Volunteering in the United Arab Emirates’ Health System—Motivations and Challenges

Background: The volunteer role has been cited as an important in supporting healthcare organizations in diverse areas such as contributing to research, health professional’s education, health care delivery, health policy development and patient administration. Proper motivation of volunteers is required for sustaining volunteer performance, while encumbrances to optimal engagement in health systems need to be addressed. This study aimed to inves-tigate the main factors that motivate volunteers to participate in the UAE healthcare system, along with exploring the barriers and challenges being faced. Methods: This study was designed as a quantitative cross-sectional study in United Arab Emirates (UAE). A purposive sample of the Adult citi-zens and residents using purposive sampling directed at all major health volunteer recruitment agencies in UAE, who have volunteered at least once in the health system over the preceding 12 months. Participants Adult UAE residents were selected by a purposive sampling method from February to April 2017. Data were collected through electronic questionnaires using mod-ified Volunteer Motivation Inventory (VMI). Data were analyzed from 667 adults’ residents who were reported to volunteer at least once in healthcare opportunities. Results: About 53% (n = 290) of the volunteers in this sample were full time employed individuals. Almost 63% (n = 422) were female. Overall, assessed self-reported motivations of volunteer participants were high. The main motivation for volunteering in healthcare opportunities in the UAE was Understanding dimension (Mean = 4.68), followed by self-esteem dimension (Mean = 4.60). volunteers who participated in this study appeared to be highly motivated. The main motivation factor was understanding dimension which allowed volunteers in healthcare to gain a new perspective on things, through practical training and learning new things, dealing with different groups in the health sector, for example doctors, nursing, patients. What makes the health sector volunteer understand them self and the world around them. Therefore the organization should focus on volunteer motivation to ensure future in-tensions of them. The four main barriers to volunteer were Individual barriers, Interpersonal barriers, contextual barriers and organizations system barriers. Concerted efforts are needed to raise awareness about available volunteer opportunities, and optimally align the motivations of volunteers with organizational objectives in the UAE health sector.


Introduction
Volunteering defines as any activity that involves spending time unpaid, doing something that aims to benefit the environment or someone (individuals or groups) other than, or in addition to, and close relatives. This can include formal activity undertaken through public, private and voluntary organizations as well as informal community participation and social action [1]. Volunteering may be defined from a functionalist perspective as voluntary, ongoing, planned, helping behavior that increases the well-being of strangers, offers no monetary compensation, and typically occurs within an organizational context [2]. Volunteers in healthcare system have a major role to play by providing entertainment activities, training patients, helping in disseminating awareness campaigns, reading for patients specially kids and older adults, providing administrative assistance, volunteering in the boards of hospitals, and volunteering in medical research.
The culture of volunteering exists in the UAE as part of the Islamic culture as involvement in relief work is a rewarding experience for the Muslim volunteer [3]. The UAE designated 2017 as the Year of Giving, with volunteering a core emphasis in the objectives of the initiative [4]. Furthermore law No. 5 of 2018 on volunteering aims to boost the culture of philanthropy and volunteering among residents in the UAE and is a one-of-a-kind protection for both volunteers and beneficiaries [5]. The Federal Authority for Government Human Resources (FAHR), in coordination with the Ministry of Community Development, launched a guide to volunteering in the work environment of government entities in 2017. The new guide explains the concept of volunteerism, its objectives and fields of voluntary work to implement the volunteer's rights and duties as well as ways to attract them to the organizational voluntary work [6].
In 2017, the UAE government launched a national volunteering platform which is a comprehensive database and accurate statistics on volunteerism at the national level for government agencies. It develops a personal record for each volunteer, the platform provides volunteering opportunities in a number of humanitarian sectors: Education, Humanitarian work, Care for the elderly, Health, Culture and arts, Sports, Environment, Community service, Hope making and International volunteerism. According to the national volunteering platform statistics as at November 2019, the total number of volunteers registered in the platform was (442,098) [7].
The healthcare system in the UAE attracts volunteers and provides them with volunteer opportunities in hospitals. For example, volunteer program in Sheikh Khalifa Medical, City was established in April 2008 [8]. Dubai Health Authority offers volunteer opportunities to enhance patient satisfaction while producing a well-deserved feeling of personal fulfillment for the volunteer, for example, Rashid Hospital Volunteer Services and Thalassemia Center Volunteers Program. Al Jalila Children's volunteer programme, "Abtal Al Jalila" (heroes of Al Jalila), around 400 volunteers have registered in the programme, with 60 active so-called superheroes who regularly visit the hospital [9]. This example highlights the link between the strategic objectives of the hospital and the volunteer program so that volunteering has added value to the institution.
Charitable organizations in the United Arab Emirates play an important role in supporting the health sector, providing voluntary opportunities for volunteers to serve the community. Example of some charities in the United Arab Emirates includes Emirates Red Crescent Society, Al Maktoum Foundation, Khalifa Foundation, Dar Al Ber Society, and Zayed Bin Sultan Al Nahyan Charitable and Humanitarian Foundation.
Health associations and community organization play active role in supporting healthcare system, where there are many health associations in the UAE, for example; Pink Caravan, the UAE breast cancer awareness initiative that highlights the importance of early detection through regular checkups [10]. "Make a Wish" Foundation, which granted more than 3000 wishes for children with critical illness. With the above-mentioned role of volunteer in healthcare system it is important to understand volunteer motive [11].
Research shows that individuals have a range of motivations for volunteering, both philanthropic and self-orientated, and several theoretical frameworks have been developed for understanding these motivations more deeply [12] [13]. For example, in a study of volunteer motivation in Mecanhelas district, Northern Mozambique Muula et al. concluded that financial incentives constitute an important motivation for volunteering in this developing nation's region. Financial incentives for volunteers should be culturally acceptable, affordable and should not negatively affect the sustainability of a health program [14]. Other studies applied functionalist theory to the question of the motivations underlying volunteerism, hypothesized 6 functions potentially served by volunteerism, and designed an instrument to assess these functions Volunteer Functions Inventory VFI. Other research hypothesize that volunteers' perceptions of inclusion are positively related to intrinsic motivation, via the satisfaction of their basic needs for autonomy, competence, and relatedness. That the result showed that team inclusion was positively related to volunteers' intrinsic motivation during their activities [15].
Clary and Snyder [16] designed theory to explain different types of motives that can determine participation in volunteer services. They identified six primary motives: Protective, Values, Social, Understanding, Career and Enhancement. The Volunteer Motivation Inventory (VMI) was based on an initial scale developed in 2002 by Mc-win and Jacobsen-D Arcy. It includes the six categories identified for the VFI by Clary and Snyder in 1998 and they added four categories which are Self-esteem, Reciprocity, Recognition and Reactivity. The VMI was further refined following pilot testing and administration to various samples of volunteers in many organizations in Western Australia [17]. In many settings volunteering does not always achieve its potential due to intrapersonal, interpersonal and contextual barriers, including lack of time, lack of mobility, lack of transport available, health issues, lack of relevant information and knowledge on where to seek volunteer work [18] [19]. Interpersonal constraints involve some kind of social interaction, may include communication issues with volunteer agency staff or the intended beneficiaries of volunteer activity [20] [21] [22]. Structural constraints, include legal and policy regulations (or their absence) on volunteering activity. Organizational or system barriers which include preparedness and suitability of health organizations to work productively with volunteers [23] [24] [25]. This study aims to assess the main motivating factors for volunteers to take part in the healthcare system, along with exploring the primary challenges faced by the volunteers in the UAE. That aim to address the knowledge gap on these areas in the UAE.
A conceptual framework for examining the topic is provided in Figure 1.

Methods
This study was conducted between February and April 2017, Arabic and English versions of a questionnaire were developed to determine the motivations and challenge volunteers in the UAE healthcare system face. The questionnaire consisted of sections on sociodemographic data, motivation factors, and barriers volunteers face. Sociodemographic characteristics consisted of information pertaining to age, gender, education, employment status, and marital status.The volunteer's motivation section consisted of 29 questions, structured in the eight domains: Career development items 1, 2 and 3 (to gain career-related experience), Protective items 4, 5, 6, and 7 (to reduce negative feelings), Reactivity items 8, 9 and 10 (addressing their own past or current issues), Recognition items 11, 12 and 13 (recognized for skills and contribution), Self-esteem items 14, 15 and 16 (increasing own feelings of self-worth and self-esteem), Social items 17, 18, 19 and 20 (to strengthen social relationships), Understanding items 21, 22, 23, 24 and 25 (to learn about the world) and Values items 26, 27, 28 and 29 (to express or act on important values).
The volunteer's constraints section consisted of 29 questions, structured in four domains. Three distinct categories of constraints to volunteering (intrapersonal, interpersonal and structural) were first proposed by Crawford and Godbey one of the longest standing and most useful [22]. Based on the nature of our study, we included a fourth constraint domain, Contextual. Consequently the four constraints domains are Intrapersonal (i.e. individual), Interpersonal, Contextual and Structural. Individual barriers items 1, 2, 3, 4, 5, 6, 7 and 8 (illness, age, study, family, and work, not interested, afraid, and financial), Interpersonal barriers items 9, 10, 11, 12 and 13 (friend don't encourage, family don't encour-age, patients, medical staff), Contextual barriers items 14, 15, 16, 17 and 18 (perceptions, comfortable, not interested) and Organizations system barriers items 19, 20, 21, 22 and 23 (in-sufficient information, financial supports, policies, training and safety and prevention).
A 5 point Likert scale ranging from "strongly disagree" to "strongly agree" from 1 to 5, respectively was utilized. Pilot study analysis was used to examine the scales of the motivation factors and barriers factors. The pilot study was conducted from a sample of 21 participants, the reliability statistics were 0.823, indicating a high level of internal consistency with this particular sample for our scale. were calculated for continuous variables, while ratios and percentages were calculated for categorical variables as appropriate. The independent t-test was used to compare mean score of volunteer motivation according to sex. One-way ANOVA test was used to compare mean score of volunteer motivation according to marital status. The level of significance was set at P ≤ 0.05. Significant independent variables and 95% CIs for the predictor variables were then calculated.

Results
The majority of participants (N = 489; 63%) were aged between 20 and 35 years.  The main motivation factors means, standard deviation and 95% confidence interval for the mean shows that we are 95% confident that the true mean for the  Table 3.
There were no statistically significant differences (P > 0.05) between male and female respondents in eight voluntary motivation elements (Table 4).
Comparison means volunteer motivation score by marital status shows a total score of 34 ± 6.12 in married volunteers, 33.9 ± 5.88 in single volunteers and 32.1 ± 8.5 in divorced volunteers. Based on the mean scores, self-esteem and social differences showed statistically significant (P > 0.05), the remaining six motivational elements (career development, recognition, reactivity, value, understanding and protective) Differences in marital status were not statistically significant (P > 0.05) as it shown in Table 5.
Motivation elements showed no statistically significant (P > 0.05) differences among volunteers according to resident Emirates, except for value motive there is a statistically significant difference between volunteers according to resident Emirates as determined by one-way ANOVA (F (6, 659) = 3.144, p = 0.005) ( Table 6).
Motivation elements showed no statistically significant (P > 0.05) differences among volunteers according to degree or level of school you have completed (Table 7). Barriers to Volunteering Items with the lowest means, indicating relatively low barriers to volunteer in healthcare opportunities in the UAE were "My family does not volunteer or allow me to volunteer in healthcare" (Mean = 1.6), "Not interested in healthcare      volunteer opportunities" (Mean = 1.6), "The community has a negative perception regarding volunteers in healthcare." (Mean = 1.7), and "I don't feel comfortable when volunteering with healthcare staff (doctors and nurses)" (Mean = 1.8). The items with the highest means indicating as barriers to volunteer in healthcare opportunities in the UAE were, "Work commitments could prevent people from volunteering in healthcare." (Mean = 3.3), "Family commitments/looking after children/the home/someone elderly or ill could prevent people from volunteering in healthcare." (Mean = 3.3), and "There is insufficient information about volunteers' opportunities in the UAE healthcare system" (Mean = 3.2) ( Table 8).
The Barriers main factors means, standard deviation and 95% confidence interval for the mean shows that we are 95% confident that the true mean for the Health main barriers factors on a scale of 1 to 5 for the population is between 1.9 and 3.0. Organizations/system barriers dimension scored the highest among respondents (Mean = 2.9), followed by individual barriers (Mean = 2.6), interpersonal (Mean = 2.06) and contextual (Mean = 2.04) as it shown in Table 9. As shown in Figure 3, participants most agreed and strongly agreed as bar-riers for volunteering in Healthcare system was organization/system barriers (33%), and least agreed (or most disagreed and strongly disagreed) with contextual barriers (17%). Four elements of volunteer barriers showed no statistically significant differences (P > 0.05) between male and female respondents (Table  10). Barriers elements showed no statistically significant (P > 0.05) differences among marital status (Table 11).
Barriers elements showed no statistically significant (P > 0.05) differences among volunteers according to resident Emirates (Table 12).
Barriers factors showed no statistically significant (P > 0.05) differences among volunteers according to degree or level of school you have completed (Table 13).

Discussion
The findings show that the main motivation for volunteering in healthcare opportunities in the UAE are Understanding dimension (Mean = 4.68), followed by self-esteem dimension (Mean = 4.60), reactivity dimension (Mean = 4.50). As the understanding dimension allow volunteers in healthcare to gain a new perspective on things, also hands on experience and learn new things also deal with variety of people in healthcare for example doctors, nurses variety of patients which allow volunteer to explore their own strengths, this supports the findings of Gage and Thapa that understanding dimension scored the highest among respondents [24]. Moreover, Ambiee [25] found that understanding functions were the next highest motivator, that understanding involves the opportunity for volunteerism to permit new learning experiences and the chance to exercise knowledge, skills, and abilities that might otherwise go unpracticed. The items with the highest means indicating relatively high barriers to volunteer in the UAE healthcare sector were, "Work commitments could prevent people from volunteering in healthcare." (Mean = 3.3), "Family commitments/ looking after children/the home/someone elderly or ill could prevent people from volunteering in healthcare." (Mean = 3.3), and "There is insufficient information about volunteers opportunities in the UAE healthcare system" (Mean = 3.2). Organizations/system barriers dimension scored the highest among respondents (Mean = 2.9), followed by individual barriers (Mean = 2.6), interpersonal (Mean = 2.06) and contextual (Mean = 2.04). The volunteer sections in the healthcare organization need to assess these factors and develop strategies that promote and support healthcare volunteer. Elements of volunteer motivation and barriers showed no statistically significant differences (P > 0.05) between male and female respondents, or degree or level of school and to resident Emirates.

Study Limitation
This study had few limitations. The cross-sectional design of the study limited the causal inference. Further in-depth study needs to be developed based on the healthcare organization size for example; hospital, clinic as well as it depends on the specialty and need for the volunteer within these organizations. The barriers assessment rest on the nature of the healthcare facilities.

Conclusions
Volunteering has a major role to play to complement health care resources in meeting demands for activities such as long-term care services for older people, providing entertainment activities, training patients, helping in disseminating health sector awareness campaigns, providing administrative assistance, volunteer in the boards of hospitals, volunteer in medical research, and raising funds for the benefit of low-income patients.
The UAE government has made great efforts in the promoting volunteering in ministries through various initiatives and laws. The level of motivation to volunteer among survey participants is impressively high. Currently, there are many opportunities to volunteer in the health field in the UAE, including government hospitals, and associations that support patients and their families.
However, this study ascertained that many volunteers do not know what volunteer opportunities exist in UAE's healthcare system. Thus, more efforts are required to raise awareness about the voluntary opportunities available in the health sector in the UAE. The volunteer sections in the healthcare organization need to assess motivation factors and develop strategy that promotes and supports healthcare volunteer. It is recommended to introduce a comprehensive policy that defines and supports volunteer in the UAE healthcare system.