Barriers of Advanced Public Health (Capstone Project)

Barriers of Advanced Public Health Nursing in Women and Children in a Muslim Population in Saudi Arabia

Introduction

The objective of this paper is to present a highlight of a project that is meant to identify and curb barriers of advanced public health nursing in children and women in a Muslim population in Saudi Arabia. The project is expected to be implemented in the summer semester and end fall semester, meaning the implementation will take place in September and October.

Define the Problem

The Constitution of Saudi Arabia mandates the government to provide all the citizens and expatriates working in the country with access to all public health care services. As a consequence, the government has been channeling more funds to the Ministry of Health over the years. For instance, the expenditure increased from 2.8% in 1970 to 6.9% in 2009, representing 5% of the country’s gross domestic product (Almaliki, Fitzgerald, & Clark, 2011). The Ministry is charged with the responsibility of planning, formulating, and managing health policies, supervising health programs, and monitoring health services that are provided by the private practitioners. In the past decade, public health remained a matter of public, health professionals, the media as well as decision makers concern in Saudi Arabia given the latest outbreaks of infectious diseases. Notably, there have been outbreaks of H1N1, H5N1, rift valley fever, the threat of Severe Acute Respiratory Syndrome (SARS), and coronavirus (MERS-CoV) (Mahmoud, Al-Zalabani, & Bin Abdulrahman, 2016).

Apart from the threat of infectious diseases, there has also been a worrying increase of chronic ailments, such as hypertension, diabetes, cancer, heart diseases, genetic blood conditions, as well as childhood obesity (Almaliki et al., 2011). With the increase in both infections and infectious diseases, some that are chronic, the significant role of public health services as well as the need to have a competent workforce cannot be underestimated. Chronic diseases are costly to treat. For instance, the annual cost of treating diabetes in the country has been estimated to be more than $ 1. 87 billion (Mahmoud, Al-Zalabani, & Bin Abdulrahman, 2016). Therefore, even though public health services have continued to improve over the years due to the government’s efforts, there are still notable barriers that special groups within the population continue to encounter. The barriers prevent the special groups, particularly the women and children from enjoying advanced public health nursing benefits. It should be noted that women and children form a core component of Saudi’s population; therefore, the government cannot meet its public health objectives if it does not address the barriers that the two groups have had to experience in their bid to enjoy fully the public health initiatives. Various factors have been noted to contribute to the barriers of advanced public health nursing in women and children in a Muslim population in Saudi Arabia. These factors include: cultural barriers, such as gender differences and religion, inadequate health literacy, beliefs and voice, and financial barriers to the access of public health.

There are a number of questions that can guide the understanding of barriers of advanced public health nursing in women and children in the Muslim communities in Saudi Arabia.

The questions are presented as follows:

• Which cultural beliefs among Muslim women affect advanced public nursing in Saudi Arabia?
• Are there care environments or actions by care providers that Muslim women consider offensive, thereby preventing them from seeking evaluation and treatment?
• Has a language been a barrier in the provision of advanced public health nursing to Saudi women and children?
• What kind of environment does a Muslim woman in Saudi Arabia consider most conducive for her healing?
• Do questions about sex affect how Muslim children respond to advanced public health nursing in Saudi Arabia?
• What are the specific practices promoted in the Islamic religion regarding Muslim females that affect advance public health nursing access, evaluation and treatment of the women in Saudi Arabia?
• Are there beliefs about gender preferences or use of physical touch that are not acceptable for advanced public health nursing for the women?

Formulation of the Plan

Population

The population to be included in this project will be women and children living in Saudi Arabia because they are considered to be exposed to many barriers that prevent them from benefiting from various advanced public health nursing programs offered by the Saudi government. According to Kronfol (2012), women and children are among the special members of the population in the Arab world, including Saudi Arabia, whose access to and utilization of advanced public health nursing remain deficient, notwithstanding the major improvements that have taken place over the past few decades. Public health programs covering ambulatory care, prevention as well as inpatient services in the countries, such as Saudi Arabia, are provided either totally free or at a reduced or nominal fee.Therefore, women and children will be considered the vital groups from whom the information needed to implement the project will be gathered. However, it is important to first understand various practices or beliefs that characterize these groups that constitute the barriers to advanced public health nursing.

There are Saudi women who still believe in the traditional health sector. Apart from the Western medical services that women and children receive in Saudi Arabia, there are also traditional practitioners who provide specific health needs. Such practitioners, who are not officially certified by the state agencies, are still found in some areas where they are considered skilled lay experts. For instance, traditional bone-setters remain effective broken bone healers because of the belief that their services are superior when compared with Western methods. Additionally, midwives are still considered skilled birth attendants, even though birthing in hospital is more prestigious.

Effective communication between the health care providers and the patients is an important step towards the provision of safe and quality public healthcare (Almutairi, 2015). Good communication is important for increased patient satisfaction, strict adherence to recommendations, as well as better outcomes. Healthcare becomes effective when it is responsive to the needs, preferences or values that patients uphold. In Saudi Arabia, the cultural setting blends the Arabic and Islamic influences (Almutairi, 2015). The attitudes and beliefs of Saudi women and parents or families with children are dictated by the customs and traditions of the Arabic community and the views of the Islamic faith. The Saudi culture is unique, thereby worsening the problem of not providing advanced public health nursing, causing possible cultural conflicts, and eventually dissatisfying the women. Most of the healthcare workers in Saudi Arabia, for example, nurses, are expatriates from other countries, such as the United Kingdom, India, Malaysia, America, the Philippines, South Africa, and Australia (Almutairi, 2015).

The professionals come from different cultural backgrounds. In fact, it is not only the cultural backgrounds that differ, but also the languages spoken by these different groups of people can create a barrier to effective communication. Most of these expatriates speak English; however, not all women and children are proficient in English because Arabic is the primary language in Saudi Arabia (Almutairi, 2015).Women, in particular those that are not proficient in other languages, other than Arabic, have reported dissatisfaction with clarity as well as the languages used by the expatriates providing advanced public health nursing services. The barriers or obstacles experienced are mostly in health education, the use of technical and medical terms, as well as the little time that public health nurses take to answer questions asked by the Saudi women (Almutairi, 2015).

Program Boundaries

The objective of the proposed program is to reduce the barriers of advanced public health nursing in women and children in a Muslim population in Saudi Arabia. To achieve this objective, a public health educational awareness campaign (PHEAC) has been chosen and proposed as the best strategy. The PHEAC will be conducted in two selected community health centers in the country. The community health centers to be selected will be those that are frequently visited by the Saudi women seeking health care needs, either for themselves or their children. The proposed community awareness program to be conducted at various health centers will be interactive where there will be a facilitator to lead to the discussions and Saudi women will be expected to participate in the discussions and give their perspectives on the matters that are considered the barriers to accessing advanced public health nursing. From the discussions, it will be easier to identify the barriers and then to propose certain strategies aimed at eliminating the barriers.

Apart from the discussion forums, the questionnaires will be administered among Saudi Muslims attending hospitals for healthcare services. The questionnaires will have questions regarding religion, dressing beliefs, communication or language, sex education to children, gender preferences during care provision, the environments considered conducive for care provision and healing, and how the lack of knowledge of these factors contribute to the barriers that are currently witnessed.

The third strategy will involve the use of capacity mapping for advanced public health nursing workforce. Training needs of the public health nurses will be assessed, as well as how the failure to provide such needs have created an opportunity for the barriers to manifest among the women and children in Saudi Arabia. The training needs will be examined from the perspective of competencies. A complete list of competencies will focus on such areas as communication and cultural skills, analytic skills, ethics and values of advanced public health, program planning skills, and management skills.

The program will be conducted in partnership with the advanced practice nurses both natives of Saudi Arabia and expatriates from other states working in the country. Before the awareness educational programs are conducted in the health facilities, the hospital or community health center administrators will be informed, but will not be mandated to attend the educational or training sessions. However, the nurses working in the selected centers as well as those working in other centers not listed for the education programs but are willing to take part in them will be encouraged to attend the trainings to offer their perspectives and also learn because they are always in a close contact with the members of the community whenever the public health initiatives are implemented.

Program Feasibility

Within the Muslim religion, there are unique public health nursing beliefs among women and parents with children that can impact social, physical and psychological health needs. The relationships between health beliefs and specific constructs have often determined the outcome of public health access, assimilation, evaluation, and treatment. The important constructs that have been determining public health nursing among women in the countries, such as Saudi Arabia, include modesty, principles of shame and honor, physical touch, gender roles, preferences for health care providers, as well as spiritual beliefs influencing the care decisions. The Saudi Muslim women, just like their counterparts from other countries that adhere to the strict guidelines of the Muslim principles advocate for respect for individual privacy and dignity, community roles, modesty issues for women and men (See Appendices B and C), gender preferences for a public health nursing provider, therapeutic touch, genuineness of a public health nursing provider, and the use of visitation and prayer of sick women.

Most of the nursing professionals working in Saudi Arabia are experts from other countries who at times assume the cultural needs that the women consider harmful, thus providing the grounds for neglect and poor nursing decisions. Therefore, it is important to verify the specific public health nursing beliefs that are needed to empower the Saudi Muslim women and children to embrace advanced public health nursing (Pruitt, 2012). Exploring the health beliefs of the Saudi Muslim women and children is necessary to dismiss various myths, and to impart health beliefs that are considered vital to the identity, as well as perceived health (Parkinson, 2011).

To study the health beliefs of the Saudi Muslim women and children as a step towards reducing the barriers of advanced public health nursing, an important aspect that needs to be considered is the Islamic medical ethics. Muslims have their health issues guided by three important sources, namely: (1) the Quran, which stipulates the five pillars of the religion (See Appendix C), including; a belief in one God, five compulsory prayers (See Appendix D), charity, fasting during Ramadan, and Hajj (2) belief in law of deductive judgment, and (3) the example of Prophet Muhammad. The sayings of the prophet are additional knowledge that can guide medical ethics and public health beliefs. Therefore, understanding the principles is critical in minimizing the barriers to public health nursing among Saudi Muslim women and children. The cultural needs that are essential for advanced public health nursing beliefs include nurturance, physical presence of female or male, support, modesty issues, as well as behaviors that create shame or honor.

Similarly, the proposed program is feasible because of the realization that certain health beliefs, such as sedentary lifestyles and stress, can cause negative consequences on Saudi Muslim women and children, but are not clearly forbidden by the Islam Sharia law. Importantly, positive relationship has been reported between health belief, for instance, religiosity, forgiveness, prayer, and lower levels of cortisol in women. Similarly, the problems of the lack of exercise, the use of fad diet, increased stress due to family responsibilities, as well as non-working status of the Muslim women has been reported. The highlighted issues are critical in advanced public health nursing. Thus, coming up with a program to address them is an important step towards minimizing the barriers of public health nursing among Saudi Muslim women and children.

Gender preference for a health care provider is an important aspect in public health access and treatment for the Saudi Muslim women. For instance, it is known that the female Muslims often prefer female nursing care providers. However, opposite sex can be accepted as care providers under limiting conditions. Nonetheless, care providers of the opposite gender are rejected at the minimum, but are refused in extreme conditions.

Furthermore, there is a chance to change the perception of Saudi Muslim women health beliefs regarding the culture of caring for other members of the family, respect and honor for family members, a feeling of community, and feminism from the perspective of Quran. For instance, feminism relates to dressing the traditional way where women wear a head covering or veil, which is considered empowering for the Muslim women. Feeling empowered can be helpful to the women, particularly when making decisions regarding health care. Therefore, while expatriates from the West or other regions working in Saudi’s health care sector may view the traditional dress as oppressing, the women, on the other hand, may view it as liberating. Changing the perception about the dressing of Saudi Muslims is an area that would help minimize the current barriers of advanced public health nursing. From the presentations, it is apparent that putting in place appropriate programs are important strategies towards minimizing the existing barriers to the women and children in Muslim Saudi Arabia.

Resources

In this program, nurses with advanced training in public health service provision will be involved during the awareness assessment sessions. Among the nurses will be those working in the Saudi Arabia’s Ministry of Health (MOH) handling occupational health issues, immunization campaigns, maternal health education, lifestyle conditions, such as obesity, and disaster preparedness. The nurses’ inputs will be crucial for the successful implementation of this program because they do interact with the selected population in most occasions, thus acknowledging the challenges that they could consider the barriers.

Apart from the human resources, there will be a need for non-human resources. For instance, successful assessments will require rooms or halls within the community centers. The government website will be a valuable resource for advanced public health nursing information.
The non-governmental organizations providing public health nursing services will be very critical during the process. Books and pens will be required to take notes of the information gathered. The assessor will have to transcribe the data provided by the women who will be taking part in the assessment. In the case of the Saudi women who will not be willing to attend the discussions, the questionnaires will be a useful resource to obtain necessary information. The questionnaires will be written in Arabic because the target population are proficient in this language.

Assessment Tools

Information will initially be gathered from the beginning of September to the end of October in 2016. During this period, the women visiting community health centers will be asked to attend awareness training sessions to be conducted in the halls within the health care facilities. In the halls where the assessments will be conducted, there will be one-on-one sessions where the questions regarding the factors that are considered to cause the barriers will be posed to the women. The responses will be recorded and transcribed later to get necessary information. Assessments will be conducted twice every week on Mondays and Fridays.

In addition, the Saudi Arabia’s Ministry of Health, particularly the Department of Public Health Database, will be assessed to gather pertinent data. This database is believed to have important information regarding the current trends in public health nursing service provision in the country. This means that a laptop will be an important tool during this process. As a consequence, three laptops will be purchased. Besides, a steady supply of the internet will be sought for various purposes.

The questionnaires will be administered to assess to the outpatient Muslim women or parents attending the selected community clinics. The questionnaires will comprise the questions regarding the women and children’s religion, dressing beliefs, communication or language, sex education to children, gender preferences during care provision, and appropriate conducive environments for health care provision and healing. The questionnaires will be administered to the women who will not be willing to attend the assessment sessions in the halls. Similarly, the questionnaires will be administered twice every month during the two months of assessment. Importantly, the questionnaires will be administered by the nurses who will have been briefed on the objectives of the project.

Conceptualize the Problem

Potential Solutions

Before the initiation of this project, a literature search is conducted to determine if the proposed topic of investigation is a serious problem currently and would require intervention to prevent it from escalating further. The important search engines that would be appropriate for providing the necessary information required to understand the problem include EBSCO, CINAHL, Cochrane, and Medline. Google Scholar is also an important search engine that provides valuable scholarly documents; therefore, it is considered for the search. The peer-reviewed articles are preferred, particularly those that are less than ten years old because they offer the most current information. Besides, the articles are peer-reviewed meaning that they are reliable. The important words that needed to be included in the search include public health, advanced nursing, Saudi Arabia, barriers, Muslim, women and children. From the searches to be conducted online, important insights will be gained, which will guide the eventual program implementation.

One of the strategies will be to engage the Muslim women and parents with children to take part in an assessment plan. The Muslim women and parents with children visiting the selected community health centers for health care services, especially for conditions or ailments that would be alleviated through the public health promotion strategies will be assessed through one-on-one interactions between the nurses knowledgeable about public health promotion and the women attending the community healthcare centers. It is believed that through the assessments, the women and children will indicate the public health nursing practices that they do not support or believe that they contribute to the barriers.

The second strategy will involve the distribution of the questionnaires to Muslim women and parents with children. This use of the questionnaires has been suggested to cater for the respondents who would not be willing to attend the one-on-one assessment sessions. It is projected that this strategy will work well with the literate Muslim women who can read and write. The questions will be drafted in Arabic because of the belief that most of these women are proficient in the language.

The third strategy will entail the extraction of information from the website of Ministry of Health. It is believed that the government of Saudi Arabia keeps vital data regarding public health programs on its website. Extracting the data could help in filling the existing gaps regarding advanced public health nursing and Muslim women and children in Saudi Arabia.

When these strategies are implemented fully, it is expected that the barriers would be identified and the ways aimed at reducing them would be proposed. The proposed strategies aimed at reducing the barriers would then be implemented by advanced public health nursing professionals. Some of the possible barriers that could be identified in the process include communication barriers, religious beliefs, code of dressing, sex education to children, and gender preferences for the public health care providers.

Risks

One of the possible risks that are likely to be witnessed during the implementation of the project is rejection. The women could reject the proposals, especially if they are to be assessed by the nurses whom they do not trust based on their cultural and religious beliefs. Rejection may occur when the women and children refuse to go to the assessment halls/rooms where they will be expected to volunteer information. Should the women reject the nurses during the evaluation stage, then the project is unlikely to achieve its objectives. The other possible risk that would occur when using the assessment strategy is a language barrier. The assessments will have to take place using a language that both the nurse assessors and the women are proficient in.

The other risk is the failure to get the most dated data or the information required from the government’s website. The government may consider some information sensitive; therefore, this information cannot be published on its website for the public to read. The government databases often provide reliable information, so if the government considers the information required for the successful implementation of this project sensitive, then there is the risk of not achieving project objectives.

There is the risk that some respondents may give false information in the questionnaires that will be distributed during the program. Some respondents (women and children) may fail to give the program a serious consideration, thus giving misleading information when filling in the questionnaires.

The language barrier and the inability to read are possible risks that may hinder the successful implementation of this strategy. The use of technical terms in the questionnaires may lead to giving wrong information even if the women and children intended to fill in the forms correctly. Technical terms may lead to misinterpretation, therefore giving wrong information.

Consequences

The successful implementation of the proposed strategies will most likely contribute to the minimization of the barriers to public health nursing in Saudi Arabia. However, if the project objectives are not met, then it will mean that the problems that have been encountered during advanced public health nursing initiatives persist.

Potential Outcomes

It is possible that through this program, the barriers to advanced public health nursing in Muslim women and children, as well as the approaches to reduce them will be identified. For instance, it is possible that there will be improved communication between the nurses providing public health services and the clients, particularly the Muslim women and children. The nurses will learn to communicate with the patients in the languages that they prefer. Similarly, the nurses will learn to use or avoid using certain words or terms when communicating with the patients. This is important in creating an atmosphere of mutual understanding between the care providers and the clients.

It is also possible that by identifying the nurses providing advanced public health nursing services, especially the expatriates from other countries, will learn to appreciate the Islamic culture of the women and provide care that incorporates such beliefs.
It is possible that the nurses providing advanced public health services will appreciate dressing as an important practice and belief among the Muslim women and children. Understanding the code of dressing for the Muslim women and children is helpful in developing the care services that value and respect the preferences.

The discussions about sex in the Islamic culture are not taken slightly. These discussions become complex when children and their parents are involved in because children are expected to remain chaste until they are married or marry. Consequently, the nurses providing services in reproductive health have to learn how to present discussions regarding sex education in a manner that does not cause rebellion or rejection of the services. It is possible that the Muslim women and children may reject some public health initiatives that seem to violate their personal and religious beliefs about sex education.

Gender preferences during care provision are very important because of the possible impacts. Muslims prefer to be served by the female nurses and not by the male ones. As a consequence, choosing the right gender during care provision has the potential of minimizing the barriers that have been witnessed over the years.

The environments considered conducive for care provision and healing have to be considered. The Muslim women and children will be assessed to determine the environments that they consider appropriate for care provision and healing. It is possible that if care is provided in the environments that are not considered conducive for healing, the public health service providers may not achieve their health objectives.

Nonetheless, if the project identifies the barriers and recommends certain strategies aimed at minimizing the barriers, then the government may achieve its public health goals. Similarly, the advanced public health nurses will be welcome more, particularly within the Muslim communities that follow strict cultural and religious beliefs. Finally, the cost of medical care will reduce while the healthy being of the chosen population will be improved significantly.