Does cross-cultural adjustment affect employee work commitment? Assessing the role of work factors within selected mission hospitals in Kenya

Employee commitment dimensions

There are several studies that have reported on EC aspects in the hospitality industry. Kara (2012), for instance, explored disparities in organizational commitment with respect to gender in five-star hotels in Ankara, Turkey. This study was part of a larger investigation of EC aspects that have been conducted in a variety of different ways. According to the results of the research, there was no statistically significant disparity between male and female workers with regard to the attitudinal commitment factor that is a component of the EC scale. On the other hand, the behavioural commitment factor reported high levels of males being committed in comparison to their female counterparts. Additionally, a different research study investigated the amount to which organizational climate, leadership styles, and job satisfaction influence EC in South African troops. According to the findings, the dimensions of emotional contagion (Affective, Continuance, and Normative) (see summary Table 1) demonstrated that it moderates favourable connections between transactional, transformational, and laissez-faire leadership styles (Makhathini & Van Dyk, 2018).

According to the findings of yet another study that was published not too long ago, EC dimensions can be modelled into three different components: affective, normative, and continuing (Yang, 2008). See also Meyer and Allen, 1991). These components play a preponderant impact in employee turnover as well as work satisfaction inside a firm. They were further proposed by Buitendach & Hendrina (2012). Affective commitment is the first component of organizational commitment, and it includes the ways in which an employee identifies with, participates in, and is attached to the organization. Employees derive happiness from their work, their fellow workers, and the atmosphere of their workplace - contributing to and supporting that satisfaction. According to Kumari and Afroz (2013), employees that have a strong affective commitment will have a greater level of participation and attachment to the firm. The organization’s capacity to perform more effectively is improved as a result of this kind of dedication. A significant level of job satisfaction and involvement, in addition to a rise in job performance, are examples of such gains (Liou & Cheng, 2010). Continuance commitment on the other hand is anchored on employee’s judgment of the cost implications of quitting or stopping a certain activity in an organization. According to Joāo and Coetzee (2012), these workers are likely to be retained by the organization either for the reason that they believe there are few viable alternatives or because there are significant costs involved with quitting the business. Employees who have a continuing commitment may only perform to the level necessary for them to keep their employment, according to research published in 2008 by Liou. The final constituent of commitment (normative) entails the experience of having a sense of responsibility to the company as a consequence of pressure from other people or the idea that it is morally acceptable to do so. This sense of obligation might be caused by the belief that it is morally correct to do so. To put it another way, it is an individual’s sense of responsibility and devotion to an institution because they suppose it’s the ethical and right thing to do (Mitonga-Monga & Cilliers, 2016). Therefore, to accurately measure institutional commitment of expatriates serving in Kenyan mission hospitals, this study adopted the characteristics given by Buitendach and Hendrina (2012).

The concept of cross-cultural adjustment

The term “cross-cultural adjustment” (CCA), in line with Takeuchi et al. (2005), is the level at which expatriates are psychologically at ease and conversant with certain characteristics of a new environment. CCA can also be seen as the difficulty or ease with which expats deal with different aspects of living and working overseas (Chen, 2019; Noman et al., 2023). It aims at helping immigrants feel more ‘at home’ and integrate into their new culture. The process of change and a reduction in uncertainty helps achieve this. The amount of uncertainty experienced by expatriates can be reduced by their capacity to imitate and/or learn behaviours that are appropriate in the new culture. Numerous studies (see Noman et al., 2023; Waxin & Panaccio, 2005; Black & Gregersen, 1991; Shaffer, Harrison, & Gilley, 1999; Palthe, 2004) have empirically verified this idea.

Cross-cultural adjustment has traditionally been regarded to include three components. The three categories of dimensions that make up cross-cultural adjustment are non-work or general adjustment variables, work-related adjustment factors, and interaction adjustment factors (Lee, Li & Wu, 2018). Non-work/general adjustment factors or the first dimension refers to how comfortable a person is with their day-to-day way of life in a new place, including the transportation, food, climate, etc. The second dimension, work-related adjustment factors, is concerned with how at ease a person is with the working circumstances in a new setting (Lee et al., 2018). The interactional adjustment component measures how well a person can communicate with others from the host nation’s culture in both professional and social settings. The third issue is known as “work-related adjustment factors,” and it has to do with the particular position’s duties, performance standards, and leadership responsibilities that are present at the new environment. This shows that depending on which of these three aspects one chooses to focus on, one can be influenced to a different degree (Reegård, 2011).

Previous research has looked into a number of different adaptation mechanisms for working across cultural boundaries. For instance, researchers like Black, Mendenhall and Oddou (1991) have investigated the process of cross-cultural adaptation as a five-dimensional process between Europe and Africa. These aspects include pre-departure training, previous foreign experience, organization selection procedure, individual skills, and non-work element considerations. The first three aspects are concerned with the problems arising before expatriates leave their home countries, such as the decision to leave those countries. The last two aspects are concerned with the time period that occurs after expatriates have arrived at their new homes in foreign countries.

Berry (2001), writing from a different vantage point, adopted an immigrant point of view. The author suggests four distinct strategies for adjusting to a new culture that are applicable to immigrants in general. However, it was discovered that these strategies also sat well with expatriates and their adjustments cross-culturally (Morley et al., 2004; Hongyu, 2014). Integration, separation, marginalization, and assimilation are the strategies that might be utilized during the adjustment process. Integration describes the process through which expatriates continue to uphold the norms and practices of their home culture while also adopting the norms and practices of their host society. Because of this, they are able to become fully functioning members of society (see Berry, 2001). Individuals who have no interest in adopting any aspects of the host culture’s norms and/or values of their own culture are said to have separated themselves from that culture. These people have made the conscious decision to continue living apart from one another in order to preserve their cultural history. When an expatriate has little inclination either to identify with their own culture or to blend in with the culture of their host nation, they are more likely to be marginalized.

As a final point, assimilation takes place when expatriates replace the traditions and practices of their home culture with those of their new host society. The expatriate has little interest in preserving his or her own culture while living abroad. According to the findings by Morley et al. (2004), integration is typically the most fruitful course of action, while marginalization and separation do not result in good adjustment. At an earlier date, Black & Mendenhall (1990) verified that cross-cultural adjustment does indeed occur in stages, particularly when applied to a multinational organizational set up (see also Bourdin, 2012). This was done in order to address cross-cultural adjustment concerns in their entirety. For example, Beil and Garcia Mayor (2018) remark in their work that there are four distinct phases, and they refer to this pattern as the U-curve. This model appears to consist of four steps, the first of which is the honeymoon period, which takes place during the first few weeks after expatriates arrive. During this stage, newly arrived expatriates are captivated by the novel and distinctive aspects of the culture and country to which they have relocated. The next step is culture shock, and it is during this stage that the expatriate realizes that certain actions are unacceptable in the new culture, but they have not yet grasped what behaviours are proper during this point of their adjustment (Delle & Mensah, 2013; Eschbach, Parker & Stoeberl, 2001).

The individual enters the third stage of adjustment when they acquire some language abilities and the ability to move about independently. This stage can last for several months. The expatriate will also learn some level of expertise in performing the new set of cultural norms during this period. The mastery stage is the fourth and last step in the process. At this point, the expatriate has typically reached their maximum level of adjustment. The individual is now aware of and able to correctly conduct the appropriate actions in order to work effectively and without anxiety as a result of cultural differences (Black & Mendenhall, 1990; Beil & Mayor, 2018; Bourdin, 2012). Due to the fact that the U-curve is applicable on a global scale, the present study decided to employ it. This decision was made because the U-curve tackle concerns that are consistent with the CCA and EC relationship of expatriates living in a foreign country like Kenya.

Problem gap

While there are numerous studies on the contribution of EC to organizations, the attempts seem to focus on its relationship with other aspects other than cross-cultural adjustment. For example, Andrew (2017) studied employees’ commitment and its effect on performance in Sri Lanka. The findings of the study depicted that the employees’ commitment is significantly related to organizational performance in the EravurPattu divisional secretariat. Another study researched employee organizational commitment in Novi Sad and the findings indicated that there was a below average level of organizational dedication among employees (Rodosavljevic et al., 2017). Additionally, Maharani and Tampubolon (2018) investigated how corporatization affects organizational commitment and elaborated on the connection between work ethics, job satisfaction, and staff commitment in Indonesian referral hospitals. In another study, Chih and Lin (2009) identified that there existed a significant relationship between total quality management, leadership style, and workers’ commitment for Taiwan’s high-tech industry.

In a different study, Dang, Tinh, and Nguyen (2020) looked at the linkage between workplace learning and foreign workers’ organisational commitment to the host cultural organisation in Taiwan. They found that workplace learning strengthens this relationship. Field and Buitendach (2012) evaluated the relationships among work engagement, job resources, employee commitment, and job demands for teachers serving in poor high schools in South Africa and found a significant relationship between these. This research was conducted closer to home in Africa.

In Kenya, numerous studies on employee dedication and other topics have been carried out. For instance, it is reported that career training has a significantly positive impact on employee commitment, while the reward system has a positive and significant impact on employee commitment. This is according to the results of a study by Molly and Korir (2020) on the moderating role of the reward system on the relationship between career training and employees’ commitment in a sample of Kenyan manufacturing businesses. However, Muthoni et al. (2020) showed that staff commitment was influenced by employee welfare in their study of the relationship between employee welfare and staff commitment at the Kenyan judiciary. Further, in their study on the impact of financial incentives on staff engagement at the Kakamega County Water and Sanitation Company, Ongadi and Juma (2020) discovered a favourable relationship between the two variables. Additionally, Ogega, Muya, and Nyaboga (2020) conducted study on the impact of gender policy implementation on employee commitment in a few Kenyan county governments and discovered that this policy’s adoption is statistically significant in predicting employee commitment.

Gathungu, Iravo, and Namusonge (2015) further demonstrated a link between organizational commitment of employees of an organization in Nairobi and transformational leadership (TL). Njoroge et al. (2015) determined the effect of TL approach on organizational commitment in technical institutions in Kenya in a different study. In Uasin Gishu County, Chepkurui and Kimutai (2020) did an investigation on the contribution of talent development techniques on staff commitment at the Kenya Forest Service and discovered that talent development is extremely important and necessary in enhancing employee commitment. This apparent lack the studies on the correlation between expatriates’ cross-cultural adjustment and employee commitment, calls into question whether, indeed, a relationship between these two aspects exists or not. This is particularly in the health sector in Kenya which has witnessed an influx of foreign medical personnel such as Cuba doctors to fill the medical skills gap (Gamier, 2021). This understanding motivated the current study – the fact that studies have overlooked have the association between cross cultural adjustment and employee commitment. It is in light of the foregoing that the study sought to assess the effect of transformational leadership on cross-cultural adjustment and employee commitment among expatriates working in selected mission hospitals in Kenya.

Empirical review

According to Hongyu (2015), “work adjustment” in the context of cross-cultural adjustment is defined as the level of emotional comfort an expatriate experiences when confronting the varied work values, expectations, and new work environment. According to Peltokorpi (2006), an expatriate’s capacity to adjust successfully to the job-related features of a given host country is influenced by the perceived ethnocentrism of the nationals of the host country as well as variations in the work values of the two countries. A view of local ethnocentrism has been shown to have a negative impact on work adjustment and loyalty to the host unit, according to research that was conducted on 250 expatriates from the western hemisphere. Open communication, individual accountability, and clearly stated performance objectives and feedback are frequently valued by Western expatriates living abroad. In contrast, Japanese employees are accustomed to following top-down directions and have a tendency to hesitate before expressing their ideas without reservation due to the cultural ideals of collectivism and verticality (Peltokorpi, 2006). This is because Japanese employees appreciate the importance of maintaining hierarchy. According to research conducted by Peltokorpi (2007), it has been discovered that Western expatriates experience increased levels of frustration as a result of the disparities in the work values of their host country.

In a separate piece of research, Peltokorpi and Froese (2009) investigated the degree to which organizational expatriates and self-initiated expatriates in Japan had different levels of success in adjusting to life in a foreign country. The findings indicated that both expatriates were adapting better to work and non-work-related aspects of their lives in Japan than they were adjusting to interaction with Japanese.

According to Selmer and Fenner (2009), it should come as no surprise that work-related variables have the most significant bearing on work adjustment. According to Selmer and Fenner (2009), individuals who are posted overseas frequently face the challenge of adapting to new procedures, new approaches to completing tasks, and an increase in responsibility (see also Noman et al., 2023). In a meta-analysis of the impact of job characteristics in expatriate adjustment it was revealed that the most important elements for work adjustment were role ambiguity or clarity (r=0.41), role discretion (r=0.43) and role conflict (r =0.46) (Beehr & Christiansen, 2001). According to Morley et al. (2004), work-related adjustment is also significantly impacted by the presence of fresh role demands and excessive role demands. According to Nolan & Morley (2014), cultural competency training (CCT) is the process that is used to prepare staff members and their families so that they have a better understanding of the work and non-work environment, as well as the culture and norms of the host nation to which they have been assigned. It is a method that is used to enlarge an individual’s skill to cope with job in a foreign atmosphere (Ying, 2013). Additionally, it seeks to build a gratitude for the culture of the host country (Hesse, 2011).

Scope of the study

Utilising a utilized explanatory research design, the study was conducted in two mission hospitals: AIC Kijabe and Tenwek chosen as case studies. The choice was informed by the fact that medical expatriates are the most sought-after personnel in the healthcare workforce (Häzaq, 2023; Parekh et al., 2016). The study had a sample of 112 participants.

Theoretical framework(s)

This study was anchored on the Three-Component Commitment and International Adjustment Theories for their ability to conceptualize the two study variables i.e. Employee commitment and Expatriate adjustment respectively. They were deemed most relevant as they formed a solid foundation not only for setting the scene for the study and reviewing of literature, but also provided a roadmap useful in developing scientific arguments and drawing important conclusions for the work. Importantly, they were using in limiting the scope of the study variables while organizing ideas. The Three-Component Commitment Theory includes a tri-dimensional model comprising of three scales represent organizational commitment - affective, continuation, and normative commitments (Meyer and Allen, 1997). These aspects provide a description of the various ways in which organizational commitment can grow and the implications that this has for the behaviour of employees. Affective commitment describes a person’s emotional interconnection to an organisation characterised by positive feelings (McElroy et al., 1993). Continuous commitment on the other hand is having “awareness of the costs associated with leaving the organisation.” It’s a calculative aspect of an individual’s perspective or estimate of the expenses and dangers related to leaving the current company (Meyer and Allen, 1991, 1997). Normative commitment describes “a feeling of obligation to continue employment.” Numerous scholars have over the years asserted that when people internalise normative conceptions of responsibility and obligation, they are obliged to prolong their involvement in an organisation (Allen and Meyer, 1990; Wiener and Vardi, 1980; Iverson and Buttigieg, 1999; McDonald and Makin, 2000).

The framework of international adjustment theory, originally provided by Black, Mendenhall and Oddou (1991) and modified by Beil and Garcia Mayor (2018) postulate that there are two elements that can influence an expatriate’s ability to adapt to their new culture - anticipatory adjustment which takes place before moving overseas and in-country adjustment, which takes place in the host country. In the context of this study, great emphasis was taken on the in-country adjustment component associated with expatriates who are currently working in mission hospitals in Kenya. Specifically, they include work adjustment i.e. adjustment to employment (the new job-related elements, such as individual performance, duties, company’s social support, and issues of supervision); interaction adjustment i.e. adjustment to dealing with host nationals (relational adaptation that takes interactions with the novelty of the culture into account); and general adjustment (adjustment to the general environment) referring to the living conditions in the host country and which is normally influenced by the logistical support provided by the company as well as the cultural uniqueness (Black, Mendenhall and Oddou, 1991; Beil & Garcia Mayor, 2018).

Against the foregoing, an illustrative framework conceptualising and illustrating the variables under study and their constructs was developed (see Figure 1). The work-related cross cultural adjustment factors (role novelty, organizational culture novelty, and organisational social support) represented the study’s independent variable. On the other hand, employee commitment (affective, continuance, and normative) was the dependent variable while age, gender, and marital status of the respondents were the control variables (held constant) for the study. in summary and in line with the study’s research aim, employee commitment was hypothesised to be influenced by cross cultural adjustment.

Figure 1. Conceptual framework.

Study areas

The study was conducted in two purposively selected mission hospitals in Kenya - AIC Kijabe and Tenwek mission hospitals. The choice was informed by their large number of expatriate doctors in the country making them made them ideal for the study.

Research design

The study adopted an explanatory research design given that the study aimed at establishing a causal relationship between variables in a study (Saunders, Lewis and Thornhill, 2012).

Target population

The study had a total target population of 156 expatriate medical practitioners from whom the study sample was derived (Table 2). The sample included those employees who had served in the field for over a year.

Sampling

The study employed a simple random sampling method to ensure equal chance of participants being included in study (Bryman & Bell, 2011). With a 95% confidence level, the sample for this study was calculated using Taro Yamane’s formula (Yamane, 1973) deriving a sample size of 112 respondents. Following the sample calculation, a census was applied where data was collected from all members of the sample. The calculation is presented as follows.

Where:

n = sample size required

N = number of people in the population

e = allowable error (%)

n = 112

The specific sample size of each selected hospital was as summarized in Table 3.

Research procedures and ethics statement

Data collection

Data was gathered via self-administered questionnaires (see Thiong’o, 2024). Closed-ended questions with pre-defined questions were employed to obtain quick and direct (Kothari, 2004). Further, it allowed a high degree of consistency and compatible responses. The replies were evaluated using a Likert measurement scale with a range of 1 to 5 (applying the codes 1 = Strongly Disagree to 5 = Strongly Agree). For cross-cultural adaptability, a higher score is desirable.

The questionnaire consisted of 4 major parts (refer to Thiong’o, 2024). Part A of the questionnaire consisted of demographic information with eight (8) questions adopted from Hesse (2011) and Beil and Garcia Mayor (2018); part B comprised the factors influencing employee commitment with one (1) major question containing twenty three (23) sub-questions as adopted from Anne (2011); part C entails factors influencing cross-cultural adjustment of expatriates with one (1) major question comprising of thirty eight (38) sub-questions adopted from Beil and Mayor (2018); Black, Mendenhall, and Oddou (1991); and Liao (2010).

Piloting

A pilot study was carried out in Kapsowar Mission Hospital prior to the main study. With a bed capacity of 140, the pilot hospital shared characteristics with the study hospitals (a vibrant expatriate population providing a wide array of services). Based on the recommendations of Mugenda and Mugenda (2003) of a pre-test sample of 10%, the researchers chose a sample of 12 respondents for piloting (see also Treece, 1982; Saunders, Lewis, and Thornhill, 2009).

Validity and reliability tests

To ensure the quality of data instruments, validity and reliability tests were conducted. Validity of the instruments was assessed by caring out a factor analysis alongside considering views of expert opinions. The necessary adjustments were then made. A reliability test was conducted through a pilot study. According to Warrens (2014), Cronbach’s alpha values vary from 0 to 1, with a value of 0 signifying low dependability and a value of 1 signifying excellent reliability. A Cronbach’s alpha value of 0.7 is usually the required standard for the interpretation of the study instrument’s reliability (Warrens, 2014; Wessa, 2024 - see also free software at https://www.wessa.net/). In line with the foregoing, the results of the pilot study revealed that the employment commitment variable with 23 items (α=0.989) and the cross-cultural adjustment with 38 items (α=0.989) were found reliable. Similarly, transformational leadership variable with 18 items (α=0.982). Reliability results are summarized in Table 4.

Reporting guidelines

To ensure replicability of the study, a reasonable attempt has been made to provide details on how the study methodology was conducted alongside the necessary supporting documentation to corroborate the results (see extended data). Specifically, the study adhered to the provisions of the ASSESS tool (see recommendations by Ryan et al., 2022, pp6 and 7) on author citations and descriptions on the rationale for the study, choices for study respondents, study design, theory, and study sites among others.

Response rate

Out of the total number of questionnaires administered (112) to the target respondents, 105 were returned and found to be dully filled. This was a 93.75% response rate (Table 5); deemed very good according to recommendations of Mugenda and Mugenda (2003).

Demographic characteristics of respondents

The study sought to establish demographic information such as gender, age, academic level, years of service, overseas working experience, working in other countries other than Kenya, and whether the expatriates stayed with their families. From the results the majority of the respondents identified as men (64.79%), were between the age bracket of 30-39 years (62.86%); had a bachelor’s degree (52.38%); had served between 10-20yrs (47.62%); had overseas working experience (90.48%); had worked elsewhere other than Kenya (80.95%); and did not live with their families (94.24%).

A cross tabulation of the above is as summarised in Table 6. The findings further indicated that there was a significant relationship between the demographics measures and Employee Commitment (χ²=101.105, df=47, p=.000; χ²=198.909, df=94, p=.000; χ²=297.394, df=141, p=.000; χ²=200.163, df=94, p=.000; χ²=105.000, df=47, p=.000; χ²=101.757, df=47, p=.000; χ²=105.00, df=47, p=.000) respectively for gender of respondents, age bracket, the highest level of education, years served in the medical field, overseas working experience, worked in other countries before working in Kenya, and stays with their family.

Descriptive statistics of variables

For this study, the descriptive statistics present the respondents’ views on the independent variable (cross-cultural adjustment) and the dependent variable (employee commitment).

The mean of all questions was lower than the theoretical mean (3) (Table 7). In other words, the frequency of the answers of ‘strongly agree’ and ‘agree’ was lower than that of ‘strongly disagree’ and ‘disagree’. Additionally, the low standard deviation indicates that the collected data were grouped close to the mean. Table 7 further demonstrates that the mean of all questions (M=3.8201 and SD=0.47661), the independent variable measured by cross-cultural adjustment, was larger than (>3). Put differently, the frequency of the answers with ‘strongly agree’ and ‘agree’ were more than ‘strongly disagree’ and ‘disagree’. Given the low standard deviation, the observed data were grouped close to the mean. The mean of all questions (M=3.5667 and SD=0.68638) was larger than (>3), meaning in other words, the frequency of the answers of strongly agree and agree are more than strongly disagree and disagree.

Furthermore, the kurtosis results for employee commitment and cross-cultural adjustment (-0.531 and 1.369 respectively) showed that the sample data had been taken from a population with a normally distributed population. It also shows how the data set was organised, with most values concentrated in the middle of the range and the remainder tapering off symmetrically towards either end.

Test for linearity

Linearity was tested to check the actual strength of all the relationships. The results (see Table 8) indicated that all the work-related factors (F=583.028, P=.000) had a significant linear relationship with the employee commitment as F-values have p <.05 and thus, can be used for regression analysis in the study.

Reliability test

Both variables (the employment commitment and cross-cultural adjustment) with a coefficient of 0.872 and .897 respectively were found to be reliable (Table 9). This is in line with a recommendation by Tavakol and Dennick (2011) that Cronbach’s alpha values of more than .7 indicate an instrument is dependable.

Correlation analysis

Correlation coefficient (r=0.868) depicted a high degree of positive correlation between the work-related factors and employee commitment (Table 10). Also, the correlation coefficient was significant as the p-value was p<0.00 and was less than the significance level (α=0.01). Therefore, work-related factors had a high positive correlation and significant relationship at 0.868 with employee commitment.

Regression analysis

Regression analysis was used to determine the direct effect of independent variable on the dependent variable (Table 11).

Coefficients

The results (Table 12) indicated that Beta2 for work-related factors had a negatively significant influence on employee commitment (β=-1.033 p=0.000), this implies that for every increase in the work-related factors, the employee commitment will decrease by the beta coefficient value of 1.033. The null hypothesis was hence rejected (Table 13).

These findings contrasted with a study by Zakariyaa, Othmanb and Abdullahb (2018) in Malaysia who found that work-related factors were positively significant with job performance of expatriates (β=0.041, p=0.000). However, it agreed with Florkowski and Fogel (1999) who revealed that perceptions of local ethnocentrism had a negative effect on work adjustment and commitment to the host unit, particularly when cultural distance was low. This is the case with Lii and Wong (2008) studying the antecedents of overseas adjustment and commitment of expatriates indicating that work role characteristics was a significant predictor for the adjustment and commitment of the expatriates.

Ethics and consent

The design and implementation of the current study involved human subjects (expatriate employees based in mission hospitals) and, therefore, had to adhere to set guidelines and clear scientific research principles as stipulated by the WMA Declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/). Several underlying principles were followed as required by established ethical standards and protocol in Kenya. These included: informed consent from respondents to participate in the study, maintenance of anonymity, confidentiality, and privacy of respondents and the information they provided, and finally the right to withdraw from the study at any given time.

A detailed application describing the study and how each of the foregoing issues was adhered to was made for consideration by an independent research authority in Kenya, the National Council for Scientific, Technology, and Innovation (NACOSTI) (https://research-portal.nacosti.go.ke/researcher/ApplicationGuidelines.html). A written approval (license number NACOSTI/P/22/15466) covering the period of study ending 28^th January 2023 was issued to the researchers on 28^th January 2022. Following this approval, the study commenced and after completion a copy of the study findings was submitted as a standard requirement.

This study involved human participants (expatriate employees). Draft consent detailing the study objective and terms of engagement during the study was incorporated in the questionnaire and submitted for ethical application. Upon approval, the requirement for respondents to fill in and sign consent was waived by the ethics board (the current study was deemed to: present ‘no risk of harm’ to participants, and that the waiver would not negatively influence the subjects’ welfare/rights), right to withdraw from the study, and the maintenance of anonymity had to be observed (see recommendations by Kambhampati, Menon & Maini, 2023; Mahajan, 2023). Against the foregoing, licensing, and ethical authorisation to carry out the study was acquired from the relevant authority in the land – the National Commission for Science, Technology, and Innovation (NACOSTI) (license number NACOSTI/P/22/15466). Further to this, written permission to conduct the study in the individual facilities was sought in writing from the hospital management through the local administration where the respective study sites are located.