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UNIT II ■ Community Health Across Populations: Public Health Issues
tool. 18 In July 2021, because of an inadequately devel- oped global plan for COVID-19 vaccines and therapeu- tics, only 83 countries were able to administer at least one dose of a COVID-19 vaccine in more than 30% of their population, leaving 133 countries with vaccine rates below 30%, which highlights the disparity. 18 Low- and middle-income countries were unable to achieve the research, surveillance, development, manufacturing, and distribution processes necessary to meet the needs of their respective populations. Health Disparity in the United States Comparing groups based on racial and ethnic categories provides a starting point for illustrating health dispari- ties in the United States, with the strong caveat that this does not mean that these differences are attributable to genetic differences but rather differences in availability of resources. Again, the IMR illustrates significant differ- ences in birth outcomes. Although the overall IMR for the United States in 2019 was 5.58 per 1,000 live births, it was almost double for blacks (10.46 per 1,000 live births) and much lower for Asians (3.51 per 1,000 live births) (Fig. 7-2). 3 Yet when the data are examined based on geography, differences in IMR by state range from less than 3.21 per 1,000 live births (New Hampshire) to 8.71 per 1,000 live births (Mississippi). 3 Access to resources, distribution of resources, rurality, and pov- erty are important risk factors for infant deaths and help explain the differences seen between racial groups that have a higher percentage living in poverty. When ■ WHY IT MATTERS: Disparities Nursing Practice Focus: Disparities are amenable to change by addressing SDOH. Things to Consider: Although the term disparities is often interpreted to mean racial or ethnic dispari- ties, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent among populations, there is disparity. Race or ethnicity, sex, sexual iden- tity, age, disability, income, and geographic location all contribute to an individual’s ability to achieve good health. What Does It Mean for the Nurse? It is impor- tant to recognize the impact that social determinants have on the health outcomes of specific populations. Healthy People strives to improve the health of all groups. 4
and Hispanic persons are more likely to have ineffective communication with health-care providers, possibly be- cause of medical mistrust, which can result in providers and patients not discussing how to manage chronic dis- ease. This lack of communication or miscommunication suggests that disparities may be because of inconsistent management by providers of chronic disorders, such as diabetes, heart failure, and asthma, which are prevalent in patients who belong to an underrepresented group. In order to address this problem, nurses and health-care providers need to be aware of their unconscious bias to- ward persons based on their race, ethnicity, income, and insurance status. Doing so will lead to developing com- munication strategies that aid in relationship building between the patient and the nurse. Being purposeful and empathetic in patient conversations can help to build trust between patients and persons providing care. ■ CELLULAR TO GLOBAL At the cellular level, the APOE-e4 genotype has been identified as the greatest risk factor for developing Alzheimer’s disease. 16 Although women globally have nearly a double lifetime risk of developing Alzheimer’s disease by age 65, it is not known if this disparity is because of a biological difference, such as a biological woman’s susceptibility to the influence of APOE-e4 based on an interaction with estrogen, or an influence of the SDOH. 17 Given that women may be more likely to work part time without health insurance and have lower income, they might not have the finances to af- ford medications, which would delay the onset or pro- gression of Alzheimer’s disease compared with men. Health Disparity Globally Health disparities are seen across the globe, affecting di- verse patient populations. Multiple factors contribute to these disparities, including age, geography, and SES, as well as discrimination based on gender, sexual identity, race, and ethnicity. These disparities are facilitated by so- cial and economic inequities across and within countries. Some examples of global inequities include death from preventable diseases such as malaria, tuberculosis, and pneumonia, as well as challenges in managing chronic disorders such as hypertension and type 2 diabetes. An example of the impact of global health disparities was demonstrated with the implementation of access processes for COVID-19 vaccines. Specifically, the pol- icies that govern the ability to develop, distribute, and achieve therapeutics were unstable as an essential health
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