Noura A. Abouammoh

7.3. Strengths and limitations of the study

This section highlights some of the strengths and limitations of the current study including methodological and cultural challenges.

7.3.1 Strengths of the study

This exploratory study provides a unique contribution to the cultural competency literature and evidence base by being the first to explore IMGs’ experiences in providing care to local patients in SA. It looks at cultural competence from a different angle where physicians are IMGs who are expected to provide care to local patients. The findings of this research have provided rich qualitative data that helps to develop our knowledge of cultural competence among IMGs, which has a direct effect on the quality of care provision.

The current study is unique in that it raised a sensitive topic - the existence of prejudice in medical interaction - and provided an opportunity to explore the underlying reasons for this, IMGs’ feelings about it and its consequences for the quality of health care.

Review papers remain the main source of data in most previous papers published in SA in relation to cultural competence. This is the first study carried out in SA to use in-depth qualitative analysis to explore the relationship between IMGs and their patients from both perspectives.

Quality of care related literature in SA is overwhelmingly drawn from the patients’ perspective and this study addresses this gap by recruiting IMGs as well. Therefore, a further strength of this study has been the fact that IMGs’ voices were represented when they have been previously ignored in quality of care related research.

Telephone interviews helped to include IMGs who were not willing to be interviewed at the health care premises. Although detecting facial expressions, building rapport and having a comfortable setting to speak freely with the interviewer are easier to establish in fact-to-face interviews, the researcher was still able to detect pauses and hesitations. Furthermore, one IMG obviously felt more comfortable when interviewed by phone as he probably thought that the researcher would be less judgmental over his discourse compared to face-to-face interviews. Telephone interviews were completed without any interruption as they were carried out away from health care premises.

7.3.2 Limitations

The findings have been shaped based on Saudi culture, making it difficult to generalize in terms of other cultures. For example, patients’ prejudicial views on IMGs, in SA, were developed based on the situation of expatriate workers who mostly occupy manual jobs. Nonetheless, it is possible to theoretically argue that the results of the current study could be applied to the same or similar cultures such as those in the Arab Gulf Cooperation Countries, which include Kuwait, the United Arab Emirates, Qatar and Oman, because these countries have a similar healthcare system, with a high proportion of care being provided by IMGs to local patients.

7.3.2.1 Methodological challenges

Maximum diversity was achieved with regards to IMGs’ gender, spoken language (Arabic or non-Arabic) and years of experience. Male IMGs were slightly over-represented, as they were more willing to be interviewed.

In order to obtain a better understanding of the issues under investigation, the researcher was interested in including the views of extreme cases. However, the views of “hard to reach” patients, who refrained from seeing their IMGs, were difficult to ascertain, as physicians found it difficult to identify these patients among all the patients registered in the PHCC, and were not cooperative when it came to recruiting them. However, this was compensated to some extent by interviewing patients who were specifically identified by the IMGs as “non-compliant” patients.

The vignette style of interviews is known to facilitate discussion in this type of work, as it uncovers details of participants’ experiences and their views on each other. In some cases during the current study, participants responded at first to the vignette style but with the progress of the interviews, they felt more comfortable providing direct responses concerning their own experiences. On the other hand, most participants found it easier to relate to their own experiences from the beginning of the interview. Thus it was decided during the data collection phase to use more direct questions relating to participants’ experiences.

7.3.2.2 Cultural challenges

The study involved some cultural challenges. For example, being a female researcher interviewing male participants in a conservative culture such as SA, could have discouraged male patients from speaking freely and comfortably. For example, in accordance with cultural norms, Saudi male patients avoided eye contact with the researcher and sometimes preferred to provide concise responses. However, to overcome this limitation, the researcher used appropriate probing questions, started general conversations and referred to the patients using the names they preferred such as “uncle.X” to develop rapport with them. Furthermore, to ease communication and gain the male participants’ respect, the researcher wore a “Niqab” that is a face cover, which only reveals the eyes, when interviewing male participants, to avoid negative views, as in Saudi culture people tend to view women who show their faces critically. The researcher wore a “Abaya”, which is a black, wide traditional clothing women wear when they appear in public in SA, rather than a white lab coat which female professionals are allowed to wear at work places, to give patients a sense of belonging and help them to easily share their perceptions.

Participants’ views on the study, as the researcher would be sharing the findings in the UK, may have limited the number of patient participants. On occasion patients were reluctant to reveal their responses, because of their concerns that a critical view about the quality of care would be shared with the Western world. Thus, they were protective about the reputation of the Saudi health care system and quality of care. For example, one patient who explicitly expressed his negative view about sharing information with “people” from the UK followed each of the undeniable challenges in the cross-cultural medical encounter in SA, such as language, by confirming its existence in the Western world. In contrast, the IMGs were happy to share their views, as they believed in the constructive purpose of the research and, according to them, it was the first time someone was paying attention to their experiences. A small number were hesitant and apologetic about revealing their views as the researcher belonged to their patients’ culture.