Noura A. Abouammoh

List of Tables

Table 1.1	Different characteristics of type 1 and type 2 diabetes mellitus
Table 6.1	IMGs’ characteristics
Table 6.2	Patients’ characteristics

List of Figures

Figure 1.1	Map of the Kingdom of Saudi Arabia
Figure 2.1	Sunrise model
Figure 2.2	Patient-centred interaction model
Figure 2.3	Overlap between patient-centred care and cultural competence at the interpersonal level
Figure 5.1	Overview of the research process
Figure 5.2	Exterior view of one of the PHCCs in SA
Figure 5.3	Recruitment and consent process

Preface

In 2008 I graduated from medical school in Riyadh, Saudi Arabia (SA). During the internship year, I chose to spend two months of training in the Family Medicine specialty at the University hospital, although it was not one of the obligatory rotations that interns were required to do. Throughout that period, I was expected to run a clinic, under the supervision of one of the academic staff who was a family physician.

During that period, I was often asked by international medical graduates (IMGs) to leave my clinic and help them to communicate with the Saudi patients. I was translating and interpreting information between IMGs and patients and sometimes educating patients about their health condition; teaching the IMGs about what was acceptable to do and say to Saudi people and what was not; and writing down some Arabic words for them to memorize. As interpreting services were not available for physicians and patients in this University hospital, and IMGs are not required to speak the Arabic language in order to work in SA, I wondered how IMGs run their clinics when no one is available to assist them.

I undertook my Master’s degree in Sheffield thus, was myself an “international” student. However in my case, the university supported me both academically, by providing academic writing and reading courses free of charge and non-academically, by assigning a personal tutor to assist me with non-academic issues. Additionally, I attended weekly activities that were arranged by the university to help students to interact with other students and get to know the culture. Because the university I attended in the UK recognized the value of developing students’ language competence and cultural knowledge, and provided opportunities for this, I was easily able to complete the purpose of my visit to the UK successfully.

Similarly empowering services are not available to “international” physicians in SA and this fact may influence the purpose of their visit, which includes providing care for local people. A specific interest arose as I recognized that exploring IMGs’ experiences in caring for local patients is an under-researched area.

Introduction

This thesis concerns the exploration of the experiences of IMGs and patients with type 2 diabetes mellitus (T2DM) from one hospital and eight community-based primary health care centres (PHCCs) in Saudi Arabia (SA), using qualitative interviews.
This thesis comprises seven chapters:
Chapter 1: Describes the background of the topic. It introduces the Kingdom of SA where the study was conducted. It gives an overview of the Saudi Arabian health care system and provides background information on the status of IMGs in the country.
Chapter 2: Presents an overview of the evolution of cultural competence in health care. It highlights the history, discusses definitions and presents the key developmental stages of the models of cultural competence. Additionally, it shows the differences between cultural competence and patient-centred care models of communication.
Chapter 3: Critically reviews the research on the effectiveness of cultural competence training on quality of care. This is followed by a review of the literature focusing on IMGs’ and local patients’ experiences and presents the challenges, already identified, as well as facilitators, to effective cross-cultural communication. The final section focuses on Saudi-based research regarding cross-cultural care.
Chapter 4: This chapter presents the study rationale and outlines the key points from the literature review, which helped to focus the current research. It then articulates the research aims and objectives.
Chapter 5: Describes the methodology of the study. It discusses the rationale for using a qualitative methodology for this type of research and the reasoning behind employing focus group and semi-structured interviews as the method of data collection. It recognises anticipated and encountered ethical issues related to this study. The chapter then presents the methods used, including the settings, sampling strategy, sample profile, recruitment, research encounters and discussion of the process of collecting the data. Data analysis is described including the challenges to managing the data and writing them up. The final section of this chapter evaluates the quality of the qualitative study.
Chapter 6: Explores, in detail, the key findings of the study. This chapter includes three sections, each of which explores a different theme. The first section discusses the relationships between IMGs and local patients and the effect of these on care provision. The second section presents the effect of IMG-patient cultural discordance on IMGs’ ability to provide culturally sensitive lifestyle advice. The third section presents strategies used and proposed by IMGs and local patients to facilitate cross-cultural communication.
Chapter 7: In the Discussion chapter, a brief recap of the study is presented in the first section. In the second section, key findings are presented and then situated in terms of the related, relevant literature. The ways in which this study coheres and contrasts with previous research and how it contributes new insights are presented and discussed. The third section evaluates the strengths and limitations of this study before it considers its implications for policy and practice and priorities for future research. The final section forms the conclusion of the thesis.