key: cord-0019131-huav01g8
authors: Ezeonwu, Mabel
title: The Role of African Nurse Diaspora in Addressing Public Health Priorities in Africa
date: 2021-07-12
journal: Glob Qual Nurs Res
DOI: 10.1177/23333936211031501
sha: de431984da8a47f43e86acd0de932bcb5d257266
doc_id: 19131
cord_uid: huav01g8

African countries experience many complex public health challenges that, to tackle, require coordinated, multi-stakeholder, collaborative partnerships at local and global levels. The African nurse diaspora is a strategic stakeholder, contributor, and liaison to public health interventions, given their roots in the continent, their professional connections in the west, and their ability to build an extensive network of global partners. Using a descriptive qualitative approach that amplifies the voices of the Africa nurse diaspora, this study provides an insider view of the continent’s public health priorities and what roles the diaspora can play to improve health and population outcomes. Findings show that Africa’s high disease burden is generally preventable but compounded by enduring socioeconomic challenges. Against this situation, African-born nurses in the diaspora are uniquely positioned to mobilize both local and global stakeholders in coordinated global health policy interventions and actively engage communities in preventive care while earning their trust.

Although nurses and midwives account for more than 50% of the global health workforce, many countries suffer nursing and midwifery shortages, a problem that is projected to only worsen in the continent of Africa by 2030 (World Health Organization [WHO] , 2021a). This situation is mainly owed to the outmigration of African-born nurses: Among the 2.3-million health workers (excluding refugees) who immigrate to the U.S. alone, 20% are registered nurses and, of them, 24% were born in Africa (Batalova, 2020) . Given suboptimal work conditions in many African countries and globalization's expanding of available markets, international migration of nurses is unavoidable and unstoppable (Renzaho, 2016) . So, how must struggling African countries with high disease burdens deliver basic healthcare to their communities and respond to complex emerging needs (Stuart-Shor et al., 2017) ?

Communities in Africa are affected by a wide range of obstacles and issues: Communicable diseases such as malaria, HIV/AIDS, and tuberculosis, continue to pose major threats to health while non-communicable diseases (NCDs), such as mental health disorders, injuries, violence, and cardiovascular and endocrine diseases, are now on the rise (Gouda et al., 2019; WHO, 2014) . The everyday difficulties created by these diseases are further compounded by complex social challenges, including adolescent pregnancies (Kassa et al., 2018) , poor water and air quality, poor sanitation, environmental degradation (Bradshaw et al., 2019; Yang et al., 2020) , poor housing (Tusting et al., 2020) , political instability and conflicts (Atti & Gulis, 2017) , social and ethnic stratification and inequality (Ichoku et al., 2013) , hunger and food insecurity (Ngcamu & Chari, 2020) , corruption, under-resourced health care systems (Langlois et al., 2020) , and poverty (Worku & Woldesenbet, 2015) .

The key to tackling the majority of Africa's public health challenges lies in primary care; however, existing primary healthcare systems in many low-and middle-income countries, the majority of which are in Africa, fail to provide highquality, comprehensive, patient-centered, and integrated care 1031501G QNXXX10.1177 1 University of Washington, Bothell, USA (Langlois et al., 2020) . More specifically, these countries' systems are not equipped or prepared to undertake community-based care with sufficient confidence in infection prevention, control, and effective referral mechanisms (Rasanathan & Evans, 2020) , often due to under-resourcing, fragmentation, lack of accountability, and poor governance (Langlois et al., 2020) . Furthermore, Africa is not a monolithic population but a continent of 54 countries with distinct political, religious, and cultural characteristics influenced by Anglophone, Francophone, Spanish, and Portuguese colonial backgrounds (Arthur, 2006) ; as such, one-size-fits-all solutions will not serve these diverse patient groups. Tackling Africa's health crisis requires coordinated efforts and robust partnerships between national governments and international communities who, together, must pool financial resources, knowledge, and expertise (United Nations [UN], n.d.) and inform the development of targeted public health policies (Richards, 2006) .

Of this global community, the diaspora of African nurses is an important constituent and key stakeholder for sustainable development in this eclectic continent. First and foremost, the goal of community and public health nursing is to improve a population's wellbeing by focusing on health promotion and the health maintenance of individuals, families, and groups within communities (Nies & McEwen, 2015) . In this sense, nurses, in general, are key players in providing and ensuring universal access to healthcare and positioned to make significant contributions to the UN's Sustainable Development Goals (SDG) as advocates, managers, leaders, care providers, educators, and researchers (Wilson et al., 2016) . Now, specifically in Africa, the nurse diaspora can serve as critical bridges between healthcare providers and communities as well as between local and global partners, given their ability to connect with both their adopted countries of practice and their countries of origin. That is, African-born nurses who have trained and practiced in the west and have multinational exposure but are well-versed in cultures and traditions specific to African regions are capable of contributing their expertise to, for instance, the many Western-sponsored public health programs and initiatives that are cropping up particularly in the sub-Saharan region (Mwisongo & Nabyonga-Orem, 2016) . Rather than simply carrying out the priorities of these programs' funders, these nurses can effectively honor the needs and concerns of their local patients while managing their health and wellbeing.

This work comes naturally to Africans in the diaspora, who are not detached from their continent's socioeconomic and health issues. Healthcare workers, in particular, maintain both personal professional ties within their countries of origin and, regardless of where they migrate, remain actively engaged in improving their communities' living conditions by supporting people's health, education, and social structures (Richards, 2006; Wojczewski et al., 2015) . Although their engagements are often siloed or focused on individual or small group endeavors, these professionals are recognized as mediators and active networkers in a globalized and transnationally connected world (Wojczewski et al., 2015) .

The African nurse diaspora is an indispensable part of a concentrated effort that could change the face of public health in Africa. Still, literature on this key group as a voice and force in identifying and remedying Africa's extensive public health problems is lacking. Therefore, this study examines how the African nurse diaspora can provide the leadership required to improve public health outcomes in this continent.

This study employed a cross-sectional qualitative descriptive approach to understand and highlight the views of Africanborn nurses who currently live and practice in the U.S. More specifically, these nurses were asked to share their views on (1) public health priorities in Africa and (2) the roles that the African nurse diaspora could play to improve public health in the continent. The design is appropriate, given that the inquiries were based on straightforward descriptions of a phenomenon (Sandelowski, 2000) derived from direct characterizations made by individuals who have experience and deep insights regarding the issues (Polit & Beck, 2014) .

Interviews were conducted face-to-face and by phone. Settings for the in-person interviews varied, depending on the participants' preferences for locations, which included public and university libraries, participants' homes, and workplaces (e.g., office or employee rest area), and coffee shops. Phone interviews were conducted at mutually agreedupon times.

This study recruited a sample of 25 African-born nurses who earned their baccalaureate nursing degrees from University of Washington, a major public university in the U.S. Pacific Northwest between 2010 and 2014. Data saturation was reached when no new information or themes were observed in the data (Sandelowski, 2000) . Participants were identified through the nursing school's student advisers and contacted through emails and phone calls to request their involvement in the study. The inclusion criteria demanded participants to (1) be 18 years or older, (2) have at least a baccalaureate nursing degree, and (3) be born in an African country.

Data was collected using open-ended, semi-structured questions asked during 30-to 60-minute interviews, which were audio-recorded and documented in the form of detailed field notes. Two participants declined to be audio-recorded but approved of notes being taken. Interviews were conducted between 2015 and 2017, and examples of key questions included:

From your perspective what are the health priorities of Africans living in Africa? 2)

What roles could you and other African nurses in the diaspora play to improve public health in Africa?

Eight participants described themselves as males while 17 described themselves as females. In addition to English, they all spoke one or more languages, including the native language of their countries of origin, and held clinical, academic, and leadership positions in the U.S. Table 1 presents these and other demographic characteristics of the participants.

Approval for this research project was obtained from the Institutional Review Board (IRB) of the University of Washington with IRB application, Human Subjects Division (HSD) # 47481-ED. All study protocols adhered to the institution's ethical principles.

Detailed information regarding the study was provided to participants whose questions were systematically answered. Informed consent documents were provided to and signed by the participants prior to all interviews. For phone interviews, participants were emailed their informed consent documents, and detailed information about the study and their rights as participants were read aloud to them.

Participation was fully voluntary. Each participant's proper name was replaced with a code in the digital audio recording and field notes. All participant identifiers were kept separate from the data.

Recorded interviews and notes were transcribed verbatim. Qualitative content analysis was used to analyze the data using the framework provided by Graneheim et al. (2017) and Graneheim and Lundman (2004) . The units of analysis were the texts of all the recorded interviews, which were subsequently condensed into one text. Keywords, phrases, and sentences that characterize Africa's public health priorities and the African nurse diaspora's roles were identified and highlighted. The textual data was then sorted by common ideas and carefully coded according to their differences and similarities. Unifying themes and sub-themes related to public health priorities and nurse diaspora roles emerged and constituted the study findings.

As described before, the study' researcher conducted one-onone interviews with each of the participants, whose audio and written data were transcribed and cross-checked to ensure content validity and accuracy. Graneheim et al. (2017) describe trustworthiness as an overarching concept that provides a comprehensive sense to the entire study and threads through the entire research process. Elements to earning trustworthiness include (1) finding credible participants who have the experience of the phenomenon studied (i.e., credibility), (2) recruiting an adequate number of participants who generate enough quality data to uncover significant variations (i.e., transferability), (3) developing clear coding rules for differentiating between categories and sub-categories to address dependability issues, and (4) ensuring that the voices of the participants (i.e., quotes and stories), not of the researcher (i.e., credibility and authenticity), are prioritized in the research findings. Ultimately, a study is trustworthy if it can robustly show the logic of how the themes connect to each other as well as to the work's overall objective. These elements were evident in this study with ample amounts of participants' quotes and voices threaded throughout the report.

Although this study was open to nurses from all African countries who met the inclusion criteria, the final sample of respondents represented nine African countries in the sub-Saharan region. The participants have family members and acquaintances still residing in those regions and are well connected to their respective home countries, traveling back, on average, once a year. Given their deep understanding and knowledge of the sub-Saharan African context and their expertise as nurses, the participants offered detailed insight into priority public health issues within the region and, more notably, recommended ways in which the nurse diaspora can support improvement efforts, build capacity, and provide leadership through participation in multilateral programs. As shown in Table 2 , two major themes and several sub-themes were identified.

This study's participants all presented a global vision of the continent through the frame of public health issues and solutions; however, because of the diversity amongst the individuals, certain perspectives did differ. While no gender-based differences were noted, subtle nuances related to the diaspora's engagement of health literacy, women and sexism, and reproductive health issues varied depending on the participants' regional nationalities. That is, West African participants strongly supported educating girls to give them a pathway to financial independence while East Africans focused more on improving basic health literacy and curbing early marriages for girls. East African participants also recommended mobilizing the African nurse diaspora for medical mission trips to African countries more than the West African participants did.

High preventable disease burden and low health literacy. Of the 25 participants, 23 stated that many Africans suffer and die unnecessarily from minor infections and illnesses and complications related to chronic diseases that can often be prevented and controlled. A participant stated, "There [is] lots of cancer (mostly breast cancer), high blood pressure and stroke. We are seeing diabetes more than we have ever seen before. It's shocking how much we have right now" (P3). The participants agreed that this disease burden is caused by individuals, families, and communities lacking access to basic healthcare as well as education and awareness regarding the pathophysiology of their conditions, disease transmission, prevention, and treatment. Lack of access to timely, appropriate health screenings was also identified as a key contributor. Additionally, participants noted that many women continue to die during pregnancy and childbirth from hemorrhage, infection, and other associated maternal complications. Limited knowledge and poor access to birth control, as well as malnutrition particularly while pregnant and breastfeeding, were described as contributors to these deaths.

Socioeconomic and health systems issues. Poverty and lack of access to basic resources are constantly looming obstacles in Africa. Participants provided the following examples of these condition:

• • Lack of water as a basic resource at health care facilities and at homes. • • Poor infrastructures such as hospitals, clinics, and maternity homes. • • Lack of basic care items such as medicines and vaccines, blood products, diagnostic tools, and point-ofcare machines.

Although many predisposing factors exacerbate disease exposures (e.g., internal wars, hunger, inadequate shelter, lack of clean air, poor environmental conditions, and urbanization), most participants tied the dearth of resources to inefficient healthcare systems that are propagated by corrupt politicians who fail to prioritize the health of their citizens. Participants described insufficiently trained healthcare workers as another major public health problem, one attributable to lack of resources, insufficient nursing schools, poor working environment, and, more than ever, out-migration. One participant stated, "You go all over the world, there are our nurses and doctors. If they're not in the U.S., they're in Australia, UK, Canada, or Saudi Arabia. They're trained by the continent, but they go and work somewhere else" (P12). This participant also observed that western leaders often commend nurses while African leaders never appreciate nurses for their hard work.

Mobilization, team building, and partnership development. Participants acknowledged that they alone cannot tackle the broad and complex public health issues that trouble this multifarious continent. Twenty-one of the 25 participants stated that addressing key challenges will take extensive mobilization, collaborative efforts, and partnerships within but also beyond nursing. As one participant noted, "We cannot go as nurses alone, but we can help by using our skills and collaborating with communities and organizations" (P11).

Almost all participants agreed that the first critical step is to build a team of committed stakeholders that includes (1) the African nurse diaspora identified through university and college alumni networks as well as nurse diaspora associations of different African nations, (2) other African healthcare workers in the diaspora including doctors and pharmacists, (3) African diaspora communities at large, and (4) nurses who currently live and practice in Africa. The goal is to build teams that can function effectively with shared public health goals for the continent.

Participants noted that a strong team of U.S.-trained, African-born nurses, for example, can and should develop alliances with various stakeholders in Africa such as (1) health professionals living and working in Africa, (2) healthcare organizations such as hospitals and clinics, (3) local community organizations, (4) schools, (5) religious communities, and (6) foreign, non-governmental organizations and agencies that work on global health programs in the continent. Participants also suggested that the nurse diaspora should avail themselves to global public health and actively participate in the UN's development programs in Africa.

According to the participants, nurses are well-positioned to support disease prevention and health promotion efforts in Africa because they possess broad professional skills, have access to resources and professional networks, and wield political influence. To improve health knowledge among communities in Africa, the nurse diaspora agrees that health education efforts must be focused on creating awareness surrounding disease processes, fundamental infection control strategies, and general wellness. Areas of emphasis include proper handwashing, timely vaccinations, adequate nutrition, proper garbage disposal, women's health, and prevention of sexually transmitted infections and parasitic infections. A participant shared:

We have to go back to the basics. People should wash their hands. . .if it rains, drain the water-collecting containers to prevent mosquitos from breeding. Little things like these will go a long way to make a difference and prevent a major medical need. (19) Chronic disease prevention and management were also priority areas of education. Participants expressed the need to educate communities about the etiology, clinical manifestations, prevention, and management of diseases such as diabetes and hypertension. They, however, recognized the complex logistics surrounding public health education and outreach, especially in a continent as diverse and expansive as Africa; thus, they proposed multiple forms of engagement including (1) conducting one-on-one health education with each nurse's immediate and extended families and friends in the diaspora, urging them to educate their own families and friends back in Africa; (2) executing healthcare missions only served by the African nurse diaspora; (3) participating in medical missions to Africa that are organized by other African healthcare providers in the diaspora; and (4) joining purposeful international organizations and groups that organize medical mission trips to Africa.

The majority of participants expressed a clear need for the nurse diaspora to go home to Africa and be physically involved in primary care efforts and infrastructural building; with that being said, they also noted that those who cannot make it physically can still support the outreach efforts by (1) creating digital presentations and education materials for topics of interest in a variety of appropriate languages; (2) conducting virtual education workshops using PowerPoint and audio and video recordings; and (3) engaging in informal education campaigns on social media platforms that are available and accessible in African countries.

Improving women's health. A quarter of the participants believed that improving women's health and social status is foundational to public health in Africa and, in fact, addressing women's health should take precedence over all other needs. One of the participant suggested, "The best way to start improving public health in Africa is to address women's health starting from high school because girls in high school will grow up soon to be women" (P10).

The participants stated that the nurse diaspora can help improve women's health by providing direct funding for and mentoring support in educational (general and health-related) and entrepreneurial activities that can empower women and girls. They raised examples of direct actions such as (1) providing financial and material resources to families who may then encourage their girls to go to school and (2) providing those same resources directly to women, particularly those living in villages, so they are motivated to work toward financial independence.

Considering the high level of maternal deaths and disabilities in Africa, the participants noted that nurses who work with women during pregnancy, childbirth, and postpartum can be supported through extra training on basic obstetric and newborn competencies. A participant stated, "We could prevent many fatalities if we train the nurses to do simple things, as simple as stimulating babies to get their first breath, resuscitating babies using the neonatal resuscitating program, managing postpartum hemorrhage, and women's health in general" (P9).

As stated, critical areas of training include managing common obstetric complications such as postpartum hemorrhage and performing neonatal resuscitation. The participants suggested that African-born nurses with experience and training in obstetric and newborn/neonatal care can be directly involved with the in-person training of local nurses and midwives through planned mission medical trips or virtual simulation training programs. Such activities could also be sponsored by the nurse diaspora.

Supporting public health infrastructure. Most participants agreed that poverty at individual and country-wide levels and grossly inadequate healthcare resources damage public health in Africa. There also exists a considerable lack of adequately trained healthcare providers, particularly nurses who, furthermore, lack the tools and supplies to provide care to patients.

With this in mind, over 60% of participants stated that the African nurse diaspora can provide material and financial resources to support Africa's public health infrastructure. For instance, the diaspora can collect and ship essential items and equipment to healthcare facilities in Africa as well as coordinate individual contributions and group fundraising efforts, which can be promoted through social media such as Facebook, Instagram, and Twitter. Participants stated that the funds raised can be used to (1) support health education and outreach efforts including those surrounding women's health, (2) build the physical infrastructure necessary to deliver accessible care, (3) provide clean water sources to enhance sanitation, (4) provide care items such as medication and diagnostic equipment, (5) encourage technology development that can enhance public health education, (6) support wages and benefits of African-based nurses, and (7) procure books for nursing schools.

In addition to directly supporting public health activities in Africa, such funds can be slated to sponsor African nursing students in the diaspora who, as part of their practicum experiences, may then travel and participate in health missions in African countries. This strategy can effectively promote academic partnerships between the nurse diaspora community and nursing programs in their countries of residence while introducing future African nurses to public health in the continent.

Some participants also noted that funding partners for these public health agendas can be recruited in Africa. As a participant puts it, "To be honest, there is money in Africa. It's finding the right people that can invest. We can start something, and they might want to help. If we do nothing, it will not happen. We have to start" (P6). Still, most participants expressed confidence that the nurse diaspora can raise enough funds once mobilized to support multiple programs.

Building trust and cultural understanding. Participants expressed a sense of belonging within their home countries and described themselves as representatives for Africa, referring to the continent and/or their respective countries as "our home," "our family," "our people," "our country," "our continent," and "where we grew up." And, because of their enduring kinship with their home, a quarter of the participants stated that, through active engagement, the African nurse diaspora can help foreign public health entities and programs earn the trust, excitement, and acceptance of local Africans. They believe that Africans will listen to people who look like them even if their languages are different, thus highlighting the importance of representation and cultural and ethnic alignment. A participant stated:

Trust is number one for someone to open up to you. We grew up there, we know the culture, we know when they say yes or no, what that means. We know the tricks about our culture and our people. If we are more involved, we will do much better and people will trust us. They will open up for us. (P4) The participants lamented that the experienced African nurse diaspora is often left out of most global health programs in Africa, which are often served by foreign governmental and non-governmental organizations. A participant described how only people who have lived with local and regional customs, and worked in those social structures can truly grasp and, thus, empathize in a meaningful manner:

There are lots of cultural issues, only the Africans can understand them, not outsiders. I argue with my mother about female circumcision. In order to be accepted in the community, you have to be circumcised. They believe so much in the culture and tradition. I get it, but others will not. (P12) In this way, the African nurse diaspora can facilitate cultural understandings of their communities and educate other stakeholders, particularly foreigners, on specific values and traditions of the locale. Even if African-born nurses may not be able to physically participate in outreach activities, they can still equip their partners with information, techniques, and manners that will help them respectfully navigate Africa's vast cultural landscape while placing patient trust at the center of their work.

Africa's public health issues, including the disproportionately high infectious and chronic disease burdens, point to more significant social issues at large including low health literacy, socioeconomic conditions, and deficient primary care systems that are underfunded, overstretched, and understaffed (African Development Bank, 2013) . Furthermore, a shortage of well-trained and amply equipped healthcare workers, quality medicine, and poor infrastructure all remain threats that highlight how grossly limited the continent's capacity is to assess, diagnose, treat, and manage diseases (Holst et al., 2020) . These factors influence not only the health and welfare of communities but also represent a wider set of forces and systems that shape daily life for people who are born, grow, work, live, and age in those communities (WHO, 2021b) . That is, many people in Africa currently live and work while carrying life-threatening conditions that remain undiagnosed and, thus, untreated.

To tackle these problems, intersectional public health interventions in Africa must be carried out by collaborative teams and multi-sectoral stakeholders who actively invest in local communities. The United Nation's SDG goal on multi-stakeholder partnerships shows that, while top-down, short-term, single-sector approaches generally cannot deliver long-lasting results or changes, engaging all societal sectors in a bottom-up approach, and supported by top-down experience, technology, finance, and global coordination, lead to deliberate and targeted sustainable outcome (United Nations, 2020). Extensive mobilization of willing actors at all levels is, therefore, a prerequisite for population health improvement.

The international community and regional development institutions can play active roles in building the capacity of African health systems as well as in mobilizing financial support (African Development Bank, 2013) . However, African healthcare professionals working abroad, including nurses who have out-migrated, are pivotal in carrying out identified programs and initiatives with the buy-in of local African communities. This study affirms that the African nurse diaspora has lived experience and intimate knowledge, both personal and professional, of Africa's lack of material and human resources and its reverberating effects on society. And this lack is exactly where the diaspora's involvement fits in.

According to this study's finding, the core to supporting Africa's public health is in health education that focuses on disease prevention and promotion of healthy and hygienic practices. Although most African countries lack the capacity and technology for quality or timely disease surveillance, public awareness, and education of basic disease prevention strategies can go a long way. WHO (2020) points out that, through health literacy efforts and multisectoral actions that increase healthy behaviors, health promotion empowers people to increase control over their health and its determinants. Nurses have a strong foundation in health promotion, preventive health, and chronic disease management (Nies & McEwen, 2015) ; with the added ability to effectively communicate these concepts to local communities, the African nurse diaspora can be instrumental in actions that support primary healthcare in the continent.

This study's participants proved to maintain strong connections to Africa, irrespective of how long they have been away from the continent. To them, Africa is home. This commitment, alliance, and love for their countries uniquely position the diaspora as links between local and global partners. Past studies support this finding and affirm that Africa's migrated health workers are willing to return and actively participate in the development of its healthcare systems (Poppe et al., 2016; Stuart & Russell, 2011) . The enthusiasm to return to African is however not shared by all the diasporas. For example, Poppe et al. (2016) pointed out that people are not always willing to return, often due to the same reasons why they left in the first place, such as persistent wars and internal conflicts that pose safety risks, institutional crises related to poor living conditions and lack of basic resources such as clean water, and their family's stability since some have settles in their adopted countries.

The African nurse diaspora can partner with foreign entities such as government agencies and global organizations that conduct public health initiatives in Africa. For instance, the U.S. government-sponsored Global Nurse Capacity Building Program, Medical Education Partnership Initiatives (MEPI), and Nursing Education Partnership Initiatives (NEPI) all seek to increase the number and quality of nurses and midwives in Africa (Center for Disease Control and Prevention, 2017; Goosby & von Zinkernagel, 2014) , thus representing a prime opportunity for African-born nurse scholars to offer their expertise and insight. It is imperative that the nurse diaspora actively seeks out opportunities for global engagement and leadership in such multilateral programs.

In the same lieu, leaders of exchange programs in nursing and healthcare (Goosby & von Zinkernagel, 2014 ) that operate in African countries must recognize the particular potentials of the nurse diaspora and, therefore, actively seek out African indigenes as participants and collaborators. Intentional recruitment of qualified African nurses in the diaspora will boost the success and sustainability of interprofessional and multicultural programs while also placing a face of legitimacy, trust, and representation on even foreigner-led efforts in Africa. As the study shows, familiarity, as well as intimate cultural and ethnic understandings of local customs, are key to long-lasting program implementation that is not only accepted by community members but also expands the knowledge of foreign program stakeholders and participants.

A key strength of this study is that it captures the voices of the African nurse diaspora as they speak, firsthand, on how they can be involved in improving health outcomes in Africa. The participants represent diverse demographics in terms of age, gender, and nursing practice background; however, all have a deep understanding of the sub-Saharan African context and strong expertise in global health as nurses with robust clinical, academic, and leadership backgrounds. Many were also experienced migrants. Amplifying their capabilities and earnest desires, this study is significant to Africanborn nurses in all western societies, African public health policy advocates, and global public health policymakers.

In terms of limitations, this study's participants were all recruited from a single university in the U.S. While their responses could have been affected by experiences specific to their location, they were recruited and interviewed years after they had graduated from this institution. Finally, though attempts were made to recruit participants from as many African countries as possible, the ones compiled were not representative of all African countries.

Africa's public health challenges are as many and diverse as the continent itself. In addition to common infectious and chronic diseases that lead to significant deaths and disabilities among all population demographics, a host of socioeconomic and health systems factors provide conditions that promote ill health and insufficient education surrounding prevention, diagnoses, and treatment. Addressing Africa's public health issues demands multi-stakeholder collaborations and partnerships supported, if not led, by the African nurse diaspora.

This key group has the earned ability to support public health improvement efforts by mobilizing key stakeholders and partners, providing accessible health education and relatable community outreach for preventive care, and providing financial resources for individuals and communities as well as infrastructure. As important stakeholders, strategic contributors, and essential liaisons, these professionals can provide the leadership necessary to make multilateral, multi-stakeholder programs succeed in Africa. In particular, the African nurse diaspora's deep understanding of various regions and cultural values specific to them position them as unique resources in improving Africa's health outcome sustainably and for the long term.

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The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors received no financial support for the research, authorship, and/or publication of this article.

Mabel Ezeonwu https://orcid.org/0000-0002-6246-3153