GLOBAL HEALTH DISPARITIES

by Group 5 (Ortega, Padilla, Pagente, Panollera, Potot)

Global Health Disparities

As is the case within each individual country, there are large disparities in health and well-being
at the global level, which result from complex political and economic processes. Differences in
health and well-being between countries are difficult to measure. The most commonly used gross
measurements of health are morbidity, which measures illness, and mortality, which measures
death; these measures are generally used with regard to a specific disease, such as diabetes.

Greatest Burden of Mortality from Diabetes:

● Mexico
● Central and South America
● Africa
● South Asia
● Southeast Asia

Maternal Morbidity and Mortality due to Preventable Diseases: sub-Saharan Africa

Mortality due to cancers: Industrialized countries such as the United States

The Changing Landscape of Global Health

Over the past 50 years, significant efforts have been made to improve the well-being of people
living in low-income countries. These efforts, including maternal and child health interventions,
water and sanitation improvements, and HIV/AIDS prevention and treatment, have resulted in a
reduction in morbidity and mortality due to infectious diseases and childbirth. The causes of
death in countries at the extremes of national income are still very different, but as national
income increases, causes of morbidity and mortality begin to approximate those of industrialized
countries (GBD 2013 Mortality and Causes of Death Collaborators, 2015).

As deaths due to infectious diseases and maternal mortality decline, people are living longer
around the world: life expectancy at birth has increased by 6 years since 1990, with the largest
increases in low-income countries. Noncommunicable diseases are a more important cause of
years lost of life than they were in 2000; this reflects successes in managing communicable
diseases, and neonatal, infant, and child mortality (World Health Organization, 2014).

The three major causes of death globally, are now ischemic heart disease, stroke, and chronic
obstructive pulmonary disease, which make up 32% of all deaths (GBD 2013 Mortality and
Causes of Death Collaborators, 2015). Childhood obesity is increasing: globally, the prevalence
of overweight and obese children has grown from around 5% in 1990 to 7% in 2012. In Africa,
the number of overweight children increased from 4 to 10 million over the same period (World
Health Organization, 2014).

Nurses around the globe need to develop new and appropriate skills to meet the needs of an older
population with a greater incidence of chronic disease, while still maintaining the ability to
combat acute conditions such as diarrheal disease and lower respiratory tract infections that
continue to threaten the lives of children.

MILLENNIUM DEVELOPMENT GOALS

In 2000, leaders of countries around the world met at the United Nations to define and com-mit
to a systematic approach to reduce extreme poverty. This commitment, laid out in the United
Nations Millennium Declaration, was organized under eight goals known as the Millennium
Development Goals (MDGs).

The 8 Millennium Development Goals

1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.
3. Promote gender equality and empower women.
4. Reduce child mortality.
5. Improve maternal health.
6. Combat HIV/AIDS, malaria, and other diseases.
7. Ensure environmental sustainability.
8. Develop a global partnership for development.

The eight MDGs have been used by countries and development institutions around the world to
guide efforts to mitigate poverty, hunger, and disease (United Nations, n.d.).

Three of the MDGs relate directly to global health: Goal 4: Reduce Child Mortality; Goal 5:
Improve Maternal Health; and Goal 6: Combat HIV/AIDS, Malaria, and Other Diseases.

Reduce Child Mortality

One of the targets under Goal 4 is to reduce the under-five mortality rate by two-thirds. Although
this target is not on track to be met by 2015, the under-five mortality rate declined by 47%
between 1990 and 2014, and 19% of participating countries have achieved the target in their
country as of December of 2014 (United Nations,n.d.).

Research has shown that the declines in under-five mortality during the period from 2000 to
2015 can be attributed, at least in part, to development assistance and the effects of interventions
aimed at reaching the MDGs. Specific interventions that have contributed to success in this area
are reduction of mother-to-child transmission of HIV, government policy changes, increased
development assistance for health, and health system strengthening. Another important factor in
increased child survival is maternal education, which matters more than income. High fertility
rates that have continued in some countries limit gains in this area, making expansion of
contraception programs a priority for child survival goals.

Moving forward, reaching MDG 4 will require continued investments in maternal education,
income growth, and the development and application of new health technologies

In addition to their typical clinical roles in community health centers and hospitals, local nurses
also play a large role in child survival programs, including the following:
 ● Integrated management of childhood illness
● Immunization techniques and promotion
● Early postnatal visitation
● Managing and monitoring local child survival activities
● Capacity building and supervision of community health workers
● Delivering maternal and child health and child survival home care services, including
prenatal outreach
● Education about and promotion of reproductive health and family planning techniques
● Promotion of breast-feeding

Improve Maternal Health

Goal 5. Improve maternal health is supported by two targets:
Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
Indicators
5.1 Maternal mortality ratio
5.2 Proportion of births attended by skilled health personnel
Target 5.B: Achieve, by 2015, universal access to reproductive health
Indicators
5.3 Contraceptive prevalence rate
5.4 Adolescent birth rate
5.5 Antenatal care coverage (at least one visit and at least four visits)
5.6 Unmet need for family planning
Although the number of women dying due to complications during pregnancy and childbirth has
decreased significantly—by 50% since 1990—this target is not on track to be achieved at the
global level by 2015. These deaths, 99% of which happen in low- and middle-income countries.

Availability of essential obstetric services alone does not guarantee good outcomes; outcomes
are highly dependent on the quality of the interventions provided. Obstacles in meeting these
targets include delayed or inappropriate implementation of interventions, inflexible health care
scope of practice hierarchies, failure to prevent and treat infection, and failure to recognize the
severity of the maternal condition in a timely fashion.

Nurse–midwives play an important role in reducing maternal mortality by providing

· evidence-based prenatal care and delivery care. Nurses also have a role in health
promotion, encouraging the use of skilled birth attendants, repatterning or negotiating
potentially harm- ful cultural practices, recognizing danger signs during pregnancy
and childbirth, and promot- ing family planning methods (Joshi, Sharma, &
Teijlingen, 2013).
 · Nurses collaborate with profes- sional midwives and community health workers to
encourage pregnant women to get appropriate prenatal care (Amieva & Ferguson,
2012). As the patient advocates, nurses can ensure that mater- nity care is available
and accessible to all segments of the population (Amieva & Ferguson, 2012).

Combat HIV/AIDS, Malaria, and Other Disease

The three targets for Goal 6 are:

● 6.A: have halted by 2015 and begun to reverse the spread of HIV/AIDS

● 6.B: achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it

● 6.C: have halted by 2015 and begun to reverse the incidence of malaria and other major
diseases (United Nations, n.d.)

New infections with HIV have been decreasing globally since the development of the MDGs,
and with increased access to ART, people are living longer with HIV. Each year, fewer people
die of HIV/AIDS. Although treatment is still far from universal, it has expanded, with ART
delivered to 9.5 million people in 2012 alone.

New cases of tuberculosis (TB) have been declining for over 10 years, with mortality from TB
falling 45% since 1990. An emerging threat to this achievement is the emergence of multidrug-
resistant TB.

The incidence of malaria has fallen by 25% globally, 31% in the WHO Africa region, and
mortality due to malaria has decreased by 42% globally. The incidence of and mortality related
to neglected tropical diseases have also declined, and leprosy has been eliminated from 119 of
the 122 countries where it was previously endemic.

Dengue fever, however, continues to grow, frustrating efforts at eradication (World Health
Organization, 2014).
The HIV/AIDS epidemic that began in the 1980s galvanized global public health action; few
public health crises have led to as many health care innovations. While prevention through
education and treatment with ARTs remain mainstays of the battle against HIV, new approaches
to prevention, care, and treatment are showing promise.

The WHO strategy promulgated in 2010 for prevention of mother-to child transmission
(PMTCT) of HIV promotes a

comprehensive approach with four components:

● primary prevention of HIV infection;

● prevention of unintended pregnancies among women living with HIV;
● prevention of HIV transmission of a woman with HIV to her infant;
● and provision of appropriate treatment, care, and support to mothers living with HIV and
their families (WHO, 2010).

Critical to prevention and treatment of HIV is timely identification of HIV-positive individuals

and counseling of all patients regarding their HIV status.

Since 2007, the WHO and its partner organizations and ministries of health around the world
have promoted voluntary medical male circumcision (VMMC).VMMC programs have
contributed to the development of innovative circumcision methods, such as devices that do not
require injected anesthesia or sutures, and also provide an opportunity for reinforcement of HIV
prevention messages and HIV counseling and testing; such interventions are critical. An area that
continues to evolve in HIV prevention is preexposure prophylaxis using tenofovir (PrEP).

Nurses play an enormous role in HIV/AIDS prevention, care, and treatment, especially in this era
of increasing task shifting. In addition to traditional roles in health promotion and education,
nurses are taking responsibility for initiating and managing ART and providing VMMC services.

KEY CONCEPT IN GLOBAL HEALTH AND INTERNATIONAL NURSING

When working internationally, nurses should be aware of certain guiding concepts that have
come to form the basis of global public health work, particularly partnership and sustainability.

● Partnership is the idea that development is not a package delivered by experts but rather
collaboration among peers with complementary and equally important expertise.
● Sustainability is the idea that interventions should be easily maintained by the target
community or country after outside support has ended.
● Availability, the presence of a product or service in a community;
● Accessibility, the ease of obtaining a product or service;
● Acceptability, the degree to which the product or service is culturally and social
appropriate, also have an impact on the success of global health interventions.

The most exciting innovations and effective projects are the result of what is known to
some as South–South partnerships, where professionals from lowincome countries share their
knowledge and solutions directly with one another.

PARTNERSHIP

In the arena of global public health, visiting nurses work alongside local nurses to
develop evidence-based solutions to local problems. Expatriate nurses contribute their unique
perspectives, experiences, and education, while local nurses contribute their insider
understanding of the national health system and local cultures. Effective partnerships between
foreign and local nurses can result in creative, evidence-based, appropriate, and sustainable
solutions to local healthcare challenges.

Leffers and Mitchell (2011) developed a conceptual model to guide nurses in

establishing productive partnerships for global health that builds on community-based
participatory research and public health.

● According to this model, a variety of factors must be considered when visiting

nurses partner with local nurses and other health care professionals.
● Visiting nurse factors include cultural perspectives, personal attributes, personal
expectations, and knowledge of the host country.
● Host partner factors include expectations of the visiting nurse and the impact of
social, economic, environmental, and political status of host country wants or
needs.
● Critically, the model points out that “past experience with colonialism,
subjugation, and being powerless in similar settings will influence the willingness
of host community partners to engage with the (visiting) nurse partners.”

PROCESS FOR PARTNERSHIP

Engagement, the first step of partnership development, is a two-way (visitor–host) process

characterized by cultural bridging, collaboration, capacity building, and mutual goal setting.

● Cultural bridging relies upon the visiting nurse’s openness to the experience of the host
country and host partners, and involves crosscultural communication, mutual respect, and
mutual learning.
 ● Collaboration requires the development of teamwork based on the needs of the host
partners, respect for the constraints faced by host partners, and the resources available to
the visiting nurse and the host partners
● . Capacity building refers to contributions made by the visiting nurse to improving the
education, institutions, or leadership of the host community and partners, which
empowers them to take leadership of the project and facilitates sustainability.
● Mutual goal setting allows the visiting nurse and host partners the opportunity to tie
together their mutual interests, diverse resources, and diverse capacity toward a shared
desired outcome that guides their work together

SUSTAINABILITY

● The concept of sustainability means that once a project is completed, its results can be
maintained by the community or government without further outside input.
● According to the Leffers and Mitchell model, seen in Figure 15-3, the partnership
developed influences program factor inputs, which, together with the partnership, impact
project processes.
● In sustainable projects, these factors contribute to positive outcomes (Leffers & Mitchell,
2011).
● Program factor inputs include design and implementation, organizational
setting/resources, and the broader host community.
- Design and implementation of a project begins with effective community
assessment, during which time the project implementation team and
participants identify needs, existing infrastructure, traditional and
professional health care practices, community strengths, and community
leader’s/opinion leaders.
- The organizational setting includes an assessment of the resources available
for project implementation and sustainability.
FOUR PROCESS THAT CONTRIBUTE TO SUSTAINABILITY

Leffers and Mitchell identify four processes that contribute to sustainability:

1. adaptation and change,

2. ongoing assessment,
3. leadership, and
4. collaboration

Availability, Accessibility, and Acceptability

● Availability means that a product or service exists within the country or community in
question. Availability depends on registration, quality assurance systems, policy and
financing, procurement, distribution, provider knowledge, and end-user knowledge
(Venture Strategies Innovations, n.d.).
● Accessibility means that the people for whom the product or service is intended are able
to obtain it. Accessibility depends on knowledge of the existence of a product or service
as well as the ability of an individual to obtain it within a given socioeconomic context.
The availability of a service may be meaningless if the individuals it is designed to help
cannot access it.
- Three critical elements of accessibility are location (is the product or service
available where it is needed?); stigma (do people fear using the product or service
 because it might stigmatize them in their community?); and cost (can the intended
beneficiaries afford the product or service?).
● Acceptability means that the product or service is culturally and socially acceptable to the
individuals it is designed to benefit.

Reference:
Transcultural-Concepts-in-Nursing-Care-Margaret-M.-Andrews-and-Joyceen-S.-Boyle-3.pdf