Noura A. Abouammoh

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Experiences of International Medical Graduates Caring for Type 2 Diabetes Patients in Saudi Arabia: Perspectives of Physicians and Patients

Noura A. Abouammoh

A thesis submitted to the University of Sheffield as partial fulfilment for the degree of Doctor of Philosophy

January 2015

Faculty of Medicine, Dentistry and Health

School of Health and Related Research


It would have not been possible to complete this thesis without the help of the wonderful people around me, to some of whom I can give particular mention here. First and foremost I would like to express my sincere gratitude to all the physicians and patients who participated in this study. I very much hope that I have done justice to their voices. I am also very grateful to King Saud University for their financial support, and to the University of Sheffield for their academic support.

This thesis would have not been possible without the help, support and patience of my supervisors, Dr. Sarah Barnes and Professor Liddy Goyder, to whom I am forever grateful and truly indebted. They guided the research process by giving generously of their time and vast knowledge. They were always available and ready to answer my questions. Their critical questioning, enthusiasm, encouragement and faith in me throughout helped me in producing the final version of this thesis.

My thanks also go to Lucy Gell for finding time to provide her insights regarding parts of this research, and to Hannah Fairbrother for being there whenever I needed her academic advice. For any errors or inadequacies that may remain in this work, of course, the responsibility is entirely my own.

I am also thankful to all my colleagues and friends here in the UK for providing emotional support, and to all my siblings who gave me their unequivocal support throughout, as always.

I would like to thank my wonderful husband, Wassim Aldebeyan, for his sustained, long distance support and great patience at all times. My great appreciation goes to my lovely son, Ahmad, for gently lightening the intensity of academic study.

Last but not least, I would like to dedicate this thesis to my parents; to my father, Abdulrahman Abouammoh, the most hard working man I know, for providing me with continuous feedback and emotional and practical support, and my mother, Mona Alruzaig, for taking care of me and Ahmad when I most needed it. My mere expression of thanks likewise does not suffice.



Around 80% of the physicians working in Saudi Arabia providing primary health care are international medical graduates from other countries. They may not share their patients’ cultural background or language, yet are expected to deal with local patients with chronic health conditions, such as type 2 diabetes mellitus, who need culturally sensitive lifestyle advice.

Study aim

To explore and understand challenges and facilitators to effective communication between international medical graduates and patients with type 2 diabetes mellitus and how this may influence care provision in Saudi Arabia.


Data were collected in three phases: i) A focus group discussion with 6 international medical graduates from one hospital and 13 semi-structured interviews with international medical graduates from the hospital as well as 8 primary health care centres. ii) Semi-structured interviews with 16 Saudi patients with type 2 diabetes mellitus and iii) follow-up interviews with 5 international medical graduates. Data were analyzed with the aid of NVivo using thematic analysis.


Most of the international medical graduate participants reported that dealing with local patients was challenging because patients did not trust them for culturally-related reasons. Prejudice among local patients towards international medical graduates was identified, and this contributed to patients not acknowledging international medical graduates’ ability to provide culturally sensitive advice. Furthermore, some international medical graduates had a stereotypical view of local patients, which had led to an inflexible approach when advising patients. Both groups of participants identified contrasting expectations regarding relationship-building style. Participants also identified self-adopted strategies to overcome communication barriers and suggested new ones.


Findings suggest that efforts need to be targeted towards changing patient attitudes, as well as addressing the training needs of international medical graduates, in order to enhance the effectiveness of diabetes management and improve overall the delivery of health care in Saudi Arabia.

List of Abbreviations


Cultural development model


Cultural diversity and universality theory


General practitioner


International Diabetes Federation


International medical graduate


King Khalid University Hospital


The Ministry of Health


National Health Service


National Institute for Health and Care Excellence


Primary health care centre


Purnell model for cultural competence


Quality of life


Randomised controlled trials


Saudi Arabia


Saudi Commission for Health Specialisties


Shared decision making


Saudi Licensing Exam


Type I diabetes mellitus


Type II diabetes mellitus


United Kingdom


United States


World Health Organization

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