Noura A. Abouammoh

4.2 Research questions:

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  What does the interaction between IMGs and local patients with T2DM look like in SA?
  
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  What are the barriers faced by IMGs in delivering effective diabetes care to patients in SA?
  
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  What are the strategies and facilitators used by IMGs to deliver effective diabetes care in SA?
  

4.3 Study aim

To elicit in-depth information from IMGs and local patients with a view to providing recommendations to feed into SA policies relating to public health and IMG training.

4.4 Study objectives:

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  Identify and recruit a sample of IMGs from hospital-based and community-based primary health care clinics.
  
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  Identify and recruit a sample of T2DM patients from hospital-based and community-based primary health care clinics.
  
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  Obtain a general understanding of the issue under investigation by conducting a focus group discussion with hospital-based IMGs.
  
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  Analyse findings from focus group discussion to inform the development of a topic-guide for in-depth interviews with IMGs and T2DM patients.
  
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  Conduct in-depth interviews with IMGs to elicit their experiences of interacting with patients and their perceived role in treating T2DM patients.
  
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  Conduct in-depth interviews with Saudi patients with T2DM to explore their perceptions of IMGs’ role in caring for their condition, and the advice given by these physicians.
  
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  Use thematic analysis to draw out key findings from the data.
  
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  Use the findings to draw up recommendations to improve the quality of physician-patient interaction in T2DM care in SA.
  

Chapter 5

Methods

5.0 Introduction

This chapter describes the study methodology and methods developed to explore the research questions outlined in Chapter 4. A discussion of the researcher’s epistemological position, decisions made regarding methodology, and methods proposed, is provided in this chapter.

A focus group discussion and face-to-face semi-structured interview techniques were chosen to obtain an in-depth understanding of the experiences of and possible facilitators and barriers to effective communication between IMG primary health care physicians in SA and the patients they care for with T2DM.

For a deeper exploration of the issues under investigation, data were collected in three phases from two different sources, i) IMG primary health care physicians and ii) Saudi patients with T2DM. Phase 1 involved a focus group discussion with IMGs from one hospital-based primary healthcare clinic, and semi-structured interviews with IMGs from eight community-based PHCCs. This was followed by phase 2, which involved semi-structured interviews with Saudi patients with T2DM from the hospital-based clinics and the community-based PHCCs. Phase 3 involved follow-up interviews with some of the IMGs for further exploration of issues raised by both IMGs and patients.

5.1 Research perspective

How do we understand reality? What is our relationship to it? And how can we find out about it? These questions are referred to as the ontology, epistemology and methodology of a piece of research. Responses to these philosophical questions inevitably shape the way in which research is conducted, as well as the assumptions made about the data generated.

There are two main ontological positions: realism and relativism (Bryman, 2008). Realists or positivists assume that there is one external reality that can be accessed directly by researchers to produce definite knowledge. By contrast, relativists assert that there is no independent reality, and that people construct their own reality through interpretation (Bryman, 2008). Between the polarised dichotomy of realists and relativists, subtle realism asserts that there is an underlying reality, which can be studied, however the data generated to reach that reality is influenced by subjective interpretations of the participants (Hammersley, 1992). This can be further influenced by the researcher’s interpretation of the respondents’ accounts.

The current study is logically connected with the subtle realism philosophy, which was convincing because people having different perspectives emphasises the fact that they give different meanings to everyday reality. Furthermore, the belief in the existence of an independent reality acknowledges the fact that for reasons beyond their control, people experience and perceive reality differently.

Constructivism is the major epistemological approach for qualitative research. Constructivists believe that the world is complex and subjectivity in interpreting social realities does exist (Bryman, 2008). Furthermore, constructivists believe that people are surrounded by social realities, which are difficult to measure statistically. Social research is characterized by the interaction between the researcher and the study participants, which inevitably influences the study’s findings (Silverman, 2010, Hammersley and Atkinson, 2007). Snape and Spencer (2003) explain what is meant by constructivism as follows:

“displaying multiple constructed realities through the shared investigation by the researchers and participants of meaning and explanations” (p. 12)

The researcher’s role is understanding how meanings are given to reality through peoples’ interaction (Guba and Lincoln, 1994). Qualitative researchers believe that each individual is unique, and to understand them, the researcher should talk to them, listen to them and observe them in their natural setting (Guba and Lincoln, 1994).

Based on a constructivists’ position, qualitative research aims to answer questions such as ‘what’, ‘how’ and ‘why’ of a phenomenon from the participants’ accounts rather than the researcher’s point of view. Although the researcher should strive to represent the respondents’ own interpretations as faithfully as possible, he or she should acknowledge that they add a further layer of interpretation in terms of their own research focus and theoretical insights.

Entering the research setting with a set of stated hypotheses may lead to failure to discover the real nature of the phenomenon. This is true because adherence to hypotheses may keep the researcher away from seeing the research findings in a broader sense and may interfere with the participants’ experiences of a particular phenomenon (Spencer et al., 2003).

Qualitative methodology was chosen for this research because meeting the aims of this study requires an in-depth understanding of the circumstances, experiences and perspectives of IMGs and T2DM patients themselves in communicating and interacting with one another. A further reason for choosing this methodology is the nature of the output sought from the research, as this study provides a detailed analysis and offers interpretation of cultural-related issues, which are difficult to explore quantitatively. Furthermore, as one view of reality is believed to be obtained through individuals’ eyes (Snape and Spencer, 2003, Silverman, 2010), this study explores questions such as: what is there that can be known about experiences and communication between physicians and patients in cross-cultural clinical settings? Why does a relationship take a certain form? How does this affect care for patients with T2DM as perceived by IMGs and patients in SA? These kinds of questions are better explored using qualitative methodology (Bryman, 2008, Silverman, 2010). The complexity of the subject matter was accepted in advance, as this was evident from the academic literature (discussed in 3.3) dealing with cultural competence and communication in cross-cultural medical settings and in managing chronic health conditions such as diabetes. It is important that the researcher conveys a complete picture, as far as possible, of this complexity (Snape and Spencer, 2003).