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All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Exemplars of Health Policy
in Specific Countries
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AN: 1815214 ; Regina Dorman, PhD, APRN, Mary De Chesnay, PhD, RN, PMHCNS-BC, FAAN.; Case Studies in Global Health Policy Nursing
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5
Localization of the Nursing Workforce
in the Sultanate of Oman
Christie Emerson
Due to rapid economic development during the past 40 years, the c ountries
in the Arab Gulf Cooperation Council (GCC) are heavily r eliant on
migrant workers across all sectors of the workforce, from highly skilled
professionals to unskilled laborers (Al-Riyami, Fischer, & Lopez, 2015;
Zerovec & Bontenbal, 2011). In an attempt to reduce dependence on foreign
labor and solve the unemployment status of nationals, GCC countries
have implemented national labor policies to localize all sectors of their
workforce. Localization is the process of replacing expatriate workers with
nationals to decrease reliance on expatriates in the labor force (Swailes,
Al Said, & Al Fahdi, 2012; Zerovec & Bontenbal, 2011).
Similar to the other countries in the Gulf region, the Sultanate of Oman
has faced the problem of high domestic unemployment alongside heavy
reliance on an imported workforce (Zerovec & Bontenbal, 2011). For this
reason, in the early 1990s, government leaders formulated a strategic national
development plan that included a focus on Omanization, the replacement of
expatriate workers with Omani nationals. The healthcare workforce has been
particularly dependent on skilled migrant workers due to the rapid expansion of Omani healthcare services and lack of qualified Omani healthcare
professionals. In accordance with the Omanization policy, since 1990 the
Ministry of Health (MoH) in Oman has expanded education and training
for nurses in an attempt to increase Omanization of the nursing workforce
85
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(Al-Riyami et al., 2015). Omanization for nurses has been higher than for
physicians (Ghosh, 2009), yet the percentage of Omani nurses is still only
59% (Ministry of Health [MoH], 2014). The purpose of this chapter is to
describe why localization of the nursing workforce in Oman is important,
examine current policies and reports that relate to localization of the nursing
workforce, and summarize the results of fieldwork activities undertaken to
understand Omanization of the nursing workforce from various perspectives.
RATIONALE
The World Health Organization (WHO, 1946) constitution states that
“the highest attainable standard of health is a fundamental right of every
human being” (para. 1); however, equitable access to health services is
impossible without an adequate supply of health workers. Campbell et al.
(2013) estimated a worldwide shortage of 7.2 million health workers, with
83 countries facing a health workforce crisis. While nursing is not the only
healthcare profession with a shortage, it is the most critical because nurses
deliver the highest percentage of patient care at all levels and because of
the immensity of the shortage of nurses (Oulton, 2006). According to
Buchan and Calman (2005), the shortage of qualified nurses is one of
the biggest obstacles to achieving the United Nation’s (UN) Millennium
Development Goals (MDG) for improving health and well-being of the
global population. According to Loversidge (2016), nursing workforce
regulation has a significant impact on the adequate supply of qualified
nurses, and the WHO encourages member countries to enact policies to
address shortages of nursing workforce (WHO, 2013).
Similar to other countries facing nursing shortages, Oman has
depended on a migrant nursing workforce in order to meet the healthcare
needs of the people since modernization of the healthcare system began
in 1971. While nurse migration can offer mutual benefits to both source
and destination countries, it also has potential negative effects on healthcare in both countries. For this reason, in 2010, the WHO developed the
WHO Global Code of Practice on the International Recruitment of Health
Personnel (WHO, 2010) which states:
Member States should strive, to the extent possible, to create a
sustainable health workforce and work towards establishing effective
health workforce planning, education and training, and retention
strategies that will reduce their need to recruit migrant health
personnel. (p. 5)
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5 Localization of the Nursing Workforce in the Sultanate of Oman 87
A shortage of qualified nurses affects access to quality healthcare, and
while a migrant nursing workforce is a common solution, it has potential
negative effects. Therefore, localization of the nursing workforce in Oman
is an issue of relevance to nursing. General information about Oman, the
history and structure of the Omani healthcare system, and the h
istory
of the Omani nursing workforce are provided in order to situate an
examination of policies regarding Omanization of the nursing workforce.
BACKGROUND
The Sultanate of Oman, with a population of 3.6 million (WHO, 2015a),
is a high-income country located in the southeast corner of the Arabian
Peninsula. It is bordered by the Kingdom of Saudi Arabia and the United
Arab Emirates (UAE) to the west, Yemen to the south, the Strait of Hormuz
to the north, and the Arabian Sea to the east (MoH, n.d.). The median age
is 26 years, with 23% under 15 years old and 4% over 60 years old. Life
expectancy is 79 years for females and 75 years for males. The leading
cause of death is cardiovascular disease (WHO, 2015a).
The Omani system of government is an absolute monarchy. Sultan
Qaboos bin Said al Said is the monarch and head of state (Central
Intelligence Agency, 2016). A renaissance in the country began when
Sultan Qaboos came to power in 1970 (Al Awaisi, Cooke, & Pryjmachuk,
2015; Alshishtawy, 2010). Prior to 1970, Oman’s economy was based
primarily on agriculture and fishing. However, with the discovery of
oil reserves, it has undergone a time of rapid economic growth (Aycan,
Al-Hamadi, Davis, & Budhwar, 2007; Zerovec & Bontenbal, 2011).
As described previously, this rapid growth necessitated a dependence on
migrant workers in all sectors of the workforce, but by the late 1980s the
government recognized the limitations that dependence on a migrant
workforce would have on future development of the country. In the mid1990s, a long-term economic development plan known as “Vision 2020”
was adopted, which contained a policy for Omanization of the entire
workforce (Aycan et al., 2007).
Prior to 1970, healthcare in Oman was limited and sparse, with the
Oman people relying predominantly on traditional medicine. There were
only two hospitals (12 beds in total), both located in Muscat, overseen
by the American Mission. Only a few, mostly expatriate, physicians and
nurses, with a limited number of Omani paramedic staff, ran the hospitals.
Additionally, there were 10 clinics in the interior of the country staffed
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by healthcare assistants, with periodic visits by the Muscat hospitals’
medical teams. At this time, the citizens of Oman had no other options
for healthcare services (Funsch, 2015).
In 1971, the MoH was established and given responsibility for the
organization and development of the National Health System of Oman.
Health planning has been accomplished through a series of 5-year plans
initiated in 1976. Thus far, health planning has gone through three phases.
The first phase, 1976 to 1990, focused mainly on building the health
infrastructure. The second phase, 1991 to 2005, focused on decentralization of the health services and the establishment of 10 health regions.
Beginning in 2006, a new phase began which concentrated on disease
prevention and health promotion in the community (Alshishtawy, 2010).
Alongside these 5-year plans, the MoH developed a healthcare Human
Resources Development Plan that focused efforts on strategies and plans
for further development of healthcare human resources and for a gradual
and smooth Omanization of the healthcare workforce (WHO, 2006).
At the time of the Omani renaissance in 1970, there were only five
Omani nurses (Al-Riyami et al., 2015). Since that time, the MoH has
established diploma nursing institutes across the country in an effort
to provide students with access to nursing education opportunities in
close proximity to their homes. The availability of local nursing training
has significantly contributed to Omanization levels (Alshishtawy, 2010).
In 1975, there were only 450 nurses working in Oman (Alshishtawy,
2010), most of whom were migrants. However, by the end of 2014, there
were 14,623 working nurses, 59% of whom were Omani (MoH, 2014).
There are currently nine diploma programs, two RN to BSN programs,
and two university BSN programs. Additionally, the MoH has established
the Oman Specialized Nursing Institute to offer post-diploma certificates
in nursing specialties (MoH, 2014).
CURRENT OMANIZATION OF THE NURSING WORKFORCE POLICIES
As previously described, health planning in Oman has been accomplished
through a series of 5-year plans from the MoH. The current 339-page plan
describes the National Health Policy of the Sultanate of Oman; strategic
directives for health development in Oman; visions, goals, and objectives of
the plan; and the domains for objective achievement. As the 2016 to 2020
plan is not yet publically available, the 2011 to 2020 plan was reviewed for
the most recent Omanization of the nursing workforce policies.
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5 Localization of the Nursing Workforce in the Sultanate of Oman 89
Goal 7 of eight total goals of the National Health Policy of the S ultanate
of Oman states: “Development and training of Omani workforce in all
health professional categories in order to achieve high levels of Omanization
or self-sufficiency in health workforce” (MoH, Sultanate of Oman, 2011,
p. 2). The following statement, located in the nursing care domain in the
document, addresses how Omanization should be achieved:
In order to speed up development processes, the Ministry has expanded
in the establishment of colleges of nursing in the various governorates
and regions to a total of 12 Nursing Institutes that graduate 7703
nurses up to the year 2010. Thus, the ratio of Omanization cadres
had reached 66% in 2010, but exceeded 95% in some areas. For the
sake of the ministry to continue to develop its human resources, it
provides internal or external scholarships to some of the nursing staff
to get diplomas specialist or bachelor’s degree or master’s in order
to achieve the vision of the ministry and the needs of the required
qualified staff. (MoH, Sultanate of Oman, 2011, p. 51)
This policy provides clear evidence of the priority placed by the Omani
government on Omanization of the nursing workforce.
REVIEW OF THE LITERATURE
Review of the scholarly literature from the last 10 years identified issues
relevant to localization of the nursing workforce in Oman. Search terms
were Oman, GCC, localization, Omanization, nursing workforce, healthcare
workforce, and workforce. The articles were reviewed for themes regarding
effects of localization on the work environment and the impact on nursing.
There was wide variation in the disciplinary sources, methodology, and
sampling of the articles. The articles reviewed were from three disciplines:
business and economics (Al-Waqfi & Forstenlechner, 2010; Forstenlechner &
Rutledge, 2010), health policy (Ghosh, 2009; WHO, 2015b), and nursing
(Al Awaisi et al., 2015; Al-Riyami et al., 2015; Kamanyire & Achora, 2015;
Shukri, Bakkar, El-Damen, & Ahmed, 2013; Wong et al., 2015). Various
types of methodology were utilized in examining issues of localization.
These included the following: qualitative methods using focus groups
(Al-Riyami et al., 2015), case study (Al Awaisi et al., 2015; Ghosh, 2009),
quantitative questionnaires (Al-Waqfi & Forstenlechner, 2010; Shukri
et al., 2013), integrative literature review (Wong et al., 2015), and systematic policy review (Forstenlechner & Rutledge, 2010; WHO, 2015b).
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Sampling for the qualitative and quantitative studies included both
Omanis and migrants.
One theme identified in the literature was that in order for localization
policies to be effective, the Omani nationals must be educated so that they
have the necessary skills to assume the work currently done by migrants.
Al-Waqfi and Forstenlechner (2010) concluded that in the UAE, another
GCC country with similar localization policies, a lack of competence due
to poor training can lead to negative stereotyping of nationals and poor
relationships in the workforce. In a systematic review of WHO documents
from 2007 to 2012 regarding nursing, nursing workforce issues and nurse
migration were both identified as problems that need to be addressed (Wong
et al., 2015). WHO (2015a, 2015b) policy recommendations included a
priority that “Countries have a national nursing and midwifery workforce
plan as part of the national health workforce plan” (p. 700). In a qualitative
study by Al-Riyami et al. (2015), Omani nurses and Omani nursing students
were interviewed about the Omanization policy. One of the themes identified in this study was that Omani nursing education must be improved for
Omanis to be adequately prepared to take over for experienced migrant
nurses. The Omani participants also reported the need for baccalaureate
level nursing education to successfully meet the challenges of nursing work.
Kamanyire and Achora (2015) also concluded that a baccalaureate degree
is necessary for nurses to provide adequate nursing care.
Another theme that emerged was, that in spite of the barriers,
Omanization in the health workforce should continue. Ghosh (2009)
concluded that careful planning has been initiated to make improvements
to the Omani healthcare workforce, and that this careful planning should
continue. Shukri et al. (2013) found that both male and female students
at Sultan Qaboos University had positive attitudes toward the nursing
profession, and the authors recommended that policy makers continue
efforts to increase awareness of the positive value of nursing so that the
Omanization of the nursing workforce can continue. Al-Riyami et al.
(2015) concluded that the Omani nurses and Omani students found value
in Omanization but believed that the process should be slowed down. They
also believed that migrant nurses were often their best mentors. Conversely,
Al Awaisi et al. (2015) found that there was a tense relationship between
new graduate Omani nurses and migrant nurses during their first year of
practice. Forstenlechner and Rutledge (2010) suggested that localization
policies could generate distrust between national and migrant workers
but also believed that localization should continue.
A few articles specifically addressed Omanization of the nursing workforce
(Al Awaisi et al., 2015; Al-Riyami et al., 2015; Ghosh, 2009; Kamanyire &
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5 Localization of the Nursing Workforce in the Sultanate of Oman 91
Achora, 2015; Shukri et al., 2013; Swailes et al., 2012). However, other
articles addressed localization in other GCC countries or in the healthcare workforce, but did not specify nursing (Al-Waqfi & Forstenlechner,
2014; Forstenlechner & Rutledge, 2010; WHO, 2015b; Wong et al., 2015;
Zerovec & Bontenbal, 2011). There are certainly gaps in the literature on
Omanization in the nursing workforce. There were no articles regarding
patient perspectives of Omanization of the nursing workforce, and none
that addressed patient outcomes. Other areas for further research include
the perspectives of migrant nurses and nursing administrators.
FIELDWORK SUMMARY
In order to add the perspective of nurses who work in Oman to my
understanding of Omanization of the nursing workforce, nurses employed
in various positions at a large academic medical center in Oman were
informally asked about the impact of Omanization policies on them.
Additionally, nurse educators at a university college of nursing were also
asked about their perspective on Omanization. The informants can be
divided into the following categories: Omani nursing administrators,
managers, and clinical nurse specialists (CNS); migrant nurse managers
and CNS from various countries of origin; and migrant nurse educators
from various countries of origin. Both male and female nurses were
represented in all categories of informants.
Omani nursing administrators explained that while Omanization is a
National Health Policy, the hospital had no particular policy that requires
the hiring of Omani nurses. It is just understood that Omanization is
the goal. Also, as the BSN is the minimum education requirement for
employment, and although they would like to hire more Omani nurses,
they can only recruit and retain a very few. Only 24.6% of the nursing
workforce at this facility is Omani. Migrant nurses are valued and are
paid the same as the Omani nurses, but the administrators know that
they will eventually return to their countries of origin.
Omani nursing managers and CNS expressed that they value their
migrant nurse colleagues. They believe that the migrant nurses are needed
for their expertise and to train Omani nurses. Most of these nurses stated
that nursing was not their first choice of study, but that they now believe
that the work is important and enjoyable.
Some migrant nurse managers stated that they have been in Oman
for many years (20–30 years), but they plan to return to their country of
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origin as required when they retire. Since most contracts are for 2 years,
one migrant nurse manager said that if a migrant nurse wants to stay in
Oman, they must bring something special to the workforce, be willing
to work hard, and be appreciative of the opportunity to work in Oman.
According to the nurse educators, Omani students are often hard to
motivate because they are not excited about nursing. There are currently
no Omani nurse faculty or administrators; all are migrants. They expressed
frustration at heavy workloads and frustration that they are not respected
in the university community. Most believed that this perceived lack of
respect was due to their migrant status and a lack of respect for nursing.
A nurse recruiter for an international nursing recruitment agency was
also interviewed but did not add a new perspective on Omanization of
the nursing workforce. From the informal interviews, the most common
theme is that both Omani and migrant nurses understand the need for
Omanization of the nursing workforce and accept it. Both respect the
contributions of the other to patient care. While the Omani nurses have
advantages that the migrant nurses do not, both groups believe that they
work well together. Further fieldwork should include discussions with Omani
and migrant patients about their views of the impact of Omanization.
Further discussions with nursing administrators about safety and quality
issues related to Omanization would also add important information.
SUMMARY AND CONCLUSION
Analysis of policies regarding localization of the nursing workforce in
Oman indicates that it is an important issue. The Omanization policy
in the National Health Policy of the Sultanate of Oman is part of the
larger context of localization workforce policies in all the GCC countries
and across all sectors of the workforce. The policy is also influenced by
the government priority to provide quality healthcare to the people of
Oman. Achieving this priority requires an adequate nursing workforce
mixed with the desire for increased self-reliance. Also of importance
in the analysis are the WHO recommendations regarding migration
of nurses. This migration can have a negative impact on the migrating
nurses’ country of origin as well as on the patient care outcomes in the
host country (WHO, 2010).
A review of pertinent literature reveals that there are few studies that
examine localization specifically in Oman and even fewer that specifically
exam localization of the nursing workforce. Although few studies target
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5 Localization of the Nursing Workforce in the Sultanate of Oman 93
Omanization of nursing specifically, some studies from other disciplines
are generalizable to nursing. Further research is needed on the impact of
Omanization of the nursing workforce on patients as well as best ways to
facilitate and implement Omanization.
Perspectives gained from fieldwork in Oman show that both migrant
and Omani nurses understand the need for Omanization policies. Both
groups respect the contributions of the other and generally work collaboratively for the good of the patients. Further fieldwork should be done
to investigate how patients view Omanization of the nursing workforce.
Efforts to localize of the nursing workforce are not unique to the S ultanate
of Oman; other GCC countries are facing similar problems. Oman has
experienced huge growth and many changes in a short time, but careful
planning and implementation of localization policies has accomplished
gradual progression toward Omanization of the nursing workforce. There
is a need for continued attention to the effects of Omanization, alongside
careful evaluation to make the process as smooth as possible.
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6
Perspectives of Culture and Chronic
Disease in the United Arab Emirates
Jennifer Cooper
Sharon Brownie
The United Arab Emirates (UAE) is a rapidly developing country comprised
of a multinational population with varying educational backgrounds,
cultural practices, and religious beliefs (Loney et al., 2013). Impacted by
social and environmental factors, the built environment and c ontemporary
lifestyles pose major public health challenges to this modern Arab and
expatriate world with noncommunicable (NCD) and chronic disease an
increasing concern. The aforementioned challenges significantly contribute
to morbidity and mortality in the UAE (Rahim et al., 2014). NCD and
chronic disease is not isolated to the UAE alone, but forms part of a global
health crisis, requiring international global health policy, collaboration,
and action (Hajat, Harrison, & Shather, 2012).
CONTEXT
Comprised of seven Emirates, the UAE is situated southeast of the Arabian
Peninsula, sharing borders with Oman and Saudi Arabia (Loney et al.,
2013). This small, newly formed nation is known for its involvement in
world trade and its modern industrial progress. A 1995 national census
97
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reported a total UAE population of 2.7 million, with 20% UAE n
ationals
(National Census, 1995). The remainder of the population was from
India, Pakistan, East Asia, and Europe (National Census, 1995).
Twenty-year growth to 2015 estimates a total population increase to
9.7 million, with a total of 13% UAE nationals (UAE National Bureau
of Statistics, 2015).
The UAE has experienced and continues to experience rapid changes
in economic development and urbanization with significant impact on
lifestyle behaviors and culture (Alhyas, McKay, & Majeed, 2012). These
lifestyle changes have caused an increase in NCDs such as cardiovascular
disease, cancers, respiratory disease, and type 2 diabetes. Risk factors for
these diseases, such as tobacco use, physical inactivity, and an unhealthy
diet, have also increased and led to a rise in obesity and hypertension
within the UAE and the wider Arabian Gulf Region (Arab, 2003).
TRADITIONAL CULTURE AND FAITH
Culture assists in specifying which behaviors, beliefs, and practices are
acceptable in a society. The differences among cultures, beliefs, and practices
influence an individual and population, groups, lifestyle, and health
behaviors. Culture influences social institutions, social groups, and, in turn,
individuals, population health, and illness (Jirojwong & Liamputtong, 2012).
Prior to 1971, the UAE did not exist as a country and was known as
the coast of Oman (Al-Fahim, 1995). In the 1800s, it was known as the
Trucial states and the locals lived a Bedouin lifestyle on the land; or, they
lived by the sea, where pearling and sea diving were their main forms of
trade (Al-Fahim, 1995). The Bedouins lived in encampments in the desert
or by the sea, and each area of Bedouins belonged to a specific tribe which
had its own traditions and customs; their identity was associated with either
their desert or sea existence (Al-Fahim, 1995). In the 1800s, the British
made truce agreements with the leaders of the Trucial states and withdrew
these agreements in 1971 (Al-Fahim, 1995). In 1971, the six Trucial states
agreed on a federal constitution as an independent country now known as
the UAE (Al-Fahim, 1995). At this time, the staple food consisted of dates,
camel milk, and fish (Al-Fahim, 1995). The cultural traditions were adhered
to, including no alcohol and pork, with meat required to be slaughtered in
Islamic Halal style (World Culture Encyclopedia, 2017).
The Islamic religion is the cornerstone for all Muslims and is the
religion followed by most of the population in the UAE (Central Intelligence
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 99
Agency, 2005). The Islamic faith involves submitting oneself to God and
following the five pillars of Islam.
The five pillars of Islam include the following:
Shahadah: Reciting the Muslim faith
Salat: Performing prayers five times a day
Zakat: Proving monetary assistance to the poor and less fortunate
than oneself
Sawm: Fasting throughout the holy month of Ramadan
Hajj: Completing the pilgrimage to Mecca once in a lifetime.
In the UAE, the official language is Arabic; however, English is the
language of commerce and social service delivery. In the 1950s and
early 1960s, before the discovery of oil, UAE nationals consumed and
bought only necessities; however, with the discovery of oil and globalization, a Western lifestyle has resulted in evolving cultural changes.
Rapid changes can bring about challenges in individual health and
population health which impact social, cultural, and environmental
characteristics.
The Emirati culture is known for its hospitality and socializing with
friends and family. Most guests are greeted with coffee and dates (World
Culture Encyclopedia, 2017) and the main meal shared with the family is
the daytime meal. At large social gatherings, food is generously shared and
is part of socialization. The importance of sharing food together is a vital
component of the Emirati culture (Brownie, 2015). Food consumption is
heavily influenced by changes in food availability in the UAE (Boutayeb
et al., 2012). Despite the many changes influenced by globalization, the
traditions among family within the UAE culture remain of vital importance
to the lifestyle of UAE nationals. UAE nationals are heavily influenced by
family; conformity and commitment to the group are paramount (Vel,
Captain, Al-Abbas, & Al-Hashemi, 2011).
Culture also influences an individual or population group’s health
behavior, perception of health and health maintenance, response to an
illness, and the type of care they seek (Huff & Kline, 1999; Kleinman,
1980). The effect culture has on population health is influenced by
the complexities of the cultural, biological, social, and psychological
challenges which impact on chronic disease prevention, management,
and premature death.
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MODERN CULTURE AND FAITH
The UAE is one of the most diverse countries in the Gulf Corporation C
ouncil
(GCC), attracting many foreign investors and many expatriates, which
has influenced traditional culture and values (Potter, 2011). The country
is a major modern metropolis featuring five-star hotels, lavish shopping
malls, and cuisine from all over the world (Potter, 2011). The older UAE
nationals will recall a rural environment, while the younger generation
is familiar and comfortable living in a modern, urban, and Westernized
society. Western influences have influenced Arabic dress, entertainment,
and marriage (Benesh, 2008). In some Arabic families, p
artners can be
chosen instead of an arranged marriage. There is also support and acceptance for Arabic women to be educated and join the workforce (Khelifa,
2010). These changes have been the result of significant societal changes
due to economic development, the promotion of higher education, and the
desire to create a strong workforce of both male and female UAE nationals.
However, despite the Westernized influences, fundamental values such as
the influences of traditional society, culturally defined dress, the Islamic
faith, and the importance of family remain a constant guiding force which
affect behavior and actions (Al-Khazraji, 2009).
IMPACT AND CONSIDERATION FOR HEALTH
RISK FACTORS
Although there have been positive changes in the UAE’s thriving and
modern society, some changes have brought about challenges to the health
status of its population. The contemporary lifestyle of UAE nationals is
characterized by poor diet, high tobacco use (24% males), and physical
inactivity with an associated high BMI average of 29 kg/m2 across the
UAE total population (Hajet et al., 2012). Risk factors contributing to the
health status of the UAE population and increasing the risk of developing
NCD and chronic diseases are outlined below.
Tobacco Use
One of the main risk factors contributing to the development of r espiratory
disease in the UAE is tobacco use. According to Hajet et al. (2012), “smoking
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 101
rates are very high in young National males, with 16% of 18- to 20-year-olds,
27% of 20- to 29-year-olds and 28% of 30- to 39-year-olds” being smokers, but
less than 1% of women smoke. The smoking rates are also high among
non-national males as they predominantly originate from Southeast Asia
and India, which also have high rates of smoking (Health Authority Abu
Dhabi Statistics Report, 2014). There are also many misconceptions about the
safety of the use of the tobacco pipe (shisha) and Midwakh, which are both
common practices of smoking throughout the Gulf r egion, but p
articularly
in the UAE (Akl et al., 2010; Jayakumary, Jayadevan, Ranade, & Mathew,
2010; Kandela, 2000; Maziak, Eissenberg, & Ward, 2005). A
ccording to the
Global Youth Tobacco Survey, tobacco pipe use among the 13- to 15-year-old
age group has risen from 18% in 2002 to 29% in 2005 (Vupputuri et al.,
2016). In children aged between 13 and 15 years who participated in the
Global Youth Tobacco Survey, 82% had tried a cigarette before the age of
14 years (Vupputuri et al., 2016). These alarming statistics require utmost
attention from the public health sector and offer a challenging environment
for the promotion tobacco control.
Culture and cultural habits are determinants that impact this population group. Smoking among males and some females in the UAE is
a habit enjoyed with friends and family (Islam & Johnson, 2003). It is
a social and cultural norm and is seen as part of the country’s cultural
hospitality (Chaouachi, 2000).
Physical Inactivity
Physical inactivity increases the risk of NCD, including cardiovascular
disease, type 2 diabetes, cancers, and respiratory disease. Physical inactivity
and sedentary lifestyles have been identified as the fourth leading risk
factor for mortality globally (World Health Organization [WHO], 2017).
In 2012, as part of the Lancet physical activity series working group, the
effects of physical inactivity on major NCDs worldwide were reviewed as
part of an analysis of the burden of disease and life expectancy (Lee et al.,
2012). Physical inactivity was found to be attributable to 6% of the burden of
disease from coronary heart disease, 10% of breast and colon cancer, and 7%
of type 2 diabetes (Lee et al., 2012). Inactivity contributes to mortality, and if
there was a 10% to 25% increase in physical activity, it is estimated that the
average life expectancy across the world’s population would increase by 0.68 to
0.95 years (Lee et al., 2012). Physical activity is essential for healthy lifestyles,
self-efficacy, sportsmanship, and a reduction in developing risk factors for
preventable lifestyle diseases such as obesity and type 2 diabetes (Bailey, 2006).
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Food Consumption/Unhealthy Diet
The rapid environmental changes of urbanization and the availability,
affordability, and accessibility of fast food have affected overall food
consumption (Loney et al., 2013). Some of the traditional foods of the
UAE included meats such as chicken, lamb, mutton, and fowl, while rice
was introduced to the traditional diet when traders moved to the region.
Cheese, dates, and eggs were also staples in the traditional diet, with
camels being used to transport camel milk. The meat, rice, and spice
dishes originate from Saudi Arabia but are also an original staple of the
traditional Emirati diet, alongside coffee shared with houseguests, family,
and friends (Al-Fahim, 1995).
Fast food is consumed at least once a week and sometimes daily
by residents of the UAE (Rizvi & Bell, 2015). According to the YouGov
health survey conducted in 2015 with UAE nationals and expatriates
(n = 1,030; m = 646 and f = 385), 7% ordered fast food or ate out of the
home daily (Rizvi & Bell, 2015) and 30% consumed fast food and/or ate
out once a week (Rizvi & Bell, 2015). Poor nutrition and a consumption
of high fat foods increase the risk factors for NCD and chronic diseases
(WHO, 2013).
NONCOMMUNICABLE AND CHRONIC DISEASE IN THE UAE
NCD and chronic diseases are the world’s biggest killers. According to the
World Health Organization (WHO), 36 million individuals die annually
from NCDs (WHO, 2013). By working with individuals, communities,
and populations, risk factors associated with NCD and chronic diseases
can be reduced. Influencing public health policy is vital to addressing risk
factors, particularly those that impact long-term health outcomes for the
UAE population and globally (WHO, 2013).
CARDIOVASCULAR DISEASE
Cardiovascular disease is one of the main causes of death in the UAE
(Health Authority Abu Dhabi, 2011). In 2000, the WHO created a
document on the global burden of disease of which, for the UAE, the
main noncommunicable issues of concern were cancer, cardiovascular
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 103
disease, type 2 diabetes, high mean BMI, and high rates of smoking
among males (WHO, 2000). In response to this report, in 2008, the
Health Authority in the Emirate of Abu Dhabi developed a screening
program called Weqaya (Weqaya is the Arabic word for protection;
Hajat et al., 2012). Ninety-four percent of the adult national population
in the Emirate of Abu Dhabi were screened, and of those screened,
there were extremely high levels of obesity, type 2 diabetes, prediabetes,
hypertension, and high rates of tobacco use (Hajat et al., 2012). During
2008 to 2009, 17% were diagnosed with hypertension and 36% with high
lipids (“Weqaya Sample,” 2008).
CANCERS
The worldwide burden of cancer is reported to be rising due in part
to the growth and age of the global population, and an increasing
Westernized lifestyle, including the risk factors for NCD and chronic
disease, as discussed earlier, tobacco use, physical inactivity, and unhealthy diets.
Cancer is the third leading cause of death in the UAE among both
UAE nationals and expatriates (Statistics Centre Abu Dhabi, 2010). The
leading cause of cancer-related death in males is lung cancer and breast
cancer in females (Statistics Centre Abu Dhabi, 2015). In 2015, in the
Emirate of Abu Dhabi, 14.1% of deaths resulted from lung cancer and
12.2% from breast cancer (Statistics Centre Abu Dhabi, 2015). Other
common cancers among men in the UAE are colorectal, liver, leukemia,
and pancreatic. Irrespective of breast cancer, the other most common
cancers among women in the UAE are colorectal, leukemia, ovarian, and
lung cancer (Statistics Centre Abu Dhabi, 2015).
Culture plays a major part in the response to signs and symptoms
of illness and potential cancer diagnosis. Many UAE nationals present
themselves late to healthcare facilities for treatment due to cultural
and religious beliefs, fear, stigma, and family attitude toward treatment
(Silbermann et al., 2013). An individual’s health beliefs and practices are
influenced heavily by the sociocultural environment that surrounds them,
including family and friends, community and society (Assaf, Holroyd, &
Lopez, 2017).
The UAE has recently developed a cancer registry; however, the data
are only inclusive of public government hospitals and do not include
private hospitals (Rizvi, 2017). The Ministry of Health and Prevention is
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developing a new National Cancer Index which will allow monitoring and
surveillance of the various types of cancers and a greater understanding
of the cancers affecting the UAE population (Rizvi, 2017). The burden
of cancer could be reduced through early detection and treatment and
public health campaigns to promote smoking cessation, physical activity,
and healthy dietary intake.
RESPIRATORY DISEASE
The UAE population is at an increased risk of developing respiratory
diseases due to the high incidence of tobacco use, indoor and outdoor air
pollution, and extreme weather variations including major dust storms
and in some cases genetics (Webster, 2016). The burden of respiratory
diseases varies throughout the UAE; however, asthma, respiratory infections, sleep disorders, and chronic obstructive pulmonary disease
(COPD) remain the most prevalent respiratory conditions. According
to the WHO, the main factors contributing to respiratory diseases such
as COPD include tobacco smoke indoor and outdoor air pollution, and
exposure to occupational chemicals and dust (Webster, 2016).
Asthma is a chronic respiratory disease increasing globally, including
the UAE. In the GCC region, there is inter and intraregional variability
in asthma prevalence. In Oman, the prevalence varied between 7.8%
and 17.3% in different regions of the country (Al-Rawas, Al-Riyami,
Al-Kindy, Al-Maniri, & Al-Riyami, 2008), and in Qatar the prevalence
was 19.8% (Janahi, Bener, & Bush, 2006). In Saudi Arabia, the prevalence was 23.6% (Nahhas, Bhopal, Anandan, Elton, & Sheikh, 2012). A
study from Al Ain in the UAE illustrates an asthma prevalence of 13%
using the International Study of Asthma and Allergies in Childhood
(ISAAC) questionnaire (Al-Rawas et al., 2008), while another based
on the European Community Respiratory Health Survey (ECRHS)
questionnaire shows a range of 8% to 10% across the UAE (Alsowaidi,
Abdulle, & Bernsen, 2010).
There has also been a rise in other respiratory diseases in the UAE,
such as tuberculosis and pneumonia. According to Health Authority Abu
Dhabi (HAAD), there has been evidence of rising cases of tuberculosis
(TB). In the Emirate of Abu Dhabi in 2010, 450 cases of pulmonary TB
and 175 cases of extrapulmonary TB were registered (El Shammaa, 2011;
Qabbani, 2011).
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 105
Pneumonia is a health problem that mainly affects children under
the age of 5 years and adults over 65 years. However, figures from the
WHO show that 5% of deaths among children under the age of 5 years
in the UAE are caused by pneumonia (Howidi, Muhsin, & Rajah, 2011).
TYPE 2 DIABETES
The modern epidemic of type 2 diabetes and its association with the rising
prevalence of obesity are well established. The WHO predicts doubling the
number of individuals with type 2 diabetes in the world between the years
2000 and 2025. According to the International Diabetes Federation (IDF),
the UAE has the second highest incidence of diabetes in the world and
many of the neighboring Gulf countries are in the top eight countries in
the world with the highest rates of type 2 diabetes (International Diabetes
Federation [IDF], 2011).
Type 2 diabetes usually occurs due to environmental and sometimes
genetic factors; however, the risk of developing type 2 diabetes is substantially increased due to lifestyle risk factors, such as insufficient physical
activity and poor diet. It is often associated with individuals who are
overweight, obese, and have hypertension (Diabetes Australia, 2015).
Type 2 diabetes can often be prevented by maintaining a healthy
lifestyle including a healthy diet and physical activity. However, most
individuals need some form of medication to assist in disease management
and to help minimize long-term complications (Bate & Jerums, 2003).
INTERPRETIVE MODEL: SOCIO-ECOLOGICAL MODEL
The socio-ecological model was originally developed in the 1970s and
became a formalized theory in the 1980s. The model is used for human
development to improve the understanding of the interaction between
genetics and biology. Its original focus was on children (Bronfenbrenner,
1989). The model continued to be revised to include the interrelatedness
of the physical and social environment and the impact this has on an
individual’s attitudes and beliefs (Bronfenbrenner, 1989).
The socio-ecological model illustrates the interaction between an
individual, community, and society and where individual behaviors are
influenced by multiple factors. An individual is influenced by family,
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family history, and genetics. Communities such as schools, workplaces,
and neighborhoods also impact an individual’s behavior and attitude,
while the broader society influences an individual’s social and cultural
norms (McLeroy, Bibeau, Steckler, & Glanz, 1998). For behavior change
to be instilled, culture, e nvironment, and government policies need to
be aligned (Caprio et al., 2008).
The socio-ecological model illustrates five levels that influence an
individual’s behavior: individual, interpersonal, community, organization,
and policy (Bronfenbrenner, 1993). Each level intersects and connects
with the others so that an individual’s knowledge, values, beliefs, and
self-efficacy are influenced by many factors, such as family and friends
(interpersonal), access to information and social capital (community),
and resources and services (Bronfenbrenner, 1993).
INDIVIDUAL
The individual is situated in the center of the social-ecological model. This
level includes personal factors that increase or decrease the likelihood
of an individual making behavioral changes (Bronfenbrenner, 1989).
Individual influences include an individual’s age, gender, education level,
socioeconomic status, and self-efficacy. It also includes an individual’s
knowledge, attitudes, behaviors, beliefs, barriers, and motivation
(Bronfenbrenner, 1989).
There is a complex interplay between individual behaviors,
cultural influences, and environmental factors that is represented by
the socio-ecological model which illustrates the multiple factors that
influence behavior (Townsend & Foster, 2011). Human behaviors,
including participation in physical activity, decreasing tobacco use, and
consuming a healthy diet, are improved when an individual’s environment
supports healthy choices. The socio-ecological model acknowledges that
it requires a combination of individual, environmental, and policy-level
interventions to achieve sustainable changes in health behaviors.
INTERPERSONAL
The interpersonal environment comprises the relationships between family and friends, and an individual’s culture and values, and the society in
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 107
which an individual interacts (Bronfenbrenner, 1989). The interpersonal
environment has a significant influence on an individual’s behavior. If an
individual is surrounded by family and friends who participate in physical
activity and healthy food choices, this can impact the behavior of others
(Bronfenbrenner, 1989).
The socio-ecological model helps to explain the relationships between
the constructs of family and cultural norms: their expectations and obligations being integral to lifestyle, irrespective of the severity of an individual’s
NCD or chronic disease. An individual’s beliefs, attitudes, and behavior
are impacted and influenced by cultural norms and expectations, cultural
identity, and the wider community (Bronfenbrenner, 1989).
COMMUNITY
The community context in which social relationships are developed
include environments such as schools, neighborhoods, and workplaces.
Community also incorporates parks and recreation utilized for leisure
time with family and friends (Jirojwong & Liamputtong, 2012). The
community level of the socio-ecological model supports and illustrates
an individual’s interactions with his or her physical and sociocultural
environments (Jirojwong & Liamputtong, 2012). To reduce sedentary
lifestyles and promote healthy lifestyles, all levels of the socio-ecological
model need to be addressed.
Many environmental and social determinants of health have contributed
to and continue to have an impact on the development of NCD and chronic
diseases (Keheler and MacDougall, 2009). In the UAE, environmental
determinants such as mass urbanization, a rapid increase in population
size, and adverse weather conditions such as dust and sandstorms all
contribute to an individual’s health management (Loney et al., 2013). A
lack of health knowledge and awareness, a lack of social support (most of
the UAE population are living away from home), addiction, and stress are
also environmental impacts that contribute to the development of NCD
and chronic diseases (Jarvis, 2002). The financial accessibility and low cost
of tobacco and fast food are also contributing factors (Daniel, Cargo, &
Lifshay, 2004). For behavior change to occur, an individual requires a
supportive community, incorporating environments that influence active
living, healthy food options, and a reduction in tobacco consumption.
Community-level change can take time and requires a socio-ecological
approach recognizing the complexity of factors at various levels, including
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the community, family, and society. Positive community-level change
requires a foundation grounded in relevant cultural concepts, cultural
engagement, and self-determination (Jirojwong & Liamputtong, 2012).
The UAE government authorities are aware of the need to address
NCD and chronic diseases and their associated risk factors and have
been actively promoting public health initiatives, particularly in schools
(Regional Consultation, 2010). However, there is a continued need to
increase education and awareness among the UAE population through
multiparty strategies and awareness campaigns on the impact and long-term
health effects of consuming high fat food and a lack of physical activity
(Swan, 2017).
ORGANIZATIONAL
Individual behavioral change is influenced by organizational environments, systems, and policies (Robinson, 2008). The organizational level
of the socio-ecological model overlaps with the community and policy
levels and represents a vital component of the model incorporating
organizations such as work environments, social institutions, healthcare
and faith organizations. All individual interactions with any organizational
environment influence an individual’s food behavior, physical activity
levels, and tobacco use (Robinson, 2008). Organizational environments are
required to determine organizational systems and policies to implement
strategies to support healthy lifestyle choices (Robinson, 2008).
POLICY
Policy refers to legislation and policy making carried out by local, state, or
federal governments. There can also be local policies for schools, healthcare
facilities, and academic institutions. Some examples of policies that can
impact an individual’s behavior to make healthy choices include urban
planning, transport, and education policies ensuring physical activity
and healthy food options are available in schools. Environmental and
workplace policies also play a part in individual and community b ehavior
change (Langille & Rodgers, 2010). Policies provide the opportunity
for governments to collaborate with various organizations to promote
strategies to align with healthy lifestyles and reduce risk factors for NCD
and chronic diseases (Langille & Rodgers, 2010).
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6 Perspectives of Culture and Chronic Disease in the United Arab Emirates 109
HEALTH WORKFORCE IMPACT
The UAE population includes a unique mix of UAE nationals, e xpatriates,
and a large male labor workforce (Hunter, Robb, & Brownie, 2014).
The UAE government relies heavily on expatriate workers; however,
this reliance is changing and much of the workforce development and
capacity-building has been tailored to the employment of local UAE
nationals to ensure healthcare delivery can be undertaken by UAE
nationals (Brownie, Lebogo, & Hag-Ali, 2014). Workforce development
has been supported by local u
niversities offering medical, nursing, and
allied health degrees (Brownie et al., 2014). Due to the rapid changes
in urbanization, poor dietary intake, and p
hysical inactivity, the UAE
is burdened with high rates of NCDs and chronic diseases which are
challenging for the current workforce to provide appropriate healthcare
services (Brownie et al., 2014).
The UAE population data sets are also difficult to ascertain given
that the most recent data were published in 2010 with the latest census
data based on figures from 2005 (Hunter et al., 2014). Gaps in population
data and reliable health data also make it difficult for universities and
healthcare services alike to provide appropriate healthcare services to
meet the needs and demands of this multinational population (Brownie
et al., 2014). Through the promotion of health policy and legislation,
development of early detection strategies, ongoing surveillance, and an
increase in health expenditure, an overall reduction in NCDs and chronic
diseases could be achieved (Brownie et al., 2014).
CONCLUSION
For a reduction in NCD and chronic disease to be achieved among those
living in the UAE, there needs to be a multinational, multisectorial approach,
with commitment from all sector stakeholders. Healthcare education and
awareness campaigns need to address the risk factors and be culturally
sensitive to the needs of the population group. Education needs to be targeted at high-risk groups and be implemented in areas where the groups
are easily reached, such as schools, universities, healthcare facilities, and
labor camps. A country-wide cancer registry inclusive of all sectors and a
surveillance program for all UAE residents need to be developed to gain a
better understanding of the size of the NCD and chronic disease problems
and to aid in the development of appropriate legislation and policies. The
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social, environmental, and cultural determinants need to be encompassed
in all education, policies, and strategies to aid in the reduction of NCDs
and chronic diseases. Policy makers and government departments, in collaboration with both public and private healthcare sectors and education
institutions, are required to address the needs of this unique multicultural,
multinational population group. The socio-ecological model represents a
comprehensive approach to the design, implementation, and evaluation
of health interventions which target multiple influences on behavior including the risk factors for NCDs and chronic diseases.
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7
Infection Control in Sierra
Leone: A Global Issue
Elizabeth Holguin
The terms international health and global health are often used interchangeably.
However, international health commonly refers to healthcare issues within
the developing world, or low- to middle-income countries (LMICs).
Global health refers to issues that go beyond individual country borders
and require an interconnectedness of systems, disciplines, and policies.
We have seen, through recent outbreaks such as severe acute respiratory
syndrome (SARS), swine flu (H1N1), West Nile virus, and Ebola that the
global community can be quickly affected. Resources must be shared and
collaboration is essential to quickly stop the spread and adverse sequelae
of these diseases. As in Ebola, outbreaks often stem from under-resourced
areas that do not have the capacity to face the issue alone. It is essential to
build a global community of cooperation, alliances, and partnerships to
not only respond after the fact but to proactively prevent such breakdowns
in public health infrastructure from occurring in the first place.
This chapter provides an overview of the country of Sierra Leone, my
own experience attempting to implement an infection control program
in a government hospital located in a Lassa fever–endemic region, and
outlines several issues and challenges faced that are applicable to not
only Sierra Leone but to any LMIC as well as underdeveloped and under-
resourced areas within the United States.
117
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OVERVIEW OF SIERRA LEONE
Sierra Leone is a country in West Africa with a population of approximately 6,018,888 (Central Intelligence Agency [CIA], 2017a). English
is the official language but is used only by a literate minority. Mende is
spoken mainly in the south and Temne is spoken mainly in the north.
Krio, which is an English-based Creole first spoken by descendants of
freed Jamaican slaves who were settled in the Freetown area, is the first
language of about 10% of the population but is widely understood and
used throughout the country (CIA, 2017a). The predominant religion is
Islam (60%). Ten percent of the population practice Christianity while
30% practice other indigenous religions (CIA, 2017a).
Sierra Leone is a very youthful country; approximately 60% of the
population is under the age of 25. Sierra Leone has a very high total fertility
rate of almost five children per woman. There has been little decline due to
a desire for large families, low levels of contraceptive use, and an early start
to childbearing. However, Sierra Leone’s population is mitigated by some
of the world’s highest infant, child, and maternal mortality rates, poverty,
lack of clean drinking water and sanitation, poor nutrition, limited access
to quality healthcare services, female genital cutting/mutilation (CIA,
2017b), poor feeding and hygienic practices, and overcrowded housing
(World Health Organization [WHO], 2014a). High unemployment rates
were one of the major causes of the civil war that took place from 1991 to
2002 and unemployment is a current threat to stability (CIA, 2017b). The
unemployment rate is particularly high among youth and is attributed to
high levels of illiteracy and unskilled labor, a lack of private sector jobs,
and low pay (CIA, 2017a).
GOVERNMENTAL AND ADMINISTRATION STRUCTURE
Sierra Leone’s governmental structure is similar to that of the United States
in that it is divided into judicial, legislative, and executive branches. Sierra
Leone is divided into Northern, Southern, and Eastern Regions, and the
Western Area. The Western Area is divided between Western Rural and
Western Urban, where the capital city, Freetown, is located; the majority
of federal entities are located in Freetown. Each region is divided into
12 districts, which are further divided into chiefdoms, which are then
subdivided into sections. Each district has a council that is comprised
of district chair people, administrators, and counselors. Each chiefdom
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7 Infection Control in Sierra Leone: A Global Issue 119
is governed by locally elected paramount chiefs. In 2004, the country
divided into 19 local councils that are subdivided by 392 wards led by
elected counselors due to recent decentralization efforts (WHO, 2014a).
Sierra Leone has had extreme damage to its infrastructure due to an
11-year civil war that ended in 2002. In particular, major setbacks are
still seen today in the health and development sectors (Scott, McMahon,
Yumkella, Diaz, & George, 2014).
HEALTH ACCESS
Sierra Leone is almost last on the Human Development Report: 179 of
187 countries (United Nations Development Programme [UNDP], 2016).
Due to poverty and lack of infrastructure, healthcare is fragmented. Health
services in Sierra Leone are available through a network of health facilities.
There are a total of 1,040 peripheral health units that include 40 hospitals (23
of which are government owned), community health centers, community
health posts, and maternal and child health posts (WHO, 2014c). Besides
contending with high costs to travel to and/or long distances to preferred
healthcare facilities (Fleming et al., 2016), people needing healthcare in
Sierra Leone lack treatment of surgical conditions and an adequate supply
of anesthesia (Harris et al., 2015), childhood immunizations and adequate
care for sick children (Scott et al., 2014), prenatal care (WHO, 2014c), and
access to services for the disabled (Trani et al., 2011).
DISEASE BURDEN
Although noncommunicable diseases are on the rise with hypertension,
diabetes, and mental illnesses increasing due to lifestyle changes and drug
abuse (WHO, 2014a), the majority of illnesses and deaths are preventable
in Sierra Leone. Most deaths can be attributed to nutritional deficiencies,
pneumonia, diarrheal diseases, anemia, malaria, tuberculosis (TB), HIV/
AIDS (WHO, 2014a), and helminth infections (Pullan, Smith, Jasrasaria, &
Brooker, 2014). Malaria remains the most common cause of illness and
death and accounts for about half of outpatient visits, 38% of hospital
admissions, and 41% of hospital deaths among children under 5 years
(WHO, 2014c). The citizens of Sierra Leone, as well as nearby countries
like Guinea and Liberia, must also contend with viral hemorrhagic fevers
such as Lassa and Ebola.
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VIRAL HEMORRHAGIC FEVERS
Viral hemorrhagic fever is a term used to describe a syndrome that includes
“fever, a constellation of initially nonspecific signs and symptoms, and a
propensity for bleeding and shock” (Blumberg, Enria, & Bausch, 2014,
p. 1). There are over 30 viruses that may cause viral hemorrhagic fever
from four taxonomic families: Filoviridae, Arenaviridae, Bunyaviridae,
and Flaviviridae (Blumberg et al., 2014). Almost all are zoonoses, with the
exception of dengue hemorrhagic fever, and are usually named after the
geographic region in which the first identified case originated (Blumberg
et al., 2014). Little data exist on the exact mode of transmission from
mammals to humans, but infection is presumed to occur from contact
with the host’s “virus-contaminated excreta,” via mucous membrane or
broken skin (Blumberg et al., 2014, p. 174). Human-to-human transmission occurs with many hemorrhagic fever viruses through direct contact
with contaminated blood or other bodily fluids; this most often occurs
through oral or mucous membrane exposure while providing care to
sick family members or hospitalized patients or during funeral rituals
that often involve touching the corpse prior to burial (Blumberg et al.,
2014). Widespread outbreaks in an area are almost always the result of
a high volume of cases in a particular healthcare setting in which basic
infection control measures are no longer possible due to poverty or civil/
political unrest (Blumberg et al., 2014) and the resulting lack of gloves and
other personal protective equipment (PPE) and the reuse of unsterilized
equipment such as needles (Bausch & Rollin, 2004).
LASSA FEVER
Most viral hemorrhagic fevers are only recognized when widespread
outbreaks occur. However, Lassa fever, an Arenavirus, is endemic in West
Africa and accounts for tens of thousands of cases annually (Richmond &
Baglole, 2003; Shaffer et al., 2014). The Lassa virus is spread through
contact with Mastomys natalensis, the “multimammate rat” (Centers for
Disease Control and Prevention [CDC], 2014). The infected rodent is
able to excrete the virus through its urine for a very long time, possibly
its entire life (CDC, 2014). This particular species breeds frequently and
produces large numbers of offspring (CDC, 2014).
Transmission to humans occurs because the rodents tend to enter
homes, attracted to food that is not stored properly. There have also been
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7 Infection Control in Sierra Leone: A Global Issue 121
some cases of certain populations consuming the rodents because they
are used as a food source (CDC, 2014). Transmission can occur through
ingestion or inhalation of the Lassa virus (CDC, 2014). The virus is shed
in the urine and excrement. If humans come in direct contact with these
by unknowingly touching soiled objects, eating contaminated food, or
by exposure from open wounds, they may become infected (CDC, 2014).
Person-to-person transmission also may occur due to contact with
an infected person’s blood, tissue, secretions, or excretions; in addition,
nosocomial transmission sometimes occurs when PPE is lacking or
when needles are reused and not sterilized properly (CDC, 2014). After
a 5- to 16-day incubation period, patients may present with a fever and
many nonspecific symptoms that may include headache, sore throat,
myalgia, abdominal pain, and diarrhea (Bausch et al., 2001; McCormick &
Fisher-Hoch, 2002; Monath, Maher, Casals, Kissling, Cacciapuoti,
1974; Shaffer et al., 2014). More specific symptoms include conjunctival
erythema, retrosternal pain, and facial swelling (Shaffer et al., 2014).
In less than one-third of cases, mucosal and gastrointestinal bleeding occur
(Shaffer et al., 2014). Death results from diminished effective circulating
volume, shock, and multi-organ system failure (Peters, Lin, Anderson,
Morrill, & Jahrling, 1989; Shaffer et al., 2014). Prompt early diagnosis is
essential; there is no approved Lassa fever vaccine but the antiviral drug
ribavirin can be effective if given within the first 6 days of the disease
course (McCormick et al., 1986; Shaffer et al., 2014). Because diagnosis
of Lassa and other highly communicable diseases can be delayed, it is
essential to have a proper infection control program in place.
INFECTION CONTROL PROGRAM COMPONENTS
An infection control program has several essential components. The World
Health Organization (WHO) has put forth several necessary elements
that include prevention of transmission through standard and additional
precautions; education and training of healthcare workers; protection of
healthcare workers; identification of hazards and minimizing risks; routine practices such as aseptic technique, single use devices, instrument
and equipment cleaning and sterilization, antibiotic usage, management
of body fluid exposure, handling and use of blood and blood products,
and responsible management of medical waste; effective work practices and
procedures; surveillance; incident monitoring; outbreak investigation;
infection control in specific situations; and research (WHO, 2004).
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TRANSMISSION PREVENTION
Standard Precautions
For infection control, we focus on standard precautions that should be
followed for every patient at all times, and additional transmission-based
precautions that are case or disease specific, such as for contact, airborne,
or droplet transmission. Standard precautions include (a) proper hand
hygiene; (b) use of PPE when in contact with blood or bodily secretions;
(c) handling patient care equipment or soiled linen in an appropriate
manner; (d) prevention of accidental needle stick injuries or sharps injury;
(e) environmental c leaning, usually with a bleach solution; (f) education
on respiratory hygiene, or “cough etiquette” for patients and guests; (g) safe
injection practices; and (h) appropriate handling of waste (Borlaug, 2016;
WHO, 2004).
Airborne Precautions
Airborne precautions help to reduce airborne transmission when “droplet
nuclei” or evaporated droplets are released and spread through the air,
which may remain suspended in the air for long periods of time (WHO,
2004, p. 16). TB, measles, varicella, and SARS are spread through airborne
transmission (Borlaug, 2016; WHO, 2004). For these patients, in addition
to standard precautions, they must be placed in a negative airflow pressure
room with the door closed at all times, an N 95 particulate respirator
mask is required for anyone who has patient contact, and movement and
transport of the patient should be limited (WHO, 2004).
Droplet Precautions
Droplet transmission can happen when large particle droplets generated from the infected person (coughing, sneezing, talking, or during
procedures such as tracheal suctioning) come in contact with mucous
membranes of the nose, mouth, or conjunctivae of a susceptible person
(WHO, 2004). In addition to standard precautions, droplet precautions
consist of placing the patient in a single room or in a room with a patient
who is infected with the same pathogen, wearing a surgical mask when in
close proximity to the patient, and placing a surgical mask on the patient
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7 Infection Control in Sierra Leone: A Global Issue 123
during transport (WHO, 2004). Pneumonias, pertussis, diphtheria,
influenza, mumps, meningitis (WHO, 2004), and smallpox (Borlaug,
2016) are spread through droplet transmission.
Contact Precautions
Contact precautions help to prevent diseases that are transmitted through
direct or indirect contact with an infected person. Such diseases are norovirus, rotavirus, head lice (Borlaug, 2016), multiple antibiotic-resistant
organisms, and skin infections (WHO, 2004). In addition to standard
precautions, patients should be placed alone or with another patient
with the same pathogen, anyone having patient contact should put on
gloves and a clean nonsterile gown when entering the room, and patient
transport should be limited (WHO, 2004). In addition, all reusable items
should be cleaned and disinfected before removing from the patient’s
room and disposable items should be disposed of before leaving the
room (Borlaug, 2016).
INFECTION CONTROL PROGRAM IMPLEMENTATION
The prior section provided a discussion of infection control program
implementation in ideal conditions with easily accessible resources. This
section outlines infection control program implementation in a very
different context.
Upon arrival at Kenema Government Hospital (KGH), my first step
was to spend several days observing routine patient care and hospital
procedures. I spent time in an outpatient clinic, the nursing wards (both
adult and pediatric patients), the TB ward, the Lassa fever ward, and the
operating room. In the outpatient setting, a temporary structure similar
to a mobile home, ECG electrodes were used repeatedly from patient to
patient, so much so that they barely stuck to skin anymore. Electricity was
unreliable, a problem everywhere but especially notable in the operating
room. Nurses needed to have manual suctioning devices on hand.
Many women were scheduled for cesarean sections because their labor had
not progressed in their homes. For many, the intervention was too late for
their infants. Chickens, cats, and dogs ran freely through the wards from
time to time due to inadequately secured entry points. Window screens had
gaping holes. To protect from malaria, each bed had a mosquito net, but
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some nets had holes in them as well. Most of the mattresses were visibly
stained or soiled. Patients brought linens from home and families mainly
supplied food. Scraps of soap bars were available for handwashing next
to overused hand towels. No gloves were available in the wards unless
the nurses purchased them themselves.
The TB ward was separated by male and female. The women were
placed in a standard ward, in close proximity to nursing staff. The men,
however, were located in a barn-like structure that was over 100 degrees
inside. Some had beds and some laid only on scraps of cardboard on the
floor. The Lassa ward did provide proper isolation for patients and medical
staff did have access to PPE. However, there was inadequate capacity for
housing a large number of patients and the amount of PPE was finite.
I spoke with administrators, physicians, and nurses to ascertain the
issues that they face on a daily basis. I then identified one of the more
senior nurses as the infection control nurse. I worked with him to identify
further issues and to discuss next steps. The infection control nurse and
I collaborated on a daily basis to identify the proper mode of training
necessary for existing staff, as well as procedures for training of new
staff. In addition, we aimed to create training refresher courses and brief
competency exams for staff to complete at regular intervals.
IDENTIFIED ISSUES AND CHALLENGES
NURSING EDUCATION/LICENSING
Many of the nurses employed at KGH did not have proper education or
training. It is very difficult to provide additional training for staff who are
not sufficiently trained or familiar with the basics of nursing care. Lack
of basic infection control prevention and PPE use training is widespread
(Pathmanathan et al., 2014). Staff cannot be expected to be motivated to
learn extra material when they are not paid on a regular basis; in fact, many
were volunteering their time. Currently, there are 13 accredited nursing and
midwifery training institutions in the country (“Sierra Leone News,” 2016).
There is a major issue with illegal, unaccredited nursing and midwifery
schools throughout Sierra Leone. These schools will accept those who
do not have the required competencies to enter an accredited institution.
This, in turn, produces certified nurses who are poorly prepared to practice clinically, which negatively impacts the professional standards of
nursing (“Sierra Leone News,” 2016). Youth in rural areas are susceptible
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7 Infection Control in Sierra Leone: A Global Issue 125
to these types of institutions due to lack of accredited opportunities; of
the 13 accredited institutions, only one is located in the eastern portion
of Sierra Leone, with five in the west near the capital city of Freetown
(“Sierra Leone News,” 2016). Due to finances and logistics, many nursing
students are forced to turn to less credible, illegal options for training to
gain employment.
HUMAN RESOURCES FOR HEALTH
With the inception of the sustainable development goals (SDGs), the
healthcare workforce has become a salient issue. It is a multifaceted
issue, especially in LMICs. There are over four million people without
access to quality healthcare services, largely related to a major shortage
of workers, workers with mismatched or inadequate skill sets, and an
uneven geographic distribution of health workers (WHO, 2017). Sierra
Leone, similar to most African countries, has fewer than 20 physicians
and fewer than 20 nurses or midwives per 10,000 people (WHO, 2010).
By c omparison, the United States has 50 to 99 nurses/midwives and
20 to 29 physicians per 10,000 people, while Canada and Australia have
over 100 nurses and 20 to 29 physicians per 10,000 people (WHO, 2010).
Another major issue affecting patient care pertains to a phenomenon
known as “brain drain.” It refers to the emigration of highly talented
professionals, like nurses, doctors, scientists, and professors, usually
from LMICs to countries such as the United States, Canada, England,
and Australia, thus leaving their countries of origin with a paucity of
trained professionals. These professionals are usually attracted to a better
quality of life and additional educational opportunities. This emigration
can be especially detrimental to population health in countries that were
under-resourced to begin with.
During the recent Ebola outbreak, it was noted through a surveillance
effort that none of the surveyed districts had dedicated infection control
supervisors to coordinate infection prevention and control procedures or
quality assurance measures; those available within hospitals and holding
centers were not likely to be competent in infection control practices
(Pathmanathan et al., 2014). There were inadequate supplies of PPE as
well as improper usage by staff (Pathmanathan et al., 2014). In general,
there were notable widespread shortages of running water, incinerators to burn hazardous waste, chlorine, and blood collection supplies
(Pathmanathan et al., 2014).
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126 II
Exemplars of Health Policy in Specific Countries
SUPPLIES AND FUNDING
The sheer lack of supplies was a major barrier when attempting to implement an infection control program in KGH. How could infection control
measures be enforced when there are no gloves or soap, let alone gowns,
masks, proper facilities, etc.? I was not in Sierra Leone long enough to
determine funding issues, but from staff report, corruption may have
been a factor.
Policies are needed to ensure proper funding pathways from the
Ministry of Health down to each hospital or clinic so that patients can
be cared for in the proper manner and rest assure that they are receiving
care in a safe environment. In addition, healthcare workers should not
have to risk their lives to come to work each day. Hundreds of nurses
and physicians lost their lives in the recent Ebola outbreak. The WHO
attributes high infection rates to shortages of PPE, improper use of PPE,
inadequate staffing to cover the needs of such a large outbreak, and
compassion driving staff to work in isolation wards beyond the number
of hours considered to be safe (WHO, 2014b).
POLICY IMPLICATIONS
It is essential for nurses to obtain health or public policy positions in
national or international organizations to influence decision making at
the highest levels. As nurses, it is important to go beyond the “nursing
bubble” (Shamian, 2014) to influence factors in other health, social,
and economic domains. Nurses understand the needs of their patients
and communities. Nursing is the largest healthcare profession, with the
“potential to be a leading powerhouse for positive change and innovation”
(Holguin, Hughes, & Shamian, 2017, p. 201), and can play a critical role
in impacting the social determinants of health for their patient populations (Holguin et al., 2017). By acquiring leadership roles in government
or national organizations, nurses can ensure that the multifaceted issues
that patients face will be brought to the forefront of healthcare and social
policy decision making. As a global community, nurses in the developed
world cannot allow fellow nurses in developing countries to continue to
work in conditions that are life-threatening, or tolerate patients facing
unnecessary and preventable threats to their well-being and livelihood
on a daily basis while their basic human needs are not met. Nurses have
the power and ability to influence nursing education and regulation;
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7 Infection Control in Sierra Leone: A Global Issue 127
hospital and healthcare system policies, strategies, and guidelines; social
determinants of health for patients; and governmental or institutional
financial resource allocation.
SUMMARY
Nurses are in a unique position to assist in designing an improved
healthcare system that can lead to universal health coverage because
they understand the intricacies of patients’ needs as well as the inner
workings of the healthcare system. Nurses must secure a seat at
the policy table for real and significant change to occur. To begin making
changes in your current position, you can join your own institution’s
infection control committee, a shared governance committee, hospital
board, or local public health organization or board. It is important to join
national and international nursing organizations to form professional
relationships and support networks. Doing so will allow you to learn
from other nurses and unite as a global community, making nursing a
stronger and more effective profession.
REFERENCES
Bausch, D. G., Demby, A. H., Coulibaly, M., Kanu, J., Goba, A., Bah, A.,...
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