Implications of Global Health in Population-Based Nursing

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Implications of Global Health in Population-Based Nursing


Irina McKeehan Campbell and Gloria J. McNeal


CORE COMPETENCIES IN GLOBAL HEALTH


The American Association of Colleges of Nursing (AACN) 2005 Task Force on the Essentials of Nursing Education for the doctorate of nursing practice (DNP) has outlined the requirements of DNP practice. Throughout this book, these essentials and core competencies are addressed for multiple advance practice registered nurse (APRN) roles. Particularly relevant to global health issues are Essential V (healthcare policy for advocacy in healthcare), Essential VI (interprofessional collaboration for improving patient and population health outcomes), and Essential VII (clinical prevention and population health for improving the nation’s health). The AACN has formed an interdisciplinary collaboration with the Association of Schools of Public Health (ASPH) to develop global health competencies. There are seven core domains in the public health Global Health Model with concomitant competencies within each skill domain. Domains 1 and 2 concern community engagement, domains 3, 4, and 6 address ethical practice and social justice, and domains 5 and 7 are related to program operation (Association of Schools of Public Health [ASPH], 2011).


Exhibit 11.1 demonstrates how ASPH global health domains 1 to 4 and 6 complement AACN DNP Essentials V to VII. Healthcare delivery to individuals and populations often involves working with programs that cross political and national borders. Global health is an extension of population health. In terms of geographic scale, diseases can affect people across geographic boundaries and specific population aggregates, such as mothers and children or those who have hepatitis or are HIV positive. APRNs who implement the global health domains in practice can play a focal role in developing the models that are proposed by the Global Health Initiative (GHI), Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO), as a means for linking population health with health policy, the containment of infectious diseases, and the elimination of health disparities. The core competencies in global health complement GHI projects in domestic and international programs by promoting the following strategies: capacity strengthening, collaborating and partnering, ethical reasoning and professional practice, health equity and social justice, program management, sociocultural and political awareness, and strategic analysis.


 


EXHIBIT 11.1        ASPH Global Health Competency Model







DOMAIN 1: Capacity Strengthening


Capacity strengthening is the broad sharing of knowledge, skills, and resources for enhancement of global public health programs, infrastructure, and workforce to address current and future global public health needs.


1.1  Design sustainable workforce development strategies for resource-limited settings.


1.2  Identify methods for assuring health program sustainability.


1.3  Assist host entity in assessing existing capacity.


1.4  Develop strategies that strengthen community capabilities for overcoming barriers to health and well-being.


DOMAIN 2: Collaborating and Partnering


Collaborating and partnering is the ability to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication.


2.1  Develop procedures for managing health partnerships.


2.2  Promote inclusion of representatives of diverse constituencies in partnerships.


2.3  Value commitment to building trust in partnerships.


2.4  Use diplomacy and conflict-resolution strategies with partners.


2.5  Communicate lessons learned to community partners and global constituencies.


2.6  Exhibit interpersonal communication skills that demonstrate respect for other perspectives and cultures.


DOMAIN 3: Ethical Reasoning and Professional Practice


Ethical reasoning and professional practice is the ability to identify and respond with integrity to ethical issues in diverse economic, political, and cultural contexts, and promote accountability for the impact of policy decisions on public health practice at local, national, and international levels.


3.1  Apply the fundamental principles of international standards for the protection of human subjects in diverse cultural settings.


3.2  Analyze ethical and professional issues that arise in responding to public health emergencies.


3.3  Explain the mechanisms used to hold international organizations accountable for public health practice standards.


3.4  Promote integrity in professional practice.


DOMAIN 4: Health Equity and Social Justice


Health equity and social justice is the framework for the analysis of strategies to address health disparities across socially, demographically, or geographically defined populations.


4.1  Apply social justice and human rights principles in public health policies and programs.


4.2  Implement strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being.


4.3  Critique policies with respect to impact on health equity and social justice.


4.4  Analyze distribution of resources to meet the health needs of marginalized and vulnerable groups.


DOMAIN 5: Program Management


Program management is the ability to design, implement, and evaluate global health programs to maximize contributions to effective policy, enhanced practice, and improved and sustainable health outcomes.


5.1  Conduct formative research.


5.2  Apply scientific evidence throughout program planning, implementation, and evaluation.


5.3  Design program work plans based on logic models.


5.4  Develop proposals to secure donor and stakeholder support.


5.5  Plan evidence-based interventions to meet internationally established health targets.


5.6  Develop monitoring and evaluation frameworks to assess programs.


5.7  Utilize project management techniques throughout program planning, implementation, and evaluation.


5.8  Develop context-specific implementation strategies for scaling up best-practice interventions.


DOMAIN 6: Sociocultural and Political Awareness


Sociocultural and political awareness is the conceptual basis with which to work effectively within diverse cultural settings and across local, regional, national, and international political landscapes.


6.1  Describe the roles and relationships of the entities influencing global health.


6.2  Analyze the impact of transnational movements on population health.


6.3  Analyze context-specific policy-making processes that impact health.


6.4  Design health advocacy strategies.


6.5  Describe multiagency policy making in response to complex health emergencies.


6.6  Describe the interrelationship of foreign policy and health diplomacy.


DOMAIN 7: Strategic Analysis


Strategic analysis is the ability to use systems thinking to analyze a diverse range of complex and interrelated factors shaping health trends to formulate programs at the local, national, and international levels.


7.1  Conduct a situation analysis across a range of cultural, economic, and health contexts.


7.2  Identify the relationships among patterns of morbidity, mortality, and disability with demographic and other factors in shaping the circumstances of the population of a specified community, country, or region.


7.3  Implement a community health needs assessment.


7.4  Conduct comparative analyses of health systems.


7.5  Explain economic analyses drawn from socioeconomic and health data.


7.6  Design context-specific health interventions based on situation analysis.






Reproduced with permission: Association of Schools of Public Health. (2014). Global Health Competency Model. ASPPH, Global Health Competencies. <http://www.aspph.org/educate/models/masters-global-health/>


This chapter explores the implications, benefits, and barriers of practicing global health for the APRN. The following areas are discussed:



  How geography, climate, and demographic factors influence the causes, transmission, and outcomes of communicable and noncommunicable diseases


  Global health competencies developed by the ASPH and AACN


  Effects of multilevel contexts of global health, population, and individual health


  Relationships between global health competencies and interdisciplinary collaboration


  Health initiatives of pivotal international agencies, such as the United Nations (UN) and the WHO


  Global health educational opportunities that exist for APRNs and doctorally prepared practitioners.


Changing American Demographic Landscape


The demographic landscape of the American population has become more culturally diversified and mobile as immigrants, migrants, and refugees seeking a higher quality of life enter the United States. The number of corporate, business, student, and academic exchanges has also increased in recent decades. The APRN, working on the front lines of primary and preventive care, will increasingly encounter people from other countries. These new arrivals have an increased likelihood of having been exposed to infectious diseases, may lack vaccinations, and may be at high risk for chronic diseases. APRNs, guided by the core competencies, can work with existing stakeholders and international programs to provide optimal health services to both citizens and noncitizens in the United States.


The United States admitted over 600,000 refugees between 2000 and 2011. The United States Immigration and Nationality Act (INA), derived from the post-World War II UN 1951 Convention, defines a refugee as “someone who: is located outside of the United States; is of special humanitarian concern to the United States; demonstrates that they were persecuted or fear persecution due to race, religion, nationality, political opinion, or membership in a particular social group” (Immigration and Nationality Act, 1965). In 2009, there were more than 13 million refugees globally, these refugees live predominantly in the Middle East; Africa; Syria; South, East, and Central Asia; the Americas, and Europe (American Immigration Council, 2014). Many will seek entry into the United States.


The Immigration and Naturalization Act has regulated immigration into the United States with a systematization of various laws since 1921. The act was amended in 1965 as the Hart–Celler Act. This act made changes to the immigration quota system based on country and nationality. It was designed to maintain the same ethnic proportion in the United States as was reflected in the 1920 Census. Asians were excluded from immigration by amendments in the 1924 Act. The 1965 immigration criteria replaced nationality or country-of-origin quotas with requirements for employable skills and reuniting families with connections in the United States. Before 1965, immigrants accounted for 10% of the American population. This changed to 30% in 2000 and 37% in 2010. The distribution of the census-designated Hispanic White population increased from 25% in 1990 to 37% in 2011 (Immigration in America, n.d.).


The 2012 Census revealed that out of nearly 308 million Americans, 40 million were foreign born, including 22 million noncitizens. Of these, 1.4 million were unemployed and nearly 5.5 million lived below the federal poverty level (U.S. Census, 2012). The 2007 American Community Survey enumerates the non-English languages spoken in the United States and the level of proficiency in English. This survey identified that 55.4 million people, 5 years of age and older, spoke a language other than English at home, and 4.5 million did not speak English at all (Kominski, Shin, & US Census Bureau 2010). Such diversity in the population, with an increased rate of mobility across international borders, presents challenges for the APRN.


In 2009, U.S. immigration agents detained over 3,000 children at the Southwest border, and in 2011, 6,000 children crossed the southern U.S. border illegally. There were estimates that nearly 90,000 children would enter without permission in 2014 (Hirsen, 2014). Government services provided to undocumented immigrants include housing, public education, emergency and other healthcare. New York taxpayers paid over $147 million, Texas $78 million, and California $64 million for educational school programs for undocumented children (Federation for American Immigration Reform [FAIR], 2014). As of March 2012, nearly 12 million unauthorized immigrants were living in the United States, and state health programs have funded approximately $2 billion/year for emergency treatment of undocumented immigrants, although federal law prohibits undocumented immigrants from receiving Medicaid (Kaiser Health News, 2013; Pew Research Center’s Hispanic Trends, n.d.).


APRNs need to be familiar with federal policies that bar hospitals from asking about citizenship before providing services. The 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which is part of the Consolidated Omnibus Budget Reconciliation Act (COBRA), stipulates that hospitals deliver emergency healthcare to everyone, regardless of national origin, legal status, or ability to pay (42 U.S.C., n.d.). Such care is uncompensated at the hospital and state level, unless Medicaid funds are appropriated for various population health programs to cover charity care.


Twenty-first-century advances in communication, trade, transportation technologies, and scientific exchanges bring health issues from other continents to the threshold of the American urban and community hospital. These advances are accompanied by national security concerns, as was acutely evident with the 2014 Ebola outbreak in West Africa. APRN population-based practice has daily relevance as people bring their national, environmental, socioeconomic, and cultural contexts with them whenever they visit their healthcare provider. APRNs, who encounter individuals from other countries, need to understand and become familiar with programs or policies addressing the complex global factors influencing the context of individual and population health.


Health as an International Phenomenon

Individual health is embedded in the larger socio-ecological context of the global community. Not only does each individual’s health status affect others, but also the health of one group in a society can influence the welfare of other groups, as was evident in the 2014 Ebola outbreak. The importance of maintaining health in populations was also exemplified in the measles outbreak of 2014 to 2015. The spread of preventable disease again revealed the importance of vaccination not only nationwide but worldwide. This led to an increasing need for reinforced education regarding the evidence behind vaccination. The diffusion of medical technology and evidence-based practice can positively affect a nation’s health, much as the spread of infectious diseases can affect it adversely. The reform of international health systems to better address these issues was facilitated by the recognition of healthcare as a universal human right after World War II.


Article 25 of the Universal Declaration of Human Rights (UDHR) stipulates that all people have the right to a standard of living that guarantees health. This article was adopted by the UN Charter of 1948. In 1960, the UDHR further specified health as the highest attainable standard of physical, social, and mental well-being rather than as solely the absence of disease. Health, according to the UDHR, is achievable through the promotion of maternal and child health, reduction of mortality and morbidity, improvements in environmental sanitation, and the provision of adequate medical services (United Nations, n.d.). The UN reaffirmed health as an intrinsically valuable end by emphasizing that poor health is caused primarily by poverty and environmental conditions. A 1978 WHO conference held in Alma-Ata, Kazakhstan, a republic of the now former Soviet Union, supported the global issue of equity through accessibility to health for all, by recommending the implementation of primary healthcare and disease prevention strategies in national policies (Campbell, 1995).


The human rights movement in health, which raised the issue of equity in health status, tied universal access to comprehensive medical and health services for different social groups. Universal access implies the availability of services to all individuals and groups. Evaluating the distinctions between individual medical care and public healthcare becomes important as a means of monitoring health status, measured by indicators of equity and quality of care. Equity in access does not automatically lead to equity in health status. Equity in health status among social groups is constrained by the macro social process of the delivery of healthcare, as well as by the sociocultural, economic, and political arrangements of the community in which the delivery system functions. Global health programs have initiated various strategies to resolve these social determinants of health, increase access to basic health services, and achieve equity in outcomes.


Social Determinants of Health

The WHO conceptual framework for social determinants of health identifies five multifactorial components of population health that impact health outcomes: biology and genetics, individual behavior, social environment, physical environment, and health services. This framework accounts for the interrelationships among the determinants of health interactions; their influence on inequities; and the sociopolitical and economic influences on structural, social, and intermediary constructs affecting health and well-being (Solar & Irwin, 2010). The status of the health of a nation is an international phenomenon that is embedded within the larger socio-ecological, cultural, and political context of the global community. Arguably, the United States is the most technologically advanced country in the world, with internationally renowned medical centers and cutting-edge treatment modalities that are grounded in the tenets of Western medical scientific research. Yet among civilized nations, its healthcare outcomes, especially for preventable diseases and access to health services, lag far behind those in its counterparts with regard to multiple indicators, including infant mortality (ranked 25th) and life expectancy (ranked 23rd; Marmot & Bell, 2011).


Multilevel Model of Global Health

The growth of population-based nursing not only illustrates the need for further documentation of ethnocultural variation in health outcomes but provides an equally important mandate to translate clinical research into culturally competent programs. Population health is an emerging paradigm, differentiated from global health not only by scope but also by a focus on which groups are susceptible or at greater risk for specific diseases. Global health, on the other hand, provides a broader perspective on the extent to which the complex relations of macro structural factors of health determine the distribution of population-level and individual-level health outcomes. Macrofactors of salience explain how the environment, education policy, information technology, ethnic diversity and health disparity, geographic, socioeconomic factors, and inequities affect disease transmission and the delivery of health services across national borders.


To promote a greater understanding of the links among individual health, population health, and global health, the U.S. government has developed programs that address such relationships, domestically and abroad. The best practices and lessons learned from global health programs, such as the GHI, have demonstrated that the more acute issues visible in global environments are also relevant in the domestic context. Since GHI was legislated as a national priority in 2009, government agencies have sought to address global health challenges that may compromise well-being at home and around the world. The GHI seeks to align national security interests through collaboration with global partners to strengthen aid effectiveness. However, effectiveness in health promotion and disease prevention depends on aligning the dominant models of health, from individual clinical assessment to accessing primary care, and from population attributable risk assessment to ecological and multilevel models of health.


 


FIGURE 11.1        Micro- and Macrofactors in Obesity as Health Outcomes


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BPA: bisphenol A; HPA: hypothalamic–pituitary–adrenal axis.


Note: The life span is horizontal; factors are depicted hierarchically, individual level at the bottom of the figure to community level at top of the figure.


Source: National Research Council and Institute of Medicine (2013).


Multilevel models of global health (Figure 11.1) take into account the emergent properties of social structure, such as cultural norms, poverty, social policies, and distribution of primary care physicians, in conjunction with microlevel properties, such as genetics, gender, ethnicity, educational level, and individual health behaviors. Context or emergent properties of structure at each level refer to those characteristics that exemplify aspects of the whole unit of analysis and not the separate components of that unit. Whole units, such as population groups or health systems, have distinct properties other than the sum of their individual parts. Contextual analysis can explain the influences that a unit has within a hierarchy, and multilevel analysis can focus on multiple hierarchies of units within the same model. The individual is part of a family, ethnic group, social network, community, political group, geographic area, and country. It is a central objective in the population health perspective of healthcare to assess the context in which macro- and microunits change, given the complex nesting of individuals within social groups and cultures (Campbell, 2004, 2006; McKeehan, 2000).


Effective population health strategies aim at identifying groups at risk and specific risk factors causing poor health. Emergent properties of social structure are often not considered as determinants of health by medical practitioners. Health-promotion policies may develop two distinct intervention strategies by which health risks can be reduced for vulnerable groups as well as for the general population: (a) high-risk interventions, such as tertiary care (e.g., specialized consultative care; medical technology or surgery), which reduce high risks for a small number of individuals; and (b) population risk interventions, such as primary prevention (e.g., prohibiting lead in consumer paints, seat belt requirements), which reduce pervasive low risks for large sectors of a population (Primer on Public Health Population, n.d.).


Application of both intervention strategies is necessary to avert the “prevention paradox”; that is, individual-level interventions affect community health minimally, whereas community-level interventions have limited impact on high-risk individuals. The “prevention paradox” is paralleled by the “risk intervention paradox”; that is, the mass exposure of a large number of individuals to low levels of negligible risks, such as trans fats, may produce a larger number of disease cases than a small number of individuals exposed to high risks, such as BMI (body mass index) >35. Treating only very sick individuals leaves scarcely sick populations with minimal health treatment.


Preventing disease by shifting the population distribution of specific disease risks may be more productive than treatments directed only toward high-risk individuals. “For instance, estimates suggest that in North America a 14% decrease in the number of cerebrovascular accidents could be achieved either by decreasing the average blood pressure by 2 mmHg or by successfully treating everyone with a diastolic pressure of 95 mmHg or greater” (Association of Faculties of Medicine of Canada, n.d., para 2). Mass prevention reduces negligible risk a little for many and not at all for some, whereas most derive at least minimal benefits.


The prevention paradox proposes the concept that population health policies are developed for sick populations rather than for sick individuals, a cost borne by the “healthier” community. Global health intervention differs from medical intervention foremost in its emphasis on the socio-environmental context of individual health status. Second, global health recognizes that a continuous distribution in health status, such as blood pressure, characterizes populations. Third, global health programs are not restricted by focusing solely on the clinical designation of individuals, as potential cases for treatment, with or without disease.


A clearer understanding of global health identifies the differences in individual health, while retaining the ethnocultural context experienced by people. The multilevel model of population and global health enables the identification of health differences between individuals and between social groups. It also identifies specific structural conditions in the community that affect the health of people living there. Last, it separates the structural and ethnocultural determinants of health from the effects of individual psychosocial and health behaviors on health outcomes. For example, health disparity is part of the community context within which people live: country of origin, ethnicity, and cultural values are group characteristics. But ethnocultural factors are almost always measured at the individual level, a misspecification of the research model. The domain of preventive strategies in community health is the at-risk population as a whole and that of clinical medicine is the at-risk individual.


A multilevel evaluation of global health, therefore, gauges negligible and high-risk factors at both the population level and the individual level. As abundant research has shown, individual lifestyle behaviors, given a specific level of socioeconomic development, account for a majority of the risk factors for general well-being. A major issue is to determine which risk factors are amenable to policy interventions. Mass levels of low exposure require a mass level of intervention even if the impact is negligible, because the community will benefit as a whole, and subsequently individual members will benefit. The risk factors, which affect individual health, are not the same at the community level. Population health policy, therefore, needs multilevel research strategies that include the sui generis properties of communities and their attendant risk factors. These community properties cannot be reduced to a collective aggregate of its individual members. Access to health systems and geocultural environments may be designated as structural properties of communities rather than of individuals, and as such are the community context in which individuals live. GHIs tend to emphasize structural community factors to improve health outcomes, as is discussed in the section on the UN Millennium Development Goals.


Improvements in the quality of life depend in large part on the development of a model of health that puts the individual back into the community context. Personal risks to health under control of the individual (amount of daily sugar or salt intake) and social risks to health not directly controllable by the individual (a clean water supply) are embedded in a larger community context. Effective global programs sift through such causal complexity, expanding the biomedical model of disease to an ecological multilevel model of health.


Global health programs promote information initiatives to connect systems capable of supporting a broad range of public health functions: disease detection, surveillance, analysis, interpretation, alerting, and interventions. For example, in the WHO Health Report, “the term ‘health services’ is used to include promotion, prevention, treatment and rehabilitation. It includes services aimed at individuals (e.g., childhood immunization or treatment for tuberculosis) and services aimed at populations (e.g., mass media anti-smoking campaigns)” (WHO, 2007, p. 11).


Evaluating public health risk factors at multiple levels is even more relevant in global health in which community and cultural contexts vary significantly across geographic regions. Modifiable community factors have a direct effect on health, separately and independently from the effects of nonmodifiable individual factors and modifiable individual lifestyle practices. Individual behavioral solutions may be sought for population-level issues, when attributing or generalizing individual characteristics to the group. In designing or implementing large-scale health programs, the APRN should be aware that both individual and community contextual factors, including geographic locators, should be systematically included in public health education and research, to design effective programs (Campbell, 1995).


An effective APRN-administered population health program considers several factors:



As part of planning a population-based program, APRNs should assess which modifiable community factors have a direct effect on health, separately and independently from the effects of modifiable individual lifestyle behaviors and nonmodifiable individual demographic factors.


National Global Health Initiatives

The U.S. administration has spent over $60 billion to increase access to health services in global programs and to ensure national security since 2009. The Obama GHI prioritizes a three-pronged health strategy to contain infectious diseases and foster national security. This includes initiatives to protect communities from infectious diseases, eliminate AIDS in the new generation, and prevent child and maternal mortality (U.S. Government Interagency Website, 2014). Although infectious diseases still abound and new outbreaks of such diseases as Ebola, SARS (severe acute respiratory syndrome), and H1N1 threaten national security, vaccine-preventable diseases have been nearly eliminated in the United States. At the time of this publication, however, measles infections have reached their highest numbers (since the resurgence of 1989–1991) in the United States because of unvaccinated immigrants entering the United States and, more recently, because of inconsistent vaccination practices and parental refusal of vaccines altogether. APRNs have a role in shaping public opinion and have many opportunities to improve population health through health promotion, education, and research (see www.cdc.gov/vaccines/pubs/pinkbook/meas.html for more details about measles). Public health programs and health education, for example, have successfully contained the HIV epidemic, and many preventative programs in the United States focus on chronic diseases. Until the 20th century, communicable diseases were the singular cause of mortality, but chronic diseases now top the list. The smallpox vaccine was responsible for preventing nearly 2 million annual deaths around the world by 1980. In the 1950s, polio crippled about 35,000 children in the United States annually, but was largely eradicated through vaccination by 1979. However, several other countries, such as Afghanistan, Nigeria, and Pakistan, with absent or low vaccination rates, continue to experience high polio rates. Polio is currently spreading in the war-torn countries of Syria, Djibouti, Eritrea, Ethiopia, and Somalia (Centers for Disease Control and Prevention, n.d.-b). Another example of a preventable infectious disease is meningitis A. Although largely controlled in the United States, over 100,000 people died of meningitis A in the 1990s across Africa, spurring the CDC, the U.S. Agency for International Development (USAID), and the National Institutes of Health (NIH) to develop an affordable vaccine, MenAfriVac, for distribution. More recently, millions of dollars have been invested in a critical search for a safe Ebola vaccine. Phase-I clinical trials were successful in November 2014 (National Institutes of Health, n.d.). Such quick collaboration among national groups underscores the critical role that the United States plays in global health, as well as the interconnections between national security and public health.


Healthy People 2010 outlined national health goals for America but did not include global health as an issue. Following the 2003 SARS epidemic and 2009 H1N1 flu outbreak, Healthy People 2020 added a new global health goal “to improve public health and strengthen U.S. national security through global disease detection, response, prevention, and control strategies” (Healthy People 2020, n.d.). The 2014 Ebola outbreak demonstrates how the Healthy People 2020 connections between American health status and global developments are relevant. Diseases prevented with vaccinations are the cause of one of every five deaths among children younger than 5 years in underdeveloped countries. For example, measles was largely eradicated by 2000 in the United States, but in 2013 there were 175 cases, almost entirely because of people bringing the disease with them into the United States, where an increased number of families are choosing not to vaccinate their children, reducing the strength of herd immunity (CDC, 2014). Healthy People 2020 and the Institutes of Medicine (IOM) advocate a focal role for the United States in increasing the global capacity for establishing an infectious disease surveillance system to protect U.S. national security and to prevent the cross-border spread of diseases.


Many U.S. government agencies provide funding, human resources, and technical support to international health agencies and initiatives, including UN’s Millennium Development Goals (MDGs); WHO Global Polio Eradication Initiative; President’s Emergency Plan for AIDS Relief (PEPFAR); and CDC programs to address malaria, neglected tropical diseases (such as Ebola), and tobacco use. The U.S. administration’s health strategy in 2014 recognizes noncommunicable diseases as a leading cause of mortality globally and the second major problem faced by the United States in health-promotion and disease prevention projects. Africa is an exception, because it must still address infectious diseases as a health priority. The GHI invested $63 billion over 6 years to help partner countries improve health outcomes through strengthened health systems, with a particular focus on improving the health of women, newborns, and children. In addition, by November 2014, there was a $6.2-billion appropriations request before Congress to fight Ebola in West Africa (Senate Appropriations Committee, n.d.), and the CDC funded $2.7 million for personal protective equipment (PPE) kits to help American hospitals and to augment the Strategic National Stockpile. The Department of Homeland Security (DHS) issued travel restrictions in October 2014 on flights to the United States from Liberia, Sierra Leone, and Guinea. All flights from these three West African countries were directed to fly to one of only five airports with screening protocols in place: New York’s JFK, Chicago’s O’Hare, Atlanta’s Hartsfield-Jackson, Newark’s Liberty, and Washington’s Dulles. Although the WHO continues to issue alerts for changing incidence and mortality rates attributed to Ebola by country, the U.S. Department of Health and Human Services (HHS) instituted new travel regulations to the United States, restricting entry to anyone either sick or exposed to Ebola from Guinea, Liberia, or Sierra Leone on November 12, 2014 (National Association of EMS Physicians, 2014). The CDC and professional associations have also invested in developing education programs for health practitioners to ensure the safety of clinicians by updating protocols on patient treatment and monitoring of Ebola patients as well as developing nationwide hospital and outpatient clinic surveillance systems (AACN, 2014; American Medical Association, n.d.). The U.S. military was deployed to West Africa as part of humanitarian aid to deliver supplies and equipment and to build temporary hospitals, developing the health infrastructure required to contain the Ebola crisis (The White House, 2014).


United States and the Global Health Gap

Mortality differences among nations have been associated with various theories of health disparities between populations and countries, some of which are dependent on policy. This is an extensive list that includes socioeconomic transformation, environmental pollution, lack of an adequate social safety net, relative poverty, socioeconomic deprivation, historical and generational effects of a political heritage, regional disparities, and psychosocial stress. Other perspectives emphasize individual lifestyle such as poor health practices and violent behavior. The United States has the highest standard of living in the world, yet health indicators lag behind those of European and other high-income members of the Organization of Economic Cooperation and Development (OECD). OECD member countries control 80% of global trade and investments. The Organization for European Economic Cooperation was formed after World War II to support the reconstruction of Europe. Canada and the United States joined in 1960, establishing the OECD in 1961. Japan joined in 1964. As of 2014, there were 40 OECD countries, which participate in discussing solutions to world economic and health problems (OECD, n.d.-b).


The relationship between average income, whether gross domestic product (GDP) or per capita, and life expectancy is attenuated after a certain standard of living is achieved, as has been the case in market economies in OECD countries. Average income is weakly related to mortality within wealthier countries, such as the United States. However, the relative distribution of income, rather than average income, is more strongly associated with differences in death rates within wealthy countries. This is due to the relative deprivation of some population sectors and not others because of an uneven distribution and concentration of resources (Campbell McKeehan, 2000).


Figure 11.2 illustrates that life expectancy is higher in countries with more egalitarian distributions of income, such as those of Scandinavia, where relative deprivation is less pronounced. The effect of average income on the life expectancy of men and women in Western economies of OECD countries is consistent with a relationship between wealth and health. Health disparities increase with comparative income disparities relative to various groups having different income levels (OECD, n.d.-a). Health outcomes appear to be more closely related to how national health systems are organized than to the size of health expenditures, which are inflated by multiple private for-profit interests. In the United States, the growth in the cost of health services is not related to a concomitant growth in better health status of the population (Frenk, 2010). A study of hospital administrative costs in eight countries found that the United States has the highest costs, with 25% of U.S. hospital spending going to salaries for staff responsible for coding and billing, among other administrative costs. The Netherlands was second highest, spending 20% on administrative costs, followed by England at 16%, and Canada at 12% (Himmelstein, Jun, Busse et al., 2014).


 


FIGURE 11.2        Total Expenditure on Health as a Percentage of the Gross Domestic Product, 2012


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OECD (2013) statistics indicate that the total health expenditure of the United States in 2011 was 16.9% of the GDP and $7,662 per capita, as compared to total OECD expenditures of 9.3% of the GDP and $2,867 per capita. The United States had double the expenditure per capita ($885) for pharmaceuticals of all the OECD countries ($414) in 2011. Nonetheless, the life expectancy at birth in the United States was 78.7 years versus 80.1 years in the OECD. In 2011, life expectancy at birth for U.S. men was 76.3 and for men in OECD countries was 77.3. Although the difference in life expectancy between the United States and other OECD countries is less than 2 years, health expenditures are almost double in the United States. Recent economic research (Lorenzoni, Belloni, & Sassi, 2014) indicates that most of the growth in differences of health expenditure between the United States and OECD was due to private health sector prices, particularly pharmaceuticals, and not due to growth in provider health delivery or performance (OECD, 2013).


Health sector costs are the most important component of U.S. health expenditure growth. The authors note that the “staggering levels of expenditure” in the United States cannot be fully explained by higher wealth levels, the age structure of the U.S. population, or the larger prevalence of risk factors such as obesity. Instead, “high health sector prices are due to intense use of health-related technologies, low productivity, decentralized price negotiations, fragmentation in the insurance market, and a high level of provider concentration, as the main explanations for high spending” (Center Lorenzoni, Belloni, & Sassi, 2014, p. 84; OCED, n.d., para 7). A positive relationship between health sector prices and better health outcomes (Figure 11.3) has not been established for the United States, as comparative global health indicators demonstrate (Lorenzoni et al., 2014; OECD, 2015.).


An international comparison of U.S. health status with those of other high-income countries (National Research Council & Institute of Medicine, 2013) demonstrates that the United States had lower health outcomes on at least nine indicators: infant mortality and low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted infections, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability. These poorer health outcomes in America are attributed to several lifestyle and health system factors: a large uninsured population, barriers to accessing primary care, likelihood of having a BMI >29, and physical inactivity. The lack of primary care practitioners in the United States is notable, given that most chronic diseases are preventable (Figure 11.4). An international OECD survey found that the United States had the lowest ratio of general practitioners out of all physicians in 2009, when compared to 15 other high-income countries. The United States also has a large sector of the population living below the federal poverty level and significant income inequality, both related to poor health status.


American National Security and Global Health

Although Americans have a comparatively poorer health status than peer countries, federal initiatives, such as Healthy People 2020, try to address these health disparities. Healthy People 2020 includes the global health goal of strengthening U.S. national security by detecting, preventing, and controlling global diseases. The U.S. government, through the USAID and the CDC, actively collaborates with global health agencies and participates in global, regional, and country-specific public health programs. The two focal organizations are the UN and the WHO. The mission of the USAID is to work with governmental and nongovernmental agencies, as well as the military, providing foreign assistance to resolve and prevent instability or active conflicts around the world. The USAID works to ensure domestic security by investing in health systems, democratic institutions, and agricultural advances (U.S. Agency for International Development, n.d.-a).


 


FIGURE 11.3        Deaths from noncommunicable diseases and all causes (deaths per 100,000 age adjusted), 2008.


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Source: The National Academies. (2013). U.S. health in international perspective: Shorter lives, poorer health (p. 5).


 


FIGURE 11.4        General practitioners as a proportion of total doctors in 15 peer countries, 2009.


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Source: National Research Council and Institute of Medicine. (2013). General practitioners as a proportion of total doctors in 15 peer countries, 2009. In S.H. Woolf & L. Aron (Eds.), U.S. health in international perspective: Shorter lives, poorer health (p. 116). Washington, DC: The National Academies Press. Retrieved from http://www.nap.edu/openbook.php?record_id=13497


The Foreign Assistance Act of 1961, supported by President Kennedy, formed the USAID from several post-World War II foreign assistance programs. The USAID was responsible for promoting development by administering aid to other countries. Recently, the USAID has focused primarily on preventing hunger, promoting women’s education and health, and population planning around the world as a means to curtail political conflicts. These efforts have also entailed supporting free market economic growth, nongovernmental organizations (NGOs), and antipoverty programs. The USAID, as the main government agency tasked with ending extreme poverty and building democracy abroad, was responsible for helping to rebuild Afghanistan and Iraq by building social safety nets with healthcare and education programs in the region (USAID, n.d.-b).


The USAID has spearheaded U.S. technical and financial aid to increase health and economic self-sufficiency in the developing world through polio eradication, family planning, and maternal and child health programs. The U.S. President’s Emergency Plan for AIDS Relief and President’s Malaria Initiative are successful programs that have significantly impacted the incidence and prevalence of these infectious diseases. HHS launched the GHI in 2009 to integrate multiple government programs with global partners, as well as to cooperate with the WHO in health-promotion and disease prevention efforts.


 


EXHIBIT 11.2        USAID Global Health Program Outcomes


Jul 2, 2017 | Posted by in NURSING | Comments Off on Implications of Global Health in Population-Based Nursing

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