Thinking back on my clinical practice days, I vividly remember shuddering at the thought of the many patients leaving my Skin Integrity Clinic who did not have the "means" to adequately care for their feet or ulcers. Over the past 20 years working as a nurse scientist, I continue to shudder at the thought of many patients not having the means to engage in research for a variety of reasons including the poor social conditions of these patients' lives. One of the most common conditions is the lack of transportation to get to study site visits; a second issue is the study site location itself that is too far for individuals' travel, or the site is in an area unfamiliar to family or friends who provide transportation. Study site access continues to be a substantive problem in our academic health sciences center setting for several reasons. It is a several hours drive for individuals living in rural areas, the area is fraught with highly congested traffic, and parking is challenging. The pandemic changed the way most of us conduct our patient-oriented research by creating ways to engage individuals in their homes and keep them from having to travel long distances. Researchers and clinicians are acutely aware of these important social needs on the quality of our research and patient care. I know I speak to the choir of WOC and foot care nurses about the influence of social conditions/needs on the overall health and well-being of our patients.
These social needs, called social determinants of health (SDOH), are the societal and environmental conditions in which we are born, grow, live, learn, work, play, worship and age; they play a major role in influencing health. Research suggests that only about 20% of the positive influences on overall health are a result of health care; SDOH account for the remainder.1 According to Healthy People 2023 (https://health.gov/healthypeople) and the World Health Organization (https://www.who.int), SDOH include economic stability/socioeconomic status, education access and quality, health care access and quality, neighborhood and the built environment, community/social support networks, and employment. These nonmedical social and environmental factors substantially impact health, well-being, and quality of life; however, they also contribute to wide health disparities and inequities. They include a wider set of forces and systems such as stigma, racism, economic policies and systems, social norms and policies, and the political system itself that shape the conditions of daily life and downstream health outcomes.
Given the importance of SDOH in influencing wound healing, ostomy management, quality foot care, and continence maintenance, WOC and foot care nurses play a crucial role in identifying and addressing these factors in our patients' care plans and research protocols. For example, patients with limited access to health care may delay seeking treatment of wounds or other conditions, leading to complications and poorer outcomes. Patients with low socioeconomic status may face challenges in obtaining supplies and resources necessary to manage an ostomy or continence issues effectively. These same conditions can confound research study outcomes and deter intervention efficacy or effectiveness.
Guided by the National Institute for Nursing Research, the future agenda of nursing science and research include the promotion and improvement of the health of individuals, families, and communities. A major priority is to reach underserved populations through the lens of social, structural, and clinical determinants of health, access to care, and health equity. In my own research, I am acutely aware that SDOH must be considered during study procedures and processes that can answer questions such as: What is participants' health literacy level? Do participants understand what is being asked of them? Is there access to tablets, laptops, or cell phones? Are there reliable Wi-Fi and local cell towers so that participants can complete questionnaires? Social determinants of health are also important variables to consider for their associations with study outcomes and how they might explain these outcomes. For example, one might ask whether there are differences in healing outcomes between participants who lack access to grocers or have insufficient economic resources to buy healthy foods compared with participants with greater access to healthy foods. One needs to know if lower albumin levels associated with healing are a consequence of a disease or the result of inadequate protein intake due to lack of available foods. The intervention might have actually worked but was negatively influenced by this particular SDOH.
In response to the need to study the influences of SDOH on healing outcomes, recognizing that the patient's social environment is responsible for up to 50% variation in healing,2 my team was recently funded to conduct an observational study of the effects of social support and loneliness on wound healing outcomes in a sample of individuals with chronic leg ulcers. Loneliness is a well-known factor associated with poor health outcomes,3 but the influence on healing has received much less attention. We are enrolling individuals receiving care at 2 wound clinics who endorse high (n = 26) and low levels (n = 26) of loneliness, tracking healing during their wound treatment, collecting biospecimens to evaluate inflammatory markers (known to be elevated in response to loneliness), and measuring other health assessments such as the presence of depression, anxiety, and sleep disturbances. We are interested in determining relationships among these SDOH, biological, psychosocial, and health variables and wound healing. If we find a relationship with loneliness, the next step will be to test whether an intervention developed by team members would help mitigate loneliness and improve healing outcomes. Findings from this research have implications for WOC and foot care nursing and will lead to a better understanding of risk factors for healing and add to our armamentarium of assessments targeting social and environmental factors associated with poor outcomes. Many of us already include these factors in our assessments. Specific to our study of loneliness, we are anxious to analyze our data during the summer of 2023 and disseminate these study findings in the Journal early 2024.
We, WOC and foot care nurses, play a key role in advocating for, and becoming involved in, research and clinical projects that focus on how SDOH impact our patient populations. Assessing for SDOH during provision of care, addressing these needs, and advocating for research that examines new models that enhance "social aspects of care" for our patients will strengthen our clinical and research practices. These activities involve identifying various social, economic, and environmental factors such as: (1) conducting a social history of social support networks, occupation, education, and other demographic information that may impact health and research outcomes; (2) using screening tools such as PRAPARE and the Health Leads Screening Tool4; (3) consulting with family or friends on neighborhood and housing conditions, location of grocery stores, and transportation; (4) referring for home health screening to assess living conditions and the built environmental factors that impact health; and (5) collaborating with community resources such as community health workers and faith-based organizations.5
Understanding the impact of SDOH on WOC and foot care outcomes is essential for effective patient care-we can help address these factors by working with patients to overcome barriers to care, providing education and support, and connecting patients with community resources. I believe we do a good job of inquiring about our patient/family/caregiver abilities to get supplies, assessing home care needs, and making referrals. Taking what we do one step further includes a dedicated focus on addressing social care needs such as access to healthy foods and how the foods can be prepared and eaten, whether the patient is socially isolated or lonely, depressed, anxious, and sleeping poorly, has adequate living conditions and opportunities to be physically active, and can get out for fresh air or sunshine.
A major tenet of Florence Nightingale has as much merit today as it did over 125 years ago; it is imperative that we put patients in the best possible condition for nature to act upon them. We, WOC and foot care nurses, know the social and environmental needs of our patients are a top priority for clinical care and research. The short answer to the title question is a resounding "YES."
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