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largest state, after Saudi Arabia and the Republic of Yemen, and it covers a total land area of 309,500 square kilometres. Oman consists of diverse topography, mostly valleys, and desert, which accounts for 82% of the land mass, followed by mountains (15%) and coastal areas (3%) (World Health Organization, 2016). According to the Central Intelligence Agency (2015), Oman is classified by the World Bank as a ‘middle-income economy’, with a population of about 4,595,164 (National Centre for Statistics & Information, 2017)

Health care system in Oman

The health services in Oman are mainly managed by the Ministry of Health (MOH). The MOH funds the entire public health sector in Oman, which accounts for around 90% of the health institutions, along with a few other non-MOH and private institutions (see Figure 1- 1., which illustrates the components of the health system in Oman) (Al Dhawi and West, 2006 )

The MOH provides universal health care, through well-equipped hospitals and health centres at the primary, secondary and tertiary levels. Due to the diverse geographic nature of the Sultanates (i.e. valley, desert, mountains, and costal area), the country is administratively divided into 11 governorates (muhafazah) with 61 Wilayats (provinces): Ad Dakhliyah, Ad Dhahirah, North Ash Sharqiyah, South Ash Sharqiyah, North Al Batinah, South Al Batinah, Al Wusta, Al Buraymi, Muscat, Dhofar, and Musandam. This division assists officials with the planning and distribution of health institutions across all areas, enabling access to medical services for everyone. Figure 1-2 illustrates the administrative divisions of Oman (Ministry of Health, 2013).

Figure 1-1 Components of the health system in Oman

Figure 1-2The Administrative Divisions of the Sultanate of Oman This diagram is taken from: http://www.moh.gov.om/en/

Primary health institutions are considered the entry point for health care services. They provide numerous activities to promote health, prevent illness and treat minor health problems. These activities are carried out at local health centres, extended health centres and local hospitals. All health institutions in Oman, whether free or private, are integrated into a well-established referral system. Patients cannot move from one level to another without a referral. The following diagram illustrates the referral system among these facilities (World Health Organisation, 2006).

Figure 1-3 Referral chain (continuum of care)

The rapid growth of health institutions from two hospitals and ten clinics in 1970 to 49 hospitals, 192 health centres and 24 extended health centres today, has forced the Sultanate to recruit medical personnel from all over the world, in order to manage their care services (Ministry of Health, 2012). In order to reduce dependency on overseas personnel, and develop the ability to sustain the demand for Omanis to fill the service needs, the MOH now offers national qualifications that are open to Omanis in all specialties such as general nursing, pharmacy, information management systems, allied health and health education. The General Nursing programme is the largest programme in Oman and comprises nine nursing institutions, distributed all over the country. These institutions supply the MOH hospitals and centres with about 600 diploma graduates every year. In contrast, the other allied health institutions (e.g. pharmacy, laboratory, X-ray, dentistry) are located only in the capital city, Muscat. They produce approximately 30 diploma graduates per year (Ministry of Health, 2013). Besides the MOH institutions, Sultan Qaboos University (SQU) provides another source of medical professional graduates, such as medical doctors. In 2014, around 105 medical doctors joined various health institutions across Oman.

Child health care in Oman

As a country with a young population, the MOH in Oman has invested in increasing its health activities and programmes. For example, investment has been made so as to increase Immunisation (EPI), the Integrative Management of Childhood Illness (IMCI), the Baby Friendly Hospital Initiative (BFHI), the Control of Diarrhoeal Diseases Programme (CDD), the Control of Acute Respiratory Infections (ARI), the Prevention and Control of Viral Hepatitis B, as well as school health programmes to improve child health within the country. As a result, a significant reduction in morbidity and mortality among children under the age of five has been recorded. For example, the mortality rate for children under five years of age decreased from 27.0 to 9.7 deaths per 1000 live births (World Health Organization, 2016).

The EPI programme was launched in 1981 and it aimed to provide free immunisation services for all children under two years of age, with consistent monitoring of their developmental milestones. In 2014, the immunisation coverage among children of one year of age was reported to have increased from 97% to 100%. The EPI programme of care was extended to monitor children’s health from birth up to five years of age. Nurses and General Practitioners (GPs) play an active role in this programme, undertaking the well checks, collecting data from parents, vaccinating children and documenting this information on the

“pink card”. The pink card is a universal card, issued to all children in Oman from birth until he/she reaches five years old. The card acts as a means of monitoring child development and recording health and immunisation status for parents and professionals. In addition to the EPI, there is the School Health Programme and both programmes play distinct roles in providing comprehensive and consistent health care for children. The School Health Programme continues the monitoring for ages five to 18, meaning that there is a consistent approach to promoting children’s health from birth up to high school graduation.

Despite the benefits of this system for controlling childhood morbidity and mortality, it fails to address the psychosocial and developmental challenges experienced in childhood. There is a lack of services for children with special needs and mental health issues. Usually, specialist child and adolescent mental health services tend to be located in a tertiary care setting in the urban areas of Oman.

ASD in Oman

Little data was available on ASD in Oman until the Autism Research Group (ARG) was constituted, in September 2008. This group commenced a programme of research and, to date, has produced 16 studies that have explored various aspects of ASD in Oman: for example, the prevalence of ASD (Al-Farsi et al., 2011a); the awareness of ASD among school teachers (Al-Sharbati et al., 2015) and General Practitioners (Al-Farsi et al., 2016); the socioeconomic burden of the disorder on families (Al-Farsi et al., 2013a); malnutrition among children with ASD (Al-Farsi et al., 2011b); the association between suboptimal breastfeeding and ASD (Al-Farsi et al., 2012); and the development of a mobile application for screening for ASD (Klein et al., 2015). The ARG’s efforts have contributed greatly to providing baseline data for ASD in Oman, and it may advance the ASD infrastructure, clinical management, and community services in the country. However, most of these studies are quantitative (i.e. observational studies) and either cross-sectional (Klein et al., 2015, Al- Sharbati et al., 2015, Al-Farsi et al., 2013a) or case control (Essa et al., 2012, Al-Farsi et al., 2012, Al-Farsi et al., 2013b). This method of research, in most cases, involved the use of a structured questionnaire, with closed-ended questions that reduced one’s ability to fully understand the context of the phenomena (Creswell and Clark, 2007). Almost all of the above studies were undertaken in Muscat institutions (i.e. the capital city of Oman), with relatively small sample sizes ranging from 27 to 164 (Al-Farsi et al., 2016). Consequently, the results cannot always represent the actual number in reality, and the data cannot be accepted as robust enough to explain the views and perceptions of participants in this context. Future research might consider population studies using a larger sample size, with

and/or mixed-method studies might be the next step, in terms of the research required to provide detailed information explaining the status of ASD and its needs in Oman. It is especially important to ascertain the perspectives not only of professionals but also of parents, who are less recognised in Omani research.

A paper on the prevalence of ASD suggests that it is lower in Oman (0.14 in 1000 children) compared with neighbouring countries (2.9 per 1000 for PDD in UAE and 0.43 per 1000 in Bahrain) (Salhia et al., 2014) and with the rest of the world (7.6 per 1000 worldwide) (Baxter et al., 2015). However, this paper might not accurately present the actual number of ASD cases in Oman, as it used retrospective data extracted from one institution, which was believed to be the sole, formal source of records for children diagnosed with ASD in the country. To give a better estimation of the prevalence of ASD in Oman, future research might consider including all institutions, social or private, that deal with ASD services in the country. As the authors highlighted, future studies might collaborate with borderline institutions of other countries, such as the United Arab Emirates, Saudi Arabia, or Yemen, to identify further cases from Oman.

It seems obvious that the prevalence of ASD in Oman, along with other Arab countries, remains underestimated, due to ASD being undiagnosed or unrecognised in the community, especially the mild cases (Salhia et al., 2014). Al Farsi et al. (2013) suggest that this discrepancy may be largely influenced by a variety of socioeconomic factors, including differences in the cross-cultural presentation of ASD symptoms (which puts into question the reliability of the diagnostic tools), the lack of professional services and the lack of awareness and knowledge of ASD at the professional and community levels. Salhia et al. (2014) added that the lower levels of diagnosis of ASD among Arab countries might be due to a lack of screening programmes and difficulties in accessing care.

Prevalence figures in Oman are expected to increase because Oman is a country with a young population: 13.9% of its population are under five years of age and 33.7% are under 15 years of age (Ministry of Health, 2012). It has the 48th highest population growth rate in the world, with a demographic profile considered as ‘youth bulged’. Eighty-three percent of the population is under the age of 20 (Al-Sinawi et al., 2012) and as with any increase in population, the number of people affected by neurodevelopmental disorders, such as ASD, will also increase. Genetic occurrences in Oman, such as consanguinity and multiparity, are

common. This could potentially trigger developmental, social and/or intellectual conditions, leading to an increase in the prevalence of ASD (Al-Farsi et al., 2013a, Salhia et al., 2014).

Any rise in ASD will place greater demand on health and social care systems and have an impact on the economics of the country, in terms of supporting individuals with ASD. A recent study undertaken in Oman investigated the financial burden of taking care of children with ASD in 150 families from medium (n=80) and low (n=70) income groups (Al-Farsi et al., 2013a). The findings indicated that 8% of mothers had resigned from their jobs to care for their children. Of these, 5.7% of whom were from low-income families and recipients of welfare payments. It was estimated that 15% of a family’s monthly income would be required to care for a child with ASD in Oman, while the income may also be reduced by 41% because of lost employment opportunities, or mothers resigning from their jobs. This financial burden might increase with a rise in the number of children affected in the family. Although few studies have examined the global burden of ASD, studies in the USA and UK have estimated higher annual costs of ASD and intellectual disabilities (ID) on the economy. These costs are in the region of several millions of dollars ($2.4 million in the US) or pounds (£1.5 million in the UK ) (Buescher et al., 2014). This cost varied based on individual age. For example, during childhood the highest costs were allocated to special education services and parental productivity loss, whereas costs during adulthood fall heavily on residential care or supportive living accommodation and individual productivity. Adulthood also incurs higher costs for medical expenses. Similarly, an earlier study suggested that the cost of caring for and supporting individuals with ASD in the United Kingdom was estimated to be over £27 billion a year, of which only £2.7 billion were spent on children (Knapp et al., 2009). Therefore, early identification and intervention may reduce the estimated lifelong cost to the family and the whole society. To ensure families are supported throughout their lifespan, health care professionals and the community identified a need to improve supporting services for families affected by ASD (Al-Farsi et al., 2013a, Al-Farsi et al., 2016, Al-Farsi et al., 2011a).

Screening children for ASD within PHC practices in Oman might be an effective way to identify children at risk of ASD, whilst early intervention may reduce the potential burden on society, as well as on the families themselves. Additionally, it would help to ascertain the prevalence figures of ASD. However, a number of challenges have been recognised in the literature that might hinder the early identification and screening for ASD in Oman, such as a lack of professional and community awareness of ASD (Al-Farsi et al., 2016, Ouhtit et al., 2015, Al-Sharbati et al., 2015); a lack of required instruments and the cultural impact of

barriers, include the implementation of a culturally acceptable screening process that could be used with ease. However, this would need to be explored prior to the introduction of such a screening programme.