Globalisation and its implications for health care and nursing practice

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1 Globalisation and its implications for health care and nursing practice Bradbury-Jones C (2009) Globalisation and its implications for health care and nursing practice. Nursing Standard. 23, 25, Date of acceptance: July Summary Globalisation describes the increasing economic and social interdependence between countries. This article examines globalisation in terms of the opportunities and threats it poses to health, in particular increasing rates of non-communicable diseases. Nursing is challenged with responding to the changing health needs of the global population that have arisen as a result of globalisation. Author Caroline Bradbury-Jones is lecturer in nursing, School of Healthcare Sciences, Bangor University, Wrexham, Wales. hsse12@bangor.ac.uk Keywords Globalisation; Health promotion; Non-communicable diseases These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords. GLOBALISATION IS THE term used to describe the increasing economic and social interdependence between countries (Scriven 2005). It is characterised by high mobility, economic interdependence and electronic interconnectedness (World Health Organization (WHO) 2007a). Globalisation relates to the phenomenon that the boundaries separating individuals and societies are being eroded. Globalisation has been accelerated by technological advancement, which has had a profound economic, political and social effect in every part of the world (Seloilwe 2005). Technological advancement can improve health in a multitude of ways. However, it can also pose a threat to health through altering (and damaging) social and environment conditions, associated with, for example, increased transport and resultant pollution. Nurses should be aware of the concept of globalisation and its influences on health because the increased interconnectedness of the world means that health problems have become globalised. Therefore, in contemporary society what happens in one country matters for the rest of the world. Whereas in the past it was enough for a nation to look after itself, today that is insufficient because an increasing range of health issues transcend national boundaries (Kickbusch et al 2007). The nursing profession cannot ignore these developments and should embrace the opportunities they afford (Seloilwe 2005). Increases in non-communicable diseases More than 100 years ago, diseases such as the plague, cholera and smallpox were responsible for a considerable number of deaths and their elimination preoccupied the public health agenda (Peersman 2001). However, the 21st century heralded significant changes in the health of the global population and many serious communicable diseases were eradicated. Communicable disease as a principal cause of death has been usurped by non-communicable disease. Increased longevity Over the past 50 years average life expectancy has increased worldwide by nearly 20 years (McDaid and Oliver 2005). This trend is set to continue and projections are that for the first 30 years of the 21st century, life expectancy will increase worldwide and fewer children younger than five years old will die (Mathers and Loncar 2006). Globalisation has had an important part to play in the longevity of the world s population through for example, enhanced technology and communications; sharing of information and best practice; and relatively easy transport of vaccines, medications and health supplies. However, increased longevity is associated with certain challenges for example, higher chances of developing diseases associated with ageing such as ischaemic heart disease or cerebrovascular disease. This has become a global issue because it means there will be significant increases in the total number of deaths caused by non-communicable diseases in the next 30 years (Mathers and Loncar 2006, WHO 2007b). february 25 :: vol 23 no 25 ::

2 Collectively, chronic diseases will account for almost three-quarters of deaths worldwide by 2020 (WHO 2003). Non-communicable diseases are already the leading cause of death in the world and of an estimated 56 million deaths in 2000, non-communicable diseases accounted for 60% (Yach et al 2005). The upward trend is set to continue, and by the year 2030 the three main causes of death will be heart disease, cerebrovascular disease and lower respiratory infections (Mathers and Loncar 2006). Human immunodeficiency virus and acquired immunodeficiency syndrome Acquired immunodeficiency syndrome (AIDS) is projected to be the fourth main cause of death and is an anomaly in the general decline in communicable diseases. The number of people living with human immunodeficiency virus (HIV) continues to rise as does the number of deaths from AIDS (Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO 2006). Prevention measures are failing to keep pace with the spread of HIV (United Nations 2007) and global deaths from HIV/AIDS are projected to rise from 2.8 million in 2002 to 6.5 million in 2030 (WHO 2007b). However, with the exception of HIV/AIDS, the burden of disease attributable to non-communicable diseases is evident. Policy, research and education The worldwide trend in longevity and associated increased rates of non-communicable diseases have clear implications for nursing. Nurses in practice should be equipped to deliver care to ever increasing numbers of patients with noncommunicable diseases. The responsibility for such preparation of the nursing workforce falls on those concerned with developing nursing policy, research and education as well as individual nurses. For example, nurse education programmes must pay attention to noncommunicable diseases as a threat to global health. This is not so that nursing curricula become disease oriented, but rather that nurses can develop skills in health promotion and prevention. Similarly, nurses can be supported in delivering evidence-based care if research programmes and policies are developed around addressing non-communicable diseases as priority areas. In the UK for example, there are national policies published by the Department of Health (DH) such as the National Service Framework for Coronary Heart Disease (DH 2000), diabetes (DH 2001a) and older people (DH 2001b). These are soon to be accompanied by the long-awaited National Service Framework for chronic obstructive pulmonary disease (COPD). These national policies guide nursing practice in the UK. However, nurses should look beyond the confines of their own countries and conceive a broader, global picture of health. Developing countries A significant effect of globalisation is that non-communicable diseases are no longer confined to rich, western countries. Although non-communicable diseases still predominate in high income countries they are increasing most rapidly in poorer regions of the world, to the extent that the non-communicable disease health profile of some low income countries is beginning to mirror those of north America and western Europe (Davey 2005). Globalisation plays an important part in shifting the profile of global health in relation to non-communicable diseases. As a result of conditions such as ischaemic heart disease, cerebrovascular disease and COPD, people in developing countries are progressively experiencing the same poor health as those in developed countries. Nurses across the globe, irrespective of whether they are practising in a developing or developed country, are increasingly likely to spend a significant amount of their time caring for patients with a non-communicable disease. It is important that nursing policies, research and education are developed to address and respond to the changing profile of global health. This is crucial to prepare and support nurses to meet the demands of nursing practice brought about by globalisation. This level of preparedness of the nursing workforce is not pertinent to developed countries alone; it is relevant for nursing globally. Tobacco consumption Tobacco smoking is projected to kill 50% more people in 2015 than HIV/AIDS and be responsible for 10% of all deaths worldwide (WHO 2007b). However, the burden of disease attributable to tobacco use weighs increasingly heavily on populations in developing economies (WHO 2007b). Tobaccoattributable deaths between 2002 and 2030 are set to decline by 9% in high-income countries, but to double from 3.4 million to 6.8 million in low- and middle-income countries (Mathers and Loncar 2006), demonstrating marked global inequalities. There are indications that daily tobacco smoking is most prevalent among the lowest income households in developing economies, that is, the poorest of the poor (WHO 2007b). Obesity In relation to the impact of globalisation on nutrition, a complex picture emerges. People s diets in developing countries are becoming characterised by a higher proportion of fats and sugars (Davey 2005, Yach et al 2005). Obesity is no longer the 44 february 25 :: vol 23 no 25 :: 2009

3 preserve of developed countries; globalisation has resulted in it becoming a worldwide problem. Labelling chronic diseases as diseases of affluence is a misnomer because they are emerging in poorer countries and at an accelerated rate (WHO 2003). Health trends In summary, the major causes of death worldwide have experienced a reverse in trend over the past century from communicable diseases to non-communicable conditions. With the exception of HIV/AIDS and other diseases such as avian influenza, populations are no longer threatened by the spread of infection. Instead, risk factors associated with noncommunicable diseases, such as coronary heart disease, obesity and diabetes, pose the greatest threat to global health. However, globalisation affords opportunities that might counter some of the problems that arise; the discussion now focuses on these opportunities. Development of global strategies Combined effort is required to tackle the health problems associated with globalisation because of their depth and breadth. Decision making about how to address the effects of globalisation on health can only be achieved at global level (Scriven 2005). This, Scriven (2005) argues, is to prevent duplication and enable the development of strategies involving political, economic and policy initiatives that address the complexity of health determinants. The WHO (2005) suggests that progress towards a healthier world requires strong political action, broad participation and sustained advocacy. For the past few decades, important policies have been developed by the WHO in a bid to make this happen. The Ottawa Charter for Health Promotion was a significant historical marker (WHO 1986), which built on the progress made as a result of the Declaration of Alma-Ata (WHO 1978). At its core was the need for health promotion action to (WHO 1986): Develop healthy public policy. Create supportive environments. Strengthen community action. Develop personal skill. Reorientate health services. Move into the future. A key message was to make the healthier choice the easier choice (WHO 1986). This is significant when considering the risk factors associated with increasing non-communicable diseases as already discussed: tobacco smoking and poor nutrition leading to obesity. In relation to the link between the risk factor of smoking and non-communicable diseases, making the healthier choice the easiest choice is important. There is indisputable evidence that implementing smoke-free environments is the only effective way to protect the population from the harmful effects of exposure to second-hand tobacco smoke (WHO 2007c). Several countries have successfully implemented policies requiring indoor workplaces and public places to be totally smoke-free without encountering significant challenges to implementation (WHO 2007c). Enhanced technology and communication systems, coupled with ease of travel, could aid the exchange of information between countries in relation to implementing smoke-free environments. Globalisation offers an opportunity for sharing experiences across the globe so that, incrementally, more countries benefit from healthier, smoke-free environments. Effective prevention and management of obesity also requires an integrated approach involving action in all sectors of society (WHO 2000). To some extent the problem of obesity represents more of a challenge than tobacco consumption. This is for two reasons. First, in countries with developing economies, the problem of obesity is emerging at a time when undernutrition remains a significant problem (WHO 2000, 2003). This increases the complexity of the situation and means that strategies that take into account these problems need to be developed (WHO 2000). Second, successes in tackling the global obesity problem are scarce. According to the WHO (2000) obesity is not inevitable; it is largely preventable through lifestyle changes. However, no country has successfully reduced the overweight and obesity burden (Swanton and Frost 2007). This provides a significant challenge for nursing and highlights the need for nurses to be properly equipped to address the effects of globalisation. It would be naive to suggest that enhanced health promotion and public health competency of nurses alone would address such complex issues. However, nurse education programmes and policies such as those discussed above that support nurses in their health promotion role are important. In terms of policies developed at global level, the Bangkok Charter for Health Promotion in a Globalized World (WHO 2005) complements and develops the values, principles and action strategies of health promotion established by the Ottawa Charter (WHO 1986). The Bangkok Charter identifies actions, commitments and pledges required to address the determinants of health in a globalised world through health promotion (WHO 2005). Its focus is the need february 25 :: vol 23 no 25 ::

4 to (WHO 2005): Advocate for health based on human rights and solidarity. Invest in sustainable policies, actions and infrastructure to address the determinants of health. Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy. Regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for the health and wellbeing for all. Build alliances across organisations. Despite the potential that global policies such as the Ottawa and Bangkok Charters have to promote global health and counter the health damaging effects of globalisation, reality does not always reflect the rhetoric. For example, since adoption of the Ottawa Charter, a significant number of resolutions at national and global level have been signed in support of health promotion, but these have not always been followed by action (WHO 2005). There is a persistent gap between policy knowledge at a global level and policy implementation at country level (Magnusson 2007). This means that the efforts of policy makers and the potential benefits of globalisation are wasted. The implementation gap should be closed if improving global health is to become a reality (WHO 2005). Nursing has a collective responsibility to respond to the challenges of globalisation. Table 1 uses the example of the increase in non-communicable diseases as discussed in this article and shows four levels of responsibility in a global context. It would be tempting for nurses from any country to discount global health policy, and global health in general, as irrelevant to their everyday practice. Such matters appear far removed from the immediate and pressing demands encountered by nurses. However, to ignore such issues is to be blind to the broader context of health that will, to some extent, affect countries and their populations. Nurses are challenged to adopt a critical stance in relation to how nursing practice in their own country can be informed by enhanced political awareness at a global level. Nurse education programmes can help to support this type of knowledge and awareness, but nurses must also assume some personal responsibility. In essence, if nurses are to meet the demands of health in contemporary society they cannot ignore the impact that globalisation has on the health of patients in their care. Nursing has a collective responsibility to respond to the challenges of globalisation. The International Council of Nurses (ICN) is in an ideal position to support this endeavour. The ICN is a federation of more than 128 national nurses associations, which represent millions of nurses worldwide. TABLE 1 Nursing s global responsibility in addressing non-communicable diseases Level of responsibility Health policy Nursing research Nursing education Individual nurses Action required Developing policies at international and national levels. Focusing health policies on global issues such as an ageing population and increasing non-communicable diseases. Developing and implementing policies that reduce smoking prevalence and obesity. Providing healthcare environments globally that make nurses health promotion and public health role easier. Providing evidence for nursing practice in relation to treatment and prevention of non-communicable diseases. Disseminating research findings internationally. Sharing best practice globally. Preparing a nursing workforce capable of meeting the health needs of an ageing population. Equipping nurses as competent health promoters in addressing non-communicable diseases. Embracing the role of health promoter. Adopting a proactive stance in accessing education programmes, nursing research and contemporary global health policies to inform nursing practice. Developing a critical, political awareness. Staying attuned to the global context of nursing that influences local nursing practice. 46 february 25 :: vol 23 no 25 :: 2009

5 It supports nurses for example, in their attempts at providing quality care, developing effective health policies, reducing environmental and lifestyle-related health hazards, and contributing to policies pertaining to the determinants of health. As the international voice of nursing, the ICN could play an important role in helping nurses to rise to the challenges of globalisation. Conclusion Globalisation poses a threat to the health of the world s population, but it also presents opportunities. Enhanced interconnectivity, including technology and communications, means that it is easier for countries to work together to tackle the determinants of health. Policies developed at a global level, such as those of the WHO, can promote health provided that they are implemented in practice. Nurses can face the challenge of globalisation by being supported and prepared through relevant policies, research and education. Nurses should embrace globalisation and exploit its benefits for nursing and health care across the world (Seloilwe 2005). This implies that nurses have responsibility as individuals in relation to globalisation. The health profile of the world is changing and this has an impact on nursing. The implication is that nurses now need to think more globally. This might reasonably begin with an understanding of the nature of globalisation and its implications for nursing NS References Davey B (2005) Key global health concerns for the 21st century. In Scriven A, Garman S (Eds) Promoting Health: Global Perspectives. Palgrave Macmillan, Basingstoke, Department of Health (2000) National Service Framework for Coronary Heart Disease. The Stationery Office, London. Department of Health (2001a) National Service Framework for Diabetes. The Stationery Office, London. Department of Health (2001b) National Service Framework for Older People. The Stationery Office, London. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (2006) AIDS Epidemic Update. (UNAIDS/06.29E). WHO, Geneva. Kickbusch I, Silberschmidt G, Buss P (2007) Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health. Bulletin of the World Health Organization. 85, 3, Magnusson RS (2007) Noncommunicable diseases and global health governance: enhancing global processes to improve health development. Globalization and Health. 3, 2. www. globalizationandhealth.com/content/ 3/1/2 (Last accessed: January ) Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to PLoS Medicine. 3, 11, e442. McDaid D, Oliver A (2005) Inequalities in health: international patterns and trends. In Scriven A, Garman S (Eds) Promoting Health: Global Perspectives. Palgrave Macmillan, Basingstoke, Peersman G (2001) Promoting health: principles of practice and evaluation. In Oliver S, Peersman G (Eds) Using Research for Effective Health Promotion. Open University Press, Buckingham, Scriven A (2005) Promoting health: a global context and rationale. In Scriven A, Garman S (Eds) Promoting Health: Global Perspectives. Palgrave Macmillan, Basingstoke, Seloilwe ES (2005) Globalization and nursing (guest editorial). Journal of Advanced Nursing. 50, 6, 571. Swanton K, Frost M (2007) Lightening the Load: Tackling Overweight and Obesity. National Heart Forum, London. United Nations (2007) The Millennium Development Goals Report. United Nations, New York NY. World Health Organization (1978) Declaration of Alma-Ata. WHO, Geneva. World Health Organization (1986) Ottawa Charter for Health Promotion. WHO, Geneva. World Health Organization (2000) Obesity: Preventing and Managing the Global Epidemic. WHO, Geneva. World Health Organization (2003) Diet, Nutrition and the Prevention of Chronic Diseases. WHO, Geneva. World Health Organization (2005) The Bangkok Charter for Health Promotion in a Globalized World. WHO, Geneva. World Health Organization (2007a) The World Health Report 2007: A Safer Future: Global Public Health Security in the 21st Century. WHO, Geneva. World Health Organization (2007b) World Health Statistics WHO, Geneva. World Health Organization (2007c) Protection from Exposure to Second-hand Tobacco Smoke: Policy Recommendations. WHO, Geneva. Yach D, Beaglehole R, Hawkes C (2005) Globalisation and noncommunicable diseases. In Scriven A, Garman S (Eds) Promoting Health: Global Perspectives. Palgrave Macmillan, Basingstoke, february 25 :: vol 23 no 25 ::