Social Determinants of Health and Their Effect on Health Outcomes: A Case Study

Not a day goes by when a prescription is not filled due to cost, and not a day goes by when someone has to decide what food they can afford and still have enough money to pay rent.

There are people who do not live in neighborhoods where there are sidewalks or safe spaces for their children to play. There are communities that do not have clean air and thus have much higher rates of asthma. There are places like Flint, Michigan, where there was no clean water, and as a result, children will face a lifetime of the devastating effects of lead poisoning.

There also are places in this country where people must drive over an hour to see their healthcare provider. There are hard-working people who work two or three part-time jobs but still do not have healthcare and health insurance because it is beyond their means.

These are all examples of things that determine a person’s health. Those things are beyond the ability of a nurse practitioner to write a prescription to solve. Even good listening skills, empathy, and a good social worker cannot ameliorate the failure of our society to create equity in our communities.

Understanding the problem and finding solutions can be done through the lens of the Social Determinants of Health (SDOH).

What are the Social Determinants of Health in the U.S.?

The unfair and avoidable differences in health status seen within and between countries or even within different groups of people within the same community are attributed to SDOH.

According to the U.S. Department of Health and Human Services, “Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The circumstances of the people cared for by nurse practitioners are directly impacted by the distribution of money, power, and resources at global, national, and local levels and are responsible for health inequalities. The unfair and avoidable differences in health status seen within and between countries (or even within different groups of people within the same community) are attributed to SDOH.

SDOH can be broken down into five categories: economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social community and context.

A Case Study: The Marshallese in Northwest Arkansas

The Covid-19 pandemic has served to highlight healthcare disparities and viewing this through the framework of the SDOH provides a deeper understanding of how and why segments within our population have had much worse outcomes in comparison to others.

For example, the Marshallese (whose people came from the Marshall Islands) make up no more than 3 percent of Northwest Arkansas’ population, but in July of 2020, they had suffered half of the Covid-19 deaths in the region.

In order to understand how this occurred, we will look at the social determinants that led to such a negative health outcome and disparity.

A Brief History and Context: Who Are the Marshallese?

First a brief history, according to the U.S. Department of State, in 1944, the US gained military control of the Marshall Islands from Japan and assumed control of the Marshall Islands at the conclusion of World War II. An agreement was signed allowing the U.S. military to use several islands for nuclear testing, which they conducted from 1946 to 1958.

The Marshall Islands signed a Compact of Free Association with the United States in 1983, gaining independence in 1986. The U.S. and the Marshall Islands negotiated an Amended Compact in 2004. The compact allowed Marshallese citizens (who were eligible) to work, live, and study in the United States without a visa.

Also, as part of the compact, they were promised healthcare, which was subsequently stripped away during Welfare Reform 25 years ago. Access to Medicaid was not restored until December of 2020 after the community was decimated by the Covid-19 virus.

The World Health Organization acknowledges that the Marshallese are burdened by high mortality and morbidity for communicable and non-communicable diseases. Diabetes-related diseases and cancer remain the leading causes of death.

The Arkansas Democrat Gazette points out that, “Northwest Arkansas has the largest population of Marshallese in the United States outside of Hawaii.” Furthermore, a 2002 report noted that only 1.8 percent of Marshallese in Arkansas had a college degree. The majority came for work in the poultry processing industry earning wages significantly below the U.S. average, and at that time, 34 percent of those living in Arkansas were below the poverty line. (A search for more recent data did not provide more current information.)

Covid-19 and the SDOH for the Marshallese Community

The Marshallese have faced numerous barriers to positive health outcomes. Within the community and even amongst elected officials, there is a lack of understanding of SDOH.

During a community event organized through Facebook (“Coffee With the Mayor- Virtual”), Congressman Steve Womack stated, “I think we underestimated how the culture of some of these folks contributed to the infection rate in those minority populations because culturally they live together; there’s communal-style living in many respects.”

This statement does not acknowledge the varied environmental, economic, educational, and community factors—the context of the lived experience of the Marshallese community or the barriers to good health they face that contribute to health inequities and negative outcomes. This view assumes that Marshallese people choose to live in multigenerational homes only because of cultural norms.

However, the facts are the Marshallese have low educational attainment, and thus lower income, and work in jobs that do not provide full benefits and often have odd hours making it difficult to procure child care. Their economic situation ensures multigenerational living situations are common.

More concisely stated, they face worse Covid-19 outcomes because of the social determinants of health. Many in the Marshallese community are essential workers and must continue to work in person with high levels of exposure to other people who potentially have the Covid-19 virus.

Five Ways to Overcome Barriers and Improve the Social Determinants of Health

Thinking about SDOH can feel like an idealistic academic discussion and the solutions can seem far too difficult, but they are applicable to the clinical setting of a nurse practitioner. The current shift in our payment structure for healthcare delivery from that of fee-for-service to a value-based system will incentivize the healthcare industry and healthcare providers to develop a deeper working knowledge of SDOH and their effect upon quality healthcare and positive outcomes.

A recent report entitled “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health” stated the following: “Taking social risk factors, the negative or adverse effects of SDOH into account is critical to improving both primary prevention and the treatment of acute and chronic illness because social context influences the delivery and outcomes of healthcare.”

The National Academy of Sciences created a committee, which found that there are five complementary activities that can facilitate the integration of social care into healthcare: awareness, adjustment, assistance, alignment, and advocacy. These five activities can be modified for both an individual and the community.

These five activities can easily fit within the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Returning to the example of the Marshallese and Covid-19 we will define and move through the process. The definitions are from the National Academy of Sciences (“Integrating Social Care Into the Health System”).


Awareness “includes activities that identify the social risks and assets of defined patients and populations.”

In this case, the Marshallese people are contracting and becoming severely ill with Covid-19 at greater rates when compared to the general population. This should be part of the assessment followed by a question of why they are facing more negative health outcomes.

Recall that this community was displaced due to nuclear testing on their home islands and they lost access to healthcare here in the United States. Simply being aware of this allows for an increased likelihood of addressing those disparities with better legislation and policy as well as understanding the potential problems and barriers faced by individuals when or if they seek care.


Adjustment includes “activities that focus on altering clinical care to accommodate identified social barriers.”

Clinics, hospitals, and public health officials within the state of Arkansas had to adjust their strategy of communication and testing to reach this community, using event and educational flyers in their native language and holding mobile testing in areas where they live in order to reach the community.


Assistance refers to “activities that reduce social risk by providing assistance in connecting patients with relevant social care resources.”

Early in the pandemic, there was a lack of PPE available to reduce the risk of transmission in places of employment. As with many low-income workers, there have been devastating job losses due to the Covid-19 pandemic, and because of this, large numbers of residents have also lost housing. Local churches, nonprofits, and renters rights organizations partnered to help stop evictions and provide rehousing assistance.


Alignment includes “activities undertaken by healthcare systems to understand existing social care assets in the community, organize them to facilitate synergies, and invest in and deploy them to positively affect health outcomes.”

Health organizations within the community have an established relationship within the group, hiring bilingual staff and employing Marshallese healthcare workers in order to better serve the community, providing culturally competent and holistic care.


Advocacy refers to “activities in which health care organizations work with partner social care organizations to promote policies that facilitate the creation and redeployment of assets or resources to address health and social needs.”

Community stakeholders advocated for the Marshallese, and as a result, in December 2020, the promise of federal healthcare was restored with the passage of a coronavirus relief bill thus returning Medicaid access to the Marshallese.

All of these activities require a deep understanding of the needs of individual patients and the community in which one practices. This will require an interdisciplinary approach and partnership development within the community.

Not all problems can be solved in the exam room—thus, it is imperative that there is advocacy not only for murse practitioners as a profession but also for the underserved in our community.

Elected officials at all levels of government tend to ignore those who do not vote. There is, however, an opportunity for policies that help reduce social risk factors and improve the quality of life and health outcomes in our communities, states, and across the nation.

Many of the problems in this country could be solved if addressed through the lens of SODH.

The Importance of Civic Engagement

Civic engagement can be a key factor in ameliorating the indifference of policymakers and empowering those in our community who are struggling.

Politicians only pay attention to those they believe to be likely voters. And August is Civic Health Month: “A nationwide celebration held each August to showcase the strengthening relationship between healthcare, healthy communities, and civic participation.”

Nurse practitioners should encourage their professional organizations, employers, and healthcare systems to participate in this event to encourage voter participation. They can give patients information on voter registration and why it is important to vote. This is a non-partisan effort and there are toolkits available at Vot-ER, which provides a “healthy democracy kit” and quick links to paste into patient messages or end-of-visit handouts.

Nurses and nurse practitioners are uniquely positioned in the community to see and advocate for better policy. Getting involved in professional organizations and getting to know your elected officials can be a starting point.

While running for office is not for everyone, it is past time to elect more nurses who have a deep understanding of the issues facing their patients and are trained to listen and solve problems. We can all do our part to improve civic engagement and work to better understand and address the Social Determinants of Health negatively impacting our own communities and patients.

Celeste Williams, MSN, APRN, FNP-BC

Celeste Williams, MSN, APRN, FNP-BC

Writer & Contributing Expert

Celeste Williams is a family nurse practitioner and alumna of Southern Nazarene University and the University of Arkansas for Medical Sciences. Celeste is passionate about healthcare policy, especially its effects on rural and other underserved communities. She believes more nurses belong in all levels of government and places where decisions are made. She is active in her community through her professional organizations, local political organizations, Rotary, and her church. She lives in NW Arkansas with her husband, four children, two cats, a dog, chickens, ducks, turkeys, peacocks, and a bearded dragon.