The social determinants of health of migrant women nurses: A missing link in realizing Saudi Vision 2030?

Julie Davies¹Emily Yarrow^2*

• ¹Brunel University London Business School, London, United Kingdom
• ²Business School, Faculty of Humanities and Social Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom

Introduction We seek to conceptualize gender disparities for foreign women Saudi nurses which form the backbone of the Saudi health system. In doing so, we seek to understand policy implementation gaps and lived experiences which illustrate links between social determinants that affect workforce well-being and the general population's health. We call for a better understanding of how interventions might be designed to address socio-cultural factors and leadership development needs amongst migrant women and local Saudi nurses. This is important to improve their motivations and retention with implications for reducing gender disparities. We contribute important insights into policy implementation in developing country national reforms and intersectional inequalities with wider public health ramifications. The social determinants of health (SDOH), i.e. non-medical factors such as living and working conditions, socio-economic policies and systems, and social norms, can adversely affect health equity in the workplace and society more generally (3). Saudi Arabia is the largest country geographically in the Middle East, a high-income developing nation with an ambitious Vision 2030 Health Sector Transformation Program to enhance innovation, financial sustainability, disease prevention and improve access to high quality healthcare. Although Saudi social reforms have improved women's rights since 2019, socially constructed differences linked to gender, social status etc. create simultaneous intersectional inequalities which can adversely affect workplace well-being (4) and public health in the Kingdom. To make sense of gender disparities between national policy ambitions and lived realities in the context of wider societal inequities impacting SDOH, this article explores the following questions: 1. How do gender, foreignness and socio-cultural challenges (and other inequalities as social determinants of health) intersect to shape migrant women nurses' experiences in the context of Saudi national transformation? 2. Why do gender inequity and foreignness matter for workforce and patient well-being? 3. How do these categories help us to understand the need for leadership development interventions to address national policy-implementation gaps in healthcare transformation? Materials and methods Drawing on a narrative literature review (5, 6) and semi structured inteviews, we seek to demonstrate how gender, foreignness and other social determinants amongst the workforce intersect in a high power distance patriarchal regime. Ferrari (2015: 230) (5) states that narrative reviews "are aimed at identifying and summarizing what has been previously published, avoiding duplications, and seeking new study areas not yet addressed." We thematically analyze 18 studies (7-24), and further propose to conduct semi-structured interviews with migrant nurses. A perspective on intersectional inequalities locates foreign female nurses in social categories which perpetuate behaviors that disempower both healthcare workers and patients to frustrate national public health transformation by not addressing SDOH within the wider population. Alreshidi et al. (2021) (17) found that lack of professional growth and development were the main reasons for turnover of foreign nurses in Saudi Arabia whereas Al-Yami et al. (2018) (25) found that transformational leadership enhanced nurses' commitment, especially for older nurses. Traditional perspectives overlook overseas women nurses' status as skilled migrant employees as a valuable source of diversity (26). The proposed article advances our understanding of how socio-cultural intersections within organisational structures and interpersonal dynamics constrain migrant women nurses by mirroring social determinants of health in the wider population. Additionally, we offer a broader understanding of gender as a social category and how it intersects with foreignness in ways that enable us to re-imagine policy-practice gaps in the case of Saudi Arabia seeking to increase female workforce participation and non-oil revenue within Saudi Vision 2030 (27, 28). Results Table 1 summarizes social determinants of health applied to foreign female nurses and the general population in the Kingdom of Saudi Arabia (KSA), as well as key intersectional experiences of women migrant nurses. Please see submitted appendix table one. Discussion We recommend further research on how to improve the quality of nursing work life level (QNWL) in Saudi Arabia for expatriate and local nurses, particularly in palliative care, to extend insights from other studies in the Arab world (31). Additional research which links studies on physicians in Saudi Arabia, for example building on Ghazwani's (2022) (32) work on emotional exhaustion amongst KSA's palliative care physicians and the value of multidisciplinary support, would be valuable to mitigate feelings of detachment, depersonalization, and reduced personal accomplishment in reducing palliative care patients' suffering. These insights will be important to realize healthcare workforce plans for Saudi Vision 2030 and social determinants of health amongst the workforce and more broadly.