Noura A. Abouammoh

Table of Contents

Abstract 5

Background 5

Study aim 5

Methods 5

Findings 6

Conclusion 6

List of Abbreviations 7

List of Tables 10

List of Figures 12

Preface 14

Introduction 16

Chapter 1 20

Background 20

1.0Introduction 20

1.1 The Kingdom of Saudi Arabia 21

1.2 An overview of the general lifestyle among Saudi people 22

1.2.1 Dietary customs 22

1.2.2 Physical exercise 24

1.2.3 Alternative medicine 24

1.3 Diabetes and its management 26

1.3.1 Type 2 diabetes 27

1.3.2 Burden of type 2 diabetes 28

1.3.3 Type 2 diabetes management 28

1.3.4 Caring for patients with diabetes 29

1.3.5 Prevalence of diabetes in Saudi Arabia 30

1.4 An overview of the health care system in Saudi Arabia 31

1.5 IMGs in Saudi Arabia 33

1.5.1 The general situation of the IMGs in Saudi Arabia 34

1.5.2 IMGs in the primary health care centres 35

1.5.3 IMGs’ eligibility to work in SA 36

1.6 Summary 37

Chapter 2 38

History, definitions and models of cultural competence 38

2.0 Introduction 38

2.1 Search strategy 39

2.2 The origin of cultural competence 39

2.3 Definitions of cultural competence 43

2.4 Historical overview and critique of cultural competence theoretical models 46

2.5 Cultural competence and patient-centred care 52

2.6 Summary 55

Chapter 3 58

Literature review 58

3.0 Introduction 58

3.1 Search strategy for the literature reviews 59

3.1.1 Cultural competence training and quality of care 59

3.1.2 Cultural similarities and workforce diversity 60

3.1.3 Cultural competence in SA 61

3.2 The effectiveness of cultural competence training in terms of quality of care 61

3.2.1 Cultural competence and quality of healthcare 62

3.3 Cultural similarity and workforce diversity 66

3.3.1 Cultural competence among an ethnic minority workforce 68

3.3.1.1 Cultural issues in the IMG-patient medical encounter 68

3.3.1.2 Rapport and emotional support 71

3.3.1.3 Patient- physician power dynamic 72

3.3.1.4 Patient satisfaction and trust 74

3.3.1.5 Prejudice towards IMGs 75

3.3.1.6 Language barrier in the IMG-patient medical encounter 76

3.4 Cultural competence in Saudi Arabia 77

3.4.1 Saudi based literature in regards to cultural competence 78

3.5 Summary 82

Chapter 4 84

Scope of the study 84

4.0Introduction 84

4.1 Study Rationale 85

4.2 Research questions: 87

4.3 Study aim 87

4.4 Study objectives: 87

Chapter 5 90

Methods 90

5.0 Introduction 90

5.1 Research perspective 91

5.1.1 Techniques of qualitative data collection in the current study 93

5.1.1.1 Focus group discussion 93

5.1.1.2 Semi-structured interviews 95

5.1.1.3 The approach of this study 96

5.2 Topic guides 98

5.3 The role of the researcher in qualitative research 99

5.4 Transcription and translation 99

5.5 Methods 100

5.5.1 Ethical approval 100

5.5.2 Study design 100

5.5.3 Study Settings 101

5.5.3.1 King Khalid University Hospital 101

5.5.3.2 Primary Health Care Centres 102

5.5.4 Phase 1 104

5.5.4.1 Sampling and recruiting IMGs 104

5.5.4.1a Hospital-based IMGs 104

5.5.4.1.b Community-based primary health care IMGs 106

5.5.4.2 Data collection 106

5.5.4.2.a Focus group with hospital-based IMGs 106

5.5.4.2.b Semi-structured interviews with community-based PHCCs’ IMGs 107

5.5.4.3 Topic guide 108

5.5.5 Phase 2 109

5.5.5.1 Sampling and recruiting patients 109

5.5.5.2 Data collection 110

5.5.5.3 Topic guide 111

5.5.6 Phase 3 111

5.5.6.1 Follow-up interviews 111

5.5.6.2 Topic guide 111

5.6 Data analysis 112

5.7 Challenges to the research 114

5.7.1 Ethical issues 114

5.7.2 Challenges during recruitment and data collection 116

5.7.3 Translation and transcription 117

5.7.3.1 Back-translation 119

5.8 Evaluating the qualitative research 119

5.8.1 Credibility 119

5.8.2 Transferability 120

5.8.3 Dependability 121

5.8.4 Confirmability 121

5.9 Summary 123

Chapter 6 125

Findings of the study 125

6.0 Introduction 125

6.1 Descriptive Data 126

6.1.1 IMG characteristics 126

6.1.2 Patient characteristics 128

6.2 Language as a barrier to communication 130

6.2.1 An overview of language in medical encounters in Saudi Arabia 130

6.3 Interaction and rapport-building in cross-cultural medical encounters 133

6.3.1 Rapport-building and quality of care provision 134

6.3.1.1 Patients’ information disclosure 136

6.3.2 Different expectations between IMGs and patients 137

6.3.2.1 Shared decision making 139

6.3.3 Patient-physician power dynamic 141

6.3.4 Prejudice in medical interactions 143

6.3.4.1 Racial stereotyping 145

6.3.4.2 Positive stereotyping 148

6.3.4.3 Handling prejudice in the medical encounter 150

6.3.5 The influence of coping with cultural challenges on care provision 154

6.3.6 Summary 155

6.4 Providing culturally sensitive lifestyle advice 156

6.4.1 Awareness of the local habits and customs 157

6.4.1.1 Local diet and eating habits 157

6.4.1.2 Physical exercise 162

6.4.1.3 Traditional medicine 164

6.4.2 Patients’ attitude to IMGs’ advice 166

6.4.3 IMGs’ approaches to advising patients 167

6.4.3.1 The effect of IMGs’ stereotypical views towards patients on the provision of lifestyle advice 172

6.4.4 Summary 174

6.5 Practical strategies used by IMGs and patients to facilitate communication 176

6.5.1 Adopted strategies to overcome barriers to effective IMG-patient communication 177

6.5.1.1 Communicating in a common language 177

6.5.1.2 Non-verbal communication 178

6.5.1.3 Written information 180

6.5.1.4 Social conversations 182

6.5.1.5 Using religious expressions 185

6.5.1.6 Reliance on other health care professionals 187

6.5.2 Suggested strategies to facilitate IMG-patient interaction 188

6.5.2.1 Using interpreters 188

6.5.2.2 Courses in language and culture 191

6.5.2.3 Sharing experiences 194

6.5.2.4 Involving PHCCs’ administrators 195

6.5.3 Summary 196

Chapter 7 198

Discussion 198

7.0 Introduction 198

7.1 Key findings in relation to the research questions 200

7.2 Discussion of findings in relation to previous research 202

7.2.1 IMGs’ language and cultural competency 202

7.2.2 Patients’ attitude towards IMGs 205

7.2.3 The effect of prejudice on care provision 208

7.2.4 Strategies to overcome language and cultural barriers 213

7.2.5 Support system 215

7.2.6 Summary of the main findings 217

7.3. Strengths and limitations of the study 218

7.3.1 Strengths of the study 218

7.3.2 Limitations 219

7.4 Implications for policy and practice 222

7.4.1 Dissemination strategy 222

7.4.2 Patient education and information 224

7.4.3 IMG training 225

7.4.4 Support structure 226

7.5 Future research 227

7.6 Conclusion 228

References 230

Appendices 251

Appendix 1 Prisma Chart: Effectiveness of cultural competence interventions 252

Identification 252

Screening 252

Eligibility 252

Included 252

Appendix 2 Prisma Chart: Cultural similarity and workforce diversity 253

Identification 253

Screening 253

Eligibility 253

Included 253

Appendix 3 ScHARR Ethics Approval 254

Appendix 4 MOH Institutional Review Board Approval 255

Appendix 5 NIH Course Result 256

Appendix 6 KKUH Approval 257

Appendix 7 Information Sheet for Physicians (focus group) 258

Appendix 8 Consent Form for Physicians 262

Appendix 9 Information Sheet for Physicians (semi-structured interviews) 263

Appendix 10 Demographic Information: physician participants 266

Appendix 11 Topic Guide for Physicians (focus group) 267

Appendix 12 Topic Guide for Physicians (semi-structured interviews) 268

Appendix 13 Topic Guide for Patient Interviews 270

Appendix 14 Interview Schedule for Follow-up Interviews 272

Appendix 15 Information Sheet for Patients (Arabic) 274

Appendix 16 Consent Form for Patients (Arabic) 276

Appendix 17 Information Sheet for Patients 277

Appendix 18 Consent Form for Patients 280

Appendix 19 Demographic Information: patient participants 280

Appendix 20 Deriving a Theme 281