U.S. National Institutes of Health

Determinants of Health: Henry Street Visiting Nurses

Health Education and History & Social Studies
Three 45-minute class periods

Description: Students learn about various determinants of health using primary and secondary sources. To consider health determinants, students examine a selection of images and texts about the Henry Street Settlement Visiting Nurse Service from the 1930s.

In Class 1, students analyze primary sources—including images and documents—to investigate multiple determinants of health in the 1930s and today. In Class 2, students are assigned one of four fictional historical identities—attendees of the annual meeting of the Henry Street Settlement Visiting Nurse Service in 1934. They gather information from primary and secondary sources to form their assigned person’s perspective on what impacts individual and community health in New York City during the period when the Visiting Nurse Service worked. In Class 3, students assume their historical identities and conduct a simulated annual meeting of the Henry Street Settlement Visiting Nurse Service. During the team meeting discussions, students apply and demonstrate their understanding of health determinants in the context of the work of the Henry Street Visiting Nurse Service.

At the end of this lesson plan, students will be able to:

  • Define determinants of health
  • List at least two of four determinants of health (personal, social, environmental, or economic)
  • Identify the multiple health determinants addressed by the Henry Street Settlement Visiting Nurse Service in 1930s
  • Describe how health determinants are interconnected and need to be addressed together—e.g., individual biological and economic factors
  • Analyze, contextualize, and synthesize information from primary and reliable secondary sources
  • Form logical arguments and inferences informed by primary and reliable secondary sources

Outside / Inside: Immigration, Migration, and Health Care in the United States traces the history of ideas about immigrant health and tells the story of immigrants’ and migrants’ experiences with U.S. health care over the past 130 years. The exhibition’s digital gallery showcases photographs and documents related to the Henry Street Settlement’s Visiting Nurse Service in the 1930s. These nurses brought health care, health education, and public health interventions to New York City’s impoverished and immigrant communities during the Great Depression.

Teachers are encouraged to preview the Outside / Inside online exhibition, as well as online resources about the determinants of health, the Henry Street Settlement, Lilian Wald, the Progressive Era, and other time periods listed on the Historical Role Play Instructions handout for Class 2. In addition, teachers may reference the following online resources about conducting an historical role play:

The following words may be introduced/incorporated into the lessons:

  • industrial poor, colleagues, Progressives, primary source, secondary source, determinants of health, health determinants, social determinants of health, health inequity, Settlement House, public health, visiting nurse, house call, maternal health


  • What is Medical Care? (PDF, Word)
  • Photograph Analysis (PDF, Word)
  • Historical Role Play Instructions (PDF, Word)
  • Historical Identity Vignettes (PDF, Word)
  • Annual Meeting Agenda (PDF, Word)
  • Annual Meeting Notes (PDF, Word)

Other Materials And Set-ups:

(Preparation: Assign students to visit the Outside/Inside Digital Gallery and read the Henry Street Settlement’s article on Lilian Wald prior to Class 1.)

  1. As students enter the classroom, pass out copies of the What is Medical Care? worksheet for them to read and complete.
  2. Display What is Medical Care? and have students call out the items they selected from the sheet. Record their answers on the displayed worksheet,then invite students to share why they consider some items medical care and not others.
  3. Call out this phrase from the definition of medical care on the sheet: “…what is necessary for a person’s health and well-being….” Then, discuss the connection between this statement and the students’ two pre-class reading assignments—Lillian Wald and the Outside / Inside Digital Gallery. Tell students that the websites provide primary and secondary sources that illustrate what Wald and Henry Street Settlement visiting nurses considered “necessary for a person’s health and well-being.”
  4. Ask students to play the roles of Wald and the visiting nurses, based on the information from the two websites. Have students select items on the worksheet that Wald and the nurses would view as necessary services from Henry Street Settlement Visiting Nurse Service. Record students’ answers on the displayed worksheet.
  5. Compare the initial list of medical care items and the list from students’ role playing as Wald and visiting nurses. Summarize the conclusion that students should draw from comparing the two lists: that various factors, and not just diseases and medical tools, influence and determine individual and community health.
  6. Introduce the term, “determinants of health,” with its definition from the Healthy People 2020 website: “the range of personal, social, economic, and environmental factors that influence health status.” Briefly review listed categories of determinants as students will explore them in more detail during research in Class 2.
  7. Distribute copies of the Photograph Analysis to students. Tell students that they are to examine and analyze four primary-source photos from Outside / Inside Digital Gallery. Have students discuss in groups of three or four.
  8. Ask the groups to come together and summarize their discussions. Guide the conversation and clarify, as needed, various health determinants noted in the photos and their captions.
  9. Class 1 Evaluation: Teachers can assess students’ existing knowledge and assumptions of what medical and health care are. In addition, class and small group discussions are opportunities for evaluating students’ understanding of what health determinants are, and their ability to synthesize and to draw inferences from primary sources in relevant historical context.

(Preparation: Make arrangement for students to have internet connected devices for accessing Outside / Inside Digital Gallery and web resources listed on the Historical Role Play Instructions handout for research during this class.)

  1. As students enter the class, hand out to each student a copy of one of four Historical Identity Vignettes. Tell students that they are to assume the identity of the fictional person described on their handouts.
  2. Display Historical Role Play Instructions. As a class, review the instructions, address questions, then allow students to research and prepare for their role play. Explain that the vignettes are of four fictional people who lived in New York City in 1930s, therefore there is no one right answer, but students can make inferences informed by primary and secondary sources about that time and place, the work of Henry Street visiting nurses, and health determinants. As a class, review the instructions, address questions, then allow students to research and prepare for their role play.
  3. Class 2 Evaluation: During the research and discussion phase, teachers may assess and guide students’ understanding of how they make inferences based on historical primary and secondary sources. Teachers can also observe how students are interpreting their assigned persons’ perspectives on health, society, culture, etc.

(Preparation: Set up desks and chairs for small group discussions.)

  1. As students enter class, have them sit in groups divided by the four assigned historical identities from Class 2. Allow groups to work for about 10 minutes, discussing and revising their research notes to prepare for the role play in the simulated meeting.
  2. Call students back and hand out copies of Annual Meeting Agenda and Annual Meeting Notes. Then put students into role-play teams—each team consists of one of each of the four people from Historical Identity Vignettes.
  3. Tell teams to begin the simulated annual meeting by introducing themselves as their assigned person and moving through the agenda for about twenty minutes. Remind students that they need to justify their position on a topic based on their research. Finally, ask students to record their observations during the meeting on their copies of Annual Meeting Notes.
  4. Bring the class back together as a whole. Ask each team to share a summary of key points discussed as well as the points that generated the most discussion during the simulated meeting. Follow up with questions about why they think that those topics were so important to attendee(s).
  5. End the class with an exit ticket where students complete the following two sentences:
    • I used to think what determined a person’s health were…
    • Now, I think…
  6. Optionally, if time allows, ask students to share their responses to the exit ticket questions.
  7. Collect students’ research notes and exit tickets.
  8. Class 3 Evaluation: During the teams’ simulated meeting discussions, teachers can listen to students discussing multiple health determinants as they role play setting the Nursing Service’s priorities for the upcoming year. Teachers also assess students’ understanding of determinants of health with their research summaries for their assigned roles, Annual Meeting Notes, and exit tickets.

Teachers use class and small group discussions, completed notes and worksheets, as well as performance in the simulated meeting for assessing students’ existing and expanding understanding of factors that influence individual and community health—i.e., determinants of health.

  1. Ask students to draft a letter from the perspective of the historical persona they were assigned. The letter could take the form of a fundraising appeal, suggestions for the Visiting Nurse Service, or a letter to the editor of a newspaper about health or living conditions in New York City in the 1930s.
  2. Screen one or more episodes of the award-winning documentary Unnatural Causes: Is Inequality Making Us Sick? and discuss it with students. The filmmakers have detailed discussion guides and resources for each episode available for use on their website.

National Health Education Standards

  • 1.12.3 Analyze how environment and personal health are interrelated.
  • 1.12.6 Analyze the relationship between access to health care and health status.
  • 1.12.7 Compare and contrast the benefits of and barriers to practicing a variety of healthy behaviors.
  • 2.12.2 Analyze how the culture supports and challenges health beliefs, practices, and behaviors.
  • 2.12.7 Analyze how the perceptions of norms influence healthy and unhealthy behaviors.
  • 2.12.8 Analyze the influence of personal values and beliefs on individual health practices and behaviors.

History Content Standards (from the College Board’s AP US History Standards)

  • POL-2.0: Explain how popular movements, reform efforts, and activist groups have sought to change American society and institutions.

History/Social Studies

  • CCSS.ELA-LITERACY.RH.11-12.1: Cite specific textual evidence to support analysis of primary and secondary sources, connecting insights gained from specific details to an understanding of the text as a whole.
  • CCSS.ELA-LITERACY.RH.11-12.5: Analyze in detail how a complex primary source is structured, including how key sentences, paragraphs, and larger portions of the text contribute to the whole.
  • CCSS.ELA-LITERACY.RH.11-12.9: Integrate information from diverse sources, both primary and secondary, into a coherent understanding of an idea or event, noting discrepancies among sources.

Speaking & Listening: Comprehension & Collaboration

  • CCSS.ELA-LITERACY.SL.11-12.1: Initiate and participate effectively in a range of collaborative discussions (one-on-one, in groups, and teacher-led) with diverse partners on grades 11–12 topics, texts, and issues, building on others' ideas and expressing their own clearly and persuasively.
    • CCSS.ELA-LITERACY.SL.11-12.1.C: Propel conversations by posing and responding to questions that probe reasoning and evidence; ensure a hearing for a full range of positions on a topic or issue; clarify, verify, or challenge ideas and conclusions; and promote divergent and creative perspectives.
    • CCSS.ELA-LITERACY.SL.11-12.1.D: Respond thoughtfully to diverse perspectives; synthesize comments, claims, and evidence made on all sides of an issue; resolve contradictions when possible; and determine what additional information or research is required to deepen the investigation or complete the task.
  • CCSS.ELA-LITERACY.SL.11-12.2: Integrate multiple sources of information presented in diverse formats and media (e.g., visually, quantitatively, orally) in order to make informed decisions and solve problems, evaluating the credibility and accuracy of each source and noting any discrepancies among the data.