1. Walton, AnnMarie Lee PhD, MPH, RN, OCN, CHES, FAAN


A less restrictive term allows more room for our shared humanity.


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The term social determinants of health to describe nonmedical factors such as educational attainment, income, and social support that influence health outcomes became more widely used in health care in 2005, when the World Health Organization created their Commission on Social Determinants of Health. In 2017, Gregory Simon, psychiatrist and researcher at the Kaiser Permanente Washington Health Research Institute, argued that "the word 'determinants' doesn't allow room for resilience, hope, or effective interventions." Instead, he proposed the term social influencers of health. From this perspective, social determinants are deterministic, are seemingly fixed, and crowd out space for hope and modifiability. However, some have argued that use of an alternate term like social influencers may reduce the global recognizability of the social determinants concept and adversely affect policies and budgets by casting doubt on whether these factors are always causal.

Figure. AnnMarie Lee... - Click to enlarge in new windowFigure. AnnMarie Lee Walton

I was taught that words, their origins, and their meanings matter. My high school in New York City required us to study Latin and to pledge an ancient oath in both Latin and English that we would not desert our "comrades," and would leave our city greater than we found it. I later pursued a master's in public health and served as a training extern in the U.S. Public Health Service, where I was sent to examine why suicide in a chapter on the Navajo reservation was more than twice the national average. It was there that I began to think about health outcomes as linked to complex and communal factors like marginalization, cultural identity, and structural inequity. What the term social determinants lacked as I used it was the sense that these constructs could be modified by individual and community resilience as well as shared humanity, compassion, and benevolence.


Years later, a student in a class I taught commented, "These determinants don't apply to me, thankfully, but I see them at play all the time at work." Such a perspective made clear to me that the use of the word determinants allows many people to maintain a conceptual dichotomy between the haves and the have-nots and to set themselves apart from others. In a population health course, where I was faculty facilitator, we decided instead to use the term social contributors. We considered the option of social influencers but felt that the word influencers was too closely associated with social media. Students told us that the term contributor was a more positive, more hopeful, more fluid way to approach the same constructs. The shift from determination to contribution offers hope and the possibility of individual and collective agency not only to people in communities, but to nurses, who despite challenging factors seek ways to leave communities better than we find them.


After making this change to our common language and watching how the students use it, I find that I am no longer teaching students to ask, "What I can do for you?" but instead, "What can I do with you?" For example, drug costs affect us all. Shifting from the language of determinants, where the patient is seen to have a deficit that the nurse does not, to that of contributors, where we are all impacted and factors are seen as modifiable, expands our interventional foci. After referring patients to a pharmaceutical company for assistance in getting a medication, a nurse might also pursue a deeper understanding of the rising costs of health care and advocate for evidence-based solutions to make health care more affordable for all.


I urge nurses and educators to consider how our language may orient our thinking about our comradeship and kinship with others in our communities. I believe that to achieve health for all, we must center our work on our shared humanity and shared hope, and be willing to experience hardship and actively work for change with all.