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1 : Global Health disparities: 23 One of the greatest challenges to global health that leads to health disparities is poverty and the problems related to lack of access to adequate food, water, shelter, and health care. Most of the decline in extreme poverty rates has occurred in countries in the East Asia and Pacific regions. In addition to poverty, there are many other factors that contribute to health disparities, including racial/ethnic status, presence of physical or mental disabilities, stigma associated with certain health problems such as mental illness or HIV/AIDS, and inequitable distribution of global resources, including funding for research to address global health problems. The term “10/90 gap” has been used to characterize this imbalance, referring to the concept that only 10% of the world’s research resources are used to address the health problems that affect 90% of the world’s population. Global disease burden Although there continue to be significant disparities in the global burden of disease, there has been considerable progress in leading health indicators over the past 30 years. For example, between 1990 and 2013, the life expectancy at birth has increased from 53 to 62 years in low income countries and from 75 to 79 years in high-income countries (WHO, 2015, p. 54). Despite these improvements, there remain significant inequities in the global burden of disease, and many of these inequities are directly related to the effects of poverty and the inequitable distribution of the world’s resources (WHO, 2008b). The global burden of disease is defined as “the disability-adjusted life year (DALY), (which is a) time-based measure combin(ing) years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health” (WHO, 2008a). In 2012, The Lancet published a series of papers describing findings from the Global Burden of Disease Study 2010, which was the “first systematic and comprehensive assessment of data on disease, injuries, and risk since 1990” (Horton, 2013, p. 2053). The results showed that life expectancies were increasing across the globe and that rates of HIV, malaria, TB, and other infectious diseases were decreasing. Deaths caused by cancer and road accidents have increased, and nearly 25% of all deaths are caused by heart disease. The greatest disease risks were blood pressure followed by tobacco, alcohol, and poor diet. The Healthy People 2020 document included a global health goal to improve public health and strengthen U.S. national security through global disease detection, response, prevention, and control strategies Health Disparities-Socioeconomic emailed her about this and she said what are the trends in disease in the u.s, compare what individuals are dying from today than those early 1920s, what are some of the interventions that have changed the course of the disease progression? What are some of our behaviors that are different from those of the early 1900s? individuals today die from noncommunicable diseases and accidents compared to the 1920s; infectious diseases were what people died from in the 1920s. People died of pneumonia, tb, influenza. What has caused this change? IMMUNIZATIONS, VACCINES-I think that’s the biggest thing. Look above for more Socioeconomic aspect: Most HIV/AIDS deaths occur in Africa Around 70% of all HIV/AIDS deaths in 2012 occurred in subSaharan Africa. Globally, the number of people dying from AIDS decreased. HIV testing and counselling uptake has improved, and access to antiretroviral therapy has increased. However, many people living with HIV in low- and middle- income countries still do not know their HIV status. [So some impoverished countries do not

have access to these expensive drugs, same with TB, tb can be treated but low income countries cannot get access to drugs.] Global Health History talked about this above 2: Essential Public health achievements (59) 1. Immunizations 2. Improvements in motor vehicle safety 3. Workplace safety 4. Control of infectious diseases 5. Decline in deaths from heart disease and stroke 6. Safer and healthier foods 7. Healthier mothers and babies 8. Family planning 9. Fluoridation of drinking water 10. Tobacco as a health hazard Essential Public Health Services To improve the health of communities, community health nurses need to focus on the 10 essential public health services (Table 2.1). These essential public health services provide a fundamental framework by describing the public health activities that should be undertaken in all communities. 62

Health Care and Life Expectancy With the discovery of antibiotics in the 1940s and vaccines for mass immunizations in conjunction with significant improvements in environmental sanitation, the United States experienced a considerable decline in morbidity and mortality caused by communicable diseases. According to the Centers for Disease Control and Prevention (CDC), public health is credited with adding 25 years to the life expectancy of people in the United States Determinants of Health In public health and community health nursing practice, we use the term social determinants of health to describe a collection of challenges that have an impact on the work we do. The social determinants of health refer to conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes (CDC, 2017). Health inequities result from inequities in the social determinants of health that, in turn, result from

racial and other forms of oppression and power imbalances. Public health practitioners face numerous challenges in tackling these root causes of health inequities, including risk-averse leadership, political pushback, perceptions of the 70 limits of the scope of public health practice, and lack of capacity and resources HP2020 GoalsThe ANA Scope and Standards of Public Health Nursing Practice (2013) to provide a directive for improving the health of populations. Public Health Figures (various places in lecture/chapters) Lillian Wald, Lavinia Dock, and Margaret Sanger who established neighborhood health clinics and social services more than 125 years ago in the Lower East Side of New York City. They witnessed through home visits the flourishing of communicable diseases and maternal deaths among the growing number of immigrant and local families living in crowded conditions and in financial poverty. Observing rapid industrialization, large concentrations of people moving into cities, unsanitary environmental conditions, poor housing, poverty, misuse of child labor, infectious diseases, and short life expectancy, Lillian Wald and Mary Brewster began the Henry Street 58 Settlement House in New York City, which later became the Visiting Nurse Service of New York. There they lived and worked among the people, teaching hygiene practices, visiting the sick in homes, and crusading for better health care in all aspects of the community. Lillian Wald recognized the intertwining of health status, environmental sanitation, and social and political forces and is credited with coining the term public health nurse. Her work targeted the root causes of ill health, which meant that she had to take on institutions, politics, and social policy to effect change for the improvement of the community’s health. Lillian Wald and her staff were able to befriend the immigrant and the poor as well as wealthy bankers and businessmen who donated funds and facilities so that health and social services could be provided. [Maybe know about john snow (GOT!), figured out that water from streams contained cholera so he cleaned the water and ended cholera epidemic] Variables Impact Health Health care reform • Demographics • Globalization • Poverty and growing disparities • Violence, injuries, and social disintegration 3: Epidemiology Types of Epidemiology: Descriptive/ analytic 77 Descriptive epidemiology focuses on the distribution of frequencies and patterns of health events with groups in a population. Descriptive studies examine disease patterns and other health-related phenomena according to “person” (who is affected?), “place” (where were they affected?), and “time” (when were they affected?). Descriptive statistics provide data, information, and insight into the characteristics present in a group or population with a disease or the absence of disease in unaffected groups or populations. The question addressed is “Are there characteristics present in the affected population that are not present in the unaffected population?” analytic epidemiology seeks to identify associations between a disease or health problem and its etiology. Analytic studies are directed toward finding answers to the “how” and “why” of health and disease to determine causality. Analytic studies are concerned with the determinants of disease and seek to identify the causes of the problem.

They test hypotheses or seek to answer specific questions and can be retrospective or prospective in design. Web of Causation 94-96 from powerpoint: Demonstrates multifactorial cause of disease and is applicable to chronic and infectious disease (there’s an example in the powerpoint)  Views health problems as complex interrelationships of numerous factors • Attempts to identify all possible influences on health and illness processes • Synergism: the whole is more than the sum of its separate parts Criteria for causation 94-96 Constant: a factor that cannot vary, independent: factor that is manipulated, dependent: factor that changes because of the manipulation Association does not imply causation. If an association is found between variables, it means the variables tend to occur or change together (parallel increase or decrease); it does not prove that one variable causes the other. The first question to ask is whether a statistical relationship exists between the two factors. Before an association is assessed for the possibility that it is causal, other explanations such as chance, bias, and confounding variables are considered. Statistical methods alone, however, cannot establish proof of a causal relationship in an association. Because of the possibility of confounded results, very strict criteria for determining causation exist. An association should be evaluated against all the criteria; the more criteria that are met, the more likely it is that the association is causal. However, an association may meet all the criteria for causation that is later shown to be spurious (false or factitious association) because of factors that were not known at the time the study was done. For this reason, investigators should interpret results with great caution; they rarely consider a cause “proven.” [(Think of hypertension and salt)] The following six criteria are widely used for evaluating causation: 1. The association is strong. The strength of the relationship is usually measured statistically with RR or, alternatively, the odds ratio. The higher the RR or odds ratio, the greater the likelihood that the association is causal. 2. The association is consistent. 3. The association is temporally correct. The hypothesized cause of a health condition should occur before the onset of the condition (i.e., exposure to the risk factor should precede the onset of disease). This criterion is essential. It is the first and most important variable—if exposure did not precede the onset, the remaining facts are irrelevant because exposure could not have caused the disease. 4. The association is specific. The hypothesized cause should be associated with relatively few health conditions. Specificity measures the degree to which one exposure produces one specific disease—the uniqueness of the relationship. If the biologic response is variable, it is less likely to be causal. 5. The association is not the result of a confounding variable. Although not all potential intervening variables are identified, the alternate explanations for the association are examined carefully before considering an association causal. 6. The association is plausible and consistent with current knowledge. Any disease or injury causation association should be congruent and compatible with current biomedical and scientific knowledge and information. This depends on the state of scientific information at a given time. Prevalence vs Incidence The incidence of any health or disease condition refers to the number of people in a population who develop the condition during a specified period. The prevalence of a

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