Lupine Publishers | Commentary: Pediatric Asthma Management in the Kingdom of Saudi Arabia: The Need for Culturally Sensitive Research and Practice
Lupine Publishers- Clinical and Community Medicine Impact Factor
Abstract
Asthma is the third most common chronic disease in Saudi Arabia,
affecting two million people. Asthma is also a leading cause
of death among allergic disorders. Uncontrolled asthma may considerably
decrease the quality of life for children and their families.
Over the years, the Saudi government has included asthma as a major
concern in their strategic health plan and has encouraged
research in this area. However, paediatric asthma management remains
under-researched and needs to be investigated further in
the Saudi context. This review summarizes the recent advances in the
paediatric asthma management in Saudi Arabia, including
the need for culturally sensitive research and practice. The authors
discuss the recent context of asthma management in KSA. The
authors discuss the need for culturally and ethnically sensitive asthma
management research and practice.
Introduction
Asthma is a potentially life-threatening condition and is
one of the most common respiratory problems causing lung
airway obstruction [1]. It is a disease which has no cure but can
be controlled by use of proper medication and effective selfmanagement
through education [2]. In 2010 an estimated 300
million people were currently asthmatic globally [3]. Poor control
of asthma may also lead to frequent use of emergency departments,
hospitalization, and, in severe cases, death. Despite several decades
of advances in its control and management, asthma remains a
common worldwide health and socio-economic problem [4].
Approximately 1.4 million children aged 2-15 in the UK are
currently receiving treatment for asthma [5]. In the US, nine
million children aged under 18 years have asthma [6]. Asthma is an
increasingly significant child health problem within the Kingdom
of Saudi Arabia (KSA). Although the prevalence rate of asthma
among Saudi adults is unknown, estimations by the Saudi Initiative
for Asthma (SINA) [7] placed the overall prevalence rate among
Saudi children between 8-25 % in 2012 [8]. The prevalence of
lifetime wheeze, wheeze over one year and physician-diagnosed
asthma in children have been reported as 25.3%, 18.5% and
19.6%, respectively [9]. According to international statistics, in
2016 it is estimated that the Saudi population will comprise 29.4%
citizens aged under 15, and 67.6% aged 15-64. This indicates that
paediatric asthma continues to be a major public health concern in
KSA, especially as asthma control for many patients remains suboptimal.
For example, a recent asthma control survey conducted in
KSA showed that only 5% of child and adult patients were controlled,
31% were partially controlled, and 64% were uncontrolled [10].
Another recent cross-sectional study conducted among children
with asthma aged 4-11 years revealed that uncontrolled asthma
was present in about 59.3% of children [11]. This situation has
considerable consequences for children in reducing their quality of
life through increased hospitalisations and emergency visits [12].
For children, uncontrolled and poorly managed asthma also results
in frequent school absences, affecting their educational attainment
and future employment prospects and general life outcomes,
including health [13].
The Context of Asthma Management in KSA
Internationally, achieving effective asthma management can
be challenging for health professionals for a range of reasons,
including under-diagnosis, lack of patient education, poor health
facilities and limited treatment choices [14-15]. Such issues make
asthma management even more challenging in KSA. For example,
although there are available written protocols for the diagnosis
and management of asthma in the country, there is still inadequate
knowledge and application of these guidelines among health
care providers [16-17]. Overall, the level of awareness of general
knowledge, diagnosis, classification of severity, and management
among physicians is considered average (52%), while that of other
health professionals in general is considered low [7].
A shortage of Saudi healthcare professionals means that KSA
has long employed doctors and nurses from other countries,
resulting in the majority of healthcare professionals in KSA
being expatriates. There are also issues in KSA which make the
professional management of asthma more challenging. The Saudi
Ministry of Health (MoH) for example reported that only 38% of
its total health workforce were Saudis [18]. The use of health
professionals from other countries contributes to high employee
turnover rates and can cause barriers during clinical consultations,
as foreign professionals usually lack Arabic language skills to
communicate with children and parents [19-20].
In many other countries, including the UK and USA, asthma
management services are provided by doctors and nurses working
collaboratively. Nurses have an active role in the long-term asthma
management and education of patients [21], but this is not the case
in KSA where nursing staff typically have a negligible, ad hoc role in
asthma management [8]. As the role of nurses in asthma care in KSA
is under-developed, the burden of asthma management in Saudi
therefore primarily falls on doctors rather than being shared with
nurses. In recognition of this medical load, and the need to develop
asthma care, SINA asthma guidelines were introduced in 2009 to
mirror other national and international guidelines like GINA and
NAEPP [8,22-23], particularly highlighting the importance of good
asthma education [7].
One of the specific challenges of providing effective paediatric
asthma management in the KSA is inadequate awareness of the
condition. An estimated 50% of the populations of the major
Saudi cities of Riyadh Jeddah and Dammam do not know asthma
symptoms [24]. Public awareness campaigns regarding asthma, its
symptoms, medications, and consequences are urgently required in
KSA with specific initiatives targeted towards parents of children
with asthma, because parental lack of asthma knowledge is likely
to contribute to delays in children accessing health services and
receiving asthma treatment which may lead to higher morbidity
and mortality rates [13]. To that end, an on-going, nationally funded
nurse-led research is being conducted to enable nurses working
in KSA to better support doctors in the management of asthma
by becoming more involved in the provision of pediatric asthma
education, which requires more information about the current
nursing role in this field and how it can be improved.
In addition to these contextual barriers to effective paediatric
asthma management in KSA, there is also a lack of asthma research
specifically conducted in the country. Saudi studies have tended to
investigate asthma control or drug use using quantitative methods
such as surveys, but rarely cohort designs [12,25-26]. Most Saudi
asthma research has focused on the prevalence of asthma among
children [4,9,27-28], investigating relationships between asthma
and other factors including triggers and symptoms [29-31] and
assessment of risk factors [27,32-34]. For instance, there has been
a lack of research evaluating asthma management interventions,
including the delivery of asthma education programmes for children
and parents and their outcomes within a Saudi context. It can be
argued that some of the risk factors could be avoided by providing
children with sufficient education about asthma. Therefore, there is
a need in KSA to educate children with asthma about their illness
and to test the effectiveness of these educational programmes in
the Saudi context.
The Need for Culturally and Ethnically Sensitive Asthma Management Research & Practice
In recent years recognition has been growing of the need to
provide asthma care that is sensitive to the cultural and ethnic
needs of patients and parents [35]. A systematic review on barriers
and facilitators to asthma management in the care of South Asian
children identified some key ethnic and cultural issues, including
the impact of parental and professional knowledge and beliefs,
health service utilization pattern explanations and the impact
of prejudice and stigmatization on the improving of asthma
management, and language barriers [36]. In the UK, substantial
ethnic variations in hospital admission and deaths from asthma
have been noted in Scotland [37]. Cultural factors, including selfmanagement
and health seeking behavior as well as variations
in the quality of primary care provision, are the most likely
explanations for these differences. Such leading research on
culturally sensitive care focuses on countries like the UK and USA,
where Arabic patients/parents are an ethnic minority. However, in
countries like KSA it is necessary to conduct quantitative research
on asthma outcomes (e.g. to determine whether non-Saudi health
professionals communicating in English to Arabic children/
parents have the same outcomes such as hospital admission rates
as Saudi professionals who speak Arabic). While the vast majority
of the indigenous population are Arabic nationals, asthma services
and management are often provided by health professionals
recruited from other countries. Even where foreign personnel are
Arabic native speakers (e.g. Egyptians and Palestinians), these
professionals may have differing beliefs and values to their Arabian
patients and may also lack knowledge about Saudi culture.
Culturally and ethnically sensitive asthma care is also
needed for general care purposes, so professionals do not
misinterpret extraordinary behavior as Saudi social norms [38].
Asthma management advice and recommendations offered by
some professionals may also not fully reflect Islamic beliefs
and values, decreasing compliance among clients. When health
professionals and patients belong to different cultures, culture based misunderstandings can influence their relationships and
interactions adversely [39]. The structure of society and families
may be another factor preventing culturally specific pediatric
asthma care in KSA. In Saudi Arabia there are no laws in place
defining a minimum age of children, although numerous drafts for
possible laws and regulations have been created since 2011 [40].
For instance, children under 12 years old are seen in children’s
hospitals, whereas children above 12 years are treated in adult
hospitals.
The Royal College of Pediatrics and Child Health (RCPCH)
in the UK advocates that young people need special support to
manage their long-term condition, with emphasis on developing
positive health behaviors that continue into adulthood [41]. This
is in line with the UN Convention on the Rights of the Child, which
formally and explicitly acknowledges the rights for children under
international law to be recognized as subjects of rights, rather
than merely recipients of adult protection, and that their views are
entitled to be heard. These values are recognized in international
asthma guidelines which, for example, encourage children to be
involved in decisions made about their care, where appropriate
research on self-management conducted in western countries
may not be transferable to a Saudi context as self-management by
children may not be possible within cultural conventions (i.e. they
are socio-culturally expected and conditioned to adhere to what
their parents say).
There are other barriers which may prevent the delivery of
culturally sensitive pediatric asthma management in KSA, such
as asthma management advice being provided by female/male
health professionals to all genders. However, the current literature
on culturally and ethnically sensitive asthma care is gender blind
or gender neutral, and has totally over looked gender as a factor
that could affect asthma care and outcomes in cultural context
where the mixing of men and women is generally avoided, such
as conservative Islamic and orthodox Jewish communities [42]. In
Saudi Arabia, male health professionals never attempt to interview
or examine female patients without a chaperone (typically a father,
brother or adult son) being present. It is highly recommended to
have female nurses present if female parents and child patients are
to be accorded full recognition in decision making for collaborative
asthma care recommended internationally [38]. Although SINA
guidelines refer to partnerships between patients and healthcare
workers, these values are not in-line with the Saudi culture where
women and children are still not given full recognition, and as such
they are likely not to be involved in asthma management decisions
[7].
However, this issue has been over-looked and un-recognized
to-date. Despite the fact that SINA guidelines indicated that asthma
education program should be conducted by well-trained health
care providers with good communication skills to the families, the
cultural barriers to this are not acknowledged (e.g. the need for
specific education sessions for mothers and for fathers). There is an
urgent need for future research into this area to better understand
the issue and to identify in what ways asthma management and
education can be better tailored to the cultural needs of children
and their parents in countries like KSA. Studies of pediatric asthma
management also show indications of inadequate culturally
sensitive management different settings in Saudi Arabia.
Culturally sensitive asthma care in KSA confers a key role
on qualitative research, for instance observation of asthma
consultations might enable exploration of whether non-Saudi
health professionals are able to offer culturally sensitive asthma
care, and how the situation can be improved. During doing a
qualitative research, it can be argued that interviews could be
harder when women are covered and veiled since it is agreed that
studying verbal and non-verbal communications could not be fully
understood without obtaining the views and feelings of the people
concerned (Holloway & Wheeler, 2002; Parahoo, 2006). Obviously,
any such disadvantage was greatly reduced for me due to my
cultural competence with veiled Saudi women (see section 4.3.2).
Nevertheless, I did not merely rely on the participants’ memories,
but I also distinguished between participants’ descriptions in
words and their actions to determine any inconsistencies between
what they said and what they did (Holloway & Wheeler, 2002).
Asthma knowledge can only be applied effectively with
culturally sensitive practices and attitudes adopted by nurses
in their interactions with clients [38]. To navigate these cultural
issues, interviews with parents of children with asthma and their
health professionals enrich the nursing understanding of asthma
management and patient education in KSA, providing culturally
appropriate, tailored care and avoiding the mismanagement
common in developing countries whereby Western (cultural)
models are imported and applied wholesale, without consideration
of the local context.
Conclusion
The prevalence of asthma amongst children in KSA is high in
comparison to the rest of the world and it is increasing. This results
in significant costs for individual children, their families and the
country. This paper highlights specific contextual issues which
make effective pediatric asthma management in KSA challenging.
The need for culturally sensitive asthma care has been raised in
countries such as the UK, where Arabic patients are a minority. This
paper highlights that there is also a need for culturally sensitive
asthma care in countries like KSA where Arabic patients are cared
for by health professionals recruited from other countries who do
not share their culture, beliefs and values. Culturally and ethnically
sensitive asthma care is an un-recognized issue within pediatric
asthma care generally and needs to be better understood to be fully
addressed by qualitative research.
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