be announcing the date for our next webinar soon. So stay tuned on our website, ninr.nih.gov for the latest updates and if you have any questions about today's webinar, please reach out to [email protected] So with that, thank you again to our speakers for the excellent webinar. We so appreciate it and that I'll close us out. Thank you all for joining us and for everyone for participating. Goodbye

Good morning, everyone. I am so pleased to welcome you all to NINR's directors lecture on social determinants of health. Before we get started. I'd like to remind everyone that today's lecture will be recorded and made available through our website, ninr.nih.gov Today's event is the first in a series of webinars that we are hosting to provide an in-depth look at each of the research lenses in our 2022 - 2026 strategic plan, which we launched in May of this year. So I am excited to tell you a little bit about it. But first a couple of housekeeping notes. Next slide, please. So before we get started I would like to remind you that today's lecture will be recorded. As I said, and made available on our website. Closed captions are available, and it may be enabled at the bottom of your screen. So at NINR we are committed to leaving nursing science to solve pressing health challenges and inform practice and policy, optimizing health and advancing health equity into the future. Our mission statement reflects our belief that nursing research is the key to unlocking the power and potential of nursing. And our strategic plan describes how we want to leverage the strengths and unique knowledge and perspectives inherit to the discipline of nursing, to the benefit of all people. Next slide. The plan includes 5 research lenses. that we think will help push nursing science forward to innovate, think bigger, and greatly increase our impact. When we say lens, we're describing a perspective through which we examine a health challenge the lenses and the strategic plan are health equity, social determinants of health, population and community health, prevention and health promotion, and systems and models of care. Next slide. Today's webinar we'll focus on the social determinants of health research lens. This lens recognizes that nursing research is needed, that identifies and develops interventions delivered at the right place and the right time to target social determinants of health building on NINR's ongoing investment in this area. Research through this lens aims to discover creative solutions powerful enough to address upstream and midstream causes of health. Next slide, please. So through this webinar series we aim to help nursing researchers better understand and apply NINR's research lenses to their own work. We have 3 learning objectives for the series. First we want to provide a forum for discussion on how nursing research can help address our nation's most pressing help challenges. Second, we want to provide examples that illustrate the possibilities for scientific inquiries through NINR's research lenses. And third, we want to discuss practice and policy implications of nursing research through each of the NINR. Lenses. You can use the Q&A module to ask questions at any time during the webinar. We'll hold questions, though, until the end, and try to get in as many as possible. We're pleased to be offering continuing education credits for today's webinar. Stay with us at the end for more information, and the QR Code to scan for to obtain your credits. Next slide, please. So I am delighted that we have 2 distinguished speakers with us today to talk more about research through the social determinants of health lens, and implications for practice and policy. Our first speaker is Dr. Vincent Guilamo-Ramos, Dean and Distinguished Professor at the Duke University School of Nursing and Vice Chancellor of Nursing Affairs at Duke University He is also the founding director of the Center for Latino, Adolescent and Family Health, a Duke University. Dr. Guilamo-Ramos is a nurse practitioner, duly licensed and primary care and psychiatric mental health nursing, widely regarded as an expert scholar and leader, in adolescent and young, adult, sexual and reproductive health promotion and the social determinants of health. Dr. Guilamo-Ramos' research has been funded for 2 decades by the National Institutes of Health and various other Federal agencies. His research focuses on the role of families and promoting adolescent and young adult health among Latinos and then other underserved populations, with a special focus on mitigating the mechanisms through its social determinants shape, help outcomes and inequities. Our second speaker is Dr. Brian Castrucci, President and Chief Executive Officer of the de Beaumont Foundation. Dr. Castrucci has built the de Beaumont Foundation into a leading voice in health in philanthropy and public health practice. He is an award-winning epidemiologist with 10 years of experience, working with health departments of Philadelphia, Texas, and Georgia and brings a unique perspective to the philanthropic sector that allows him to shape and implement visionary and practical in the initiatives and partnerships, and bring together research and practice to improve public health. So doctors Guilamo-Ramos and Dr. Castrucci, welcome. We're so pleased that you could join us today, and with that Dr. Guilamo-Ramos, I will turn things over to you to get started. Thank you. Thank you very much, Dr. Zenk. It's quite an honor to be here with everyone, including my fellow panelist, Dr. Castucci. I'm gonna share my slides and i'm gonna try to get across a number of important ideas in a fairly short amount of time. And so hopefully, I can. do a good job at this. But yeah, you guys will let me know. So my talk today's entitled Future Directions in Nursing Science: A Call to Action for Mitigating the Social Determinants of Health. and I think that if I'm successful, there are actually two things that I'm hoping to do first and foremost really stimulate a discussion around some of the ways that the nursing profession that neuroscientists can really think about the new strategic plan which I personally think is terrific and some potential scientific areas that are sort of really opportunities for us to advance health equity, and then in a more personal way I'm hoping to really highlight what I see as a important moment in time, where we, as a profession as nurses, should be thinking about building on what we've done and all of the terrific work that has occurred in the nursing profession. But it in my view it's a call to action and if I'm successful. I hope that I'll be able to communicate that comments There are a couple of things that I'm planning in my presentation. You can see on the slide I'm gonna spend a very short amount of time just talking about the current dynamic context that we're in in terms of healthcare delivery, but with a particular emphasis on health equity I'm going to very quickly review all of the terrific research that has happened on social determinants of health, but with a particular lens towards what does that research mean? And what are the principles? and perhaps potential strategies that we can adopt moving forward that in my view represent a paradigm shift. And then I'm going to hopefully apply that to an actual example that I'm. currently working on now as part of the RADx-UP initiative. So undoubtedly there have been major large-scale, transformative events that have impacted our country, particularly over the last couple of years. But they've actually been going on for quite some time and some of these things represent new challenges like the Covid-19 pandemic. but our number of them represent more ongoing chronic issues that we face us a nation and you can see here, I'm just going to illustrate a couple that certainly we're experiencing demographic shifts. We're grappling with climate change issues of migration structural racism widening inequality. There's been lots of talk about inflation and many of us have experienced sort of how our dollar is being stretched to actually meet many of our needs. The growing substance use and mental health epidemic in the country. These are all things that we're facing and they have important implications. For how we think about health, equity, and how social determinants play an important role. And so here there are 3 relational forms that I think are worth mentioning. Again very quickly. The first is what I started with and mentioned just a second ago, that there have been new large scale events that represent challenges that have resulted in new inequity, and probably the most sort of pronounced example is the Covid-19 pandemic. and you can see here, for example, that Covid-19 results in immortality. Differentials between vaccinated and unvaccinated individuals. But what also is true that some of these large-scale transformative events, that we're facing right now they actually expose chronic inequities, things that have been happening in our country, and for that matter, across the globe for a very, very long time and and what's being depicted in that second relational form is that the Covid-19 epidemic had a disproportionate impact on communities of color. And again, we know that those communities have historically been the places where many inequities have had the largest impact. There's also been this interesting relationship that I'll call that third relational form where the 3 is on the right hand side of the slide a synergistic relationship. And here there are sort of challenges, that we've had for example, sort of use of substances, and in this example I'm particularly referring to opioids, and there have been record increases in overdose steps during the Covid-19 pandemic. And so again, the idea is that there have been direct new challenges. There has been awareness of historical challenges, inequities, and there has been some synergistic or amplification of more than one particular health inequity. In preparation for today, I and my research team, we worked on sort of reviewing the literature and I'm, smiling, because as a professor, this is sort of my natural place that I return, and you can see here that in PubMed. We did a search of using the term social determinants of health. And what you can see is that roughly 16,600 or 16,700 articles were identified. And really what we're striking to me is that the first paper that I could find was back in 1961 so again, SDOH not being necessarily a new concept. To us, as you know, nurses, but also to others outside of the nursing profession. But what was really striking was that in 2010 to now there was a rapid escalation, scholarship and research that was specifically identifying social determinants of health. And so part of what I'm going to present in my subsequent slides from 2010 to now, what does that research suggest? What does it really? Sort of provide in terms of thinking about where we should go? Looking forward. I think it's important to mention and for this audience no surprise, and really a review. But social determinants of health account for 80 to 90% of modifiable contributors to health outcomes. They are huge, they are important, and they are certainly some place where the nursing and other health professions need to focus. I'm happy to just report been there has been much attention to social determinants across many national organizations. I think the most pronounced is probably the Future of Nursing report, but certainly equally exciting have been the ANA, The American Academy of Nurses. I think Dr. Zenk referenced the National Institute of Nursing Research, the terrific strategic plan. This is the time for nursing to really think through social determinants of health. I think what's also true is despite all the successes that we've had in nursing, and again, this is not a new concept for us in our profession, but we're building and thinking about how we can amplify our efforts. The truth is that more than half of Americans already have a chronic disease, and the proportion with 2 or more chronic diseases is increasing. Since 2014 U.S. life expectancy has stagnated or declined, and more than half of U.S. adults delayed or skipped care due to cost last year. And these are just some very high level examples that illustrate, despite our increased attention, that really achieving health equity is something that has not come to fruition. What's also interesting in preparation for today was reading a recent article that was published in Deloitte insights, and you could see here that without progress in chronic conditions the cost of health inequities is projected to triple by 2040. And so right now, the cost of inequities today is about 320 billion dollars. But if we project out to 2040, you can see the cost of inequities being a one trillion, and this one trillion number actually speaks to the actual cost of the inequity. And so not the total cost of care, but the money that we will spend because we have not addressed. Sort of the communities with greatest need, and the ways in which those chronic conditions are inevitable. And they represent really preventable health outcomes. This slide is saying something that I feel very proud to convey, and I also realize that most of us are aware of this. But the nursing workforce, we are central to a achieving health equity. We are central to thinking about a paradigm shift that we are seeing, to doing the nursing, research and practice and changes in our academic programs, and how we truly train nurses to really help our country to achieve health equity. I want to spend some time talking about what I've called the paradigm shift, and to do that I'm gonna focus on some of that literature and kind of highlight a couple of things. But right before I do that, I think it's important to recognize that we are at a really terrific point. One example is that HHS and Healthy People 2030. There is an overarching framework. That focuses on SDOH, and you can see on the right hand side some of the areas that are being targeted. And I think what's exciting about this is that it certainly is moving, and stoh increasingly into the way we think about health in our country. But what's also true is that I when I've looked at the literature over that 10 year period from 2010 to now that sort of 10 to 12 year period a couple of things jump out. So one I think there's been a conceptual evolution initially I think there was sort of very little recognition of social determinants. There was just simply health outcomes. But over time, and thinking through the onset of social determinants. starting with that 1961 paper, there was a recognition that social determinants shape health outcomes. But what was missing was an understanding of what those mechanisms are. What later emerged was a sense that the health outcomes represent a health disparity, and that a health disparity is often tied to systematic kind of disparities. And there was this notion of vulnerability. The literature started to reflect vulnerable individuals, vulnerable communities, vulnerable populations. I think, what later evolved was this third relational form, where we have a disparity that now is referenced as a health inequity, and what that health inequity refers to is this notion of there being social injustice and there are processes that are unfair that are actually contributing to the disparity which is now being viewed as an inequity. And I also started to see notions that vulnerability was being unpacked, and that rather than being vulnerable individuals or families or communities, or populations, there was a sense that there were drivers that were impacting vulnerability, and so more in that in a little bit. So here there's been an awful lot of work in the social determinant space, and in many ways I'm going to do a disservice to that work because of time. But what I do want to get across is there a number of landmark, conceptual and empirical research studies, that actually have identified across all of that work that was depicted from 2010 to 2022, 8 principles. And you can see them reflected on the slide, and I'm very briefly gonna cover each. And so the first is principle number one, that there are underlining causes beyond individuals that are driving health and equities. And so here we have distal factors or exposures that influence individual risk. They're also protective factors, and that these exposures and risk factors shape disease and health outcomes. The second principle is that contact matters and here it's not enough to say that it's solely a function of an individual. But this landmark framework, it really characterizes what was referred to as the structural production of health inequities. And so here, risk is largely seen as being exogenous outside of the individual, and there's recognition that there are four dimensions. The physical environment, the social environment, the economic environment, and policy. And I know that Dr. Castrucci is going to talk about policy later. But I think here the risk is not solely a function of the individual, but it also is reflected in the environment. And so here's a really important way of characterizing two communities, Community A and Community B And if you think about those four dimensions of risk on the bottom, physical, social, economic, and policy think about them in relation to the sharks that are swimming in those pools, those sharks represent those four dimensions and Community B is certainly much riskier than Community A. But any of us could swim in either Community A or Community B. But our outcome would be you know different depending upon the community that we're in. It's also important to recognize that context is not deterministic. And so contextual disadvantage doesn't mean that every single person in that context will have the same a negative outcome. Assuming that that context is one that is not that is a negative one that is not supporting one health. And so there's recognition that there are sort of multiple levels. There's a micro level, a meso level and a macro level, and that those three levels that they interact in ways that they can reinforce risk or they can actually weaken the effects of negative influences, or at the opposite, strengthen the effects of positive health, promoting influences. This is a great example. In this example you have two swimmers, Swimmer A and Swimmer B You can see that in this case both communities, Community A and B have the same number of sharks. The same prevalence. But what is different is that in community a there's a lifeguard and there's medical care. There are nurses, there's a healthcare system also the individual's behavior in community a Swimmer A is actually different. They stay on the shallow side of the pool, and therefore the outcome is different. Despite the fact that there is the same prevalence of sharks and the context is the same between Community A and B below. In Community B, you can see there is no lifeguard. There is no medical care. There are no nurses, there is no public health workforce and that the behavior may be different in this case Swimmer B is actually swimming on the deeper side of the pool. And what's happening there there's greater likelihood of coming into contact with the shark, and there for having a bite Principal Number 4 is that SDOH influences health across our lifetime. There's a life course perspective, and so you can see here the early life exposure. You know, impacts what happens later on. There is an important spatial, temporal component, and that the life course framework suggests that the social, the economic, the psychological, and environmental influences that they accumulate over the course of our life, and they affect our behavior. They affect our mental health and our physical health. Biological embedding, very, very important work, a lot of this work being reflected in some of the research. Actually a lot of the research that is being undertaken and has been undertaken in nursing. And so SDOH operates through biological embedding. Biological embedding is a process by which the social conditions they initiate and they sustain biological changes that have short and long term effects on physical health and well-being. And so social conditions, they alter biological processes, the epigenetic, the neuros developmental, the immune, the engineer, the microbiome. They are stable and long-term, and they can alter biological processes that impact our health and well-being our learning or behavior over the life course. The social can be, and is the biological it's not simply that the social is the social. There's also Principal 6 which is that SDOH operates intergenerationally, and there are 3 basic relational forms from parents, parents to child. Multi-generationally within a household so in this case there's a family living in a household, and in that family there are multiple generations, and that particular social determinant, let's say, income inequalities affecting that entire family inter sort of across the generation in that household. And then the transgenerational relationship where it's not solely from parent. It's a child which is cross-generational, but there's actually multiple generations that consecutively experience that particular social determinant. And then have the negative health outcome. There's also a principle that is focused on clustering and synergistic effects. And here the impacts of social determinants of health cluster and they could interact synergistically. And so you can see here that a syndemic is defined. This 2 or more clustered epidemics that interact in ways that they can reinforce one another. There can be biological synergism a really really good example is sort of inflammation that's due to STIs, and how that facilitates the transmission or acquisition of HIV or there can be a socio-contexual synergism which really the increased risk of a given outcome. For example, sexual HIV acquisition among a particular population. Individuals who use substances can be due to sexual behavior. The main point here is that SDOH may operate through both biological and socio-contexual synergisms. There's also the echosocial framework and here, what's being expressed that social injustices, including structural racism, shaped the impact of social determinants of health. And here your social positioning, who you are you're a Latino gay man with a disability that intersectional identity impacts social processes that they can result in health inequities and again, any of the sort of biological or social exemplars are related to this eco set social framework that that way in which that process is shaping the health and equity is either through the biological embedding or through the social process. So how do we pull all this together? So this is a framework that I've been working on with a group here at the Duke University School of nursing, and one of the things that I'm trying to or we are trying to convey is that each of the principles is reflected in this heuristic, and the idea is to take a particular health inequity in a particular context and sort of map it back. It's an interesting way to kind of organize what an intervention might look like. How does that inequity relate to exposure? So really pushing away ideas of vulnerability. But how does it relate to behavioral or social exposure? How does it relate to susceptibility, which is really a biological concept that notions of resilience, despite all of the university? How can individuals, families, communities, thrive? Is there a science of resilience? How do we think about things at multiple levels, at the micro Meso and Macro? And how do we consider them in context? The family contacts and A and across the life course? So i'm gonna give an applied example and then i'm gonna wrap up, and hopefully i've been successful at conveying some importance. And so one of the products that i'm currently working on is our ct. Along with another investigator, Holly Hagan. So both Holly and I are both nurses. We service multiple pis on this randomized clinical trial, and it's part of the radics up initiative, which is a national large jail effort to really respond to the Kovat 19 pandemic in our country. We developed a nurse lead model of care that was designed to mitigate a specific health inequity. Covid 19 testing and vaccine uptake in the South Bronx, which at the time was experiencing really devastating diagnosis, hospitalizations, and depths. And we compared our nurse data model to the standard of care which is what was happening in the Department of Health. And you You know the actual healthcare system in the South Bronx. What you can see here is what I just shared, that the highest rates of COVID-19 hospitalizations in depth of any New York City borough is in the Bronx, and this happens to be the community that I was born and raised in it, spent most of my life. So it had really personal and also a professional meaning. and you can see that the Bronx has more covid 19 depths than 99% of other counties in the United States. And so truthfully. There was a huge inequity that was occurring was geographically concentrated, and the Bronx is a New York city borough that is heavily concentrated with Latinos and African Americans, and our project is taking place in public housing. Meet Miguel. Miguel is a nurse like many of us on this Webinar today, and Miguel is involved in the implementation, and also the the evaluation of a multi-level nursing intervention that is tied to these notions of nurse, that miles of care that are specifically designed to address social determinants of health but within the context of a particular health and equity. Covid 19 I don't have enough time to kind of review all the components of the nurse that'll nurse that model of care. But what I will say is that each of those pieces of the puzzle that you see on the lower right, the of the slide really speak to some of the thinking that is currently going on in my research groups thinking and also beyond here at the school of nursing here at Duke as important pieces of how nursing can advance social determinants of health. Each of the principles was applied to the intervention and reflects what we did in the Ncfp project, and I'm gonna give a couple of examples now, and share what that means. Taking it from a conceptual to an actual application. So the locus of care is in the home. We moved the testing the monitoring of the the families with Covid, the care, coordination, regarding chronic disease, and also all the testing of vaccine uptake directly to the families and so it's delivered by bilingual and bicultural nurse, community health worker, intervention teams. That partner with families there's an individualized household infection control plan that does not focus on the individual, but focuses on the contacts. The household, the family, and how that family is potentially at risk, and how risk can be mitigated. There's an explicit focus on resilience. and how that family can overcome some of the challenges that are identified in the family based mitigation risk assessment. And then also there are wraparound services that are provided by the community health workers because of all the secondary sequela that are tied to covid. But also things that were preexisting the particular community. We were working in the South Bronx Mod Haven, one of the most economically disadvantaged communities in the United States, and certainly in New York City. Their health and social, educational and vocational supports that are offered across the life course. Multi-generationally in that family's home and in the community. Health workers are wrapping those services and linking those families to additional services in their community. There's enhancement of of covid 19 immunity through offering of the vaccine and the vaccine being delivered directly to families in their home There's a theory based intervention that actually shapes, their vaccine decision making both the core dose and also boosters. There's what I've mentioned previously the family-based prevention of mitigation. So it's not about individual behavior but about families thinking through how they can collectively build mutual aid, and how they can help one another, and those in their community to prevent Covid from mentoring their household. I've mentioned some of the care coordination from the community health workers. But here the nurses are involved in coordination of comorbidities outside of the Covid context, because many of the services to during you know, the period when we were locked down folks could not access routine healthcare. And so our nurses and community health workers were providing care management in the home, and there's also a collaborative sort of approach that is, about families, community health workers and nurses and rather than focusing on building trust. The team focuses on how we, as a team, can convey trustworthiness. I wish I had more time to relate each of these components back to the principles, the circles that you see on the slide. They map back to the principles that were highlighted in the literature review. And then what I'm trying to suggest is that NCFP really is a an applied example of many of the concepts and ideas that I've laid out in the previous sections of my talk, a couple of pictures to show the community health workers. The nurses and the families in action. I think this makes me smile because it's my home community, and it's also me with others. Nurses and community health workers and families working to solve a real health issues in our communities. And I guess what I want to leave folks with is first and foremost, I think that the NINR strategic plan is a wonderful call to action for nurse. That SDOH and health equity research this is our time this is the time to move away from beyond simply characterizing inequities. But to truly think about how we can mitigate, how we can prevent. What are those mechanisms? Is there a science of resilient? How do people thrive despite the adversity that we face? And how can we develop a disseminate multi-level nursing, lead interventions that are collaborative, that pull on the principles that are depicted in the SDOH literature? Thank you very much. Special thanks to my team. I'm gonna turn it over to you, Dr. Castrucci. Thank you. Thank you so much, Dr. Guilamo-Ramos. That was just a terrific talk, and very quick talk. So appreciate you fitting in so much very helpful information in a short period of time. Certainly an important aspect of the new strategic plan is ensuring that nursing research informs both practice and policy. So I can think of no one better position to discuss the policy implications of social determinants of health, and our next speaker, Dr. Castrucci the floor is yours. Oh, thank you! Dr. Zenk. That was, that was awesome, that was a great presentation by Vince and I'm super happy to be here day so let me just start out I'm not a nurse, but both of my parents were nurses, so I feel, like, you know, growing up with nursing journals in the bathroom. Give me some credibility to to talk a little bit about this. This is my information I'm happy to have folks tweet this I nurse Twitter is very strong, and we should be having this conversation, not just today, but throughout throughout the year, throughout the decade. This is a conversation that keep going. So feel free to follow me I'll follow you back at Brian C. Castrucci In all transparency, I need 36 more people to get to 10,000, so help me out there in nurse community. when you think about where we are in in healthcare I think we're kind of stuck. when you think of futurists, futurist is say that we're going to have more change in the next 20 years, than we've had in the past 100. But I don't know that that's going to be true in healthcare. I think we are often stuck in an individual focus in an individual lens, and we're not really addressing the things that are making us sick. We have a an expansive and expensive healthcare infrastructure. But, it is not bugs and bacteria that are driving our health. Those things that are in our community. It's policy it's environment and the healthcare structure that we have now it's not working. It absolutely is not delivering, given what we are paying. And so in thinking about what I wanted to share with you all today is how do we get to a future not of nursing research or public health or medicine, but how do we get to a future of health, of better health? And when you think about the future, you you conceive of a future right, this is what it's going to be, and then you act. And so, as you act, you make the future right, so if someone tells you all of a sudden, Bitcoin, which I don't really even understand what that is. But if someone tells you that Bitcoin is going to be the future, you start buying Bitcoin. So your act just the the prognostication of Bitcoin got you to act in a way that created that future. So for for the 900 or so nurse leaders and researchers on this call, I want to talk to you about these kind of 8 mega shifts, things that you can do to actually help change the future of health And so I, I just wanna go through these and and share some of my thinking on these mega shifts, and how we, how we can actually get there. And so kind of the first is is this: Social needs and social determinants are different. The the link between community and personal health is indelible, and medicine is not enough. And I think we know these things. But this is how I think of healthcare right now. We are. We are asking clinical medicine to use bigger and more buckets to bail the ship, right, instead of really dealing with our issue with this is social determinant of health. Now, while I am not a nurse, I have probably unfortunately had a lot of interaction with nurses. In February I had a heart attack, and I feel great. It was like the best thing that ever happened to me do why it's the best thing ever happened to me, because I can afford Corvette, level healthcare because I didn't have to be asked the questions about hey? Do you have a 108 hours of leave for the cardiac rehab for the next 12 weeks? I didn't have to worry about what jobs I had, I have one job. It gave me a lot of paid sick leave. I didn't have to worry about that, because in right now you know, we all know this a car that drives a lot smoother than a Chevy. A Corvette's a better ride, it's more luxurious, and that in a capitalist automotive market makes sense to me. But right now we are building a healthcare system where health is a luxury item. Where, if you can afford that Corvette, you're gonna get great care, because those social determinants have already been taken care of by your community. But in communities where, where there are challenges in the community like I love Vince aside with the with the sharks, my job, I want to kill those sharks. I don't want to just stay in the shallow end of the pool. I want to figure out how we off those sharks, and how we off them in an equitable way. And and this, if you take nothing else from this from this whole talk that i'm gonna give, please take this and and call people on this every day. Here is a difference between social determinant and social needs. If someone says, look I'm addressing the social determinant in my hospital, I have a food bank for my patient. Just look at them dead in the eye and say you don't know what a social determinant is that's a social need. Social needs help us still work through an individual lens. I can mitigate my patient's housing needs, but that does nothing for the housing needs of the community. We need to understand that the only way to really get to social determinants is to think through a policy lens. A community lens. So this is something I call the Health Investment Opportunity Framework. We have given a really poor dichotomy of upstream downstream. It's not binary. Right that's a problem. We said, okay, go upstream, and so someone takes one step upstream, and they're like, look I did it. No, it's many steps upstream so in our lowest. If you look in the two different colors, it's individual lens versus community lens, in that individual lens you can be downstream which is the community. And then you I'm sorry the individual is the the healthcare, the clinical environment. Then midstream midstream is that non medical social needs? And then we could even get to individual level policy individual upstream, where we talk about something like the earned income tax credit, which is still something I get as an individual, and I have to actually get, but there's a community accrual there, but it's still the individual lens. Then let's talk about community food banks, meals on wheels, that is community level, but it's very downstream. It still requires a lot of individual action. It is not sustainable. It only lasts as long as we can pay for it. And then you look at things like community midstream that's where, where Kaiser Permanente is doing impact, investing to build housing. But ultimately that keeps decisions about housing in the hands of the private sector. We need to get to community upstream. We need evidence based in our policies. We need research on policies like rental inspection, and complete streets, that when you are in Box 6 you are addressing the social determinants of health. But if one I do only helps one patient at a time that social need. Don't let people get away with confusing them. Changing the health narrative or changing the narrative to health and building partnerships. Someone asked in the Q&A, whether social determinants of help was the right word. I don't care what the word is I don't care if any. We don't even have to agree the 900 of us on this call. What we think this word needs to be is irrelevant. Because we know the concept. Those that we are trying to influence, elected business leaders, other people in other sectors. We need a word and a language that resonates with them. We need to rebuild trust by having better communication. Communication research should be something nurses are leading we need more communication research. That's the way we're going to build partnerships. We cannot do this alone. You know let's be honest, public health got it but handed to it throughout the pandemic. It's partly because we didn't have the credibility with the schools, and the business leaders to do some of the actions that we wanted to do and we need these partnerships. Now something that we've done just as some reference we have this this tool kit called PHRASES. It, public health reaching across sectors, and yes, for those who do. You have never been to schools of public health. We have a whole class in acronym, where we have to go through the class, and everything has to be an acronym. So PHRASES stands for public health reaching across sectors. It is the communications toolkit for the chief health strategist. And later this month our book, talking health will be released and that's really talking about how we talk about health, so that people understand that you know. I often say to folks when you look at the former President, you remember his campaign? What did he want to do to Hillary? And whether you're a Democrat or a Republican? You remember, he wanted to lock her up? We talk about how we say, well, health is 3 hours later, that's what health is. 3 words versus 3 hours we need better communication. Policy is the prescription for better health there's nothing more important than that, No matter what we're doing, all of our policies are just trying to control the flow of disease, we need to shut off the spigot. Throughout the pandemic, we said things like, if you are sick you should stay home from work. Well, i'm not staying home from work if it means my kids don't eat. If it means I lose my house. I need paid sick leave, we're one of 2 nations that don't have a national paid sick leave standard, us in South Korea, the only 2 industrialized nations without without a paid sick leave standard. And then, if you, if you are if you're sick you should isolate into one room of your home. But what if my home only has one room, our policies actually can change the environment, I always tell I'll tell a very quick story of you playing Monopoly with my son, and I told him one day you know you always lose. You should be the boat instead of the car. Well, he played as the boat, and he still lost. We enacted a set of policies, rule changes where if I go around "Go" I get 200, but he gets 300. If I landed a property, I pay all the rent. He plays half the rent. If you want the outcome of the game to change, you must change the rules that govern that game. That's what policy can do for us. I encourage you to check out cityhealth.org. City Health is a partnership between de Beaumont and Kaiser. We have policies that are evidence-based, and we rate the 75 largest cities in the country previously. The 40 largest cities in the country as to the quality of each of those policies, and whether they have them and an overall level because policy is what's going to change the way that we are healthy it's policy takes care of the sharks. That's what we need we need, policy to intervene at that level. Data. I gotta mention data here because data are the original sin. If you are talking about how health, equity and you think data somehow deliver you. You know, high quality information. It may do that, but data are biased. Health, equity, and disparities start with how you collect the data. Who's at the table when you define the the actual instrument. All of our Covid messaging was done with a sample of 1,200 Americans, and it left out any number of nuanced communities and different perspectives. Data are something we have to think about and we have to develop political will to actually mobilize the data that exists. Let's not forget that we sent a robot to Mars to engage in robot tourism. It got out it took pictures. it send pictures back. That was pretty awesome. We sent a robot to Mars to take pictures. I got bunch of kids in my community who are hitting the ER routinely with asthma and they're in different schools, and they're in different pediatricians offices, on different insurance and seeing different hospitals, and I can't find out that those four kids all live in the same apartment building. I can't find that out. That's because of political, but I can sure as heck put a robot on Mars to take pictures. How are our priorities? Where our priority to making those kids healthy? Is it sending robots to mars? And then held equity cuts all of it. Hopefully you've seen the new updated 10 essential services of public health. It centers health equity. It's in our data, it's in our policies. We have to be very thought when you look at health, policy, and equity, why was it so easy to take smoking out of public housing developments, but not so easy to get smoking out of casinos. What do you think that had something to do with power and equity? So we have to think about equity, not saying the word. We work on health equity. We need to have an operationalization of what that means. Where are we actually doing? And and we need to make sure that our researchers are diverse and I'm sure you know, NINR is thinking about this. How do we diversify our PI? The universities that get our money? How do we make sure that they are paid, get extra points in their application? When you were paying community members to bring their expertise, not just putting them on some sort of panel where they are unpaid and are giving volunteer services. Pay people for the expertise that they bring. And remember that when we talked about Covid, Covid was the match. But we in this country provided a whole lot of kindling, that's why we have not fared as well as so many other nations, because we have been stacking for centuries. These sticks in Covid lit that match. Love you to check out Healing Through Policy. This is something that we worked on with the American Public Health Association the National Collaborative for Health Equity, and these are policies that advance racial healing because you can't you you know, if you have a fish tank you can't just deal with the fish and every so often you have to change the water and clean the tank. Policy does that. There are policies that cities now that they've all made great declarations. CDC made a great declaration racism of public health crisis, but short of that going on a t-shirt, they've done very little else. Policy can advance racial healing in our nation I wish you know I'm like Captain America on this stuff. I could do this all day, but hopefully we've left some time for question. You all nurse leaders. nurse researchers it's on you to help us get to these mega shift in our thinking and in our action. Thanks, everybody, for for giving me some time today. This is really enjoyable. Thank you. Thank you so much. Dr. Castrucci. That was excellent. and thank you both for the really inspiring talks. Really really appreciated it. So let's start with questions and we will get to as many as we can. So the first one let's start with is for you Dr. Guilamo-Ramos. Currently healthcare research is often focused on measuring outcomes at the individual level. This can result in ascribing blame to the individual for poor health rather than the meso and macro factors. So how can we incorporate measures that influence of nurse fled interventions at those higher levels? So they'd love to hear you talk about measurement of nurse community health work for trustworthiness was this conceived as a way to measure efficacy of the intervention at the level outside of the individual. So hopefully I did okay, conveying the question. So I think that was a great question, and thank you. Dr. Zenk and the individual that asked that question. So I completely agree. My short answer would be to say that we do need to measurement that's not solely at the individual level. But that is going to necessitate that conceptually that we're thinking through. What is it that we're actually trying to measure and how do we best align that conceptual sort of understanding to measurement at the appropriate unit of analysis? And so if that's a family or that's an institution or if that's in a community, that we then have measures that are precise, allow us to understand how some factor that is exogenous in that visual is actually shaping a health outcome. But I would argue that we still need to understand also how individuals are perceiving and experiencing that exogenous factor, and that both of those things are true and will allow us to better understand the phenomena. So this is for you, Dr. Castrucci. There are so many factors and interventions being used. How do you know which of these is making a difference? So this is never going to be bench science, right? I get that question from my board at times, like, how do you know that policy works? Well, you know what we have to do is the research on the policy. Like, no one says to you, you know well, let's see there's Lipitor work for you. We should do a study for you. No, we we do the pharmaceutical trials. We know the medication works, and then we apply it. And so I think what we have to do in a community setting where understanding like. Listen in my next life i'm coming back as a bench scientist. I'm going to mix ooze A with powder B. And I'm gonna look this what happened. But what I know is that when I do an intervention in my community, I had McDonald's open 5 sites right? So I never can control for everything. But we need is the good research on the policy. We need evidence-based policy to show the work, and then we need to apply it. And and maybe it's gonna work differently in some communities than others like. Listen. Some people have drug reactions, some drugs aren't as effective for some as others. But but we still take the medication and policy is that medication for our community. Yeah, right again. You don't run a trial every time your doc gives you a prescription. We shouldn't have to run a trial every time that we're doing a policy, and so that's I understand, and I'm an epi, I love evaluation. But this is a community context, and evaluation becomes challenging because there are so many confounders happening at the same time. Thank you. So let me transition back to you, Vince. So you you talked about by biological factors and embedding. So that concept. So for nursing researchers who are currently focused on basic science or the biological underpinnings of health, how can they start to incorporate at some aspects of social determinants of health into their research if they haven't done that to date. How could they get started? That's a terrific question, and I think what I like about that question so much, Dr. Zenk is that it really speaks to one of the areas that has been a historical long term competency and nursing, and it allows us as a profession to kind of build on what we've done and so I'm thinking about areas like symptoms science and other sort of more biologically based sort of research programs. I would say that, recognizing that those symptoms are occurring in our broader context, and I think nursing has done that, and that it's important, then, to illustrate how those biological processes are related to social phenomena. So one thing that we might consider is that while we're doing that sort of basic work on sort of pathophysiology and sort of what's happening in a very biological sense, are there more social kinds of measurements that can then be correlated or related to those processes. So we start to see some of those relationships, and as we make changes we have experimental manipulations on social processes. Do we see changes biologically? I mean to me that would be one example of exciting work that would help advance our contribution. So we might have chance for one more question so i'm gonna ask you both to respond. Starting with you, Brian. So what are your recommendations? For nursing and public health to collaborate and address the leading causes of pregnancy associated with deaths in the United States, due to homicide, suicide, and drug overdose? Do you mind commenting on that first Brian? We've known this is again. This is not an issue of needing more science. This is an issue of political will. We run maternal death reviews forever on the public outside with nurses and clinicians, and it's not the fact that we don't know why people are dying, but we lack the political will to change the system. such that it prevents these deaths. I mean implementation science is something you know, NINR should should be engaging in, you know. Someone asked in the questions, how do we change policy? In City Health we've changed 50, some odd policies in just a couple of years. This is the implementation science of it. We impacted 36 million people. So we have to ensure that there's access to health care. We have to ensure, you know, again, we can do a whole lot of research and out. Listen might be really clear on this let's stop all the research on housing. Let's stop all the research on hunger. We know how to, we know what to do about people who are homeless. You get them a house. we know what to do about people who are hungry. You give them food. But not just today. You have to build systems that sustain and address people's hunger. We know in the EMR all the places there are food insecurity, don't build a food bank. Don't build a food bank, build a grocery store. And that's the hospital putting up cheap cash, you know. Cash with a low interest rate and that's the city council not having taxes on that grocery store because they're serving a public good. This is what we have to do is to change our thinking, it's not research. None of us are researchers. Okay? No, we have 813 people. None of you are researchers. You don't run, Dr. Zenk, you don't run the National Institute of Nursing Research. You run the "National Institute of Nursing Change," the "National Institute of Nursing Impact." That's what we have to do. Research is a tool to get us there, but embody the change, know where you're going. That's what we need to do. So really distinctly I guess what I would say, I'll pick up on where Dr. Castrucci left off, I think, first and foremost, doctors think I would say that as a nurses, we need to fully embrace, that I think many of us do but I would like us all to do this, that we are in the largest segment of the health and public health workforce, and that we have a contribution to nursing science, to practice, and to education; that we should fully step into what is rightfully ours, and be able to really lead in terms of shaping the agenda around achieving health equity. I also would say that we have conceptual models, our science, our interventions, our policy recommendations. The kinds of clinical care that we provide, there's value in the nursing perspective and I think that it's time to kind of operationalize that and to hold it up as really helping to achieve what we collectively want to do and then I would say, you know, lastly, I do believe that there is lots of room for additional research, but that research will bend itself to addressing real problems in the community, in families, in contexts, and that will be responsive to what I see being the focus of the terrific NINR strategic plan, the challenges that are facing our society today and in the future. And so thank you very much for that. Thank you both. I wish we had more time. but those were great closing remarks. So, unfortunately we will need to close. So as a reminder, though to our participants continuing education, credits are available. So please scan the QR code on this slide for a link to a short survey in order to receive your certificate. A webinar evaluations and continuing education certificates are provided by the Foundation of Advanced Education and the Sciences. This organization was created by the NIH to facilitate a collegial environment and provide educational opportunities to the scientific community. So you can visit their website to learn more about their workshop and course offerings. So we would like to thank FAES for supporting our mission and this lecture series. Next slide, please. So thank you again so much to today's speakers, Dr. Guilamo-Ramos and Dr. Castrucci. We are so grateful to you for sharing your knowledge and expertise with us. We'll be announcing the date for our next webinar soon. So stay tuned on our website, ninr.nih.gov for the latest updates and if you have any questions about today's webinar, please reach out to info@ninr.nih.gov So with that, thank you again to our speakers for the excellent webinar. We so appreciate it and that I'll close us out. Thank you all for joining us and for everyone for participating. Goodbye

Transcript for:Exploring Social Determinants of Health

Transcript for:
Exploring Social Determinants of Health