Global Trends & Nurses’ Role

Thank you to Abeer Alharthi, MSN, RN, Ph.D. Student, Johns Hopkins School of Nursing, and Yvonne Commodore-Mensah, Ph.D., MHS, RN, Associate Professor, Johns Hopkins School of Nursing for this article on the cardiovascular health of immigrants and displaced persons.

Nurses play a crucial role in advancing health equity as outlined in the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report.¹ The report specified that “By 2023, state and federal government agencies, health care and public health organizations, payers, and foundations should initiate substantive actions to enable the nursing workforce to address social determinants of health and health equity more comprehensively, regardless of practice setting.”

Consistent with this agenda, nurses should champion the cause of ensuring that vulnerable populations can achieve cardiovascular health.

Current Global Trends

Migration is a global phenomenon, and immigrants and refugees are among the most vulnerable populations globally. The United Nations (UN) estimates that there were around 281 million international immigrants globally in 2020, which equates to 3.6 percent of the global population.²

The COVID-19 pandemic has also impacted migration trends with travel restrictions resulting in thousands of migrants being stranded and in need of humanitarian assistance.² According to the United Nations High Commissioner for Refugees (UNHCR), the size of displaced populations has dramatically increased to 89 million people by the end of 2021.³

Several factors have contributed to the migration and displacement of populations, including climate change, political instability, wars, and ongoing conflicts that force people to flee their homes to prevent persecution, violence, and human rights violations.³ The ongoing war in Ukraine has resulted in 13 million Ukrainians displaced internally and across their country’s borders.³

Immigrant populations consist of diverse groups, including refugees, asylum seekers, and internally displaced people. While there are immigrants who choose to flee their countries for better work opportunities and quality of life, the majority of immigrants, such as refugees and asylum seekers, flee their homes due to fear of being persecuted because of ethnicity, political or religious affiliation, and nationality.³

Impact of Migration and Displacement on Health

The refugee settlement process may take years, and displaced populations settle in refugee camps where they endure poor living conditions in which basic resources such as nutrition and water are limited. Before leaving their country of origin, immigrants and refugees experience limited access to healthcare services due to poor health systems disrupted by conflict or disasters that may lead to poor self-management of chronic illnesses. Specifically, lack of sanitation and hygiene during migration exposes migrants to communicable diseases.²  

Global efforts have been traditionally focused on addressing the immediate health needs of displaced populations related to infectious diseases and outbreaks.² However, lack of continuity of care during migration and other unmet social needs exacerbate existing chronic conditions including cardiovascular disease leading to higher morbidity and mortality rates.² Thus, migration has recently been acknowledged as a social determinant of health because the conditions surrounding migration often worsen health inequities and expose immigrants and refugees to poor health outcomes.⁴

Cardiovascular Consequences of Migration and Displacement

The cardiovascular consequences of migration and displacement have not been adequately prioritized.⁵ Recent literature has captured the impact of migration on cardiovascular health among immigrants and refugees. Al-Rousan and colleagues found a significantly higher prevalence of cardiovascular disease risk factors among refugees than among non-refugee counterparts.⁶ Another study that investigated cardiovascular disease risk factors among Cambodian and Somalian refugees who had resettled in the U.S. observed significantly higher rates of hypertension and diabetes compared to the general U.S. population.⁷ Commodore-Mensah et al. examined the association between length of stay and cardiometabolic risk, reporting that immigrants who had resided in the US for at least ten years had a higher prevalence of hypertension, overweight/obesity, and diabetes mellitus than U.S.-born White adults.⁸  A qualitative study among nurses providing care to immigrants diagnosed with heart failure in Sweden suggested that nurses should be sensitized to cultural differences and tailor counseling to the patient’s health literacy level to improve self-care adherence.⁹

It is noteworthy that while some studies have demonstrated that migration and displacement may be associated with poor cardiovascular health, limited studies have examined the associations between social determinants and cardiovascular health among immigrants and refugees in their countries of resettlement. Doing so may permit the host countries to tackle the sociopolitical and cultural barriers that prevent them from accessing healthcare services to promote cardiovascular health.

Nurses’ Role in Promoting the Cardiovascular Health of Immigrants and Refugees

Immigrants and refugees face various health concerns that require early and rapid interventions to prevent adverse health outcomes.¹⁰  Nurses are pivotal in promoting cardiovascular health as they are equipped to provide equal and equitable healthcare in diverse settings.¹

The intersections of multiple social determinants of health during migration and upon settlement in host countries must be considered to inform patient-centered care. For example, lack of healthcare access during migration, along with language barriers, may significantly impact health. Therefore, nurses should design and implement community-based interventions to advance the cardiovascular health of immigrants and refugees.

A collaborative process should be established between nurses and members of immigrant and refugee communities as it facilitates understanding of the sociocultural issues that could potentially influence their cardiovascular health. Nurses should also support local and national policies that humanize immigrants and refugees and provides them an equal chance to attain optimal cardiovascular health.

Related Resources

• CE Course: Cardiovascular Health Among Immigrant, Displaced, and Unhoused Populations
• How Can Chinese Immigrants in Western Countries Take Care of Their Cardiovascular Health?

References

1. Wakefield M, Williams DR, and Le Menestrel S. The future of nursing 2020-2030: Charting a path to achieve health equity. National Academy of Sciences; 2021.
2. World migration report 2022. World Migration Report 2022. (n.d.). Retrieved November 2, 2022, from https://publications.iom.int/books/world-migration-report-2022 
3. United Nations High Commissioner for Refugees. (n.d.). What is a refugee? UNHCR. Retrieved November 2, 2022.
4. Castaneda H, Holmes SM, Madrigal DS, Young ME, Beyeler N and Quesada J. Immigration as a social determinant of health. Annu Rev Public Health. 2015;36:375-92.
5. World Health Organization. “World report on the health of refugees and migrants.” (2022).
6. Al-Rousan T, AlHeresh R, Saadi A, El-Sabrout H, Young M, Benmarhnia T, Han BH and Alshawabkeh L. Epidemiology of cardiovascular disease and its risk factors among refugees and asylum seekers: Systematic review and meta-analysis. International Journal of Cardiology Cardiovascular Risk and Prevention. 2022:200126.
7. Marshall GN, Schell TL, Wong EC, Berthold SM, Hambarsoomian K, Elliott MN, Bardenheier BH, Gregg EW. Diabetes and Cardiovascular Disease Risk in Cambodian Refugees. J Immigr Minor Health. 2016 Feb;18(1):110-7. doi: 10.1007/s10903-014-0142-4. PMID: 25651882; PMCID: PMC4526445.
8. Commodore‐Mensah Y, Ukonu N, Obisesan O, Aboagye JK, Agyemang C, Reilly CM, Dunbar SB and Okosun IS. Length of residence in the United States is associated with a higher prevalence of cardiometabolic risk factors in immigrants: a contemporary analysis of the National Health Interview Survey. Journal of the American Heart Association. 2016;5:e004059.
9. Patel H, Szkinc-Olsson G, Lennartsson Al Liddawi M. A qualitative study of nurses’ experiences of self-care counseling in migrant patients with heart failure. Int J Nurs Sci. 2021 Jun 1;8(3):279-288. doi: 10.1016/j.ijnss.2021.05.004. PMID: 34307776; PMCID: PMC8283704.
10. Commodore-Mensah Y, Shaw B, Ford M. A nursing call to action to support the health of migrants and refugees. J Adv Nurs. 2021 Dec;77(12):e41-e43. doi: 10.1111/jan.14970. Epub 2021 Jul 13. PMID: 34254703.1.         
11. United Nations High Commissioner for Refugees. 2019. Responding to the Challenge of Non-Communicable Diseases.