Noura A. Abouammoh

5.7 Challenges to the research

5.7.1 Ethical issues

All research studies that include human subjects generate ethical concerns. Conducting research that includes understanding people and using their voices and perceptions to generate data requires the researcher to be aware of and account for a number of ethical concerns when conducting qualitative research.

Autonomy, confidentiality and privacy are some issues that create dilemmas when conducting a piece of research that includes human subjects. Informed consent in relation to this research included discussion of the purposes, aims, objectives and potential benefits of the study to the study participants, in order to allow autonomy.

The researcher handled data confidentially. The research findings did not identify any of the PHCCs included in the study. A letter and a number were used to refer to each PHCC. The letter referred to the region in Riyadh from which the centre was selected, for example; N, E, S and W referred to north, east, south and west, respectively. The number referred to its serial number in the study - for example, N1 meant the first PHCC that was included from the northern region.

The research findings did not identify any of the participants who had taken part. Participants were numerically coded and transcripts were anonymised.

As patients were revealing personal information regarding their lifestyle and health, and as both patients and IMGs were sharing their opinions about each other, all the transcripts and records were saved on a password-protected computer and were stored securely in a locked cabinet.

Discussing a patient’s condition and their interactions with IMGs could have raised some sensitive issues. The first was related to the patient’s condition; for example, patients may have revealed non-compliance or misuse of their treatment. The second was related to the relationship with their physicians, for example, not understanding them, in a way that might affect their health. It was proposed that these problems should be dealt with by advising the patient to raise the issue with their physicians or with the manager/ supervisor of the PHCC, according to the nature of their complaints.

Although it was not expected that the questions would cause anxiety or stress, the nature of in-depth questioning can be stressful. Thus, participants were informed of their right to refuse to answer any question and to withdraw from the study at any time without giving any justification.

5.7.2 Challenges during recruitment and data collection

Several challenges arose during the recruitment and data collection process. The time for the focus group discussion was changed twice before it eventually took place in July 2012. During the recruitment of IMGs to the focus group, the researcher experienced difficulty in gathering physicians together at the same time, as they did not prioritise contribution to research projects. For example, two IMGs did not have a clinic on the day of the focus group and they were not willing to come to the hospital just for the sake of the discussion. Having the focus group conducted in the month of Ramadan, when people are fasting, was also a possible drawback.

Face-to-face interviews with IMGs were frequently interrupted by either colleagues from the PHCC or by patients. During some interviews, the researcher had to wait outside the clinic to allow IMGs to pursue their duties and see patients in their clinics. In other PHCCs, the manager and supervisor referred patients to other physicians during the time of the interview.

Nurses helped in the recruitment process by advising the researcher to approach patients whom they identified as eligible. However, the researcher was advised by a nurse to approach a patient, who she later realised had hearing difficulty and thus was impossible to conduct an interview with.

It was noted that physicians, including those who agreed to assist the researcher in contacting hard to reach patients, were not collaborating in this regard and only 4 patients were recruited through their physicians. According to the IMGs, it was difficult for them to identify and select “hard to reach” patients because of the large number of patients they follow. However, they informed the researcher when patients with poor diabetes control came to the clinic so the researcher could approach these patients after they introduce the study to them.

A female patient had to leave before completing the interview, as her husband was not willing to wait until we finished. This was a shortcoming that should have been anticipated as interviews with patients were conducted at the health care premises while they were visiting their physicians.

5.7.3 Translation and transcription

In order to analyse all transcripts in one language, digital audio-recordings were transcribed by the researcher, either in Arabic or in English. She then translated Arabic transcripts into English. The translations were based on conveying meaning, as word-by-word translation from Arabic to English would not have made sense.

Loss of the meaning through translation could have threatened the validity of the study as the collected data went through three phases before it was presented to be read and interpreted by the reader

Interviewer in Arabic

Interpreted and translated by

Interpreted by

Transcribed by

Interviewer to English

Participant in Arabic

Reader in English
Figure 5.4 Transcription and interpretation process of Arabic interviews
Measures to reduce potential loss of meaning were undertaken. It has been argued that in order to preserve the meanings of the interviewees’ accounts, the researcher should adhere to the original language as much as possible before translating it (Temple and Young, 2004). However, in this study, the researcher considered translation as a part of producing the final results of the study. The researcher was the one who collected, translated and interpreted data. She speaks both Arabic and English, and data were collected in the two different languages. For practical reasons, the data needed to be unified, so it was better to translate into the English language at an earlier stage without risking loss of meaning. Furthermore, being transparent about translation issues that were confronted gives readers a better insight into potential loss of meaning through translation.

Interviews in Arabic were translated to English. If there was no exact meaning for one word, the researcher looked for the closest meaning in English. For example, patients used the expression “To God we complain” which is actually used by Saudi people to refer to their helplessness in dealing with their problems. If the researcher had been from a different culture, she might have interpreted this comment as patients’ refusal to open up about their complaint. Furthermore, back-translation was applied to information sheets, consent forms and most of the translated transcripts (see section 5.7.3.1). Audio recordings of the follow-up interviews, which were conducted in Arabic, were transcribed immediately in English.

It should be noted that interviewing physicians of different ethnic backgrounds might have uncovered different approaches to knowledge and experiences that would be described by non-Arabic speakers using English, their second language, and received by the researcher, who also speaks English as a second language. To keep the risk of loss of meaning to a minimum, adequate probing of the issues and the iterative approach of study were applied.

5.7.3.1 Back-translation

Back-translation was needed to ensure transcripts were appropriately translated. Interviews were sent to a professional translation service in Riyadh. Two Sudanese translators worked in the centre. They shared the Arabic language with the researcher and the patient participants, but not the cultural background. However, the researcher was able to assess their translation and convey what she saw as being closer to the real meaning if this had not been achieved.

Going through the back-translated texts helped the researcher to compare texts and point out some of the weak points in her own translation. For example, the researcher used “IMGs” on different occasions where participants actually used “اطباء اجانب” “foreign physicians”, “أطباء وافدين” “expatriate physicians” and “اطباء متعاقدين” “contracted physicians” to refer to IMGs.