Noura A. Abouammoh

5.2 Topic guides

Semi-structured interviews and focus group discussions consist of a schedule of open-ended questions to guide interviewers through the issues under investigation. Prompts are then used in order to elicit more detail and these might diverge according to the responses given during the interview (Britten, 1995, Bryman, 2008). Probing responses of the interviewee offers understanding beyond that of superficial questioning (Legard et al., 2003). Examples of probing include, “How did you feel about that” /”Can you tell me more about that” and so on. The current study used topic guides that were based on the key themes arising from the literature which were relevant to the research questions. This created a systematic flow and allowed spontaneity in questioning, with the researcher prepared to alter the order and sometimes the wording of questions to follow the emerging ideas during the actual interview (Arthur and Nazroo, 2003). The topic guide ended with an open question to enable areas that were not anticipated from previously researched IMGs’ experiences as described in the published literature.

5.3 The role of the researcher in qualitative research

As mentioned in 5.1, the researcher’s role in qualitative research is understanding how people give meaning to reality through interaction (Guba and Lincoln, 1994). Green & Thorogood (2004) have suggested that there are two types of perspectives that may influence the findings produced as a result of qualitative research. The emic perspective, or the insiders’ standpoint, is when the researcher is a member of the culture or the group and hence is familiar with the culture being studied. In contrast, the etic perspective, or the outsiders’ standpoint, is when the researcher is not familiar with or not a member of the culture under investigation. If the researcher is part of the culture under investigation, he or she may be able to bring more knowledge, as they are more familiar with expressions, sentiments, ways to communicate and establishing rapport (Green and Thorogood, 2014). At the same time, being an outsider may enable the researcher to look at participants’ experiences with a fresh pair of eyes without preconceived assumptions. More specific issues in regards to researcher’s reflexivity is discussed later in this chapter (see section 5.8.4)

5.4 Transcription and translation

People who speak different languages perceive and interpret the world differently (van Nes et al., 2010, Temple and Young, 2004, Tsai et al., 2004). Furthermore, the evidence for the experiences discussed, gathered from the interviews, is indirect evidence. This means, for example, that this evidence does not feature the interviewees’ own words, but the ideas, thoughts and meanings of people’s accounts, which are produced in the form of texts (Polkinghorne, 2005). Studying human experiences is a challenging area, as experiences are usually multi-layered and complex (Polkinghorne, 2005). Translation can add to the complexity of producing valid findings. As data in this study were collected from patients and Arabic-speaking IMGs in Arabic and were translated to produce findings in English, the preservation of meanings originating from the data in the source language could be at risk (van Nes et al., 2010). Issues that arose during the transcription and translation of data in the current study are presented later in this chapter (see section 5.7.3).

5.5 Methods

5.5.1 Ethical approval

Before recruitment and data collection, ethical approval was obtained from the School of Health and Related Research (ScHARR) Ethics Committee and the Saudi Ministry of Health Institutional Review Board (Appendices 3 and 4). The researcher passed a web-based training course “Protecting Human Research Participants” in order for the application to be approved by the MOH (Appendix 5). A letter of approval was obtained from the Head of the Family Medicine Department at the King Khalid University Hospital (KKUH) to conduct the focus group and approach patients from the hospital (Appendix 6).

5.5.2 Study design

The qualitative research design included three main phases (Figure 5.1):

Phase 1: This encompassed two methods of data collection:

1. 
   Focus group discussion with IMG family physicians from hospital-based primary healthcare clinics.
   
2. 
   Semi-structured interviews with IMGs from community-based PHCCs.
   

Phase 2: This encompassed:

1. 
   Semi-structured interviews with Saudi patients with T2DM attending community or hospital-based primary health care clinics.
   

Phase 3: Encompassed:

1. 
   Further follow-up interviews with IMGs.
   

Focus group discussion with hospital-based physicians

Interviews with community-based physicians

Develop topic guide for patient interviews

Identify initial key issues and develop topic guide for interviews

Responses need further exploration by physicians

Responses fully explored

Phase 1

Phase 2

Interviews with patients from hospital and community clinics

Follow-up interviews

Phase 3



Figure 5.1 Overview of the research process

An iterative approach was adopted to allow each stage to inform the next.

The focus group and the semi-structured interviews were conducted over a period of nine months in 2012/2013. An additional month was needed to conduct the follow-up interviews.

5.5.3 Study Settings

This study was conducted in the capital city of SA, Riyadh. It is located in the central region and is one of the biggest multicultural cities in the country.

5.5.3.1 King Khalid University Hospital

The KKUH was specifically selected for the study because most family physicians in this hospital are non-Saudi IMGs. It is a secondary care hospital that serves a large segment of the population, including patients from a range of socio-economic circumstances. Furthermore, the KKUH was chosen for practical reasons, which include the researcher’s familiarity with the hospital and its systems.

The primary healthcare clinics at the hospital are located in a new building, which also houses clinics dealing with other specialised areas of medicine. The hospital and the University staff are seen, as patients, in another two different clinics within the same building. The same physicians are working in rotation around the three different clinics. Male and female waiting areas are on different sides of the building, although they are close to each other. Male physicians treat male patients, and female physicians treat female patients. In case of a shortage of female physicians, male physicians are allowed in the female section to see female patients, however the opposite is not permitted.

Patients who visit the hospital-based clinics do not expect to see the same physician each time they visit the clinic because physicians rotate between clinics on a regular basis.

5.5.3.2 Primary Health Care Centres

The Saudi MOH has already started to standardize the design of all PHCCs. A large number of PHCCs look like the centre shown in figure 5.2.



Figure 5.2 Exterior view of one of the PHCCs in SA
Each centre has two entrances, one for males and another one for females. The two sections are connected from the inside by a window to facilitate exchange of documents. One male manager, working with the help of a female supervisor from the female section, is responsible for each PHCC.

Each PHCC has three to four physicians, depending on the community it serves: a paediatrician and two or three general practitioners. Two different days of the week are specified by each PHCC to see patients with chronic diseases. Additionally, there is one qualified nurse for antenatal care.

The KKUH and the PHCCs provide free services for Saudi nationals and, with some restrictions, to non-Saudi nationals.

If equal distribution of physicians and patients throughout all community-based PHCCs is assumed, then three general practitioners are assigned to each clinic, with each clinic serving approximately 10,000 patients (MOH, 2012). There is no available data regarding socio-economic status. Based on local knowledge, however, different regions can be identified which represent different socio-economic levels. North and East of Riyadh City represent middle to high socio-economic levels and South and West represent lower socio-economic levels.

Community-based PHCCs were recruited according to the socio-economic level of the community they serve: high/middle and low. The clinics were identified from the website of the Saudi MOH by searching clinics by neighbourhood (MOH, 2011). Four clinics from each socio-economic level were selected based on the researcher’s knowledge of the region.

The manager of each clinic was contacted by telephone or personally to explain the study, seek approval and gain information relating to the physicians working at the PHCC. If the manager of the clinic either did not agree to allow the researcher to conduct the study in his PHCC, or did not respond to the researcher’s phone calls, or if no IMGs were found, another PHCC from the same region was contacted (Figure 5.3).

Contact the manager of the community-based primary health care clinic

Agree research

Decline research

End of process

IMG declines research

End of process

Sign informed consent and included in the research

Physicians meeting inclusion criteria

Explain study and invite to participate

Present

Not present

Contact IMGs

IMG agrees
End of process
Figure 5.3 Recruitment and consent process