Expanded Conceptual Framework for Ethical Action by Nurses on the “Further Upstream and Farther Downstream” Determinants of Health Equity

Abstract

Determinants of health (DOH) are key predictors of health, wellness, morbidity, and mortality. The more familiar social DOH are not the only DOH. By themselves, the social DOH do not adequately explain how individuals and populations achieve and maintain health equity or inequity. Other DOH also exert political, economic, and institutional forces at all levels of the socioecological systems in which humans interact with their environment. According to the American Nurses Association, the Nursing Code of Ethics is a "non-negotiable moral standard for the profession" (Fowler, 2015a, p. viii). Provision 9 of the Code of Ethics states that social justice is of primary concern for social ethics (p. 159) and that professional nurses are obligated to advocate for and integrate principles of social justice into nursing practice and health policy (p. 151). In search of conceptual explanations for these phenomena, and to locate health equity/inequity within a wide array of upstream DOH, a comprehensive review of the interdisciplinary professional literature and conceptual analysis were conducted. A new conceptual framework that acknowledges nursing's collective responsibility for ethical action for transformative change was developed. The framework addresses both "further upstream" antioppression efforts and "farther downstream" efforts to remediate the impacts of health inequity. The purpose of this Policy Watch column was to introduce a new "Expanded Conceptual Framework for Ethical Action by Nurses on the 'Further Upstream and Farther Downstream' Determinants of Health Equity" (Fornili, 2022).

The development of aGender, Inclusion and Diversity Frameworkfor inclusive Nature-based Solutions in cities

“…The above mentioned inequalities are not merely coincidental. On the contrary, they can be seen as symptoms of oppressive political, economic, and institutional forces at all levels of socio ecological systems (Bronfenbrenner, 1977;Fornili, 2022). Oppression is defined as "discrimination backed up by systemic or structural power" and involves biased information, stereotyping, prejudice and discrimination (McGibbon, 2021).…”

What is “determinant” in the social determinants of health? A case seen through multiple lenses

“…Grayson et al (2022), for example, observe that many studies reduce social determinants to mere demographic characteristics, descriptive items from a patient intake screening to be transferred to a manuscript table, without substantive analysis of the mechanisms by which they actually influence health experience. Fornili (2022), citing McGibbon (2021), has argued for a more ethics‐oriented “expanded conceptual framework” identifying injustices “further upstream and farther downstream” from the “factors” and “domains” that appear in nursing social‐determinants policy and training documents. Baah et al (2019) and Dickman and Chicas (2021) note that the language we use in talking about social determinants can divert attention from the actors and actions actually to blame for them, preventing scrutiny of health's “political determinants”—the power relations, policy choices, and structures of governance that perpetuate marginalization and exploitation but operate behind the scenes of more readily observable social conditions.…”