Families at Higher Risk for Poor Health Outcomes

Core Concepts

Social determinants of health: the five domains

The Healthy People framework groups SDOH into five areas: economic stability (employment, income, expenses, debt); education access and quality (literacy, early childhood education); health care access and quality (insurance, providers, health literacy); neighborhood and built environment (housing, transportation, safety, parks, food access); and social and community context (support systems, discrimination, civic participation). A quick way to remember the lens: ask where a family lives, works, learns, plays, and prays — and who helps when things go wrong.

Risk factors by domain

• Economic: poverty, unemployment, no or inadequate insurance, medical debt.
• Social and educational: low educational attainment, low health literacy, food insecurity, unstable housing or homelessness, limited transportation, weak social support.
• Access to care: late or no prenatal care, rural or underserved locations, language barriers, immigration-related fear of seeking care.
• Behavioral and health: tobacco, alcohol and substance use, poor nutrition, inactivity, and preexisting chronic conditions (e.g., hypertension, diabetes) that raise pregnancy risk and require provider management.
• Psychosocial: intimate partner violence, chronic stress, depression and anxiety, adverse childhood experiences, and adolescent pregnancy.
• Systemic: discrimination and bias within health care, historical mistrust rooted in past abuses, and structural racism.

Disparity vs. inequity — and why the words matter

A health disparity is a measurable difference in health outcomes between groups (e.g., higher maternal mortality in one population than another). A health inequity is a disparity that is avoidable, unfair, and rooted in unjust systems. Exams love this distinction: all inequities are disparities, but not all disparities are inequities. Structural racism refers to policies and practices embedded in institutions — including health care — that disadvantage some groups regardless of individual intent.

Protective factors: what moves families out of the risk zone

• Early, regular prenatal care — the single most studied protective behavior.
• Group prenatal care models and doula or community health worker support providing education and continuity.
• Food and income assistance (e.g., WIC and related programs) that reduce material hardship.
• Home visiting for new families and case management coordinating medical and social services.
• Strong social support — partners, family, faith communities, and peer groups.
• Trauma-informed care — asking "what happened to you" alongside "what's wrong with you," and building safety and choice into every interaction.

The nurse's role: screen, support, refer

• Screen privately and nonjudgmentally for food, housing, safety, substance use, and mood, with a normalization statement — "we ask everyone" — to reduce stigma.
• Support with a strengths-based approach: identify what the family already does well and build on it.
• Refer and advocate: connect families to social work, case management, food assistance, and community programs per facility policy; document social needs and barriers in the record.
• Stay in scope: nurses screen, educate, support, and refer — diagnosing conditions and prescribing treatment belong to licensed providers, and specific screening tools and referral pathways vary by institution.

Common Confusions