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Population Health for Nurses

10.1 Factors That Influence Health Practices

Population Health for Nurses10.1 Factors That Influence Health Practices

Learning Outcomes

By the end of this section, you should be able to:

  • 10.1.1 Identify factors that influence individual health practices.
  • 10.1.2 Describe how the interaction of genetics, behavior, environmental and physical influences, medical care, and social determinants of health interact to determine a person’s health and well-being.

Dynamic and complex interactions among a person, their community, the environment, and society at large influence the overall health experience of clients and communities. Clients’ health depends on more than just their own decisions and personal health practices, or health behaviors. Health behavior encompasses the actions, habits, activities, policies, and procedures of individual clients, communities, organizations, and governments that can either support or undermine health. The term “behavior” can carry a judgmental or negative connotation that implies blame or moralizes health choices, when in reality the health behavior depends on numerous factors.

For example, whether or not a client participates in physical activity outside of their working time may appear to be their choice, and whether or not a client consumes microwaved meals and packaged snacks at each meal rather than eating a lot of fresh fruits and vegetables may be viewed as a preference. However, there may be some actions a client would like to take to support their health, but barriers to participation in their home, workplace, community, health system, or greater society may prevent them from doing so. Significant factors impact choices, compulsions, preferences, necessities, and other decision-making processes about health and related activities.

Socio-ecological models (SEMs) are models that offer a way to study and organize how personal, situational, community, societal, political, and other contexts affect client and community health behaviors and outcomes. Socio-ecological perspectives are a focus of this chapter. Before discussing SEMs in more detail, this section explores some of the concepts that can shape, and be shaped by, health behavior.

The Roots of Health Inequities

Labeling Client “Behavior”

Many factors influence client “compliance” or “adherence” to care plans, suggested health interventions, or engagement with what is generally accepted as a healthy lifestyle. Assigning feeling, meaning, or blame to client health behavior without a thorough consideration of other socio-ecological factors can do serious harm. For example, clients may be labeled “noncompliant” when documenting or discussing a medication plan instead of naming factors such as pharmacy access, financial situations, or unpleasant side effects. This labeling of clients can influence how other providers interact with the client, creating an inequity in providing health care.

(See Cox & Fritz, 2022.)

Case Reflection

Factors That Influence Health Practices

Read the scenario, and then respond to the questions that follow.

While generally healthy, Mo has been diagnosed with dyslipidemia for which he takes atorvastatin; he also has seasonal allergies that he manages well with daily over-the-counter loratadine and fluticasone under the direction of his primary care nurse practitioner. Mo wears corrective lenses. He has the occasional tennis elbow flare-up during his busy seasons at work. About once or twice per year, he experiences respiratory bronchitis and uses an albuterol inhaler as needed. The bronchitis can be particularly bothersome, which motivates him to get his seasonal immunizations like flu and COVID-19 as soon as his local pharmacy has them in stock. Sometimes, he says it is tough to sleep because he lives near the highway, which can be noisy overnight. He has not had any prior surgeries. His family history is significant for dyslipidemia and coronary artery disease; his mother (living) and his father (deceased over 20 years) had type 2 diabetes mellitus and chronic lymphocytic leukemia. Mo has never had genetic testing but is of Ashkenazi Jewish descent. Aside from seasonal allergies, he has no known allergies, and his immunizations are up to date.

Mo states he does not mind the physical nature of his landscaping work, but each year it seems a bit harder to work quickly. He proudly tells you he also works on his own yard, having planted 100 tulip bulbs for the coming season. He lives with his wife in a single-family home in a small town about 30 minutes by car from the capital city. He uses the 5-mile bicycle and walking path once a week in nice weather. Mo’s town has several grocery stores and a large farm where he is able to buy organic produce. Mo has two adult children who do not live at home and one grandchild. His daughter is a nurse, and his son works in finance. Mo spends as much time as possible with his family and socializes with friends a few times per month.

  1. Identify three components of Mo’s profile that are health-promoting, are risk-reducing, or may affect his health in a positive way.
  2. Identify three components of Mo’s health that present health risks, present safety concerns, or may affect his health in a negative way.

The Centers for Disease Control and Prevention (CDC, 2019) recognize five main factors that influence health:

  • Genetics
  • Behavior
  • Environmental and physical influences
  • Medical care
  • Social factors

These factors are discussed below. While reading about these factors, think about how each component identified as either supportive or potentially detrimental to Mo’s health could be categorized. The cultural beliefs, norms, values, and practices of clients and families can influence individual definitions, understanding, and experiences of health. For more information on culture and health, see Cultural Influences on Health Beliefs and Practices.


Family health history helps identify strong risk factors or predictors for acquiring certain conditions and disorders and alternatively for lowering the risk of health conditions. Genetics involves the study of how genes, traits, and diseases are passed from one generation to the next. Although genetic associations can be robust, genetics are still only one component in an overall health picture. As heritability and the presence of certain genes or attributes are measurable, scientists can calculate the impact of genetics versus lifestyle, social, and other factors on specific health risks. Some health conditions can have exceptionally strong genetic linkages, with a high likelihood that if one or both biological parents have a condition, their offspring will have it, too. For example, while the risk of developing breast cancer in the general population is 12.9 percent, children of parents with a certain gene mutation have a 50 percent risk of inheriting the mutation, dramatically increasing the risk of developing cancer (National Cancer Institute, 2020). Some aspects of health may be loosely related to genetics. The heritability of lifespan is only estimated to be between 7 and 25 percent (van den Berg et al., 2019), which suggests that there are many other factors that contribute to how long a client may live beyond the age of their oldest relatives at death.

Mo has a few possible genetic health risks. His parents were noted to have dyslipidemia and coronary artery disease as well as type 2 diabetes mellitus and cancer. Mo may be at increased risk of these conditions from a genetics standpoint, but he may also have had exposure to environmental and lifestyle factors similar to his parents that can precipitate these conditions. Mo is also of Ashkenazi Jewish descent. Ashkenazi Jews are one of several ethnic groups known to carry an increased likelihood of select genetic conditions (National Gaucher Foundation, 2023).


Broadly, behavior encompasses the way a person acts, the mannerisms they display, and the conduct they employ. Health behavior refers to specific actions that support or undermine health. Some individual health behaviors, such as staying adequately hydrated and participating in mindfulness practices like meditation, journaling, or guided imagery, can lower the risk of conditions or lead to improved health. Other health behaviors can precipitate or worsen conditions, such as smoking and getting insufficient sleep. Behavior is one of many factors that can influence client health, and all clients do not have the same access to engaging in select health-promoting behaviors.

Many recognized structures, inequities, and ideologies, as well as broad societal organization, have a greater influence on health behavior than individual choices and nonconscious processes (Rejeski & Fanning, 2019; Short & Mollborn, 2015). These external factors can create barriers or opportunities that influence the ease with which individuals can engage in health-promoting behaviors. Think back to the examples at the start of this section: a client who does not engage in physical activity and a client who does not eat fruits and vegetables. The client who does not participate in leisure-time physical activity may not have safe places to walk in their neighborhood or might work odd hours that leave little daylight time for walking and jogging. The client who eats mostly packaged foods may not live near a grocery store that sells any fresh fruits and vegetables or sells them at affordable prices. These situations highlight the significance of city planning, equitable access to jobs with daytime hours, and community buying power that could incentivize a full-service grocery store chain to locate a store in the neighborhood. These factors outweigh the influence of clients’ personal activity and meal preferences or conscious health decisions. A comingling of other health factors affect whether individuals are aware that a particular factor supports or hinders health.

Mo engages in some health-supporting behaviors, such as keeping up social contacts and participating in physical activity. He also regularly takes medication in support of his identified health conditions and has agreed to receive immunizations as scheduled. Some of his behaviors represent health risks and require further assessment. For example, the physical nature of his job has been a challenge and at times exacerbates his tennis elbow.

Environmental and Physical Influences

When thinking of health and the environment, one may consider several aspects such as access to drinking water and exposure to air pollution. While clean air and water are essential to physical and mental well-being, other aspects of the environment can dictate health status (Figure 10.2). The primary environment for most people is their home. Even dwellings that clients note as pleasant, comfortable, and preferred can represent health risks. For example, clients who live in multiunit buildings (e.g., apartments or condominiums) and do not smoke still face a health risk if other people in their building smoke in their own home units, on balconies, or outside of the buildings in designated smoking areas that are in close proximity to the living area (Willand & Nethercote, 2020). If the physical environment around a client’s home or place of work has a well-marked, smooth, tree-lined sidewalk, this can support engagement in outdoor physical activity. Similarly, living near nature or being able to see green space from a window in the home supports self-esteem, life satisfaction, and happiness and helps clients avoid depression, anxiety, and feelings of loneliness (Soga et al., 2021). Alternatively, living near a highway places a client at risk for hearing constant noise and being exposed to pollution and has been associated with neurodegenerative disorders such as Alzheimer’s disease, multiple sclerosis, and Parkinson’s disease (Yuchi et al., 2020). A healthy home environment may not be available in densely populated areas. For many people, opportunities to relocate from an unhealthy home environment to an improved setting may not be affordable.

A person sits at a restaurant table that holds an ashtray with a burning cigarette in it while other patrons stand and sit nearby.
Figure 10.2 One of the big reasons for indoor smoking bans is to protect workers from secondhand smoke, an environmental contaminant. While everyone may experience serious health consequences following exposure to secondhand smoke, not everyone faces the same risk. Children, adolescents, and individuals who are non-Hispanic Black, have lower incomes, have less education, live in rental or multiunit buildings, live with a smoker, and work in certain industries face a disproportionate risk of secondhand smoke exposure. (credit: “Smoke-free area” by Vasile Cotovanu/Flickr, CC BY 2.0)

The Roots of Health Inequities

Home Air Quality: Environmental Racism

“Redlining” was a discriminatory home loan practice that emerged in the United States in the 1930s when banks would deny mortgages or offer loans on unfavorable terms to clients and families based on their race. Redlining led to neighborhood segregation and ongoing disparities. Modern-day disparities in air quality can be linked to these nearly 100-year-old practices. Researchers studied the association between air pollution and redlining in 202 cities across the United States. They determined that BIPOC communities, particularly Black and Hispanic people, are exposed to higher levels of air pollution despite general improvements in air quality across the nation. One reason for poor air quality in these communities is the presence of hazardous industrial factories in redlined neighborhoods. While banks and lenders today may have antidiscrimination practices in place and there is legislation meant to prevent redlining, the health impact of this racist practice persists. Higher levels of contaminants such as nitrogen dioxide and fine particulate matter present in formerly redlined neighborhoods can contribute to premature death, chronic conditions across body systems, environmental allergies, cognitive problems in children, and complications with reproductive and fertility health. See Structural Racism and Systemic Inequities for more information on redlining and Environmental Health for more information on the negative effects of pollution on health.

(See Lane et al., 2022; Manisalidis et al., 2020.)

The physical environment to which a client has access can impact health and behavior. Consider Mo: Mo exercises regularly in nice weather. He lives in a town that has a 5-mile biking and walking path that he uses for walking and jogging. This walking path gives Mo a safe place to participate in physical activity. If Mo lived in a city that did not have such a path, would he be able to walk for 5 miles on the sidewalk? Would he need to dodge oncoming traffic while jogging? If there was not a path designed specifically for walkers and joggers, would he consider outdoor physical activity too much of a hassle? Without a place to exercise outside, would he need to join a gym? Could he afford to join a gym? Mo is in an ideal position where he enjoys exercise and has access to resources that allow him to exercise in the community environment. On the other hand, living next to a highway may pose a threat to Mo’s health due to poor air quality, conditions that are not conducive to sleep, and risk for neurodegenerative disorders.

Medical Care

Medical care refers to services rendered by a health care clinician during visits to clinics, offices, hospitals, surgical centers, schools, labs, and other places. Access to medical care can improve health through prevention, diagnosis, treatment, or palliation of illnesses, injuries, and diseases. The presence or absence of barriers to medical care for clients and communities influence their health behavior. Access to medical care provides clients with preventive health screenings, symptom management, and access to treatment and medications to manage chronic conditions. Access to care depends on many factors, such as a client’s insurance status and comfort or trust in specific providers or in the health system as a whole (Greene & Ramos, 2021).

Members of marginalized communities face additional barriers to finding a provider who might welcome them and understand their needs. Older adults, LGBTQIA+ clients, and clients with language barriers are a few examples of those who might have physical access to care but do not fully receive the care they need due to factors such as systemic ageism, heterosexism, and stigma in health settings (Al Shamsi et al., 2020; D’cruz & Banerjee, 2020; Gibb et al., 2020). Caring for Vulnerable Populations and Communities shares more information regarding the care of populations vulnerable to marginalization, discrimination, and exclusion in the health setting. Even factors that change day to day can impact medical care. For example, scheduling and attending a medical appointment involves: finding time to make a phone call, being able to succinctly describe the health concern, finding a convenient day and time to attend an appointment around work and other commitments, ensuring access to and money for transportation to get to the appointment, paying for the copay in the setting of lost wages, and more. Geographic access to a hospital or care provider can also differ for many Americans in rural versus urban environments. For example, although the United States has climbing maternal morbidity and mortality rates, in recent years access to perinatal services in rural communities has decreased, and these communities have a nine percent greater probability of severe maternal morbidity and mortality compared to urban residents (Kozhimannil et al, 2019).

Mo sees his primary care provider annually and as needed. The primary care clinic is situated in Mo’s town, and he finds it easily accessible. This makes his quarterly visits for monitoring of chronic conditions easy, and Mo has never missed an appointment for a cholesterol check. Mo can quickly see the primary care provider for an evaluation of his respiratory health and inhaler refills as needed. If he ever needed surgery or inpatient care, he could easily access the larger hospitals in the capital city, which is only about 30 minutes away by car. Further, his daughter is a nurse, which gives him access to extra support. She can help him make sense of any of the primary care provider’s recommendations or test results and can help him prepare to explain his health issue in a succinct manner to make the most of any visit scheduled. The same is not true for many Americans. Health inequities are apparent and harmful when clients face barriers such as limited health plan coverage, living far away from hospitals and clinics, language barriers, or lack of family support. Any barrier to care access can impact a client’s ability to receive care, which can lead to poor health outcomes and continuation of society-wide health inequities.

A Crisis in Maternal Care Access

An increasing number of locations in the United States are becoming “maternity care deserts,” leaving pregnant clients and families without access to birth centers or hospitals and providers that can provide obstetric care. In a 2022 report, March of Dimes determined that the growth of these deserts was affecting nearly 7 million people of childbearing potential and over a half million babies. March of Dimes developed a companion site to the report with summaries and interactive maps. Please note, the report refers to women and mothers. Authors and editors of this textbook acknowledge and support that women and mothers are not the only clients with childbearing potential.

Visit the links, and then respond to the following questions.

  1. What are the health consequences of living in a maternity care desert?
  2. Is your school or home in an area considered a maternity care desert?
  3. How do clients receive medical care when living in a maternity care desert?
  4. What individual health behaviors are impacted when living in a maternity care desert?
  5. What might it take to eliminate maternity care deserts?

Social Determinants of Health

Social determinants of health (SDOH) have crossover with the factors previously discussed, but they also bring different perspectives and antecedents to a client’s full health picture. Other chapters within this textbook discuss SDOH in greater depth. Briefly, per Healthy People 2030, social determinants of health are the conditions and environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (Office of Disease Prevention and Health Promotion [ODPHP], n.d.-a); they are discussed at length in Social Determinants Affecting Health Outcomes. Social determinants across domains, including a client’s economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context can influence or are influenced by the factors associated with health behavior.

Not all clients have the same access to engaging in healthy behaviors and lifestyle interventions. For example, teen clients have identified support from caregivers, family members, and peers regarding healthy eating and exercising and access to organized sports as two factors essential to facilitating a healthy lifestyle (Cardel et al., 2020). What happens to teens without such supports? There are many benefits to outdoor play for children and teens alike (Chaudhury et al., 2019; McCormick, 2017), and nurses might suggest increasing outdoor play time to families during health encounters. Unfortunately, not all clients and families have the same access to recreational areas, parks with amenities such as play structures, vegetation, and outdoor spaces with tree canopy and shade coverage in their neighborhoods (Kephart, 2022). How might a nurse approach suggesting increased outdoor activity for families that are not afforded access to safe green space (Figure 10.3)? While nurses can acknowledge that health behaviors can bolster or hinder personal health and wellness, they must remember that placing ultimate accountability for engaging in health behaviors solely on an individual is not in alignment with nursing practice principles of justice and equity.

A small child runs through a hallway inside a house.
Figure 10.3 A preschool-aged child plays tag indoors. When communities do not have access to robust green space, nurses can counsel families on creative indoor physical activities. Nurses can recommend activities that encourage movement, fun, and family bonding, such as online guided dance or exercise classes on sites like YouTube or different indoor games for children of all ages. (credit: “Playing Tag with Milly” by Donnie Ray Jones/Flickr, CC BY 2.0)

Mo’s social determinants affect his experience of health. He considers himself economically stable. He finished high school, he is employed full-time, and he owns a home. He has health plan coverage and, as discussed, can easily access health services when he needs them. He enjoys the environment in his own backyard and can access outdoor recreation space in his neighborhood. Mo has a positive social and community context. His job does pose health risks to both his musculoskeletal function (tennis elbow) and respiratory wellness (allergies and bronchitis). He knows that living near the highway can affect his sleep, and he might be surprised to hear about the risks that traffic and pollutants pose to his respiratory conditions—and to the vibrancy of his tulip garden! All in all, Mo’s social determinants contribute to a positive experience of health.


None of the factors that influence health behavior exist, form, evolve, or influence on their own. Similarly, barriers or health risks relevant in one factor or category can worsen those in another and perpetuate inequalities and injustices in health. Intersectionality considers how more than one disadvantage can interact for clients on an individual level and reflect the inequities and injustices at the systems level. Racism, classism, colonialism, sexism, heterosexism, and ableism are a few of the structures that result in systems-level oppression and privilege (Crenshaw, 1991). Intersectionality focuses on systems of oppression and privilege, not individual identities, and while all people have intersecting social identities, not all people belong to groups that are harmed by oppressive structures or supported by subsequent privilege (Aguayo-Romero, 2021). Considering the intersectionality of genetics, behavior, environment, medical care, social determinants, and societal structures allows for a better understanding of the complexity of health and illness across the population. It also serves as a reminder to all clinicians that addressing disparities, inequities, biases, injustices, and other problems that perpetuate oppression in health care is a priority that must be addressed to promote health for all.


This CDC video defines intersectionality and explores its role in health outcomes.

Watch the video, and then respond to the following questions.

  1. How would you define intersectionality?
  2. What different groups do you belong to?
  3. The video states that public health professionals can use the intersectionality framework as an equity lens. What does this mean?

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