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Population Health for Nurses

5.1 Demographic Factors

Population Health for Nurses5.1 Demographic Factors

Learning Outcomes

By the end of this section, you should be able to:

  • 5.1.1 Define demographics.
  • 5.1.2 Describe the fastest-growing demographics in the United States.
  • 5.1.3 Discuss characteristics of underrepresented populations.
  • 5.1.4 Examine how projected population changes challenge public health policies and the implications for health care services.

Demographics are statistical data regarding the characteristics of the people living in a particular place, describing them based on categories such as age, race, ethnicity, sexual orientation, gender identity, ability, education level, income level, and marital status. Individuals belong to many demographic groups. For example, a person may belong to one group based on age, another based on race, and a third based on geographic location. This section examines demographics, focusing on rapidly growing underrepresented populations and on how the growth of these populations affects both public health policies and the provision of health care services.

Fastest-Growing Demographics

U.S. Census Bureau forecasts indicate that the United States will continue to experience significant demographic shifts in the next 40 years. By 2060, the U.S. population is expected to increase by 79 million people (U.S. Census Bureau, 2020), and changing demographics will have major implications for the national health care system. Community health and public health nurses must prepare to serve these changed populations. A more diverse nursing workforce will lead to better health outcomes for populations (American Association of Colleges of Nursing, 2023). This section reviews the most rapidly expanding population groups within the United States.

Baby Boomers

One way to categorize populations is by generation, a period spanning about 20 to 30 years that includes everyone who is born and lives their lives at approximately the same time, experiencing similar social and cultural events. Until recently, baby boomers, or the generation born from 1946 to 1964, made up the largest generation in the United States—76 million births—and 71.6 million living adults in 2019 (Fry, 2020). As this large demographic group ages, the number of individuals over the age of 65 continues to increase. For example, although older adults represented 8 percent of the total population in 1950, they made up 16 percent of the population in 2020 and are projected to represent nearly 25 percent of the total population in 2060 (see Figure 5.2) (Centers for Disease Control and Prevention [CDC], 2022d).

The U.S. Census Bureau estimates that by 2030 all individuals in the United States categorized as baby boomers will be over 65 years old, marking a significant shift toward an older average age in the U.S. population (America Counts Staff, 2019). The growth of the baby boomer population is significant for nurses and other health care professionals because older adults tend to have a higher prevalence of health issues and chronic diseases, such as Alzheimer’s disease, diabetes, hypertension, and arthritis, that are related to aging (CDC, 2022d). As the proportion of older adults in the population increases, the incidence of age-related health conditions and deaths will also increase. Consequently, the need for health care services in nursing homes, long-term care, and home health care facilities in the United States will grow.

A bar graph shows the aging of the U S population, comparing 1971 to 2021. The percent of the population aged 0 to 4 fell from 8.3% in 1971 to 5.7% in 2021. The percent of the population aged 5 to 19 fell from 29.1% in 1971 to 19.1% in 2021. The percent of the population aged 20 to 34 fell slightly from 21% in 1971 to 20.2% in 2021. The percent of the population aged 35 to 49 rose from 16.9% in 1971 to 19% in 2021. The population aged 50 to 64 rose from 14.7% in 1971 to 19.2% in 2021. The population aged 65 or older rose from 9.9% in 1971 to 16.8% in 2021.
Figure 5.2 The number of individuals over the age of 65 in the U.S. population is growing. (data source: U.S. Census Bureau; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Racial and Ethnic Minorities

Another projected demographic change in the U.S. population is a shift in the numbers of racial and ethnic minorities in relation to the population as a whole. Ethnic minorities are population groups with a shared culture, tradition, religion, language, history, or other factors living in communities or areas where most people are from a different ethnic group. Between 2020 and 2060, the U.S. Census Bureau predicts major changes in the racial and ethnic diversity of the U.S. population. For example, the number of non-Hispanic White individuals is expected to decrease dramatically. In 2020, there were approximately 199 million non-Hispanic White individuals in the United States; that number is expected to fall to approximately 179 million by 2060, a 10 percent decrease. The decline in the non-Hispanic White demographic is related to a decrease in overall births and an increase in deaths over time.

During the same 40-year period, individuals who identify as two or more races are projected to be the fastest-growing racial or ethnic group in the United States. The U.S. Census Bureau estimates that Asian people will make up the second fastest-growing ethnic group, and Hispanic people will be the third fastest. The projected increase in the number of individuals who identify as Hispanic is attributed to an increase in the number of children born to parents who identify as Hispanic in the past decade, while the projected increase in net international migration is the primary driver for an increase in the number of individuals who identify as Asian. The U.S. Census Bureau also estimates that the population of individuals who are considered foreign-born will increase from 44 million in 2016 to approximately 69 million in 2060, making up 17 percent of the U.S. population (2020).

For nurses and other health care professionals, these rapidly changing demographics are significant because they have implications for the prevalence of disease and health disparities. The CDC defines health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations” (CDC, 2020a, para. 1).

Heart disease, cancer, diabetes, and stroke are the most common causes of illness, disability, and death in the United States (CDC, 2022a). Underrepresented populations, such as ethnic minorities, tend to be impacted the most by chronic diseases—conditions like hypertension, diabetes, kidney disease, heart disease, and cancer—that individuals live with for a year or more that require ongoing medical attention, limit the activities of daily living, or both. Underrepresented populations are defined as subgroups within a population, often identified by race, ethnicity, age, sex, gender, sexual orientation, or socioeconomic status, whose representation in society is disproportionately low relative to their numbers (National Institutes of Health [NIH], 2023b). Chronic diseases affect certain racial and ethnic groups more than others:

  • Between 2017 and 2018, diagnosed diabetes prevalence was higher among American Indians/Alaska Natives, people of Hispanic origin, and non-Hispanic Black people than among White people (CDC, 2020c).
  • In 2018, Asian people comprised 6 percent of the U.S. population but accounted for approximately 2 percent of new HIV cases (CDC, 2020b).
  • Asian/Pacific Islanders have tended to experience the highest rate of hepatitis B when compared with other ethnic groups. As such, rates of hepatitis B-related mortality remain higher among Asian/Pacific Islanders than among than their ethnic counterparts (CDC, 2020b).
  • In 2018, the rate of tuberculosis among Asian people was 31 times higher than all people reported as having been diagnosed with tuberculosis nationwide (CDC, 2020b).

Black and Hispanic people and Alaska Natives experience worse health outcomes on several measures when compared with their White counterparts (NIH, 2023b):

  • Alaska Natives, Hispanic people, and American Indians are at higher risk of being uninsured (Tolbert et al., 2022).
  • Black, Hispanic, and Asian adults were less likely to receive care for mental health conditions as of 2021 (Hill et al., 2023).
  • Approximately six in 10 Hispanic, Black, and Alaska Native adults did not receive a flu vaccine in the 2021–2022 flu season compared with less than one-half of White adults (Hill et al., 2023).
  • Life expectancy at birth was shorter for Alaska Native people and Black people between 2019 and 2021 (Hill et al., 2023).
  • In 2021, infant mortality rates were twice as high among Black people and Alaska Native people (Hill et al., 2023).
  • In 2021, Black and Alaska Native women experienced the highest rates of death related to pregnancy (Hill et al., 2023).
  • In 2021, Black and Hispanic children were more than twice as likely to experience food insecurity (Hill et al., 2023).

Healthy People 2030

Reduce the Proportion of Adults Who Don't Know They Have Prediabetes

According to Healthy People 2030, approximately 38 percent of individuals living in the United States, age 18 and older, have undiagnosed prediabetes. The goal of this Healthy People 2030 objective is to decrease the proportion of American adults who have prediabetes from the baseline of 38 percent in 2013 to 33.2 percent by 2030. Healthy People 2030 discusses resources for individuals such as weight loss, healthy eating, and increased physical activity to reduce the risk of prediabetes.

According to the CDC (2022b; 2020c), African Americans, Hispanic/Latino Americans, and American Indians, Pacific Islanders, and some Asian Americans are at elevated risk of developing prediabetes.

(See Office of Disease Prevention and Health Promotion [ODPHP], 2023c.)

Unfolding Case Study

Part A: Demographic Factors

Read the scenario, and then answer the questions that follow.

Jose is a 53-year-old Hispanic male who has presented to the clinic with anxiety and with chest pain radiating to the right arm. Jose was recently let go from his job and has not been able to find employment. He is accompanied to the clinic by his wife and his mother. Jose indicates that he does not like coming to the doctor’s office, and he becomes more anxious as the nurse completes his health assessment. His vital signs are as follows:

  • Blood Pressure: 126/82 mm Hg
  • Respirations: 18 breaths/minute
  • Heart Rate: 130 beats/minute
  • Oxygen Saturation: 98 percent on room air

Other findings from the nurse’s health assessment of the client are as follows:

  • Neurological: Within normal limits.
  • Respiratory: Lungs clear to auscultation.
  • Cardiovascular: Increased heart rate, but normal heart sounds. No peripheral edema noted.
  • GI: Within normal limits.
  • GU: Within normal limits.
  • Pain: Radiating to the right arm 5 on a scale of 1–10.
When assessing Jose, what factors about his ethnic background should the nurse consider?
  1. The client is at a higher risk for certain health conditions because of his ethnic background.
  2. The client has the same risk for certain health conditions as anyone else his age.
  3. The client is a member of a minority group that is decreasing in numbers over time.
  4. The client is a member of a minority group that is eligible for additional health-related resources.
How can Jose’s employment status potentially affect his health?
  1. He will be covered by Medicaid, so there should be no long-term effects.
  2. He can continue to receive health care in the local emergency department.
  3. He is more likely to be affected by a health disparity.
  4. His temporary unemployment status should not permanently affect his health.

Vulnerable Populations

According to the National Collaborating Centre for Determinants of Health (NCCDH), “vulnerability occurs when people are exposed to multiple layers of marginalization, including barriers to social, economic, political, and environmental resources that overlap to increase the risk of poor health. Individuals and communities are vulnerable to, live in vulnerable conditions or are forced into vulnerability rather than being labeled as vulnerable people/populations/groups” (NCCDH, 2023, para. 1). Ethnic and racial minorities are examples of vulnerable populations as many individuals within these groups are at risk of experiencing health disparities. Individuals experiencing poverty—many of whom identify as members of ethnic or racial minorities—are another demographic at risk of poor health outcomes related to lack of access to health care. For example, a 2020 report on income and poverty in the United States revealed the following (Shrider et al., 2021):

  • Between 2019 and 2020, real median household income decreased 2.9 percent to $67,521.
  • The total number of people with earnings decreased by 3.0 million, and the number of individuals who worked full-time year-round decreased by 13.7 million between 2019 and 2020.
  • There was a 1.2 percent decrease in real median earnings for all workers.
  • The official poverty rate increased from 10.5 percent in 2019 to 11.4 percent in 2020.
  • In 2020, 37.2 million people were living in poverty, up from 33.9 million in 2019.

Sexual and gender underrepresented populations, which “include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex” (NIH, 2023a, para. 2), are another vulnerable population that is growing. The number of individuals identifying as lesbian, gay, bisexual, or transgender rose significantly between 2010 and 2020. As of 2017, there were approximately 11.4 to 12.2 million adults living in the United States who identified as lesbian, gay, bisexual, or transgender (National Library of Medicine, 2020).

The population of individuals with disabilities is another growing vulnerable population. Between 2008 and 2019, rates of disability among children under age 18 increased by 0.4 percent (Young & Crankshaw, 2021). Children who identified as American Indian and Alaskan Natives and those living in poverty had the highest rates of disability (Young & Crankshaw, 2021). In its Annual Report on People with Disabilities in America, the University of New Hampshire Institute on Disability (2023) states that the percentage of Americans with disabilities increased from 13.2 percent in 2019 to 13.5 percent in 2021.

For nurses and other health care professionals, these changing demographics are significant because they present challenges in areas across society, including in the workforce, education systems, and health care systems. Vulnerable populations tend to have more health issues such as preventable diseases (e.g., diabetes, hypertension, and obesity) and poor access to care, which leads to increased mortality (deaths) and morbidity rates (diseases). An increase in mortality and morbidity reflects increased health disparities (American Association of Colleges of Nursing, 2023). Members of the lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender plus other unknowns (LGBTQIA+) community—particularly youth—are at increased risk for negative health and life outcomes related to discrimination and stigma. The risk of suicide and substance misuse is high within this age group (CDC, 2023b). Individuals with disabilities are more likely to smoke and have obesity, heart disease, and diabetes. One in four adults in this population is also less likely to have a dedicated health care provider or receive an annual check-up (CDC, 2019a).

The Roots of Health Inequities

What Causes Health Inequities?

The World Health Organization (WHO) defines health inequities as “systematic differences in the health status of different population groups” (2023, para. 2). Health inequities are the result of human-made systems that favor one group over another. As a result, an unequal distribution of power occurs. The following have been identified as the structural root causes of health inequities: racism, sexism, classism, xenophobia, heterosexism, and ableism. These inequities can occur at the institutional level (how organizations treat others), interpersonal level (individuals’ behaviors toward each other), and the internal level (how individuals view themselves). Watch the video for more information about the causes of health inequities.

In addition to experiencing more health issues, members of underrepresented communities tend to distrust the health care system because of racism, bias, and perceived mistreatment. For example, in a Kaiser Family Foundation survey, 78 percent of individuals who identified as White said they trusted their doctors, although only 59 percent of those who identified as Black said they trusted theirs (Hamel et al., 2020).

As discussed in Structural Racism and Systemic Inequities, much of this distrust is due to systemic racism—the institutional unfair treatment of individuals based on race—and discrimination against racial minority populations in the United States. The perception by members of underrepresented communities that racism will be present often leads this population to choose not to seek health care. The resulting poor health outcomes further exacerbate health disparities between groups within a population. Such disparities are especially present in cancer screening, neonatal care, pain management, end-of-life care, and the treatment of cardiovascular disease (Huzar, 2021).

Individuals tend to have better health outcomes when they receive care from providers who are familiar with their culture (Nair & Adetayo, 2019). Health care providers should work toward developing greater cultural competence—the ability to understand and work with people of cultures other than one’s own—which in turn increases trust within communities. The box below provides some suggestions for strategies nurses can use to increase client trust. Also see Culturally and Linguistic Responsive Nursing Care and Managing the Dynamics of Difference for more information on this topic.

Guidelines for Increasing Trust with Clients

  • Learn about the client’s culture and ensure it is central in every aspect of the client’s care.
  • Include the client and their family in the care process.
  • Work to build trust with your client before and during the client care process.
  • Be open and transparent with the client when communicating.
  • Assess whether the client understands what you have taught them (health literacy).
  • Be mindful of the degree to which the client has access to health care resources, and ensure you have mechanisms in place to address barriers, such as transportation, housing, and health insurance.
  • Involve the interdisciplinary team in the client’s care to ensure all aspects of the client’s life and health issues are addressed. This would include professionals such as the physician, social workers, nutritionist, and health educators.

(See The Institute for Functional Medicine, 2023.)

Needed Policy Changes

To provide appropriate care to a changing population, policies and programs devoted to achieving health equity must be developed. Health equity refers to “the state in which everyone has a fair and just opportunity to attain their highest level of health” (CDC, 2022g, para. 1).

The CDC’s Office of Health Equity is on the front lines of achieving health equity through its CORE Strategy, which is an integration of health equity into every element of the work of the organization. CORE is an acronym for the following goals (CDC, 2023a):

  • Cultivate Comprehensive Health Equity Science—The CDC Office of Health Equity will facilitate and accelerate the principles of health equity across all CDC programs, policies, and funding structures.
  • Optimize Interventions—The CDC Office of Health Equity will engage partners to address gender discrimination and gendered racism in the workplace.
  • Reinforce and Expand Robust Partnerships—The CDC Office of Health Equity will engage partners to mobilize around developing and implementing strategies to address health disparities and long-term health inequities, which includes the social determinants of health.
  • Enhance Capacity and Workforce Engagement—The CDC Office of Health Equity will work to diversify the public health workforce.

One health policy with which most people are at least somewhat familiar is the Patient Protection and Affordable Care Act of 2010, also known as the Affordable Care Act (ACA). The primary goals of the ACA are to (U.S. Department of Health and Human Services [HHS], 2023a):

  • Improve the affordability of health insurance to more individuals (Figure 5.3).
  • Expand the Medicaid program, a state-operated health insurance program for those who are living in poverty or are disabled.
  • Provide support for medical care delivery methods that are designed to yield lower health care costs.
A line graph shows the number of uninsured individuals under age 65 by race from 2009 through 2019. The number of uninsured Hispanic or Latino people decreased from 32% in 2009 to 30% in 2013 and then sharply decreased again to 21% by 2015. As of 2018, 20% of Hispanic or Latino people were uninsured. The number of Black non-Hispanic people who were uninsured increased slightly from 19% in 2009 to 20% in 2010 and then decreased to 19% in 2013. The number decreased sharply decreased to 11% by 2015, and as of 2018, 12% of Black not Hispanic people were uninsured. The number of Asian non-Hispanic people who were uninsured remained stable from 2009 to 2012 at 15% and then sharply decreased to 7% by 2015, where it remained through 2018. From 2009 to 2013, 13% of White non-Hispanic people were uninsured. By 2015 the number of White non-Hispanic people who were uninsured decreased sharply to 8%, where it remained through 2018.
Figure 5.3 This graph shows the lack of health insurance among people in the United States under age 65 by race and Hispanic origin. (Those over age 65 are covered by Medicare and Medicaid.) (data source: National Center for Health Statistics, National Health Interview Survey [NHIS] and Health, United States, 2020–2021,; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

5 Things About the Affordable Care Act

This video provides a brief overview of the ACA, the 2010 law that increases health insurance options and provides additional health care rights and protections to all citizens, improving access and reducing disparities.

Watch the video, and then respond to the following questions.

  1. How does the ACA protect clients with preexisting medical conditions?
  2. What are some preventive services covered by the ACA? How do such services improve clients’ health?

Medicaid is a national program, jointly funded by each state and the Centers for Medicare and Medicaid Services (CMS, 2022), a federal agency. The program provides health coverage to the following populations: eligible low-income adults, children, pregnant clients, older adults, and people with disabilities. Medicaid is administered by individual states according to federal requirements. Each state independently determines its population’s Medicaid coverage and eligibility; to be eligible, an individual must fall within a certain financial category. One outcome of the ACA was to lower Medicaid eligibility requirements, thus increasing opportunities for those needing it; each state determined whether to expand Medicaid.

As of 2023, 38 out of 50 states and the District of Columbia had adopted and implemented expanded Medicaid; Wyoming, Kansas, Wisconsin, Texas, Mississippi, Tennessee, Alabama, Georgia, South Carolina, and Florida chose not to adopt Medicaid expansion, and South Dakota and North Carolina had adopted expansion but had not implemented it (Rudowitz et al., 2023). States that chose to expand Medicaid experienced an average reduction in poverty of 0.917 percent, or approximately 690,000 individuals lifted above the federal poverty line (Chee, 2019; Zewde & Wimer, 2019). These expansion states experienced increased state revenue as well as cost savings in other government programs that provide services that overlap with Medicaid (Guth & Ammula, 2021). Hospitals and other health care providers in expansion states have seen their profits and revenues increase (Guth & Ammula, 2021). In the states that have not adopted the Medicaid expansion, individuals fall into the coverage gap where their income is too high to qualify for Medicaid but too low to quality for subsidies offered by health insurance plans through the ACA Health Insurance Marketplace (Kagan, 2022). The uninsured rate in these states is almost double the rate of uninsured in states that have expanded Medicaid (15.4 percent compared with 8.1 percent) (Rudowitz et al., 2023). If all states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become eligible for coverage (Rudowitz et al., 2023).

Medicare, a federal health insurance program, provides health insurance coverage to individuals over age 65 and to those with specific disabilities who are younger than 65. Different parts of Medicare cover different services. Medicare Part A pays for inpatient hospital visits, skilled nursing facilities, hospice care, and some home health care; Part B pays for some outpatient care, doctor’s visits, and preventive services, and Part D covers the cost of prescription drugs (, n.d.; Medicare Resources, 2023). Sixty-five million Americans receive insurance coverage through Medicare. This includes 57 million older adults and almost 8 million younger adults who have disabilities (Kaiser Family Foundation, 2023). Unlike Medicaid, Medicare is both funded and controlled by the federal government. To address the increasingly aging population—as well as increases in the number of individuals with disabilities—additional Medicare funding is necessary. By 2030, the percentage of American citizens who do not work and rely on those who are employed will exceed 70 percent. Medicare is expected to deplete its reserve by 2035 if the trend of the aging of America continues its current trajectory. In order for Medicare to continue providing for the growing number of recipients, policy change will be needed to fund the program.


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