The csdh framework divides all social determinants into two broad categories: structural determinants, including public, social, and economic policy, as well as socioeconomic position and social class; and intermediary determinants, including material circumstances, behavioral and biological factors, and psychosocial circumstances (solar & irwin, 2010).

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Conceptual frameworks provide structured representations, written or visual, of interrelated concepts or variables. Such representations can then be used to better understand these relationships and guide nursing practice. Two conceptual frameworks which can be used in public health nursing include the Ecological Model and the World Health Organization’s Commission on the Social Determinants of Health (CSDH) Framework. Both focus on the social determinants of health and, thus, may be used to address the issue of health inequity. The Ecological Model identifies five “levels of influence”: intrapersonal or individual, interpersonal, institutional factors, community factors, and public policy (National Cancer Institue, 2005). The CSDH framework divides all social determinants into two broad categories: structural determinants, including public, social, and economic policy, as well as socioeconomic position and social class; and intermediary determinants, including material circumstances, behavioral and biological factors, and psychosocial circumstances (Solar & Irwin, 2010).
Using the Ecological Model, the micro-level corresponds to the intrapersonal or individual level. Racial minorities frequently experience health inequities. If a man or woman of color, for instance, delays routine cancer screenings (e.g., breast cancer, colorectal cancer), that choice may be due to a simple lack of knowledge, or, as is often the case, due to personal mistrust in the healthcare system, based on experiences of racial discrimination by healthcare providers, both personal and historical, as in the case of the Tuskegee Syphillis study or of the involuntary sterilization of indigenous women (Blakemore, 2016). Individual knowledge deficit may be remedied using health education; however, a mistrust of medical providers ties closely to the interpersonal, institutional, and community levels of influence, which, as the model recognizes, are all interrelated. At this meso-level, a more generalized mistrust of the healthcare system among communities of color may additionally foster a personal mistrust of medical providers; the public health nurse (PHN) and other public health officials working within this level must work to re-build trusting relationships and partnerships with communities of color. Institutions and continuing education may require healthcare providers to take training on racial bias and culturally competent care; medical institutions and healthcare organizations may also work to recruit healthcare professionals from communities of color, who racially and culturally represent those communities. Healthcare organizations can work at the meso-level to expand access to preventive screening services within communities of color, adjusting locations and operating hours such that more individuals may be able to receive services. Finally, knowledge deficit regarding the importance of preventive care and screenings may be a more broad community- (i.e., meso-) level issue, in which case, the PHN may provide health education within the community, for example, at a health fair, community event, or local businesses, such as barber shops and salons.

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