Paediatric Asthma Management in the Kingdom of Saudi Arabia: The need for Culturally Sensitive Research and Practice

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, hospitalisation, 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].


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, hospitalisation, 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 paediatric 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][30][31] and assessment of risk factors [27,[32][33][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 There are other barriers which may prevent the delivery of culturally sensitive paediatric 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 make reference 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-recognised 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 paediatric 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-recognised issue within paediatric asthma care generally and needs to be better understood to be fully addressed by qualitative research.