II Copyright 2018. Springer Publishing Company. 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 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE AN: 1815214 ; Regina Dorman, PhD, APRN, Mary De Chesnay, PhD, RN, PMHCNS-BC, FAAN.; Case Studies in Global Health Policy Nursing Account: mdcc.main.ehost EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 86    II Exemplars of Health Policy in Specific Countries (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) EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 88    II Exemplars of Health Policy in Specific Countries 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. EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 90    II Exemplars of Health Policy in Specific Countries 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 & EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 92    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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. REFERENCES Al Awaisi, H., Cooke, H., & Pryjmachuk, S. (2015). The experiences of newly graduated nurses during their first year of practice in the Sultanate of Oman: A case study. International Journal of Nursing Studies, 52, 1723–1734. doi:10.1016/j.ijnurstu.2015.06.009 Al-Riyami, M., Fischer, I., & Lopez, V. (2015). Nurses’ perceptions of the c­ hallenges related to the Omanization policy. 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All use subject to https://www.ebsco.com/terms-of-use 94    II Exemplars of Health Policy in Specific Countries International Journal of Human Resource Management, 18(1), 11–32. doi:10.1080/09585190601068243 Buchan, J., & Calman, L. (2005). Summary: The global shortage of registered nurses. Geneva, Switzerland: International Council of Nurses. Campbell, J., Dussault, G., Buchan, J., Pozo-Martin, F., Guerra Arias, M., Leone, C., . . . Comett, G. (2013). A universal truth: No health without a workforce (Forum Report, Third Global Forum on Human Resources for Health). Geneva, Switzerland: Global Health Workforce Alliance and World Health Organization. Central Intelligence Agency. (Ed.). (2016). Oman. Retrieved from https://www .cia.gov/library/publications/resources/the-world-factbook/geos/mu.html Forstenlechner, I., & Rutledge, E. (2010). Unemployment in the Gulf: Time to update the “social contract”. Middle East Policy, 17(2), 38–51. doi:10.1111/j.1475-4967.2010.00437.x Funsch, L. 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Y., Liu, H., Wang, H., Anderson, D., Seib, C., & Molasiotis, A. (2015). Global nursing issues and development: Analysis of World Health Organization documents. Journal of Nursing Scholarship, 47(6), 574–583. doi:10.1111/jnu.12174 World Health Organization. (1946). Constitution of WHO: Principles. Geneva, Switzerland: Author. Retrieved from http://www.who.int/about/mission/en/ World Health Organization. (2006). Health system profile: Oman. Cairo, Egypt: Author. World Health Organization. (2010). The WHO global code of practice on the international recruitment of health personnel (Sixty-third World Health Assembly, Document WHA 63.16). Geneva, Switzerland: Author. World Health Organization. (2013). Global health workforce shortage to reach 12.9 million in coming decades. Geneva, Switzerland: Author. Retrieved from http:// www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/ World Health Organization. (2015a). Oman: WHO statistical profile. 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All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 98    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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. EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 100    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 102    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 104    II Exemplars of Health Policy in Specific Countries 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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, EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 106    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 108    II Exemplars of Health Policy in Specific Countries 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. 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Retrieved from https://www.thenational.ae/uae EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 6 Perspectives of Culture and Chronic Disease in the United Arab Emirates    115 Weqaya sample of 112, 301 UAE nationals in the Emirate screen in 2008–2009. (2008). Abu Dhabi: UAE University and Health Statistics Analysis, Health Authority Abu Dhabi. World Culture Encyclopedia. (2017). Culture of UAE. Retrieved from http:// www.everyculture.com/To-Z/United-Arab-Emirates.html World Health Organization. (2000). Global burden of disease, version 3. Geneva, Switzerland: Author. World Health Organization. (2013). Global action plan for the prevention and control of non-communicable disease 2013–2020. Retrieved from http:// apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1 World Health Organization. (2017). Noncommunicable diseases and their risk factors. Retrieved from http://www.who.int/ncds/introduction/en EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 118    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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. EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 120    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 122    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 124    II Exemplars of Health Policy in Specific Countries 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 EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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). EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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; EBSCOhost - printed on 10/12/2021 2:59 AM via MIAMI DADE COLLEGE. All use subject to https://www.ebsco.com/terms-of-use 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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