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 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.

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.

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.

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).

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.

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

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.

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).