Noura A. Abouammoh

5.5.4 Phase 1

5.5.4.1 Sampling and recruiting IMGs

5.5.4.1a Hospital-based IMGs

IMGs from the hospital were invited to a focus group discussion by email. The information sheet and consent form (Appendix 7 and 8) were attached to the emails sent, which were circulated on behalf of the researcher by the secretary of the Department of Family Medicine to all IMG family physicians who were available during the recruitment period. The information sheets provided described the aims and objectives of the study as well as explicitly stating, both that participation was voluntary, and that a potential participant’s decision regarding whether to participate or not would not affect their work.

Purposive sampling was used to ensure a wide range of characteristics was represented in the group. Characteristics included different age groups (<40 and >40), gender, and length of experience in SA. IMGs were invited to participate if they had at least two years’ experience of working in SA to ensure a reasonable amount of interaction with Saudi patients.

Sufficient time was given to the participants to read and understand the information sheet and to decide whether to participate. IMGs from the KKUH were explicitly asked to be involved in a focus group discussion where other IMG participants would be present.

IMGs who were interested in participating were asked to contact the researcher by email or by telephone or pass their details to the secretary of the Department of Family Medicine at the KKUH. After one week, the secretary of the department circulated follow-up emails to those physicians who had not responded. The researcher, then, approached IMGs personally to talk about the research.

Twenty-one of the total of 28 family physicians working at the KKUH were IMGs, of whom seventeen IMGs were available in July 2012. The IMGs who were available were invited by email through the department secretary with a view to bringing together 10 – 15 participants. This range of participants was chosen as it would be manageable for the researcher and at the same time could allow variations in responses. The researcher visited the clinic twice and re-invited the IMGs who were available at the time of her visits.

5.5.4.1.b Community-based primary health care IMGs

The researcher was asked by all the recruited PHCCs’ managers to personally approach the IMGs. The researcher visited each clinic to develop a rapport with the IMGs who were interested in participating. The researcher provided the IMGs at the PHCCs with information sheets (Appendix 9). IMGs were asked by the researcher to contact her by telephone or email if they agreed to participate after they were handed the information sheet. The researcher re-visited the same PHCCs after one week to remind the IMGs about the study, answer their questions and arrange interview times. Potential participants were offered a choice of face-to-face interview or telephone interview.

It was intended to recruit approximately 7 – 10 IMGs from PHCCs in the two different socio-economic levels. Flexibility was allowed to decrease or increase the sample size according to data saturation.

As with the focus group, purposive sampling was used to ensure maximum diversity. IMG participants differed in terms of gender, age and years of experience.

5.5.4.2 Data collection

5.5.4.2.a Focus group with hospital-based IMGs

Physicians from the hospital who had agreed to participate were invited to a focus group discussion that was led by the researcher. Consent forms were signed and demographic data were collected at the beginning of the focus group (Appendices 8 and 10).

Before obtaining any written consent, participants were asked whether they had read and understood the purpose of the study and what it entailed. They were also asked if they had any queries concerning their participation.

The focus group discussion was recorded using a small Dictaphone and it was conducted in English. It was explained to the participants that they had the right to ask the researcher to stop the recording before the focus group discussion or at any time during its progress.

The focus group took place in the Family Medicine Department’s seminar room and lasted 65 minutes. Before starting the discussion, it was made clear to the IMGs that their withdrawal from the study was allowed at anytime without any implications for their work.

To avoid distractions during the discussion, the researcher arranged with a fourth year medical student to handle late arrivals, collect the forms and take notes.

As two IMGs were happy to participate, yet not available at the time of the focus group, they were individually interviewed using the topic guide used to guide the focus group discussion (Appendix 11).

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

Interviews with the community-based IMGs took place at the PHCCs they worked at, or by telephone. Each interview started with obtaining demographic information about age, gender, nationality, and years of working in SA (Appendix 10).

Interviews followed a topic guide (Appendix 12), and were conducted in English for non-Arabic speaking IMGs. The Arabic-speaking IMGs were given the choice of English or Arabic and all preferred to be interviewed in Arabic. For culture-related reasons, only female IMGs from the PHCCs, and female patients, were asked to choose the place in which they were comfortable with being interviewed.

The length of the interviews ranged from 35 – 55 minutes. The researcher sought agreement from the IMGs about the feasibility of re-contacting them for another interview, should the need arise.

Field notes were taken by the researcher during and after each interview to enable reflection and support data analysis (Legard et al., 2003).

5.5.4.3 Topic guide

Topic guides for this study were developed based on the topic guides of previous, similar studies (see section 3.3.1) (Dorgan et al., 2009; Díaz and Hjörleifsson, 2011; Jain and Krieger, 2011), and amended according to the research questions for this project. The topic guide for the focus group discussion covered IMGs’ perceived roles in caring for patients with T2DM, challenges to providing care and suggestions to support their contribution in caring for Saudi patients in particular (Appendix 11). The focus group discussion helped identify key issues, which fed into the topic guide for individual interviews.

Topic guides for the semi-structured interviews with IMGs covered these issues in more detail (Appendix 12) focusing on areas such as how IMGs provide advice to T2DM patients, what their views on providing care to Saudi patients, and the challenges and facilitators to effective communication. The topic guide was designed in a vignette style to facilitate discussion by encouraging participants to talk about experiences, opinions and attitudes, and to express their feelings in a non-judgmental setting (Johnson et al., 2006, Greenhalgh et al., 1998). The vignette referred to fictitious characters, namely Dr. Afzal as an IMG and Mr. Ahmad as his patient (Appendix 12). Females’ names, Dr. Sonia and Mrs. Aisha, were used when interviewing female participants.