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Module 3/ Writing Nursing English

Overview
The discussion board for this module provides two articles.  You are asked to compare and contrast the articles. There are several compare/contrast resources listed in the Instructional Materials folder for Module 3

Instructions

1. Read the two articles.  The reference material follows.  The complete articles are available in the Instructional Materials folder for Module 3. In the

American College of Obstetricians and Gynecologists (ACOG). (2018). Committee on Health Care for Underserved Women Opinion No. 729, Importance of social determinants of health and cultural awareness in the delivery of reproductive care. Journal of Obstetrics & Gynecology, 131(1), 43-48. https://doi.org/10.1097/AOG.0000000000002459


Click here
 to download the pdf

Skolnik, R. (2021). Health determinants, measurements, and the status of health globally.
Global health 101, (4th ed., pp. 104-133).


Click here
  to download the pdf

You can also 
read the ebook
.

           

2. Write two (2) paragraphs (250-300 words).  One paragraph will compare the purpose and the audience in the two articles.  The second paragraph will contrast the purpose and the audience of the two articles.  Remember the distinction between comparison and contrast. See resources in the Module 3 Instructional Materials folder.

3. Cite at least two (2) articles in the initial post in addition to the ACOG and the Skolnik articles.  Remember that references for Discussion Boards must also adhere to the APA Manual 7th edition formatting.

4. You will respond to the initial post of two (2) peers.  Each response will be between 100-150 words.  Each response will include at least one (1) article in addition to the ACOG and Skolnik article.

For the Initial post:

· You must post your initial posting before you can view your peers’ posts.

· The lenght of this discussion is to be 250-300 words.

· Two (2) (2) references are required for the initial post. These two (2) references are in addition to the ACOG and the Skolnik articles. 

· To post the discussion board click on the “Click to Launch” link OR on the on “Discussions” tab in the menu bar on the left-hand side of the Blackboard screen. Post the material in the forum titled “M3-A3 Compare/Contrast Two Articles”

For the response post:

· Each student will read the information posted by peers and will write a response to two (2) peers. You cannot post a peer response on the same day that you posted your initial post.

· Each response to a peer is to contain a minimum of 100-150 words. Be sure to respond thoughtfully.  Consider explaining why you agree or disagree with the peer’s posting.  Consider providing examples to support or reject the peer’s claim.  Be professional in your responses.

· A minimum of one (1) reference is required for each discussion response to a peer.

· Post in the forum titled “M2-A3 Social Determinants of Health in the US”

Due date:

· The initial post is due by 11:59 PM EST on the Friday of the relevant week of class. There is a 10% deduction for each day a post is late until 11:59 PM EST Sunday. for the post.

· The responses to peers must be posted by 11:59 PM EST Sunday.  No posts will be accepted after this time.  

· Any material posted after 11:59 PM EST on the relevant Sunday will be zero (0) points.

Refer to 
Rubric
 for evaluation guidelines

· Point value: 20

· Due Date: See Course Calendar/Checklist

104

Courtesy of Mark Tuschman.

CHAPTER 2
Health Determinants, Measurements,
and the Status of Health Globally

LEARNING OBJECTIVES

By the end of this chapter, the reader will be able to do the following:

¦ Describe the determinants of health
¦ Define the most important health indicators and key terms related to measuring health

status and the burden of disease
¦ Discuss the status of health globally and how it varies by country income group, region,

and age group

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AN: 2247214 ; Richard Skolnik.; Global Health 101
Account: s8447892.main.eds

105

M
Vignettes

aria is a poor woman who lives in the highlands of Peru. She is from an ethnic group
called Quechua. In Peru, poor people tend to live in the mountains and be indigenous, be

less educated, and have worse health status than other people. In Eastern Europe, the same
issues occur among ethnic groups that are of lower socioeconomic status, such as the Roma
people. In the United States, there are also enormous health disparities, as seen in the health
status of African Americans and Native Americans, compared to white Americans. If we want to
understand and address differences in health status among different groups, how do we
measure health status? Do we measure it by age? By gender? By socioeconomic status? By
level of education? By ethnicity? By location?

Yevgeny is a 56-year-old Russian male. Life expectancy in Russia in 1985 was about 64 years
for males and 74 years for females. It then fell to about 59 years for males and 72 years for
females in 2001, before rising again to 67 for males and 77 for females in 2016. What does
life expectancy at birth measure? What are the factors contributing to the earlier decline in life
expectancy at birth in Russia? What has happened to trends in life expectancy in other
countries? Which countries have the longest and shortest life expectancies, and why?

Sarah is a 27-year-old woman in northern Nigeria. While women in high-income countries very
rarely die of pregnancy-related causes and have a maternal mortality ratio of about 10 per
100,000 live births, the maternal mortality ratio for women in low-income countries like Sarah is
about 500 per 100,000 live births. This is 50 times higher than that in the best-off country
income group. What does the maternal mortality ratio suggest about a country? What does it
say about the status of women in that country? What does it indicate about the access of
women to obstetric and emergency obstetric care of appropriate quality?

Abdul is a 4-year-old in northern India. For every 1,000 children born in South Asia in 2016,
about 50 will die before their fifth birthday. The rate of child death is even higher in sub-Saharan
Africa. In the cohort of 1,000 children born there in 2016, almost 80 will die before they are five.
These two regions have the worst child mortality rates.

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106

The Importance of Measuring Health Status
If we want to understand the most important global health issues and what can be done to
address them, then we must understand what factors have the most influence on health status,
as well as how health status is measured.

This chapter, therefore, covers two distinct but closely related topics. The first section concerns
what are called . That section examines the most important factorsthe determinants of health
that relate to people’s health status. The second section reviews some of the most important
indicators of health status and how they are used.

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107

The Determinants and Social Determinants of Health
Why are some people healthy and some people not healthy? When asked this question, many
of us will respond that good health depends on access to health services. Yet, as you will learn,
whether or not people are healthy depends on a large number of factors, many of which are
interconnected, and most of which go considerably beyond access to health services.

The World Health Organization (WHO) defines the as the “range ofdeterminants of health
personal, social, economic and environmental factors which determine the health status of
individuals or populations.” WHO defines the social determinants of health as the “conditions in
which people are born, grow, live, work and age.”

There has been considerable writing about the determinants and social determinants of health,
which different organizations depict in a range of ways. The next section builds on the work of a
number of actors and agencies. It briefly discusses the determinants and social determinants of
health and how they influence health. It is essential to understand these concepts if one wants
to understand why people are healthy or not and what can be done to address different health
conditions in different settings. shows one way of depicting the determinants ofFIGURE 2-1
health.

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108

FIGURE 2-1 The Determinants of Health

Reproduced from Dahlgren, G., & Whitehead, M. (1991). .Policies and strategies to promote social equity in health

Stockholm, Sweden: Institute for Futures Studies. Retrieved from http://www.iffs.se/media/1326

/20080109110739filmZ8UVQv2wQFShMRF6cuT.pdf

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109

The first group of factors that helps to determine health relates to the personal and inborn
features of individuals. These include genetic makeup, sex, and age. Our genetic makeup
contributes to what diseases we get and how healthy we are. One can inherit, for example, a
genetic marker for a particular disease, such as Huntington’s disease, which is a neurological
disorder. One can also inherit the genetic component of a disease that has multiple causes,
such as breast cancer. Sex also has an important relationship with health. Males and females
are physically different, for example, and may get different diseases. Females face the risks
involved in childbearing. They also get cervical and uterine cancers that males do not. Females
have higher rates of certain health conditions, such as thyroid and breast cancers. For similar
reasons, age is also an important determinant of health. Young children in low- and
middle-income countries often die of diarrheal disease, whereas older people are much more
likely to die of heart disease, to cite one of many examples of the relationship between health
and age.

Individual lifestyle factors, including people’s own health practices and behaviors, are also
important determinants of health. Being able to identify when you or a family member is ill and
needs health care can be critical to good health. One’s health also depends greatly on how one
eats, or if one smokes tobacco, drinks too much alcohol, or drives safely. We also know that
being active physically and getting exercise regularly is better for one’s health than is being
sedentary.

The extent to which people receive social support from family, friends, and community also has
an important link with health. The stronger the social networks and the stronger the support
that people get from those networks, the healthier people will be. Of course, culture is also an
extremely important determinant of health.

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Living and working conditions also exert an enormous influence on health. These include, for
example, housing, access to safe water and sanitation, access to nutritious food, and access to
health services. Crowded housing, for example, is a risk factor for the transmission of
tuberculosis. The lack of safe water and sanitation, coupled with poor hygiene in many settings,
is one of the major risk factors for the diarrheal disease that is associated with so much illness
and death in young children. Nutrition is central to health, beginning at conception, and families
have to be able to access appropriate foods to promote good health. Of course, even if other
factors are such important determinants of health, one’s health depend on access todoes
appropriate healthcare services. Even if one is born and raised healthy and engages in good
health behaviors, access to health services of appropriate quality is important to maintaining
good health. To address the risk of dying from a complication of pregnancy, for example, one
must have access to health services that can carry out an emergency cesarean section if
necessary. Even if the mother has had the suggested level of prenatal care and has prepared
well in all other respects for the pregnancy, in the end, certain complications can only be
addressed in a healthcare setting.

PHOTO 2-1 The circumstances in which people live have a profound impact on their health.

This is a slum in Jakarta, Indonesia. In what ways would living here influence the health of the

slum dwellers?

© Nikada/E+/Getty Images.

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111

A range of socioeconomic factors, including culture, education, and socioeconomic status, are
important determinants of health. The broader environment is also a critical health determinant.
Socioeconomic status refers to a person’s economic, social, and work status. It is highly
correlated with educational attainment. People with higher educational attainment have better
economic opportunities, higher socioeconomic status, and more control over their lives than
people of lower educational status. As one’s socioeconomic status improves, so does his or her
health.

More specifically, education is a powerful determinant of health for several reasons. First, it
brings with it knowledge of good health practices. Second, it provides opportunities for gaining
skills, getting better employment, raising one’s income, and enhancing one’s social status, all of
which are also related to health. Studies have shown, for example, that the single best predictor
of the birthweight of a baby is the level of educational attainment of the mother. Most of us
already know that throughout the world there is an extremely strong and positive correlation
between the level of education and all key health indicators. People who are better educated
eat better, smoke less, have less obesity, have fewer children, and take better care of their
children’s health than do people with less education. It is not a surprise, therefore, that they and
their children live longer and healthier lives than do less well-educated people and their
children.

Culture also exerts a profound impact on health. Culture shapes how one feels about health
and illness, how one uses health services, and the health practices in which one engages. In
addition, the gender roles that are ascribed to women in many societies also have an important
impact on health. In some settings, women may be treated more poorly than men and this, in
turn, may mean that women have less income, less education, and fewer opportunities to
engage in employment. All of these militate against their good health.

The environment, both indoor and outdoor, is a powerful determinant of health. Related to this
is the safety of the environment in which people work. Although many people know about the
consequences of outdoor air pollution for health, fewer people are aware of the consequences
of indoor air pollution to health. In many low- and middle-income countries, families, and usually
women, cook indoors with poor ventilation, thereby creating an indoor environment that may be
full of smoke and that increases the risk of respiratory illness and asthma. The lack of safe
drinking water and sanitation is a major contributor to ill health in poor countries. In addition,
many people in those same countries work in environments that are unhealthy. Because they
lack skills, socioeconomic status, and opportunities, they may work without sufficient protection
from hazardous chemicals, in polluted air, or in circumstances that expose them to occupational
accidents.

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PHOTO 2-2 The lack of access to safe water and sanitation causes people to seek water from

unsafe sources and is a major risk factor for child deaths. Children are shown here washing

their dishes in a river. What can be done to improve access to safe water and sanitary disposal

of human waste in resource-poor environments?

Courtesy of Mark Tuschman.

The approach that governments take to different policies and programs in the health sector and
in other sectors also has an important bearing on people’s health. People living in a country that
promotes high educational attainment, for example, will be healthier than people in a country
that does not promote widespread education of appropriate quality because better-educated
people engage in healthier behaviors. A country that has universal health insurance is likely to
have healthier people than a country that does not insure its entire population because the
uninsured may lack needed health services. The same would be true, for example, for a country
that promoted safe water supply for its entire population, compared to one that did not.

As we think about the determinants of health, we should be aware that increasing attention is
being paid to the social determinants of health. In 2005, WHO created a Commission on the
Social Determinants of Health. WHO published the commission’s report in 2008. The report
highlighted some of the following themes :12

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¦ Health status is improving in some places in the world but not in others.
¦ There are enormous differences in the health status of individuals within countries, as well

as across countries.
¦ The health differences within countries are closely linked with social disadvantage.
¦ Many of these differences should be considered avoidable, and they relate to the way in

which people live and work and the health systems that should serve them.
¦ People’s life circumstances, and therefore their health, are profoundly related to political,

social, and economic forces.
¦ Countries need to ensure that these forces are oriented toward improving the life

circumstances of the poor, thereby enabling them to enjoy a healthier life as well. The global
community should also work toward this end.

We should also note the importance to health of child development, including the ways in which
families nourish and care for infants and young children, beginning at conception. Being born
premature or of low birthweight can have important negative consequences on health over the
life course. There is a strong correlation between the nutritional status of infants and young
children and the extent to which they meet their biological and intellectual potential, enroll in
school, or stay in school. In addition, poor nutritional status in infancy and early childhood may
be linked with a number of noncommunicable diseases later in life, including diabetes and heart
disease. There is also considerable evidence that a range of stressors, including poverty,
abuse, and discrimination, have a powerful impact on the health of children that may continue
through adulthood.

Finally, as we think about the determinants and social determinants of health, it is important to
consider how, directly and indirectly, different factors influence health. One framework for such
consideration is shown in . This framework places the determinants of health intoFIGURE 2-2
three categories based on the directness of their influence on health: root causes at the
macro/societal level; underlying causes at the meso/community level; and proximal causes at
the immediate/interpersonal level. Viewing the determinants of health in this manner should
also be helpful in assessing why health conditions exist and what can be done to address them.

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FIGURE 2-2 Selected Examples of Root, Underlying, and Immediate Determinants of Health

Modified with permission from Bouwman, L., Wentink, C., & Ormond, M. (2017, April 6). Global Health, W3 Tutorial 3:

Determinants [Powerpoint Slides], Based on Northridge.

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115

Key Health Indicators
It is critical that we use data and evidence to understand and address key global health issues.
Some types of health data concern the health status of people and communities, such as
measures of life expectancy and infant and child mortality, as discussed further hereafter. Some
concern health services, such as the number of nurses and doctors per capita in a country or
the indicators of coverage for certain health services, such as immunization. Other data
concern the financing of health, such as the amount of public expenditure on health or the
share of national income represented by health expenditure.

There are a number of very important uses of data on health status. We need data, for
example, to know from what health conditions people suffer. We also need to know the extent
to which these conditions cause people to be sick, be disabled, or die. We need data to carry
out disease surveillance. This helps us understand if particular health problems such as cancer,
influenza, polio, or malaria are occurring, where they are infecting people, who is getting
infected, and what might be done to address these conditions. Other forms of data also help us
to understand the burden of different health conditions, the relative importance of them to
different societies, and the importance that should be given to dealing with them.

If we are to use data in the previously mentioned ways, then it is important that we use a
consistent set of indicators to measure health status. In this way, we can make comparisons
across people in the same country or across different countries. There are, in fact, a number of
indicators that are used most commonly by those who work in global health and in development
work. These are listed and defined in .TABLE 2-1

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TABLE 2-1 Key Health Status Indicators

The section that follows will examine these key indicators of health status in two ways, first by
World Bank region and second by country income group. The graphics will reflect a number of
points quite starkly:

¦ There is a very strong correlation between country income group and health status. The
lower the income group, the lower the status; the higher the income group, the higher the
status.

¦ In all cases, sub-Saharan Africa has the worst health indicators of all World Bank regions,
and South Asia has the second worst health indicators.

You will understand better as you progress in your study of global health that part of the
relatively low health status of sub-Saharan Africa and South Asia related to the fact that theseis
are the two regions with the lowest per capita income. However, as you will read about here
and elsewhere, their relatively low health status also has to do with government policies and
programs, the lack of safe water and sanitation, low levels of education, and a number of other
factors.

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117

It is also important to understand that country income level does not have to determine a
country’s health status. Rather, as you will also read about throughout this text and elsewhere,
resource-poor countries that make wise policy choices in fair ways enable better health forcan
their people than their income level might suggest. This has certainly been the case for a
number of countries whose development history is well known, such as Cuba, Sri Lanka, and
China. Thus, it will be essential as you think about key issues in global health to always keep in
mind questions about which policies can help to achieve the best health for any population at
the least cost and in fair, doable, and sustainable ways. In light of all this, let us now turn to
exploring the specific health indicators.

Among the most commonly used indicators of health status is . Lifelife expectancy at birth
expectancy at birth is “the average number of additional years a newborn baby can be
expected to live if current mortality trends were to continue for the rest of that person’s life.”

In other words, it measures how long a person born today can expect to live, if there were
no change in their lifetime in the present rate of death for people of different ages. The higher
the life expectancy at birth, the better the health status of a country. In the United States, a
high-income country, life expectancy at birth in 2016 was about 79 years; in Jordan, a
middle-income country, life expectancy was 74 years; in Sierra Leone, a very low-income
country, life expectancy was 52 years.

FIGURE 2-3 shows life expectancy at birth by country income level. This figure shows an
exceptional correlation between country income group and life expectancy. It also shows the
range of life expectancy across country income groups, from 63 years in low-income countries
to 29 percent higher, or 81 years, in high-income countries.

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FIGURE 2-3 Life Expectancy at Birth by World Bank Country Income Group, 2016

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years). Retrieved from https://data.worldbank

.org/indicator/SP.DYN.LE00.IN?end=2016&locations=XD-XT-XN-XM&start=2016&view=bar

FIGURE 2-4 shows life expectancy by World Bank region. It reflects the points noted
previously, with sub-Saharan Africa and South Asia having the lowest life expectancy. It is also
important to note that the region with the highest life expectancy has a life expectancy that is 19
years, or about 30 percent, greater than the region with the lowest life expectancy.

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FIGURE 2-4 Life Expectancy at Birth by World Bank Region, 2016

Data from The World Bank. (n.d.). Data: Life expectancy at birth, total (years). Retrieved from https://data.worldbank

.org/indicator/SP.DYN.LE00.IN?end=2016&locations=Z4-ZG-8S-ZJ-Z7-ZQ&start=2016&view=bar

The is a measure of the risk of death that is associated with childbirth.maternal mortality ratio
Because these deaths are more rare than infant and child deaths, the maternal mortality ratio is
measured as “the number of women who die as a result of pregnancy and childbirth
complications per 100,000 live births in a given year.” The rarity of maternal deaths and
the fact that they largely occur in low-income settings also contribute to maternal mortality being
quite difficult to measure. Very few women die in childbirth in rich countries; for example, the
maternal mortality ratio in Sweden in 2016 was 4 per 100,000 live births. On the other hand, in
very poor countries, in which women have low status and where there are few facilities for
dealing with obstetric emergencies, the ratios can be over 700 per 100,000 live births, as they
were in 2016, for example, in the Central African Republic, Liberia, Nigeria, Somalia, and South
Sudan. In the worst-off country for maternal health, Sierra Leone, the maternal mortality ratio is
estimated to be 1,360 per 100,000 live births.

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FIGURE 2-5 gives the maternal mortality ratio by country income group, and FIGURE 2-6
shows the same data by World Bank region.

FIGURE 2-5 Maternal Mortality Ratio by World Bank Country Income Group, 2015

Data from The World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate, per 100,000 live births). Retrieved

from https://data.worldbank.org/indicator/SH.STA.MMRT?end=2014&locations=XM-XD-XT-XN&start=2014&view

=bar

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FIGURE 2-6 Maternal Mortality Ratio by World Bank Region, 2015

Data from World Bank. (n.d.). Data: Maternal mortality ratio (modeled estimate, per 1,000 live births). Retrieved from

https://data.worldbank.org/indicator/SH.STA.MMRT?end=2015&locations=Z4-8S-ZG-Z7-XU-ZJ-ZQ&start=2015

&view=bar

As suggested earlier, the pattern of the maternal mortality ratio, by both country income group
and region, is similar to that for life expectancy. However, the differences among regions and
country income groups are even greater. The low-income group, with the worst maternal
mortality ratio, has a 50 times greater rati