key: cord-1010548-965p26mf
authors: Link, Denise
title: Social Herd Immunity
date: 2020-09-04
journal: J Nurse Pract
DOI: 10.1016/j.nurpra.2020.08.012
sha: c47616037d9faedb7c9e18537acfc74e4c7f0b52
doc_id: 1010548
cord_uid: 965p26mf

nan

Quality Care for Women's Health Social Herd Immunity Denise Link One year ago, I was preparing to welcome the beginning of 2020 with an extended visit with children and grandchildren. I greeted the new year with much anticipation as it would include my retirement from full-time teaching. My newfound freedom would be spent mostly in travel with my husband either to places on my personal "bucket list" or in more family time. Little did I imagine that soon, my contact with not only my family but students, friends, and colleagues would be limited to electronic communication on the telephone or via audio video Internet connection. At one point, I was "sharing" a children's book with the grandchildren by holding the pages up to my computer camera while reading the text. Not a very satisfying experience to say the least, although my daughter reported afterward that the kids were discussing the book in such detail at dinner that when they could not remember the name of the story, she could correctly identify it as Robinson Crusoe. So, while at the time I was not sure that the children were gaining much from the reading, the feedback provided some evidence that my efforts were not completely in vain.

I think that I can safely assume that none of us imagined how in a few short months, our lives would change so radically. COVID-19 struck with a vengeance, leaving death and physical, mental, social, and economic damage in its path, some of which will take generations to repair. There were those in the public health field who predicted that a pandemic would occur and that we were not positioned globally or nationally to respond to it in ways that would minimize harm and loss of life. Although we were aware of the existence of inequities in access to personal and community resources that impact health, the pandemic amplified both the gaps in the social safety net and the consequences of the failure to act effectively to remedy the problems. The shortcomings were especially apparent in our primary health care system that struggled to respond to the demand for care due to decades of neglect and fragmentation. As has been mentioned before in this column, women and other vulnerable groups are disproportionately affected when our systems are inadequate to manage a surge in patients when a crisis occurs.

In July, The Commonwealth Fund published a 2-part report 1 on the need to transform the primary care system so that it works better for everyone, but especially for women. In the first part of the report, the authors discuss the factors that prevent women from obtaining the physical care they need. The way in which women's health care is delivered via a reproductive system silo makes it necessary for women to obtain services from a variety of professionals, none of whom alone have the expertise to address women's unique physical, mental, and social needs as they transition from puberty, to childbearing years, and through menopause. Women report that they are more satisfied with their OB/GYN providers; unfortunately, most OB/GYN providers do not offer primary care services. In addition, only 20% of the programs in this "women's health" medical specialty offer content on menopause. 1 Meanwhile, only a third of medical schools include genderspecific topics in their curriculum, 1 so that most physicians who choose a primary care role are not adequately prepared to provide comprehensive care for women in ways that take into consideration the impact of gender and social influences on health and the expression of disease states in women. Family and adult nurse practitioner programs offer content on women's health, but they are not sufficient in depth and breadth in didactic or supervised clinical practice hours.

The authors then address some of the social factors that affect the quality of health care and access to that care for women. There are barriers to care that have major implications for the paid and unpaid labor force. Sixty percent of US workers are women, and many of them are employed in essential service roles. Women are primarily the unpaid caretakers for dependent children and elderly or disabled family members. Therefore, ensuring that women are able to obtain the care they need when they need it can have a positive impact on a country's economy and security. Yet, women in the US have significantly poorer health outcomes compared with other developed countries. 1 In part 2 of their report, Zephyrin et al offer recommendations for how to reform the primary care system so that it is more effective in meeting the needs of all groups. In addition, they provide a framework for changes that will specifically focus on women. These include sex-specific care for those conditions unique to women such as pregnancy and menopause: sex-aware care for conditions that are expressed differently in women; and gender-aware care that is inclusive of the health care needs of the LGBTQIA community. Lastly, a more robust primary care system must be developed using team-based care and technology to facilitate continuity of care for women across the lifespan. 2 Both medical and nursing curricula must be enhanced to prepare clinicians who can create and practice in fully integrated environments that can effectively and efficiently respond to women's unique healthcare needs.

In a recent editorial in the Journal of the American Medical Association, Williams and Cooper 3 explained why applying a purely clinical approach to solving our health care inadequacies will not provide the needed results. They offer strategies to effect changes in policies and systems that will create what they call a "social herd immunity" to the effects of negative social factors that are the true

The Journal for Nurse Practitioners j o u r n a l h o m e p a g e : w w w . n p j o u r n a l . o r g determinants of health outcomes. For example, where women live is a strong predictor of their health status. Neighborhoods segregated by race, ethnicity, and low income experience systemic disinvestment in schools, small business, grocery stores, primary care practices, safe open spaces, clean air, and safe drinking water. When these essential characteristics are weak or absent, there is a corresponding negative impact on health. As a group that disproportionately experience adverse life events, women are particularly vulnerable when the social support systems they need are not available or inadequate. The strategies that the authors recommend for all vulnerable, underserved populations can be applied to remove barriers and improve the health of women. First, the problems women experience must be acknowledged for work to begin on solutions. Next, there must be clarity that women are at a greater disadvantage when the social environment is lacking, especially Black and Brown women. Lastly, a sense of empathy for the situations that particularly affect women must be developed to stimulate political action. Perhaps our common experiences with COVID-19 will provide that empathetic spark and lead to a better society and primary care system to benefit all, including women.

Transforming primary health care for womendpart 1: A framework for addressing gaps and barriers

Transforming primary health care for womendpart 2: The path forward

COVID-19 and health equityda new kind of "herd immunity

is a Clinical Professor Emerita at Arizona State University Edson College of Nursing and Health Innovation

/ The Journal for Nurse Practitioners xxx (xxxx) xxx