Annotated bibliography – Nursing and Leadership styles

The health care climate today is extremely challenging even for skilled nurses with strong, different styles of leadership as they relate to health care and nursing. Looking at ways in which different leadership styles have a positive or negative influence on a variety of factors, can assist nurse leaders in moving forward toward organizational goals. The purpose of this annotated bibliography is to read three peer reviewed scholarly articles on nursing leadership, and critically analyze each article in the areas of comprehension, application, analysis, and evaluation as it related to this course.

Annotated bibliography

Article 1

McCay, R., Lyles, A. A., & Larkey, L. (2018). Nurse leadership style, nurse satisfaction, and patient satisfaction: A systemic review.

Journal of Nursing Care Quality

,

33

(4), 361-367.

https://doi.org/10.1097/NCQ.0000000000000317

Comprehension

The article by McCay, Lyles, & Larkey (2018) was a literature search that was decreased to the use of 14 cross sectional articles on using the three outcomes headings of: staff outcomes, organizational outcomes, and patient outcomes. The articles were from different organizational settings and on different continents. The constant theme of the articles showed that positive leadership styles that were in the relational model realm yield positive outcomes with nurses.  The articles all seemed to lack specifics regarding patient satisfaction.

Application

In the course materials I have read and listened to so far, it is evident to me that leadership styles that are more democratic in nature, and include all stake holders are the ones that seem to work the best. When your stake holders all have a say in the process, they are bound to want an organization to have a positive outcome.  Northouse (2018) brings up many universal positive leadership traits, and through out several chapters related to how they positively influence followers.

Analysis

The article notes some common strengths and weakness of the articles reviewed.  “The most common weakness noted in th 14 studies were related to sampling and design” (McCay et al. 2018, p. 364). Many of the article had samplings of convenience and probability sampling, this could account for some bias in the literature.  Many 0f the articles reviewed, ten in total had a strength of using a theoretical framework to guide their sudy. “Using the GRADE (Grading of Recommendation) system for reviewing evidence” (McCay et al. 2018, p. 364). Using a consistent framework across articles makes them more credible in their research. The analysis found that leaders that used positive styles had better nurse satisfaction. My personal analysis of this literature review is that I agree it is a necessary key objective to utilize positive leadership styles to gain satisfaction among nurses, and patients.

Evaluation

It is important to review leadership styles and what their impact is on nurse and patient satisfaction in order to meet the continuous, and often tumultuous landscape of health care in today’s world.  Through examining how different style, personalities, traits, and tasks influence nursing factors we can better reach our goals in our organizations.

Article 2

Moon, S. E., Van Dam, P. J., & Kitos, A. (2019). Measuring transformational leadership in establishing nursing care excellence.

Healthcare

(4), 1-11.

https://dio.org/10.3390/healthcare7040132

Comprehension

This article looked at nurse managers who self-reported a transformational leadership style, and how it impacted the ability to establish excellent nursing care. The research took place in Australia, and looked at how nurse managers who utilized this specific leadership style were able to influence magnet recognition within hospitals. Transformational leadership styles showed higher nurse job satisfaction, higher nurse retention, and better patient outcomes to name a few areas.

Application

Nurse leaders that lead by example and allow their followers to have a say in the goals of the organization have been shown to have more positive outcomes with staff.  The lecture models, and readings from the course thus far have shown supporting evidence, and examples that leaders with transformational styles have more positive outcomes then dictator or hands-off leadership styles. Northouse (2018) gives many examples of transformational leaders who have overcome adversity, using positive personality traits and characteristics that have influenced many lives and gone on to conquer great things.

Analysis

Magnet recognition is a status that shows that excellent nursing care has been achieved at an institution. It tells patients who may come to your institution that there is a high level of patient care. In this study seventy-eight nurse managers were chosen as the final group, and they voluntarily answered a survey to measure leadership styles. The Multifactor Leadership Questionnaire Form 6S (MLQ-6S) was used for the survey.  “Significant association was found between nurse managers education and differences in the intellectual stimulation scores, which overall increased with a higher qualification” (Moon, et al. 2019, p.11). One of the major weakness the study identified was that just because nurse managers identified themselves has having high intellectual levels, and transformational leadership styles, there was no way to prove their actions met their personal identifications. The study makes the conclusion that leaders who are transformational, and work in an environment where nursing excellence is upheld have better staff and patient outcomes.

From a subjective standpoint, I can see a self-reported survey having many limitations.  Even using a researched, and accepted questionnaire there are limitations to self-reporting from leaders. Sometimes people think they act in a certain way, but their feelings about how they carry out their leadership skills may not be shared by their staff.

Evaluation

Magnet status has become a goal for health care institutions who want to show patients that they are committed to nursing excellence. “The impact of transformational leadership is recognized by the American Nurses Credentialing Center (ANCC) through the Magnet Recognition Program” (Moon, et al. 2019, p. 1). I feel it will continue to be importance for nursing to continue to investigate the types of leadership styles that further positive nursing outcomes for the future.

Article 3

Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Imporatnce of leadership style towards quality of care measures in healthcare settings: A systemic review.

Healthcare

,

5

(73).

https://doi.org/10.3390/healthcare5040073

Comprehension

This review summarized a total of eighteen different studies on leadership style and how those styles related to quality of care measures in a variety of different healthcare settings.

Application

The article makes the conclusion that democratic or transformational leadership styles have more positive outcomes of quality of care measures. Transactional leadership styles tend to have negative or weak outcomes for healthcare settings. Many of the past two weeks course material have pointed toward these findings. In Northouse (2018), some of histories most influential leaders had strong transformational leadership styles.

Analysis

As in Moon, et al., 2019, this analysis of the literature from major date bases found the most commonly used tool was the Multifactor Leadership Questionnaire, MLQ. Safantou, et al. (2019) found that the main quality of care measures that had positive outcomes with a transformational or similar type leadership style were improvement of direct healthcare services, and a more positive organizational culture. In contrast, a leadership style such as transactional, or even laissez-faire, had a negative effect on patient outcomes, and organizational culture.

From my personal standpoint, I was not surprised by the findings of the literate review. The major question that the review asked was: “Which is the relationship between styles of leadership in healthcare settings and quality of care?” (Safantou, et al. 2019, p.2). Having worked on patient outcomes committees at the hospital for falls, restrains, and sepsis in Intensive Care Unit, I have seen first hand how leadership styles can influence both nursing job satisfaction, and quality patient outcomes.

Evaluation

I see the value of this review being the importance to groom young nurses, and seasoned nurses’ leaders alike to learn and embody the traits of positive leaders.  The implication to continue to research and review leadership style in the literature and the direct correlation to nursing, patient, and organizational outcomes is important for the future of nursing.

To summarize Huber (2018), healthcare is rapidly changing, and the relationship between leadership skills for nurses and the future of healthcare are intimately connected. As we continue to study leadership, and the impact different styles have on nursing, we can continue to improve the healthcare settings in which we work. I feel it is important to note that leadership is not a linear line with an end, it is a back and forth continuum. As our complex healthcare system continues to grow, and change, so will our need to continue this important work of studying leadership and how it relates to our nursing practice.

References

• Huber, D. L. (2018). Leadership and management nursing care management. (6th ed.). Elsevier.
• McCay, R., Lyles, A. A., & Larkey, L. (2018). Nurse leadership style, nurse satisfaction, and patient satisfaction: A systemic review.
  
  Journal of Nursing Care Quality
  
  ,
  
  33
  
  (4), 361-367.
  
  https://doi.org/10.1097/NCQ.0000000000000317
  
• Moon, S. E., Van Dam, P. J., & Kitos, A. (2019). Measuring transformational leadership in establishing nursing care excellence.
  
  Healthcare
  
  (4), 1-11.
  
  https://dio.org/10.3390/healthcare7040132
  
• Northhouse, P. G. (2018). Introduction to leadership. Concepts and practice. (4th ed.). Sage Publications, Inc.
• Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Imporatnce of leadership style towards quality of care measures in healthcare settings: A systemic review.
  
  Healthcare
  
  ,
  
  5
  
  (73).
  
  https://doi.org/10.3390/healthcare5040073
  

Contents (Jump to)

CHAPTER 1 : INTRODUCTION

CHAPTER 2: BURDEN OF MALNUTRITION IN MALAYSIA

CHAPTER 3: CURRENT MALNUTRITION INTERVENTION PROGRAMMES-The aims, strategy and evaluation

3.1 Breastfeeding program

3.2 Rehabilitation Program for Malnourished Children

3.3 Other Main Nutrition Intervention Programs

CHAPTER 4: DISCUSSION

To compare with the developed countries

CHAPTER 6: CONCLUSION

CHAPTER 7: REFERRENCE

CHAPTER 1 : INTRODUCTION

Malnutrition in all its forms is defined as all forms of poor nutrition. It relates to imbalances in energy, and specific macro and micronutrients- as well as in dietary patterns. Conventionally, the emphasis has been in relation to inadequacy, but it also applies to excess intake or inappropriate dietary patterns. It is a wide term commonly used as alternative to under-nutrition but technically it also refers over-nutrition. Child malnutrition was associated with 54% of child death (10.8 million children) in developing countries in 2001, although is it rarely the direct cause of death.

Undernutrition is the direct result of inadequate dietary intake, the presence of disease, or the interaction of these two factors. The risk of dying from a disease as twice as high for mildly malnourished children, 5 times as high for those moderately malnourished and 8 times greater for children classified as severe malnourished when compared to normal children (UNICEF 1996). Underlying causes for malnutrition are varied. Infections among children, including helminthiasis can contribute to malnutrition, manifested as anaemia, stunting and/or impaired childhood development. Recurrent sickness and diarrhoea among infants who are not breastfed can result in malnutrition and eventually impact their normal growth and development. Tuberculosis among young people and adults is linked to poor nutrition. On the other hand, dietary patterns are shifting from traditional diets to diets in which predominantly processed foods are consumed. These foods are of limited nutritional quality, in many cases rich in saturated fats, sugar and salt.

While the burden of undernutrition among children and chronic energy deficiency (CED) in adults continue to be major nutritional concerns in many parts of Asia, the burden of overweight and obesity is becoming increasingly widespread in the region (

Khor 2008

). Overweight and obesity are defined as abnormal and excessive fat accumulation that present a risk of health. They are associated with non-communicable diseases such as stroke, hypertension, cardiovascular disease, type 2 diabetes and certain form of cancer.

Apart from that, recent research showed that undernutrition during early life can later lead to overweight or obesity by prompting energy conservation mechanism in the body that can persist into adulthood. Severe nutritional deprivation in fetal and early post-natal period followed by a rapid catch-up growth in early childhood is now known to increase the risk of overweight and obesity (

Florentino 2014

). WHO (2008) estimates more than 1.4 billion adults, 20 and older, were overweight which over 200 million men and nearly 300 million women were obese. Overall, more than 10% of the world’s adult population was obese. The global prevalence of overweight and obesity in children aged five to 19 years is 10% (

Kipping et al. 2008

). It was also reported that worldwide prevalence of overweight and obesity in preschool children increased from 4.2% in 1990 to 6.7% in 2010 and the prevalence in Asia is 4.9%, with the number of affected children was about 18 million and this trend is expected to reach 9.1%, or 60 million, in 2020 (

Onis et al. 2010

).

CHAPTER 2: BURDEN OF MALNUTRITION IN MALAYSIA

From the period before and after several years of independence, Malaysia was an underdeveloped country with high rate of poverty and hunger. Poverty is closely associated with limited access to healthy food and poor access to health care leading to problems such as undernutrition and other related illnesses.

Recent National Health and Morbidity Survey (NHMS) IV has revealed that the prevalence of underweight and wasting for children aged below 18 years is 16.1 and 17.8% respectively and it was reported 6.1% children were obese. Study by

Poh et al. (2013

) among children 6 months to 12 years showed that the prevalence of overweight (9·8 %) and obesity (11·8 %) was higher than that of thinness (5·4 %) and stunting (8·4 %). It would appear that the results of the NHMS 2011 indicated a higher prevalence of undernutrition than that of overnutrition, while Poh et al. (2013) reported the opposite was true. It may be due to different cut-off point as NHMS using CDC (2000) while Poh et al. (2013) using WHO growth chart or could be due to the different sampling protocol. We can conclude that Malaysia still shows higher prevalence of undernutrition and at the same time increasing trend of overweight and obesity.

Developing countries including Malaysia are in a state of rapid economic transition as a result of generally improving incomes, increasing industrialization, urbanization and globalization. This has given rise to changing lifestyle and diet from one with high level physical of activity and diets based mostly on plant food, to one with higher level of sedentary lifestyle and diet of increasing energy based such as high carbohydrate, high sugar and high in fat. The excess energy from these foods may affect adult and children within the family differently. For instance, young children may easily use up the excess energy and still be underweight while adults may end up gaining weight. These changes in consumption and physical activity lead to rising prevalence of overweight and obesity especially in adults consequently increasing in NCD.

The changes in socio-economic developments over the years in Malaysia have brought an improvement in the overall nutritional status of the country. However, pockets of malnutrition still exist, particularly among the rural areas. Therefore, Malaysia now has to face double burden of malnutrition (DBM) as the new trend emerge in.

CHAPTER 3: CURRENT MALNUTRITION INTERVENTION PROGRAMMES-The aims, strategy and evaluation

The aim of nutrition program is to plan, implement and develop nutrition services to achieve and maintain the nutritional well-being of the population and promote healthy eating practices. The program aims to monitor and evaluate the nutritional status of Malaysian population and assist in nutritional surveillance. It also to plan, implement and evaluate the nutrition health programs, activities and promotion.

Nutrition interventions to improve the nutritional well-being of the Malaysian population have been implemented by the Ministry of Health in collaboration with other ministries. The programs and activities that have been carried out include alleviation of macronutrient and micronutrient deficiencies, nutrition promotion and improving household food security.

3.1 Breastfeeding program

Malaysia has outlined a few strategies in order to combat malnutrition in children and adolescents. It starts from birth of the baby by promoting exclusive breastfeeding up to six months of age as according to National Breastfeeding Policy. The aim is to ensure the baby get the benefits and nutrient from breast milk. Study shows that breastfeeding is protective against infections and Sudden Infant Death Syndrome (SIDS) and this effect is stronger when breastfeeding is exclusive (

Fern R. Hauck 2011

).

In 1993, the Ministry of Health (MOH) Malaysia adopted the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI). This initiative aims to increase breastfeeding among all women in Malaysia in line with the WHO recommendation of at least six months of exclusive breastfeeding, to empower women to make right choices on feeding their babies and to create conducive conditions in hospital and thereafter for women who wish to breastfeed.

In addition, MOH initiated Baby Friendly Clinic project in 2006 targeting health clinics and rural clinics in Malaysia. It aims to encourage mothers to breastfeed their babies exclusively from birth up to the first six months and continue until two years old.

Study by

Tan (2011

) showed the prevalence of exclusive breastfeeding among mothers with infants aged between one and six months was 43.1% (95% CI: 39.4, 46.8). Prevalence of timely initiation was 63.7% (CI: 61.4 – 65.9) and the continued prevalence of breastfeeding up to two years was 37.4% (CI: 32.9 – 42.2) (

Fatimah Jr et al. 2010

). The findings suggest that the programmes implemented in the last ten years were effective in improving the prevalence of ever breastfeeding, timely initiation of breastfeeding and continued breastfeeding up to two years

3.2 Rehabilitation Program for Malnourished Children

The main macronutrient deficiency problem among Malaysian children is protein and energy malnutrition. This is manifested in children of being underweight for their age. Rehabilitation Program for Malnourished Children, better known as “Food Basket Program” has been started by Ministry of Health in 1989 as an effort government to increase the health and nutritional status among children under 6 years old (

Ministry of Health 2009

). In these program children that fulfilled the criteria will be given “food basket” to help them have a balanced and nutritious diet so that they could have optimum physical and mental growth. The children were also given close attention and appropriate treatment on any sickness, health education and proper health care.

The criteria for eligibility are children aged between 6 months to 6 years old who are severe underweight (weight-for-age less than -3SD of the median) or moderate underweight (weight-for-age between -2SD and -3SD) and from hardcore poor families (household income less than RM430 or RM110 per capita for Peninsular Malaysia; less than RM540 or RM115 per capita for Sabah and less than RM520 or RM115 per capita for Sarawak).

The objectives of the programme are to improve health and nutritional status through food and micronutrient supplementation, to improve health through provision of sanitary facilities and clean water supply and to improve health through providing education on health and nutrition.

They are given foods and multivitamin supplement every month until they are recovered, with the minimum period if six months of supplements. The basic food items include rice, wheat flour, anchovies, cooking oil, dry green bean, biscuits and full cream milk. These food supply approximately 102% to 140% of the child’s Recommended Daily Allowance (RDA) for calorie and 204% to 222% RDA for protein. There were 13 choices of food basket available to qualified children for an estimated price of RM150 for each basket. The number of recipient for this programme has decreased since it began, from 12,690 children in 1989 to 5157 in 2009 (

Ministry of Health 2011

).

In 2010, under the National Key Results Areas (NKRA), this programme was extended to the poor and vulnerable poor family (household income less than RM2000 a month) through the 1Azam Programme. Meanwhile, in 2012, under the Government Transformation Programme, this programme was also extended to the natives in Perak, Pahang and Kelantan through the Community Feeding Programme (PCF) and the provision of food baskets (

PEMANDU 2012

).

3.3 Other Main Nutrition Intervention Programs

Full cream milk powder

is distributed through the Maternal and Child Health Clinics to underweight children aged 6 months to 7 years, pregnant women who have not gained adequate weight, and low income lactating mothers with multiple births. One kg of milk powder for each underweight child is given per month for 3 consecutive months, after which each case is reviewed and supplementation is continued if necessary.

The School Supplementary Feeding Program (SSFP)

of the Ministry of Education provides a free meal to primary schoolchildren from poor families. Each meal is estimated to provide one-quarter to one-third of the recommended daily allowances (RDA) for energy and protein. The main objective of SSFP is to improve the health and nutritional status of children, especially those from the rural areas, through a provision of a wholesome and balanced meal. Other objectives are to improve health and food habits and to prevent the occurrence of malnutrition among school children, to educate children on food selection, to encourage the participation of parents, teachers and public in the welfare of the school and to strengthen health and nutrition programs in schools.

The Ministry of Education also provides milk in 200-mL packages to primary schoolchildren.

The School Milk Programme (SMP)

runs simultaneously with the Supplementary Food Scheme. The programme is targeted for poor students whose family income is below the poverty level. Besides, to ensure students receive a well-balanced diet in school, the programme is also aimed at increasing the quality of health and nutritional value of food for primary students for better physical growth, mental health and general well-being. The SMP also encourages students to consume milk early in their life. In 2010, this programme has been rebranded to 1Malaysia Milk Programme.

CHAPTER 4: DISCUSSION

Many developed and developing countries showing reducing trend of undernutrition but increasing trend of overweight and obesity. However, rising in overweight is not necessarily associated with a fall of underweight or stunting. Developed countries mainly facing overnutrition problems and the focus of nutritional programme is to combat overweight and obesity especially among children as it becoming one of the most significant challenges in public health.

However, in most developing countries especially in Malaysia, we can still see higher prevalence of underweight and stunting especially among children but with gradual decreasing trend. With the ongoing socio-economic transition in Malaysia, accompanied by the demographic and health transition and changing food supply and consumption patterns, overweight and obesity especially among adult and adolescent has becoming a public health epidemic. Increasing trend of obesity among adult and with high prevalence of underweight among children gives rise to DBM phenomenon and this phenomenon affects many developing countries.

The co-existence of under and overnutrition not only occurred within the country as a whole, but also within households. Study by

Ihab et al. (2013

) among sample in rural area found that the prevalence of overweight mother/underweight child (OWM/UWC) pairs was 29.6%, whereas the prevalence of normal weight mother/normal weight child (NWM/NWC) pairs was 15.2%. A household with an underweight child and an overweight or obese adult is the typical dual burden household for developing countries undergoing rapid transitions. This phenomenon will be a big challenge especially for food intervention programs to be implemented in the future. Undernutrition affects physical and mental health and performance throughout the lifespan, while overnutrition gives rise to an increasing rate of chronic diseases occurring at earlier and earlier ages.

Though known interventions exist for undernutrition and overweight/obesity independently, clear, evidence-based recommendations for the prevention of DBM have not yet emerged. Thus, new and innovative strategies will be required to counter the rise of the DBM in Malaysia. Collaboration across sectors, accompanied by an effective coordination mechanism, should join the efforts of those within and outside the nutrition community to address the DBM. Improving country-level capacity to coordinate nutrition actions is critical. Countries with both child stunting and women’s obesity rarely implement comprehensive interventions, and in 2010 only one quarter of countries with the DBM had coordination mechanisms to address both problems (

WHO 2013

).

Current nutrition interventional programmes should be continued and at the same time there is an urgent need to come out with new strategies to tackle both side of malnutrition. Country need to engage and coordinate new stakeholders, combining multi-sectoral and intersectoral approaches, including engaging private sector to address the complexity of issues related to the reduction of DBM.

CHAPTER 6: CONCLUSION

The emergence of DBM is a relatively new phenomenon and is most prevalent in middle income countries including Malaysia. Low income countries and high income countries are less common to have DBM as low income countries tend to have higher prevalence of underweight while high income countries tend to have higher prevalence of overweight. In order to solve the newly emerging nutrition problems in a new context requires continuous and strong effort in health and nutrition promotion. This includes the need to find effective solution for childhood malnutrition with sustainable reduction in stunting, underweight and micronutrients deficiencies, along with measures to identified and control the obesity and overweight problems.

CHAPTER 7: REFERRENCES

Fatimah Jr, S., S. H. Siti, A. Tahir, I. M. Hussain & F. Y. Ahmad 2010. Breastfeeding in Malaysia: Results of the Third National Health and Morbidity Survey (NHMS III) 2006.

Malaysian journal of nutrition


16

(2): 195-206.

Fern R. Hauck, J. M. D. T., Kawai o. Tanabe 2011. Breastfeeding and reduced risk of Sudden Infant Death Syndrome: a Meta-analysis

Paediatric


128

(1): 103-110.

Florentino, R. F. 2014. The Double Burden of Malnutrition in Asia: A Phenomenon Not to be Dismissed.

Journal of the ASEAN Federation of Endocrine Societies


26

(2): 133.

Ihab, A. N., A. Rohana, W. W. Manan, W. W. Suriati, M. S. Zalilah & A. Rusli 2013. The coexistence of dual form of malnutrition in a sample of rural Malaysia.

International journal of preventive medicine


4

(6): 690.

Khor, G. L. 2008. Food-based approaches to combat the double burden among the poor: challenge in the Asian context.

Asia Pacific Journal


17

: 111-115.

Kipping, R. R., R. Jago & D. A. Lawlor. 2008. Obesity in children. Part 1: Epidemiology, measurement, risk factors, and screening Ed. 337.

Ministry of Health 2009. Garis Panduan Program Pemulihan Kanak-kanak Kekurangan Zat Makanan.

Ministry of Health 2011. Semakan Separa Penggal Pelan Tindakan Pemakanan Kebangsaan Malaysia 2006 – 2015.

Onis, M. D., M. Blo¨ssner & E. Borghi 2010. Global prevalence and trends of overweight and obesity among preschool children.

The Americal Journal of Clinical Nutrition


92

(5): 1257-1264.

PEMANDU 2012. Raising Living Standards of Low Income Households. Global Transformation Programme 2.0

:

154 – 156.

Poh, B. K., B. K. Ng, M. D. Siti Haslinda, S. Nik Shanita, J. E. Wong, S. B. Budin, A. T. Ruzita, L. O. Ng, I. Khouw & A. K. Norimah 2013. Nutritional status and dietary intakes of children aged 6 months to 12 years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia).

British Journal of Nutrition


110

(S3): S21-S35.

Tan, K. L. 2011. Factors associated with exclusive breastfeeding among infants under six months of age in peninsular malaysia.

Int Breastfeed J


6

(2): 1-7.

WHO. 2013. Global nutrition policy review: what does it take to scale up nutrition action?

What has led to the Endless HIV Epidemic in South Africa?

” It is bad enough that people are dying of AIDS but no one should die of ignorance.” Elizabeth Taylor

Every human has the right to acquire and access optimal health. Over the past centuries, medicine has advanced exceptionally with more cures; however,  the closer we get to the panacea, the further it appears within reach due to the emergence of new calamities. Many epidemics have broken out in the past wiping out populations. However, the advancement of technology and medicine have enabled new methodologies to detect and diagnose diseases and have introduced innovative arrangements for effective treatment plans. Thus, the only defense for viruses is our immune system that laid the underlying foundation for the discovery of vaccines that contributed to the decrease in the mortality rate and inoculated many epidemics. Consequently, the development of vaccines provided preliminary protection as it builds up memory cells that prepare the body to fight the disease when exposed to it.  The greatest limitation to the development of vaccines has been the limited resources that are available for research and development. With all the viruses scientists have encountered to date, HIV (Human Immunodeficiency Virus) which progresses into AIDS has caused one of the greatest fatalities, first causing a pandemic then confining into an epidemic in several countries. Known as the “silent killer”, HIV starts of asymptomatic with a degradation of the immune system and the antibody test can only be taken after 3 months of acquiring the infection. It is one of the top 5 leading causes of death in South Africa with 7.2 million people affected, placing it 4th on the list of countries with the highest rates, 18.9%, of HIV/AIDS. This has caused an epidemic in the country causing numerous fatalities and lowering the quality of life. However, with proper social education and medical facilities, these rates can be drastically decreased and prevented.  Although  HIV/AIDS  fatalities have decreased in many countries,  the numbers of cases seem to escalate continuously in South Africa. Disease epidemic is a social process caused by a combination of different factors that have contributed to the manifestation of the HIV epidemic in South Africa.

The distal factors are intermediates that facilitate HIV transmission but do not act directly on it. They are the channels that expedite pathways of HIV transmission and prevalence. The proliferation in the cases is due to the misconception and perception expressed in the society regarding the virus. It all starts with a hierarchal figure whereas associated thoughts and beliefs are the norms of society. The president of South Africa stated in a UN Assembly: “When you ask the question ‘Does HIV cause AIDS?’, the question is: ‘Does a virus cause a syndrome?’. It can’t….A virus cannot cause a syndrome. The syndrome is a group of diseases as a result of immune deficiency, of the acquired immune deficiency syndrome.”  A president who states such erroneous declaration in front of the whole world gives us an insight into the decisiveness that inhabits the ideology of the South African people’s thoughts and beliefs. This denial of science has provoked and prolonged the epidemic in the country uncontrollably and cost the country the lives of millions.  This falsification and ignorance regressed the resolution to overcome HIV and led to the epidemic the country is facing.

Looking back at history, there are a series of events that have escalated to this attitude and discrimination towards HIV infected individuals. Firstly, it’s believed that HIV/AIDS originated among homosexuals (males), prostitutes and drug injection users and if you did not associate yourself with these groups you would not acquire the disease.  Moreover, it was a disease of choice and the people were blamed for having control over the acquirement and transmission of the virus. Being the only one responsible, their diagnosis was labelled as a deviant act which devalued and dehumanized an individual creating scathing stigmatization among the society. Stigmatization not only dehumanizes them but creates this barrier that impedes and deprives them of receiving medical treatment and diagnosis.  Numerous studies of HIV/AIDS-related stigma have been conducted to portray the beliefs and ignorance that disseminates the country and regressed the decline of the virus. One study conducted the traditional beliefs associated with the cause of AIDS and their attitudes towards the syndrome. Lack of education programs and isolation from the modern world has manifested beliefs among communities. 11% of those surveyed believed AIDS was caused by a supernatural power. This traditional belief states that if you enrage the spirits of ancestors or God, they will send illnesses to the individual or withdraw their protection.  Consequently, this brings a sense of repulsion and injustice of social sanctions towards the afflicted. As a conclusion, ignorance has been correlated with the negative HIV/AIDS-related stigmatization which has hindered testing and treatment. Another study focuses on the correlation of discussion and knowledge of the virus with stigmatization. The study shows that living in high prevalence areas provides greater exposure to People Living with HIV/AIDS (PLHA) and a channel of communication between the infected person and an individual. This exchange will reveal the reality of living with the virus and the present knowledge of treatment, perceived availability of antiretroviral drugs, and prevention services provided to battle and manage the disease. Furthermore, decreased fear, misunderstanding and blame are found among individuals who had personal/direct contact with PLHA not expressing the negative HIV-related stigmatization present in the society. On the contrary, areas with low prevalence expressed the highest negative attitudes towards PLHA affecting the availability of the treatment program (ARV) and hastening the spread of the virus. Unsupportive communities dehumanize the infected individual disrupting their daily lives as their disfiguring symptoms progress with no aid.

Economic deprivation has forced women to sell their bodies for basic human survival disregarding any risk of sexually transmitted infections that they may contract. This desperation for survival, to get food, pay rent, raise their children, have urged women to renounce their human rights to male dominance. Moreover, the subservient role of women is a social convention that is socially punishable by the community. There will be social, physical and economic costs to pay for violating men’s power,  the local norm; this includes abuse, loss of financial support, stigmatization, shame and sometimes their lives. Men exploit women’s economic vulnerability to impose risky sexual behaviors that strip’s women’s health and integrity.  This subjects women to unsafe sex as the men reject using a condom, making them highly susceptible. Masculinity is defined by “flesh to flesh” sex as it is necessary for good health, to maintain the blood/sperm within the body. Informants spoke about the dangers of sperm accumulation that leads to a range of mental and physical problems. Furthermore, they emphasized “flesh to flesh” sex was the only pleasurable way to meeting sexual desires and masculinity discouraging the use of condoms.  Moreover, violence and force are factors that prove their masculinity that they have to impose on women.  However, sex is the currency which will outweigh all the pain and violence women endure. Disobedience will cost them abuse, stigmatization and social rejection.

A study was conducted to examine the psycho-social context of HIV transmission among commercial sex workers in a gold mining district. Most of these men have migrated and left their families in order to make a living and support themselves. However, this puts them in dire situations in which they are housed in single sex hostels. This has attracted commercial sex workers to settle in shacks to accommodate these single men. In a recent survey, 25% of the Miners and 69% of sex workers were HIV positive (Williams,1999).  According to social norms, men should maintain their masculinity and health by seeking intimacy and engaging “flesh to flesh” sex. Moreover, it serves as a coping mechanism for the risks and dangers of their everyday working lives. The business is treated as a supply and demand with the customer always being right; women can only comply. Women contract all sorts of STI’s, including HIV, as men refuse to use condoms and shortly they will be at their death bed. The desperation of money outweighs the life-threatening danger HIV compelling women to risk their health and life.

Dry sex is another social tradition exercised for men’s pleasure. This process involves women insert herbal aphrodisiacs, household detergents, and antiseptics into their vaginas before sex, to ensure they are “hot, tight, and dry”. Men oblige this practice as it makes their partners/sex worker feel like “virgins.” Young women have an immature genital tract with fewer mucous membranes so dry sex will increase the friction making them more susceptible to tearing. Additionally, the introduction of chemicals in the sensitive area causes irreversible damage to the female genitalia.  Furthermore, semen fluid has a higher viral load than vaginal fluid which increases the contraction receptivity. However, women are willing to take the pain and risk of HIV due to two reasons: more clients as it provides higher sexual satisfaction and vaginal discharge is seen as a sign of sickness. “Men do not like loose vaginas. If sex is wet the man thinks I have had sex with someone else and then he won’t pay me.”

Mother to child transmission (MTCT) has contributed to the high mortality rates and high prevalence rates in children. The maternal viral load directly affects the fetus/child through intrauterine, intrapartum and breast feeding; the higher the viral load, the higher the transmission rate compared to low viral load as it indicates a higher possibility. Breast-feeding has the highest risk of transmission rate ranging from 25-45%.  However, there have been many social barriers that made adherence to drug regimens or infant-feeding guidelines difficult. Firstly, HIV infected mothers have low levels of disclosure as they fear stigmatization, abandonment and violence among their community. Secondly, women have to hide the truth with using formula milk as it will expose their HIV condition. Thirdly, there are mixed messages confusing the mother’s conception of infant-feeding as posters of both breast-feeding and formula-feeding are found in the health facility. Moreover, some women entrenched with the concept of “breast milk is best”, tend to outweigh the perceived risk of HIV transmission through breast milk. Lastly, the limited access to formula feeding set by certain dates sometimes urges mothers to breast-feed as they run out of formula feeding. No mother should undergo such ruthless stigmatization that puts her and her child’s health at risk. Unity and support of their family and friends will be the only cure to overcoming this hardship.

The WHO defined Health promotion as “ enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.” HIV has transformed from a deadly disease to a manageable disease. Yet, South Africa still has the most cases of HIV infection in the world prolonging the epidemic in the region. This is fueled by the social construction that acquired the epicenter of the disease epidemic. It is like a domino effect, if you under-estimate its impact and disregarded it in the early stages, you stimulated the endless domino-effect. From 100s to 1000s to millions, the rate of HIV infected individuals peaked making it harder to control the eruption. The hard part is reversing the psychological torture and social ignorance the society implanted among its community.  Controlling the disease will require good governance for health, health literacy and healthy cities. Presidents should support the advancement of science and display factual statistics to their people and accepting the progression of AIDS.  Moreover, there should be access to health care systems and antiretroviral drugs. The most challenging task is to change the perception, stigmatization and beliefs about HIV. HIV infected individuals suffer severe discrimination that demotivates others to be tested so they don’t have to go through the humiliation and shame. There should be a renegotiation of the social and sexual identities regarding those PLHA and towards sexual behaviors. Moreover, there should be a change concerning the control of health which has been proven and achieved by the Bandura Experiment ( children are able to learn through the observation of adult behavior). Educating the young people about the prevention, treatment and transmission of the virus is essential for lowering susceptibility for contracting the virus.   However, this does not assure compliance as they have to transform it into a shared belief to conform among themselves; they should act on a community-level and not on the individualized level. In addition, condom use should be encouraged among sexually active individuals and the “flesh to flesh” masculinity social norm should be eradicated.  Unity is the key to overcoming the epidemic and the community should stand beside each other to defeat the tragedy it is experiencing and not stand against each other discriminating and dehumanizing the unfortunate. Furthermore, women should embrace their confidence, dignity and self-efficacy and not let their impoverished lifestyle coerce them into the deadly business. “Communication leads to community, that is, to understanding, intimacy and mutual valuing” Rollo May (1998)

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