patients from the united arab emirates seeking healthcare

PATIENTS FROM THE UNITED ARAB EMIRATES SEEKING

HEALTHCARE SERVICES OVERSEAS DURING 2009 – 2016:

CHARACTERISTICS, MOTIVATIONAL FACTORS AND PREFERENCES

by

Wafa Alnakhi, MSc

A dissertation submitted to Johns Hopkins University in conformity with the requirement for the

degree of Doctor of Public Health

May 15th, 2018

©Wafa Alnakhi 2018

All rights reserved

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Abstract

Background

Each year the Dubai Health Authority pays an average total expenditure of $771 million

dollars to cover on average 15002 UAE nationals seeking healthcare services overseas. There is

not enough evidence base, however, to guide patients in their decision making for choosing

treatment destinations (V. A. Crooks et al., 2013; Turner, 2011).

Purpose

The objectives of this study are to: 1. Examine the factors associated with treatment

destinations and total number of trips among patients treated overseas from the United Arab

Emirates sponsored by the DHA during 2009-2016. 2. Explore patients’ characteristics and the

motivational factors for choosing treatment destinations among the patients treated overseas from

the UAE during 2009 – 2012. 3 Explore associations between patient characteristics and

preferences for healthcare services if the treatment is made available in the UAE for the most

common conditions among patients treated overseas from the UAE during 2009 - 2012.

Methods

Secondary analysis from DHA: 1- UAE national patients who sought medical treatment

abroad sponsored by DHA during 2009 – 2016. 2- Knowledge Attitudes and Perceptions Survey

from Dubai Health Authority related to medical treatment overseas among residents of Dubai

with at least one family member who had experienced healthcare overseas during 2009-2012.

1 Average total expenditure for overseas treated patients during 2004 - 2016 2 Average number of overseas treated patients during 2004 - 2016

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Results

Choosing the treatment was associated with age, travel season, and medical specialty. The

total number of trips was associated with age, travel season, number of years being in the data set

and the medical specialty for which the patient sought treatment. The treatment destination was

associated with patient medical conditions and financial factors. Patient preferences were

associated with medical condition, age, financial factors, and family member responses if the

family member was answering on behalf of the patient.

Conclusions

This study contributes to the current knowledge related to medical travel. Findings may

help inform upstream policies aimed at regulating overseas treatment strategies at the Dubai Health

Authority.

Dissertation Readers:

Laura Morlock, PhD

Darrell J. Gaskin, PhD

Jodi Beth Segal, MD

Kevin Frick, PhD

Altijani H. Hussin. MA

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Acknowledgement

I want to thank, Dr. Wasif Alam and Dr. Eldaw Suliman, my workplace supervisors for

pushing me to apply to JHSPH; especially, Dr. Eldaw, who also guided me along the way to specify

my research questions to serve the government’s need. I like to acknowledge my workplace, Dubai

Health Authority and all its departments who provided me with the data for my first manuscript;

and Dubai Statistic Center for providing me with the Knowledge, Attitudes and Perceptions Survey

data for my second and third manuscripts. My sincere appreciation to all the faculty at JHSPH; I

applied many of the knowledge and skills that I have learned from their courses to this research

and I have become good friends with many of them. I also would like to thank all of the staff at

JHSPH; from the security guards who protected us on the streets of Baltimore to all administrative

assistants at the school who made our life so much easier as international students.

I am both professionally and personally indebted to all my friends, colleagues and

companions who sported me along the way. Special thanks to the following people who helped

me with data management and organizing my thoughts when writing my manuscripts: Knar

Sagherian, Youssef Farag, Omamah Alfarisi, and Nabil Natafgi. I am especially grateful for my

incredible family and friends in UAE, who have supported me and prayed for me to finish this

journey successfully and return home safely.

I want to acknowledge and send my sincere gratitude to my committee members. Dr. Jodi

Segal and Dr. Darrell Gaskin, whose courses provided me with a wealth of knowledge that I was

able to directly apply to my research. Dr. Kevin Frick, who always challenged me with questions,

and his door was always open to give me feedback to help me think like an economist and a

researcher. I am also lucky to have a great colleague from Dubai Health Authority be relocated

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here in the USA to be part of my committee, Mr. Altijani who has been very supportive and

encouraging.

I owe my success of finishing this work successfully to two women. My mother, who didn’t

get the chance to go to school and be educated. She can’t read and write, but always encouraged

me to be the best version of myself and to always continue learning to be the best I can be. My

advisor, Dr. Laura Morlock, who embraced me in her program and gave me all the support I needed

to accomplish this work. She believed in me and the idea that I can make a difference and bring

change to my country. At last, I am thankful to all the people in my life, who helped me finish this

journey successfully.

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Contents Abstract ........................................................................................................................................................ ii

Acknowledgement ...................................................................................................................................... iv

Introduction ................................................................................................................................................. 2

Background .............................................................................................................................................. 2

Problem Statement ................................................................................................................................... 2

Definition of Medical Travel ................................................................................................................... 4

Research on Medical Travel .................................................................................................................... 6

Conceptual Framework ......................................................................................................................... 11

Dissertation Organization ...................................................................................................................... 14

CHAPTER TWO: MANUSCRIPT ONE ............................................................................................... 15

Introduction ........................................................................................................................................... 16

Methods .................................................................................................................................................. 17

Data Source, Study Design, Variables and Measures ........................................................................ 18

Statistical Analysis ................................................................................................................................ 19

Results .................................................................................................................................................... 20

Discussion .............................................................................................................................................. 24

Conclusion ............................................................................................................................................. 29

Tables and Figures ................................................................................................................................ 31

CHAPTER THREE: MANUSCRIPT TWO .......................................................................................... 42

Introduction ........................................................................................................................................... 43

Methods .................................................................................................................................................. 44

Data Source and Study Design ............................................................................................................. 44

The Knowledge, Attitudes and Perceptions (KAP) Survey ............................................................... 46

Variables & Measures .......................................................................................................................... 49


Results .................................................................................................................................................... 58

Discussion .............................................................................................................................................. 65

Conclusion ............................................................................................................................................. 72

Tables ..................................................................................................................................................... 73

CHAPTER FOUR: MANUSCRIPT THREE ........................................................................................ 87

Introduction ........................................................................................................................................... 88

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Methods .................................................................................................................................................. 90

Data source and study design ............................................................................................................... 90

Variables and Measures ....................................................................................................................... 90


Results .................................................................................................................................................... 95

Discussion ............................................................................................................................................ 110

Conclusion ........................................................................................................................................... 115

Tables ................................................................................................................................................... 116

CHAPTER FIVE: SUMMARY AND CONCLUSIONS ..................................................................... 123

Summary Findings Manuscript One ................................................................................................. 124

Summary Findings Manuscript Two ................................................................................................ 125

Summary Findings Manuscript Three .............................................................................................. 126

Policy Implications .............................................................................................................................. 128

Strengths and limitations ................................................................................................................... 132

Priorities for future studies ................................................................................................................ 134

Longitudinal Studies ........................................................................................................................ 134

Validity and Reliability Testing Research ....................................................................................... 135

Qualitative and Mixed Method Studies ........................................................................................... 135

Cross Sectional Studies .................................................................................................................... 136

Economic Studies with Larger Sample Sizes .................................................................................. 137

APPENDICES ......................................................................................................................................... 139

Appendix for Manuscript One ........................................................................................................... 140

Appendix for Manuscript Two .......................................................................................................... 156

Appendix for Manuscript Three ........................................................................................................ 172

Copy of the Knowledge, Attitudes and Perceptions Survey ................................................................ 225

References ................................................................................................................................................ 254

Curriculum Vitae .................................................................................................................................... 261

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CHAPTER ONE: INTRODUCTION

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Introduction

Background

The United Arab Emirates (UAE) is a country that is located in the Middle East, bordered

by the Kingdom of Saudi Arabia and Oman. The UAE is a federation of seven emirates and Abu-

Dhabi is the capital with a population of 9.1 million (Agency, 2018). There are three main entities

that oversee healthcare in the UAE. The Department of Health Abu Dhabi is the government health

authority that oversees the healthcare delivery system in the Emirate of Abu-Dhabi only (Abu-

Dhabi, 2018). The Dubai Health Authority (DHA) is the government health authority that oversees

the healthcare delivery system in the Emirate of Dubai only (Authority, 2018). The Ministry of

Health (MOH) is the federal health authority that oversees the healthcare delivery system in the

northern Emirates (Prevention, 2018). By government law, all UAE nationals are provided

healthcare at no charge to them in the government sector whether it is in HAAD, or DHA or MOH

and regardless of where they reside. In addition to providing healthcare services in the Emirate of

Dubai, other main responsibilities of the DHA are to serve as a licenser and a regulator of the

medical professionals and facilities, and to ensure the alignment of the private healthcare sector

with the policies and strategies for healthcare in the Emirate.

Problem Statement

Although the government in the UAE provides “free” healthcare services to UAE nationals

in order for them to access primary and tertiary healthcare facilities as per the government law,

there are a number of patients who travel seeking healthcare outside the UAE under different

sponsorships (Dubai Health Authority Annual Statistic Books, 2016). Despite that the DHA states

they are providing good healthcare services, the UAE nationals are still seeking healthcare services

overseas. The total number of UAE nationals seeking healthcare overseas is not accurately

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calculated since there are many entities in the UAE that fund UAE nationals for their treatment

overseas in addition to the government health authorities. The number of medical travelers is

scattered among those entities; in addition, there are patients who pay out of their pockets.

Currently, there is no Emirate level or federal registry or a surveillance system that captures the

number of medical travelers from either the Emirate of Dubai or in the UAE. (Aw, 2010; Blair &

Sharif, 2012; Mokdad et al., 2014; Rahim et al., 2014)

Although there are some statistics that are published on the DHA website for the patients

who travelled through the support of the DHA, the data are incomplete regarding the numbers of

UAE nationals who travel overseas and their associated expenditures. The average total

expenditures per year for overseas treated patients in the Emirate of Dubai according to the DHA

from the year 2004 to the year 2016 was approximately 283.5 million UAE dirham, which is

approximately $77 million US dollars per year3. According to the DHA Annual Statistics Books,

the most common destinations that patients traveled to are the UK, Germany, USA, India, and

Thailand. The specialties that traveling patients sought overseas included the following: General

Medical, Surgery, Obstetrics and Gynecology, Fertility, Urology, Nephrology, Neurology, Neuro-

surgery, Orthopedics, Cardiology, Ophthalmology, Pediatrics and Pediatric Surgery, Neonatology,

Ear, Nose and Throat, Oncology, Dermatology, Gastroenterology, Dental and Dental Oral Surgery,

Hematology, Rheumatology, Endocrinology, Plastic Surgery, Vascular Surgery, Psychiatry,

Physiotherapy, Rehabilitation, and Genetic services.

The DHA began calculating on a yearly basis starting in 2004 the expenditures associated

with the number of patients and their escorts in the Emirate of Dubai seeking healthcare abroad.

In addition, the DHA has listed the breakdown of expenditures for the overseas treated patients by

3 AED * 0.27 = USD

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destination but not per patient. The expenditure categories for the overseas treatment includes:

medical expenditures, cash given to patients, transportation expenses, reimbursement for salary,

accommodation expenses, tickets to the treatment destination and other expenses. Until 2009 no

one investigated the reasons why UAE nationals traveled abroad instead of utilizing healthcare

services in Dubai or in other areas of the UAE. In 2009 DHA thought seriously of exploring the

reasons for overseas treatment by creating a Knowledge, Attitudes and Perceptions (KAP) survey

in collaboration with the Dubai Statistics Center. The DHA believes that exploring the knowledge,

attitudes and perceptions related to treatment abroad among the UAE population will help in

understanding the motivational factors and patients’ preferences when traveling abroad for health

care services (Farrokhi, 2012; K. Ruggeri et al., 2015). This study is examining the characteristics

of patients who travelled overseas seeking healthcare services who were sponsored by the Dubai

Health Authority, and is analyzing results from the knowledge, attitudes and perceptions survey

that was designed and administered by the Dubai Health Authority and the Dubai Statistics Center

during 2009-2012.

Definition of Medical Travel

Travelling internationally to obtain healthcare services is becoming an increasingly

common phenomena and is rapidly growing in the world economy (Burkett, 2007; Chanda, 2002;

Eissler & Casken, 2013; Forgione & Smith, 2007; Henson, 2015; P. C. a. F. Smith, D.A., 2007).

The term “medical tourism” it is not clearly defined. People tend to refer to all patients seeking

healthcare overseas as medical tourists, a practice which is not necessarily helpful. It is important

to differentiate between medical tourism and seeking healthcare overseas as those two terms can’t

be used interchangeably (Balaban, 2010) . According to the literature review, there are five main

components used to precisely define the phenomena of seeking healthcare overseas. The five

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components are: 1-patient mobility, 2-legality, 3-payment type, 4- complexity, and 5-flow

directions. To start with patients’ mobility, there are five categories that come under this concept:

(1) “Temporary visitors abroad” who include people holidaying abroad who use the healthcare

services for accidents or illness; (2) “Long Term Residents” or in other words, retirement

migration; (3) “Common Borders” which describes countries sharing common borders that may

collaborate in providing healthcare services; (4) “Outsourced Patients” which include people sent

abroad through health agencies with purchasing agreements driven by long waiting times,

specialties not available in home country or even to avoid high costs; and (5) “Medical Tourists”

who are patients mobile through their own volition (N. Lunt & Carrera, 2010).

From a regulatory and legal perspective seeking healthcare abroad can also be divided

into three legal categories. The first type is when the treatment is legal and ethical in both countries,

the home country of the patient and in the destination country. The second type is when the

treatment is not legal in the home country of the patient but legal in the country of destination. The

third type is when the treatment is illegal in both countries but it can be accessible and less

regulated in the country of destination (I.G. Cohen, 2012; I. Glenn Cohen, 2014).

Seeking healthcare abroad is further described by the patients’ medical conditions and

complexity levels. This definition is based on the severity and the complexity of the conditions.

The conditions that people travel for who are seeking healthcare are classified into three categories:

patients who travel seeking diagnosis and treatment for life-threatening conditions such as organ

transplants and heart surgery; serious but not life threatening conditions such as hip replacement

and gastric bypass; and medically optional conditions such as cosmetic procedures and plastic

surgery. Other authors have classified care sought as complex surgeries, elective surgeries and

preventive surgeries. Severity is also referenced in other literature as “Medical Tourism” in which

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the person is travelling and crossing the borders for the enhancement or restoration of the

individual’s health through medical intervention, or “Health Tourism” which involves travel

seeking maintenance, enhancement or restoration of individual wellbeing in mind and body

(Carrera & Bridges, 2006; Henson, 2015; Menvielle, 2011). Payment type is another component

used when defining seeking healthcare abroad which involves whether patients are paying from

their own pockets or are covered by private insurance or government coverage (I. Glenn Cohen,

2014). Another distinction used when defining seeking healthcare abroad is the flow direction

which has four different types: 1- from high income country to high income country. 2- from high

income country to low income country. 3- from low income country to high income country. 4-

from low income country to low income country (I. Glenn Cohen, 2014; Horowitz & Rosensweig,

2007; Horowitz, Rosensweig, & Jones, 2007).

Research on Medical Travel

There have not been enough empirical studies in the field of travel for the purpose of

seeking healthcare to estimate the magnitude and to understand the motivational factors (V. A.

Crooks, et al, 2010; Henson, 2015; Heung, 2010; Johnston, Crooks, Snyder, & Kingsbury, 2010;

Reed, 2008). The existence of such information is not only important to understand the

motivational factors but also to understand how people obtain information to make decisions when

seeking healthcare abroad, and to manage the follow-up care after patients return to their home

country (Horowitz & Rosensweig, 2007; Horowitz et al., 2007; E. Yeoh, Othman, K. and Ahmad,

H., 2013). The availability of this information can help governments to create and implement

appropriate strategies for improving the continuity of care (Yu, 2012). Another reason that

studying the field of overseas treatment is important is that different people have different

motivational factors when choosing treatment destinations and healthcare facilities. These

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motivational factors vary based on severity of the patient’s condition as noted previously, prior

international experience, sufficient financial coverage for the medical need, risk aversion,

demographic variables, reputation of the destination country and the quality of healthcare services

offered abroad (Heung, 2010; Horowitz & Rosensweig, 2007; Horowitz et al., 2007; Noree,

Hanefeld, & Smith, 2014). A qualitative study was conducted to look at the motivational factors

at different times before, during and after patient travel for healthcare. In this study, the

motivational factors for patients seeking healthcare abroad were based on the timeline, themes and

sub themes. Patient experience was dissected into three chronological stages of the overseas travel

experience. “Pre-travel” is the stage in which patients are conceptualizing their experience by

describing important events and thoughts that lead to travel internationally for healthcare. “Travel”

is the stage which focuses on patients obtaining the healthcare needed in the destination country.

“Post-travel” is the stage which highlights the follow up care of the patient after returning to the

home country. The time lines were further dissected into themes including motivation and research

in the pre-travel period, obtaining care during the travel period, and follow up, advice and future

healthcare needed in the post-travel period. The authors of this paper further categorized the

motivations with subthemes of perceived healthcare need, finance, dissatisfaction, and recreational

travel. Moreover, obtaining care was further described with the sub themes of logistics,

technology, concerns, reassurance, and communication (Eissler & Casken, 2013).

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Several studies have been conducted to try to understand people’s perceptions about

choosing destinations. Some studies were from the tourism perspective only, others were from the

medical tourism perspective, and some studies were specifically about patients seeking healthcare

abroad. Some research studies focused on the factors influencing choosing the destinations of

treatment and other research studies focused on factors influencing choosing the healthcare

facilities. A cross-sectional survey was conducted in Korea by interviewing people face-to-face at

Jeju International airport. The survey questions were presented in the native language of the study

participants including Chinese, Japanese and Koreans visiting Jeju Island in order to study the

motivational factors and cultural differences among the three ethnicity groups when selecting a

destination for medical tourism. By using the respondents’ socio-demographic characteristics and

a set of question items to understand people’s perceptions about medical tourism, the study

concluded that there were differences in the motivational factors among the three ethnicity groups

Pre Travel

Travel

Post travel

Motivation

Research

Obtaining Care

Follow up

Advice

Future

healthcare

Perceived

healthcare need

Finance

Dissatisfaction

Recreational

Travel

Logistics

Technology

Concerns

Reassurance

Communications

Timeline Themes Subthemes

Figure a. Thematic Analysis for Travelling Seeking Healthcare

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related to the selection of a destination, including perceptions of inconveniences and preferences

for products. The differences were found to be statistically significant by using ANOVA and factor

analysis for statistical analysis of the survey questions (Yu, 2012).

Another study was conducted in Isfahan, Iran through a questionnaire to examine the

factors influencing destination choice among non-Iranian infertile couples who were referred to

the Isfahan, Iran Fertility and Infertility Center. The authors used frequencies and chi-square tests

for statistical analysis since the questions were asked in the form of a Likert scale. The authors

concluded that there are many factors that can influence destination choice for the treatment

country. The study concluded that factors such as cost, distance from home to the country of

treatment, lack of expertise in the home country, tourist attractions, legal and moral restrictions,

and respect for the patient’s ethical and religious beliefs systems are all statistically significant

factors that influence destination choice (Moghimehfar, 2011).

In the Netherlands, a study was conducted to assess the influence of previous patients’

experience and the availability of web-based hospital performance indicators on the decision-

making process of surgical clinic outpatients when choosing hospitals for surgical treatment. The

study was conducted through an internet-based questionnaire and used adaptive choice based

conjoint analysis. The study concluded that respondents valued patient experience as importantly

as hospital based information. Respondents mostly relied on information related to physicians’

expertise, waiting time and physician communication when choosing a healthcare facility (I. B.

De Groot, Otten, W., Dijs-Elsinga, J., Smeets, H.J., Kievit, J. and Marang-van de Mheen, P.J.,

2012; I. B. De Groot, Otten, W., Smeets, H.J. and Marang-van de Mheen, P.J., 2011)

Another study was conducted in the Netherlands, to examine patients’ hospital choice when

price was not a consideration to patients as they were covered by health insurance. A utility

10

maximization model and conditional logistic regression were used to examine the relationships

between patient characteristics and hospital attributes on the choice of a facility for non-emergency

hip replacement surgery. Travel time, the hospital quality rating publicly available, and waiting

time were all factors that had a significant impact on hospital choice. Researchers considered

creating interaction variables considering travel time, hospital attributes, patients’ heterogeneity

and examined patient preferences and changes overtime. The results show that patients were

sensitive to travel time to hospitals and publicly available hospitals’ rating and waiting time.

(Beukers, Kemp, & Varkevisser, 2014).

Studies have also examined the factors influencing the destination of choice among tourists

in general. A study was conducted for example to compare the different motivational factors of

British and German people visiting Spain and Turkey for tourism only and not seeking healthcare.

The objective of the research was to determine if motivational differences existed between tourists

from the same country visiting two different geographic destinations and also among tourists from

two different countries visiting the same destination by analyzing survey data using a series of

cross tabulations, content analysis for the qualitative data, factor analysis and two tailed t-tests.

The authors concluded that there are different motivational factors between British and German

people when visiting the two destinations Spain and Turkey. The authors classified the

motivational factors using the categories of culture, fantasy, relaxation and physical reasons

(Kozak, 2002).

From the studies conducted above and from the literature review, it can be concluded that

there are many frameworks, models and theories that can be used to explain the phenomena of

seeking healthcare abroad, including the decision making involved and the choice of country of

destination. The “Health Seeking Behaviors Framework,” for example, is a framework that was

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used in health and social science research (Eissler & Casken, 2013). The framework utilizes

individual views of health and healthcare as well as other characteristics in explaining responses

to illness, wellness and health promotion. The “Maslow Hierarchy Theory” was also used in

some literature to explain a systemic approach to motivation structure. The individual needs are in

a hierarchal order of increasing motivational importance, with people differing on the needs that

are motivating their behavior (Jang, 2002). The “Smith & Forgione Model” consists of two

stages; stage-1 includes the factors of choosing a destination and stage-2 includes the factors in

choosing the healthcare facility (Heung, 2010).

Choosing a country of treatment is a complex process, and each framework, model and

theory related to this field has its own pros and cons. However, the “Push and Pull Motivational

Factors Framework” seems to be the most applicable theory for analyzing the three aims of this

thesis. The “Push and Pull Factors” can be viewed as a big umbrella that almost covers all of the

factors related to a patient’s home country and the treatment destination. In addition, the push and

pull factors theory covers the themes and the variables included in this cross-sectional study.

Conceptual Framework

As noted previously, seeking healthcare abroad has been growing which has drawn

researchers’ interests to understand the motivational factors involved. The motivation to travel in

general has been investigated by researchers in the fields of sociology, anthropology and

psychology. There are many studies which have been conducted to understand motivational factors

for tourism. A review of tourists’ motivations indicated that they can be analyzed in terms of “Pull

and Push Factors,” a finding that has been accepted by many scientists (Heung, 2010; Jang, 2002;

Mohammad, 2010). At the same time, there have been limited empirical studies conducted to

understand medical tourism and overseas treatment motivational factors. Therefore, the same

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concept of “Pull and Push Factors” will be applied for overseas treatment in this analysis.

Understanding the motivational factors influencing patients treated overseas are important for the

health planner, policy makers and governments in order to focus their work to improve the factors

that pushed the patient away from his or her home country. Moreover, such an understanding can

help in using the best practices from the country of destination and applying them in the home

country of the patients to improve the healthcare services provided.

The push factors are defined as the factors that pushed the patients to choose overseas

treatment destinations instead of having their treatment in the home country. The pull factors are

defined as the factors that attracted patients to the country of destination as they are perceived by

the patient.(V. A. Crooks, et al, 2010; Hsu, 2009; Jang, 2002; Kozak, 2002; Moghimehfar, 2011;

Mohammad, 2010). The push factors can include: health services related issues, financial related

issues and patients’ characteristics, and complexity level of the health condition. On the other hand,

the pull factors can include health services related to the country of destination, advertisements

and information, county of destination reputation, and the patient’s previous experience. Knowing

the source of information and who the patient consulted to learn about the country of treatment,

credentials of the physician, and characteristics of the facility are all very important. Based on the

source of information, the patient will choose the country of destination. Some research studies

have indicated that the source of information is a proxy for the type of society. Patients who use

recommendations from family, friends, relatives, or neighbors reflect that the patient comes from

“a collective society concept.” Whereas patients who rely on the internet are more likely to be part

of an individualistic society. (Yu, 2012)

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Figure b. Motivational Factors Framework to Choose Destination Country:

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Dissertation Organization

This dissertation is organized as three empirical manuscripts with tables and figures

incorporated at the end of each chapter. Chapter one presents the introduction. Chapter two

presents the first manuscript which includes analysis of the first aim. The aim is divided into two

parts: 1a. Examining the factors associated with treatment destinations among patients treated

overseas from the United Arab Emirates sponsored by the DHA during 2009-2016. 2b.

Determining the factors associated with the total number of trips among the patients treated

overseas from the United Arab Emirates sponsored by the Dubai Health Authority during 2009-

2016. Chapter three presents the second manuscript with the analysis of the second aim of this

thesis. The aim is exploring patients’ characteristics and the motivational factors for choosing

treatment destinations among the patients treated overseas from the UAE during 2009 – 2012.

Chapter four presents the third manuscript of this thesis with the analysis of the third aim of this

thesis. The aim is exploring associations between patient characteristics and their preferences for

healthcare services if the treatment is made available in the UAE for the cases of Bone and Joint

Diseases, Cancer, Neurological Diseases, Eye Diseases and General Surgery among patients

treated overseas from the UAE during 2009 - 2012. Healthcare services options include: 1a.

Willingness to be diagnosed and treated by a known physician in the UAE. 1b. Willingness to wait

to be diagnosed and treated by a known physician in the UAE. 2a. Willingness to be diagnosed

and treated by a visiting physician to the UAE. 2b. Willingness to wait to be diagnosed and treated

by a visiting physician to the UAE. Chapter five reviews and discusses the findings and their

implications for policy and future research. Also included are references, appendices and a copy

of the knowledge, attitude and perception survey that was used for this thesis.

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CHAPTER TWO: MANUSCRIPT ONE

Factors Associated with Treatment Destinations and Numbers of Trips among Patients

Treated Overseas from the United Arab Emirates Who Were Sponsored by the Dubai Health

Authority during 2009-2016

16

Introduction

The demand for global healthcare services is experiencing tremendous growth (Burkett,

2007; Chanda, 2002; Eissler & Casken, 2013; Forgione & Smith, 2007; Henson, 2015; P. C. a. F.

Smith, D.A., 2007). Each year the Dubai Health Authority (DHA), pays an average total

expenditure of 77 million dollars to cover an average of 1500 UAE national patients seeking

healthcare overseas (Dubai Health Authority Annual Statistic Books)4. The DHA is the

governmental entity that oversees healthcare facilities in the Emirate of Dubai in the United Arab

Emirates. In addition to providing healthcare services in the Emirate of Dubai, the DHA serves as

a licenser and a regulator of private medical professionals and facilities in the Emirate. Although

the government in the UAE provides free healthcare services to UAE nationals as per the

government law, there are a number of patients who travel seeking healthcare outside the UAE

under the sponsorship of the government. The total number of UAE nationals seeking healthcare

abroad, however, is not accurately calculated since there are many governmental authorities in the

UAE that sponsor the UAE nationals for their treatment.

Patients travelling abroad for healthcare seek an array of treatments ranging from

preventive to complex, and from low-middle income countries to high income countries. Obtaining

healthcare abroad might be associated with some risks and complications compared to obtaining

healthcare domestically (McCallum, 2007). Given the high cost of these medical services and

potential for patient risks, it is important to explore and analyze the treatment destinations and the

total number of trips for the medical specialties that patients sought abroad (I.G. Cohen, 2012; I.

Glenn Cohen, 2014; V. A. Crooks et al., 2013; Turner, 2011). This analysis will provide baseline

4 Average total expenditure and number of patients treated overseas during 2004 – 2016 based on Dubai Health

Authority Annual Reports

17

information for the government to improve polices and strategies related to seeking healthcare

abroad. Moreover, people tend to refer to all patients seeking healthcare abroad as medical tourists

which is not necessarily accurate. Medical travel is defined in this study as the movement of those

patients to the treatment destinations who were under the sponsorship of the government during

the period of 2009 – 2016. Included is travel only for the purpose of legal diagnosis and treatment,

regardless of the level of complexity. Not included is the shipment of laboratory samples or clinical

results for diagnosis and clinical consultations as a second opinion.

Methods

Aim-1a. Examine the factors associated with treatment destinations among patients treated

overseas from the United Arab Emirates who were sponsored by the DHA during 2009-2016.

Research Question-1a. Are there associations among patient characteristics or medical

conditions and treatment destinations for patients from the United Arab Emirates treated overseas

and sponsored by the Dubai Health Authority during 2009 – 2016?

Null hypothesis-1a. There are no associations among patients’ characteristics or medical

conditions and treatment destination for patients treated overseas from the United Arab Emirates

sponsored by the Dubai health Authority during 2009 – 2016 (Allua & Thompson, 2009).

Aim-1b. Determine the factors associated with the total number of trips among the patients

treated overseas from the United Arab Emirates who were sponsored by the Dubai Health

Authority during 2009-2016.

Research Question-1b. Are there associations between patients’ characteristics or medical

conditions and the total number of trips among patients treated overseas from the United Arab

Emirates sponsored by the Dubai Health Authority during 2009-2016?

18

Null hypothesis-1b. There are no associations among patients’ characteristics or medical

conditions and the total number of trips among patients treated overseas from the United Arab

Emirates who were sponsored by the Dubai health Authority during 2009-2016.

Data Source, Study Design, Variables and Measures

Secondary data analysis was performed using administrative data obtained from the DHA

which includes a large number of UAE nationals who sought medical treatment abroad during the

period 2009-2016 under the sponsorship of the DHA. The data contained the following variables:

birth date, gender, departure date, medical specialty sought abroad, and treatment destinations.

Birth date was converted to age as a categorical variable 0-4 yrs., 5-12 yrs., 13-18 yrs., 19-39 yrs.,

40-54 yrs., 55-69yrs., 70+ yrs. with the youngest age category treated as the reference group. For

gender, female was used as the reference group5. Departure date was used to create two categorical

variables and two continuous variables: 1) a total trips variable which is a discrete count with a

minimum of 1 trip to a maximum of 20 trips and defined as the total count of trips taken by the

patients to the treatment destinations; 2) a travel season variable which is a categorical variable

representing the four seasons of the year fall, spring and winter with summer being the reference;

3) a year variable, defined as the calendar year of the patient’s departure date; and 4) a variable

defined as number of years in the data set which was operationalized as “2017 – the calendar year

of the patient’s departure date for the patient’s first trip recorded in the data set.”

The medical specialty variable is a categorical variable with 103 administratively defined

medical specialties that was converted to 42 categorical variables by using the definitions of the

American Board of Medical Specialties to improve the standardization and increase the precision

5 Based on the pattern of the medical condition and age

19

of the measures. Medical specialty is defined as the area of specialty patients sought medical

treatment for at the treatment destination. Internal Medicine Oncology was used as the reference

group6. Patients who had more than one medical specialty reported in their record for a given trip

(3.2%), were removed from the analysis. Treatment destination consists of categorical variables

with 24 destinations and defined as the countries patients traveled to for medical

diagnosis/treatment. The Federal Republic of Germany was used as a reference group7. The study

protocol was submitted to the Johns Hopkins School of Public Health Institutional Review Board

where it was defined as not human subjects’ research (IRB No: 00007896).

Statistical Analysis

The statistical analyses were conducted by using Stata 13 (Stata Corporation, College

Station TX). Quality assurance and quality control of the dataset were performed by running a

wide range of summary statistics to detect missingness of key variables, and inconsistencies in the

data. Means, standard deviations (SD), and student t-tests were used for continuous variables

(Thompson, 2009). Frequency distributions, percentages, and chi-square tests were used for binary

and categorical variables (Curtis & Youngquist, 2013; Thompson & Panacek, 2008). Several

regression analysis models were constructed for this study. The first analysis was conducted

through a modified Poisson, to assess the associations between treatment destination as a binary

outcome and independent variables such as age, gender, travel season and medical specialty. Two

steps of regression analysis were built. The first regression analysis was a bivariate regression

where the outcome of interest was regressed on each independent variable separately. The second

6 Another categorical variables were created for medical specialties based on top 5, top 10 and top 15 medical

specialties were less frequent medical specialties were collapsed into others. Orthopedic Surgery was used as a

reference group. The variable with top 15 medical specialties was used for the regression model. 7 Another binary variable was created for treatment destination. Other destinations was used as the reference group.

The variable was used for the regression model.

20

regression analysis was an adjusted model, where each independent variable was adjusted for the

other independent variables (age group, gender, travel season, and top 15 medical specialties). The

modified Poisson model was used since the incidence of having the outcome of traveling to the

Federal Republic of Germany compared to other destinations was more than 10% (Zou, 2004).

The Akaike information criterion (AIC) test was performed to choose the simplest model with the

best fit; the model with the top 15 medical specialties variable had the lowest AIC (10397.44)

indicating the best fit. The second analysis consisted of a Negative Binomial model which was

used to identify factors associated with the total number of trips as an outcome as a discrete count.

Two regression analysis were built. The first regression analysis was a bivariate regression where

the outcome of interest was regressed on each independent variable separately. The second

regression analysis was an adjusted model, where each independent variable was adjusted for the

other independent variables (age group, gender, travel season, years in the data set, and top 15

medical specialties). Since the travel season and years in the data set variables were extracted from

the same data field (the departure date), the variance inflation factor (VIF) was performed to test

for collinearity; the mean VIF was (1.65) indicating there was no collinearity in the model. The

variance of the outcome was larger than the mean and the likelihood-ratio test of alpha = 0.000

indicated the appropriate selection of the model (Thorpe Jr, Gamaldo, Salas, Gamaldo, &

Whitfield, 2016). P<0.05 indicated statistical significance (Youngquist, 2012).

Results

There were 6,557 unique individual patients from the United Arab Emirates who sought

medical treatment abroad through the sponsorship of the Dubai Health Authority during 2009 –

2016. Comparisons by age group indicate that patients aged 19-39 years had the highest number

of trip counts (n=1,873; 29%), followed by patients aged 40-54 years who had (n=1,307; 20%)

21

trips, and patients aged 55-69 years who had (n=1,265; 19%) trips. Other age groups had lower

numbers of trips as shown in Table-1. The patients treated overseas travelled to 24 destinations

based on the first trip. The most common destinations visited were: Federal Republic of Germany

(n=3,029; 46%) trips, secondly United Kingdom (n=1,278; 19%) trips, and thirdly the Kingdom

of Thailand (n=938; 14%) trips. Other less frequent destinations are shown in Table-2. Of the

(n=6,557) patients who had a first trip, (n=2,339) patients travelled on a second trip overseas for

treatment. (n=1,956/2,339; 84%) travelled to the same destination on the second trip whereas

(n=383/2,339, 16.37%) travelled to a different destination on the second trip. The frequencies for

the second trip destinations followed the same pattern for the first top 4 destinations of the first

trip but were slightly changed for the top 5, 6, and 7 destinations and then returned to the same

pattern as the first trip as shown in Table-3 and Table-4.

The patients treated overseas travelled seeking treatment for 42 medical specialties. The

most frequent medical specialties patients sought medical treatment for overseas during 2009 –

2016, based on the first trip, were the following: Orthopedic Surgery (n=846, 13%), Internal

Medicine Oncology (n=825, 13%), Neurosurgery (N=629, 10%). Other less frequent medical

specialties are shown in Table-5. Of the (n=2,339) patients who travelled on a second trip,

(n=1,639/2,339; 70%) travelled for the same medical specialty on a second trip whereas

(n=700/2,339; 30%) travelled for different medical specialties. The patterns of the medical

specialties changed from the first trip to the second trip and Internal Medicine Oncology became

the most frequent medical specialty patients sought medical treatment overseas for on a second

trip during 2009 – 2016 as shown in Table-6 and Table-7. Medical specialty frequencies change

when stratified by age and gender as shown in Table-8 and Table-10.

22

Countries of destination also slightly change when stratified by age and gender as shown

in Table-9, and Table-11. Demographics, countries of destination, and medical specialties

(stratified by age and gender) frequencies change when explored by total number of trips compared

to when examined for the first trip as shown in the Appendix.

Associations with country of destination when seeking healthcare services overseas

The models examining factors associated with country of destination were adjusted for the

covariates of age, gender, travelling season and medical specialty using a modified Poisson

approach. Unadjusted and adjusted prevalence ratios are shown in Table-12. The oldest age group,

70+ years, had the highest prevalence ratio (47%) of seeking healthcare services in the Federal

Republic of Germany (PR 1.47, 95%CI: 1.27 - 1.69, p=0.000) compared to the reference group of

0-4 years. Patients treated overseas had a 16% lower prevalence ratio of travelling to the Federal

Republic of Germany in the winter season compared to the summer season (PR 0.84, 95%CI: 0.77

- 0.90, p=0.000). The top five medical conditions patients from the UAE sought healthcare services

for in the Federal Republic of Germany in comparison to the reference group of Orthopedic

Surgery were: Neurosurgery, Internal Medicine Endocrinology, Urology, General Surgery and

Internal Medicine Gastroenterology.

Patients traveling for Neurosurgery had an 11% lower prevalence ratio for seeking the

procedure in the Federal Republic of Germany (PR 0.89, 95%CI: 0.82 -0.97, p=0.010) compared

to patients traveling for Orthopedic Surgery as a reference group. Patients traveling for Internal

Medicine Endocrinology had a 16% lower prevalence ratio of seeking the procedure in the Federal

Republic of Germany (PR 0.84, 95%CI: 0.73, 0.97, p=0.019) compared to patients traveling for

Orthopedic Surgery as a reference group. In comparison to patients seeking treatment for

Orthopedic Surgery, patients traveling for Urology had an 18% lower prevalence ratio of seeking

23

the procedure in the Federal Republic of Germany (PR 0.84, 95%CI: 0.71, 0.94, p=0.005), and

patients seeking treatment for General Surgery had a 20% lower prevalence ratio of seeking the

procedure in the Federal Republic of Germany (PR 0.80, 95%CI: 0.71, 0.89, p=<0.000).

Associations with total number of trips for patients seeking healthcare services overseas

The models examining factors associated with the total number of trips were adjusted for

the covariates of age, gender, travelling season, number of years present in the data set and medical

specialty using a negative binomial approach. The unadjusted and adjusted incidence rate ratios

are shown in Table-13. The oldest age group of 70+ years had a 22% lower incidence rate ratio for

the expected total number of trips (IRR 0.78, 95% CI: 0.71 - 0.86, p=0.000) compared to the

reference group of 0-4 years. Patients treated overseas had 8% higher incidence rate ratio of

expected number of trips in the spring (IRR 1.08, 95% CI: 1.02 – 1.13, p=0.006), followed by 7%

higher incidence rate ratio of expected number of trips in the winter (IRR 1.07, 95% CI: 1.02 –

1.14, p=0.006), compared to the summer as a reference group.

Patients had a 9% increase in the expected number of total trips with every additional year

present in the data set (IRR 1.09, 95% CI: 1.08 - 1.09, p=0.000). Patients seeking treatment during

their first trip for Internal Medicine Oncology, Ophthalmology, and General Surgery were likely

to have more additional trips. Patients traveling for Internal Medicine Oncology had a 34% higher

expected total number of trips (IRR 1.34, 95%CI: 1.34) followed by patients seeking treatment for

Ophthalmology with a 15% higher expected number of trips (IRR 1.15, 95% CI: 1.05,1.26, p=003),

and patients seeking treatment for General Surgery who had an 11% higher expected number of

trips (IRR 1.11, 95% CI: 1.01, 1.23, p= 0.039) when compared to the reference group of patients

traveling on their first trip for Orthopedic Surgery.

24

Discussion

Nearly half of the patients from the United Arab Emirates who travelled overseas during

2009-2016 through the sponsorship of the DHA sought medical treatment in the Federal Republic

of Germany during their first trip. The prevalence of travelling to the Federal Republic of Germany

significantly increased with age. Patients who travelled to the Federal Republic of Germany were

more likely to seek medical treatment for Orthopedic Surgery during their first trip and more likely

to travel in the summer season. On the other hand; patients traveling for Internal Medicine

Oncology ,Ophthalmology and General Surgery had higher total numbers of trips compared to

patients traveling for other medical specialties and those who traveled in the winter and spring

seasons. In addition, the older the patients at the time of the first trip, the lower the number of

future expected total trips overseas.

Although some studies have suggested that the medical travelers’ age plays a role in the

decision to undertake medically-related travel, there aren’t many studies about the association

between age and treatment destinations (Gan & Frederick, 2013; Henson, 2015; Heung, 2010;

Kozak, 2002; Turnbull & Uysal, 1995; Yu, 2012). Some studies have suggested that the source of

information and “word of mouth” are important factors for shaping patients’ decisions before

making choices about the treatment destinations (Al-Hinai, Al-Busaidi, & Al-Busaidi, 2011; V. A.

Crooks, Kingsbury, Snyder, & Johnston, 2010; Henson, 2015; N. Lunt & Carrera, 2010; E. Yeoh,

Khalifah Othman, and Halim Ahmad, 2013). Many patients may use different sources of

information to know more about the treatment destinations, physicians’ credentials and hospital

reputations. According to the literature, there are different ways people can seek information to

make decisions about their medical travel experience such as: scholarly sources, media sources,

and word of mouth (Heung, 2010; N. Lunt & Carrera, 2010). In collective society cultures, people

25

tend to lean towards recommendations through personal contacts such as word of mouth compared

to other types of sources of information more likely to be used in individualistic societies (Yu,

2012). More qualitative studies are needed to understand people’s perceptions, motivations, and

reasons for seeking treatment overseas and choosing treatment destinations.

The burden of non-communicable diseases is rising in the UAE, and is considered a new

public health challenge due to life style and behavioral risk factors (Aw, 2010; Loney et al., 2013;

Mokdad et al., 2014; Rahim et al., 2014). Non-communicable diseases such as cardiovascular

diseases, injuries, cancers, respiratory disorders, and cerebrovascular diseases are the most

common public health concerns. In the UAE cardiovascular diseases accounted for more than 25%

of deaths in 2010 (Hajat, Harrison, & Al Siksek, 2012). Our results in this study may not fall

exactly in the same order of disease priorities when compared to the literature review, but that may

be due to the fact that our analysis was based on the patient’s first trip to the treatment destination

rather than the general frequencies of the medical specialties for which patients sought treatment

overseas over the years. Furthermore, the information on medical specialties was collected from

the administrative data from the DHA; these were not recorded by the International Classification

of Disease (ICD) codes. The medical specialties that are examined in this research were only

recorded by their general names. This necessity reduced the precision of medical specialty

categorization. It is also essential to keep in mind that the medical specialties frequencies change

between the medical specialties treated within the UAE compared to the frequencies of the medical

specialties for which patients were treated overseas.

Our results indicated that Orthopedic Surgery was the most frequent medical specialty

people travelled overseas for during their first trip. Some studies that have been conducted about

rheumatoid arthritis in the UAE and Middle East may be relevant for this finding. Patients have

26

been found to have a delay in diagnosis and low disease-modifying anti-rheumatic drug (DMARD)

utilization (Badsha, Kong, & Tak, 2008). Studies have illustrated that there is a gap between the

onset of the disease and timely referral to a rheumatologist, diagnosis and introduction to

appropriate treatment options. In addition, other studies have indicated that this lag time has been

due to many reasons including lack of public knowledge and awareness about rheumatoid arthritis,

as well as an imbalanced ratio of trained rheumatologists to the population (Zafar et al., 2012).

Hence, it is important to close these gaps through ensuring appropriate staffing levels per

population according to guidelines, increasing public knowledge and awareness, educational

campaigns through patient support groups, and media campaigns about rheumatoid arthritis. This

will lead to increased patients’ access and early detection of the disease, since studies have shown

that early intervention for rheumatoid arthritis leads to better responses to treatment and patient

outcomes (El Zorkany, 2013; Halabi et al., 2015). Although there have been nationwide efforts

recently in the UAE to improve public health knowledge and understanding about rheumatoid

arthritis, large studies are needed to evaluate these public awareness campaigns and ensure they

are reaching the largest population of patients with rheumatoid arthritis. Moreover, examining the

association between the public awareness campaigns and seeking healthcare overseas for

Orthopedic Surgery is also needed to assess the association between these two aspects, although it

is recognized that rheumatoid arthritis is only one condition that may lead to Orthopedic Surgery.

At the same time, the use of rheumatoid arthritis assessment measurement guidelines and early

interventions by following evidence based recommendations for rheumatoid arthritis may improve

patient outcomes and government health expenditures.

Internal Medicine Oncology had the highest expected total number of trips abroad. Due to

the lack of ICD codes in our available data, it was not possible to detect the variation of cancer

27

types among gender and age groups in the study. In general, there are an insufficient number of

clinical and pathological studies about cancer, in terms of patterns and incidence rate reporting in

the UAE (Al-Sharhan, 1985; Khoja, 2010; Salim et al., 2009). According to the UAE - National

Cancer Registry report for 2014 from the Ministry of Health, the incidence rate of cancer is 42

cases per 100,000 including both UAE nationals and non-UAE nationals. The most common

cancers according to the report are C50 Breast, C73 Thyroid and C18-C21 Colorectal for females,

and C18-C21 Colorectal, C61 Prostate and C91-C95 Leukemia for males. Pediatrics cases aged 0-

14 are more likely to be diagnosed with C91-C95 Leukemia, C70-C72 Brain & Central Nerves

System, and C81 Hodgkins Lymphoma (Emirates). Moreover the report illustrated the

distributions of malignant cases by age group in the UAE and showed that the age group of 55-59

years had the highest frequency of cancer which mirrors our results since the age group of 40-54

years had the highest frequency of seeking treatment abroad for cancer, followed by the age group

of 55-69 years8. Another study which reported similar results was an investigation that was

conducted in Al-Ain Hospital in the UAE. Their findings indicated that the most common sites of

malignancy were cancer of the gastrointestinal system in males, followed by breast cancer in

females (El Helal, 1997).

Ophthalmology was another medical specialty for which patients had a higher than

expected total number of trips abroad. Many studies have identified high rates of overweight and

obesity in the UAE, following the change in the diet and life style as a result of undergoing the

rapid development of the country after the oil boom. As a result of these changes, diabetes mellitus

became one of the most common chronic diseases in the UAE (Al-Maskari & El-Sadig, 2007;

Sheikh-Ismail, 2009). Currently the prevalence of diabetes in the UAE is amongst the highest in

8 Most frequent medical conditions not based on the first trip. See appendix Table 23

28

the world with some estimates putting it in the top 5 countries (Whiting, Guariguata, Weil, &

Shaw, 2011). This implies that the disease, especially when it is associated with other chronic

conditions and its complications such as retinopathy, might contribute a sizable healthcare burden

to the UAE population when it comes to ophthalmology (Saadi et al., 2007). Therefore early

screening and diagnosis may prevent long term complications. Patient education, a healthy diet,

physical activity, and effective referral to primary healthcare may reduce the chances of diabetes

and its complications.

In terms of the relationship between age and medical travel, the literature suggests that

younger adults are more likely to engage in medical travel compared to older people (Guy, Henson,

& Dotson, 2015). This matches our study findings since age groups 19-39 years and 40 – 54 years

had the highest number of trips compared to older ages 9. On the other hand, the older the patients,

the lower the expected number of trips, a pattern similar to some other studies that have noted the

inverse relationship between older age and medical travel.

It is important to acknowledge some limitations of our study. The data collected from the

DHA didn’t include ICD codes as mentioned earlier in this paper; the medical specialties were

recorded by their general names rather than disease diagnoses. This could affect the precision of

the medical specialty variable, although the American Medical Specialty Board classification was

used in an effort to achieve some standardization in data management. In addition, patients who

had more than one medical specialty reported in their record for a given trip (3.2%), were excluded

from our analysis since we assumed that including them could potentially introduce bias to the

analysis in two ways, since we are not able to access these patients’ records for more information,

9 Based on first trip and as a total frequency. See Appendix Table 15.

29

and therefore we were not able to know the primary medical specialty for which the patient

travelled. While the study is limited to patients sponsored through the DHA, we have to be careful

with generalizing the results, since the data cannot represent all the patients who travelled under

the sponsorship of other health authorities in the UAE. However, the availability of the data at the

DHA is considered as a strength since the staff at this agency supported easy access to the data for

the purpose of conducting this research. Additionally, the data can be used in the future as a

baseline to conduct longitudinal data analysis to better understand changes in the patterns of

overseas treatment related to country of destinations and medical conditions for which treatment

was sought. Such an investigation will build on the results of this study which was cross sectional

and based for the most part on the first trip for which diagnosis and/or treatment was sought

overseas.

Conclusion

In conclusion, our study is one of the more comprehensive studies related to medical travel

and therefore contributes to the limited empirical research in this field. The results demonstrated

that treatment destinations, medical specialties for which treatment was sought and age were

significant factors in understanding patterns of overseas travel for medical care. Creating an

overseas treatment registry system in the UAE would be an important step to capture all medical

travelers sponsored by the different government authorities (Alwan et al., 2010; Solomon, 1991).

Establishing a registry that contains all the essential variables such as patients’ demographics, ICD

codes, and treatment details including costs would prepare the government for conducting future

comparative effectiveness research that may lead to strategy relevant information that would

inform policies about sending patients to destinations of lower cost and high quality patient

outcomes (Atkins, 2007; Chalkidou, Whicher, Kary, & Tunis, 2009; Kurbasic et al., 2008; Sox &

30

Greenfield, 2009). In addition it would directly influence and promote informed patients’ decisions

when choosing treatment destinations.

Resources saved as a result of comparative effectiveness research can be allocated towards

prevention measures for the most common medical specialties patients travel overseas for and to

provide treatment options in the UAE whether in the government or in the private sector(Benner,

Morrison, Karnes, Kocot, & McClellan, 2010; Clancy, 2006; Gottlieb, 2009; Krumholz, 2008;

Lauer, 2010) . The results from this study can also provide an evidence base to create a “follow up

care program” for patients who received treatment overseas and for patients who had repeated

visits such as patients who traveled for treatment in Internal Medicine Oncology, Ophthalmology

and General Surgery (Beaglehole et al., 2007). These follow up care appointments should be

scheduled according to medical specialty guidelines (Del Giudice, 2009). Furthermore, to reap the

best outcomes from the follow up care, measuring patient adherence to the program would be

essential. The follow up care would help in increasing the chance of patient survival, improve

patients’ quality of life, assess patients’ overseas experience, and could provide a substitute that

allows patients to stay in the country. This type of program could lead to the reduction of

complications and risks associated with treatment overseas.

31

Tables and Figures

Table 1: Demographics and total number of trips among patients treated overseas from the

United Arab Emirates during 2009 – 2016 stratified by age and gender

1 Trip Only 2 Trips Only 3 Trips Only

4 Trips

Only 5 Trips Only

6 Trips and

above

Total

Gender

Males 2,196 (64.63) 646 (19.01) 256 (7.53) 110 (3.24) 73 (2.15) 117 (3.44) 3,398 (100)

Females 1,946 (61.60) 627 (19.85) 274 (8.67) 144 (4.56) 71 (2.25) 97 (3.07) 3,159 (100)

Total 4,142 (63.17) 1,273 (19.41) 530 (8.08) 254 (3.87) 144 (2.20) 214 (3.26) 6,557 (100)

Age group

0-4 yrs. 399 (57.74) 139 (20.12) 75 (10.85) 31 (4.49) 21 (3.04) 26 (3.76) 691 (100)

5-12 yrs. 297 (60.37) 92 (18.70) 48 (9.76) 19 (3.86) 14 (2.85) 22 (4.47) 492 (100)

13-18 yrs. 213 (62.10) 70 (20.41) 25 (7.29) 17 (4.96) 11 (3.21) 7 (2.04) 343 (100)

19-39 yrs. 1,193 (63.69) 387 (20.66) 140 (7.47) 73 (3.90) 26 (1.39) 54 (2.88) 1,873 (100)

40-54 yrs. 815 (62.36) 237 (18.13) 111 (8.49) 58 (4.44) 39 (2.98) 47 (3.60) 1,307 (100)

55-69 yrs. 805 (63.64) 243 (19.21) 99 (7.83) 46 (3.64) 28 (2.21) 44 (3.48) 1,265 (100)

70+ yrs. 420 (71.67) 105 (17.92) 32 (5.46) 10 (1.71) 5 (0.85) 14 (2.39) 586 (100)

Total 4,142 (63.17) 1,273 (19.41) 530 (8.08) 254 (3.87) 144 (2.20) 214 (3.26) 6,557 (100)

Table 2: Countries of destination among patients treated overseas from the United Arab

Emirates during 2009 – 2016 based on first trip

No. Country of Destination N (%)

1 Federal Republic of Germany 3,029 (46.19)

2 United Kingdom 1,278(19.49)

3 Kingdom of Thailand 938 (14.31)

4 United States of America 336(5.12)

5 Kingdom of Spain 240(3.66)

6 Republic of India 238(3.63)

7 Republic of Singapore 238(3.63)

8 Republic of Austria 63(0.96)

9 Kingdom of Belgium 51 (0.77)

10 French Republic 25 (0.38)

11 Swiss Confederation 20(0.31)

12 Arab Republic of Egypt 19 (0.29)

13 Korea 19 (0.29)

14 People's Republic of China 15(0.23)

15 Republic of the Philippines 12 (0.18)

16 Kingdom of Saudi Arabia 11 (0.17)

17 Republic of Slovenia 10(0.15)

18 The Hashemite Kingdom of Jordan 9(0.14)

19 Czech Republic 1(0.02)

32

20 Republic of Indonesia 1(0.02)

21 Italian Republic 1(0.02)

22 Kingdom of Morocco 1(0.02)

23 Kingdom of Sweden 1(0.02)

24 Republic of Turkey 1(0.02)

Total 6,557 (100.00)

Table 3: Patients from the United Arab Emirates travelling to the same vs. different

destination during 2009 - 2016 for a second trip

Country of Destination N (%)

Different country of destination for the second visit 383 (16.37)

Same country of destination for the second visit 1,956 (83.63)

Total 2,339 (100)

Table: 4: Top 10 countries of destination among patients treated overseas from the United Arab

Emirates during 2009 – 20016 for a second trip


1 Federal Republic of Germany 928 (47.44)

2 United Kingdom 370 (18.92)


4 United Stated of America 102 (5.21)

5 Republic of Singapore 73 (3.73)

6 Kingdom of Spain 70 (3.58)

7 Republic of India 55(2.81)

8 Republic of Austria 9 (0.46)



11 Other countries of destinations 18 (0.92)

Total 1,956 (100.00)

Table 5: The most frequent medical specialties for which patients from the United Arab

Emirates sought medical treatment overseas during 2009 –2016 based on the first trip

No. Medical Specialty N (%)

1 Orthopedic Surgery 846(12.90)

2 Internal Medicine: Oncology 825(12.58)

3 Neurosurgery 629(9.59)

4 Ophthalmology 413(6.30)

5 Neurology 372(5.67)

6 General Surgery 337 (5.14)

7 Internal Medicine: Cardiology 325(4.96)

8 Obstetrics and Gynecology 291(4.44)

9 Unspecified Pediatrics 249(3.80)

10 Internal Medicine: Gastroenterology 230(3.51)

11 Urology 198(3.02)

12 Internal Medicine: Endocrinology 176(2.68)

13 Internal Medicine: Nephrology 147(2.24)

14 Not Specified Cases 143(2.18)

33

15 Internal Medicine 140(2.14)

16 Otolaryngology 131(2.00)

17 Thoracic Surgery 126(1.92)

18 Pediatrics: Neurology 107(1.63)

19 Pediatrics: Cardiology 105(1.60)

20 Internal Medicine: Hematology 93(1.42)

21 Internal Medicine: Pulmonology 89(1.36)

22 Pediatrics: Surgery 69(1.05)

23 Internal Medicine: Rheumatology 53(0.81)

24 Plastic Surgery 53(0.81)

25 Vascular Surgery 51(0.78)

26 Physical Medicine and Rehabilitation 46(0.70)

27 Dermatology 45(0.69)

28 Screening & Check-up 42(0.64)

29 Pediatrics: Oncology 38 (0.58)

30 Pediatrics: Nephrology 35(0.53)

31 Pediatrics: Neurosurgery 26(0.40)

32 Pediatrics: Gastroenterology 23(0.35)

33 Pediatrics: Hematology 17(0.26)

34 Pediatrics: Neonatology 17(0.26)

35 Psychiatry 15(0.23)

36 Pediatrics: Endocrinology 14 (0.21)

37 Oral & Maxillofacial Surgery 13 (0.20)

38 Internal Medicine: Infectious Diseases 10(0.15)

39 Dental 10(0.15)

40 Pediatrics: Pulmonology 3(0.05)

41 Genetics 3(0.05)

42 Pediatrics: Rheumatology 2 (0.03)

Total 6,557(100.00)

Table 6: Patients from the United Arab Emirates travelling for the same vs. a different medical

specialty during 2009 - 2016 for a second trip

Medical Specialty N (%)

Different medical specialty on the second trip 700 (29.93)

Same medical specialty on the second trip 1,639 (70.07)

Total 2,339 (100.00)

Table 7: Top 15 medical specialties for which patients from the United Arab Emirates sought

medical treatment overseas during 2009-2016 for a second trip


1 Internal Medicine: Oncology 291 (17.75)

2 Orthopedic Surgery 216 (13.18)

3 Neurosurgery 154 (9.40)

4 Ophthalmology 133 (8.11)

5 Neurology 83 (5.06)

6 Obstetrics and Gynecology 75 (4.58)

7 Internal Medicine: Cardiology 65 (3.97)


34

9 Un specified Pediatrics 56 (3.42)

10 Internal Medicine: Gastroenterology 52 (3.17)

11 Urology 39 (2.38)

12 Internal Medicine: Endocrinology 23 (1.40)

13 Internal Medicine: Nephrology 30 (1.83)

14 Not Specified Cases 20 (1.22)

15 Internal Medicine 17 (1.04)

16 Other medical specialties 325 (19.83)

Total 1,639 (100.00)

Table 8. The top 5 most frequent medical specialties among patients from the United Arab

Emirates treated overseas during 2009-2016 stratified by age based on first trip, where 1

represents most frequent medical specialty and 5 represents least frequent medical specialty.

Age categories 0-4 yrs. old N

(%)

5-12 yrs. old N

(%)

13-18 yrs. old N

(%)

19-39 yrs. old N

(%)

40-54 yrs. old N

(%)

55-69 yrs. old N

(%)

70+ yrs. old N

(%)

Medical

Specialty 1

Unspecified

pediatrics

198(28.65)

Orthopedic

Surgery

84(17.07)

Orthopedic

Surgery

77(22.45)

Orthopedic

Surgery

290(15.48)

Internal

Medicine:

Oncology

241(18.44)

Internal

Medicine:

Oncology

268(21.19)

Internal

Medicine:

Oncology

100(17.06)

Medical

Specialty 2

Pediatrics:

Cardiology

72(10.42)

Pediatrics:

Neurology

47(9.55)

Ophthalmology

46(13.41)

Neurosurgery

197(10.52)

Neurosurgery

172(13.16)

Neurosurgery

152(12.02)

Internal

Medicine:

Cardiology

78(13.31)

Medical

Specialty 3

Pediatrics:

Neurology

52(8.25)

Ophthalmology

46(9.35)

Neurosurgery

27(7.87)

Internal

Medicine:

Oncology

189(10.09)

Orthopedic

Surgery

157(12.01)

Orthopedic

Surgery

143(11.30)

Orthopedic

Surgery

61(10.41)

Medical

Specialty 4

Ophthalmology

49(7.09)

Unspecified

pediatrics

45(9.15)

Neurology

25(7.29)

Obstetrics and

Gynecology

173(9.24)

General Surgery

86(6.58)

Internal

Medicine:

Cardiology

104(8.22)

Neurosurgery

44(7.51)

Medical

Specialty 5

Pediatrics:

Surgery

48(6.95)

Pediatrics:

Cardiology

28(5.69)

Otolaryngology

17(4.96)

Neurology

151(8.06)

Obstetrics and

Gynecology

85(6.50)

General Surgery

67(5.30)

Neurology

39(6.66)

35

Table 9. The top 5 most frequent countries of destination among patients from the United Arab

Emirates treated overseas during 2009-2016 stratified by age based on first trip, where 1


Age categories 0-4 yrs. old N

(%)

5-12 yrs. old N

(%)

13-18 yrs. old N

(%)

19-39 yrs. old N

(%)

40-54 yrs. old N

(%)

55-69 yrs. old N

(%)

70+ yrs. old N

(%)

Country of

Destination 1

United Kingdom

330 (47.76)

Federal Republic

of Germany 215

(43.70)

Federal Republic

of Germany 168

(48.98)

Federal Republic

of Germany

920 (49.12)

Federal Republic

of Germany 630

(48.20)

Federal Republic

of Germany 565

(44.66)

Federal Republic

of Germany 296

(50.51)

Country of

Destination 2

Federal Republic

of Germany 235

( 34.01)

United Kingdom

139 (28.25)

United Kingdom

87 (25.36)

United Kingdom

344 (18.37)

Kingdom of

Thailand 226

(17.29)

Kingdom of

Thailand 312

(24.66)

Kingdom of

Thailand 98

(16.72)

Country of

Destination 3

United Stated of

America 38

(5.50)

United Stated of

America 39

(7.93)

Kingdom of

Thailand 26

(7.58)

Kingdom of

Thailand 209

(11.16)

United Kingdom

187 (14.31)

United Kingdom

128 (10.12)

United Kingdom

63 (10.75)

Country of

Destination 4

Kingdom of

Thailand 35

(5.07)

Kingdom of

Thailand 32

(6.50)

Kingdom of

Spain 26

(7.58)

United Stated of

America 104

(5.55)

United Stated of

America 72

(5.51)

Republic of India

77 (6.09)

Republic of India

38 (6.48)

Country of

Destination 5

Kingdom of

Spain 18

(2.60)

Kingdom of

Spain 27

(5.49)

United Stated of

America 15

(4.37)

Kingdom of

Spain 87

(4.64)

Republic of

Singapore (63

4.82)

Republic of

Singapore 66

(5.22)

Republic of

Singapore 30

(5.12)


Emirates treated overseas during 2009-2016 stratified by gender based on first trip, where 1


Gender Males Females

Medical Specialty 1 Orthopedic Surgery

487(14.33) Internal Medicine: Oncology

516(16.33)

Medical Specialty 2 Neurosurgery

344(10.12) Orthopedic Surgery

359(11.36)

Medical Specialty 3 Internal Medicine: Oncology

309(9.09) Obstetrics and Gynecology

291(9.21)

Medical Specialty 4 Ophthalmology

230(6.77) Neurosurgery

285(9.02)

Medical Specialty 5 Neurology 211(6.21)

Ophthalmology 183(5.79)

36

Table 11. The top 5 most frequent countries of destination among patients from the United Arab

Emirates treated overseas during 2009-2016 stratified by gender based on first trip, where 1



Country of Destination 1 Federal Republic of Germany 1,605

(47.23) Federal Republic of Germany 1,424 (45.08)

Country of Destination 2 United Kingdom 624 (18.36) United Kingdom 654 (20.70)

Country of Destination 3 Kingdom of Thailand 515 (15.16) Kingdom of Thailand 423 (13.39)

Country of Destination 4 United Stated of America 167 (4.91) United Stated of America 169 (5.35)

Country of Destination 5 Kingdom of Spain 140 (4.12) Republic of Singapore 145 (4.59)

37

Figure 1. Distribution of total number of trips among patients treated overseas from the United Arab

Emirates during 2009-2016

36.51%

22.08%

13.63%

8.55%

6.27%4.53%

3.46%1.56% 1.38% 0.73% 0.47% 0.21% 0.23% 0.14% 0.09% 0.17%

1 2 3 4 5 6 7 8 9 10 11 12 13 16 18 20

NUMBER OF TRIP

DISTRIBUTION OF TOTAL NUMBER OF TRIPS AMONG PATIENTS TREATED OVERSEAS FROM THE UAE DURING 2009 - 2016

38

Figure 2. Total number of trips among patients treated overseas from the United Arab

Emirates during 2009-2016, stratified by age groups

05

10

15

20

Tota

l T

rip

s

0-4 yrs 5-12 yrs 13-18 yrs 19-39 yrs 40-54 yrs 55-69 yrs 70+ yrs

Total Number of Trips among Patients Treated Overseas from the U.A.E during 2009-2016, stratified by age groups

39

Figure 3. Total number of trips among patients treated overseas from the United Arab

Emirates during 2009-2016, stratified by gender

05

10

15

20

Tota

l T

rip

s

Females Males

Total Number of Trips among Patients Treated Overseas from The U.A.E during 2009-2016, stratified by gender

40

Table 12. Unadjusted and adjusted prevalence ratios for travelling to the Federal Republic of

Germany in comparison to other countries of destination

Independent Variables Unadjusted Adjusted*

PR 95% CI P-Value** PR 95% CI P-Value**

Age group

0-4 yrs. old 1.00 - - 1.00 - -

5-12 yrs. old 1.28 (1.11,1.48) 0.001 1.22 (1.06,1.41) 0.007

13-18 yrs. old 1.44 (1.24,1.67) 0.000 1.36 (1.17,1.59) 0.000

19-39 yrs. old 1.44 (1.29,1.62) 0.000 1.39 (1.22,1.58) 0.000

40-54 yrs. old 1.42 (1.26, 1.60) 0.000 1.39 (1.21,1.58) 0.000

55-69 yrs. old 1.31 (1.16,1.48) 0.000 1.35 (1.18,1.55) 0.000

70+ yrs. old 1.49 (1.30,1.69) 0.000 1.47 (1.27,1.69) 0.000

Gender

Female 1.00 - - 1.00

Males 1.04 (0.99,1.10) 0.080 1.00 (0.95,1.05) 0.987

Travel Season

Summer 1.00 - - 1.00 - -

Fall 0.99 (0.93,1.06) 0.841 1.01 (0.95,1.08) 0.693

Winter 0.82 (0.76,0.89) 0.000 0.84 (0.77,0.90) 0.000

Spring 1.03 (0.96,1.11) 0.366 1.03 (0.97,1.10) 0.337

Medical Specialty Orthopedic Surgery 1.00 - - 1.00 - -

Internal Medicine: Oncology 0.50 (0.45,0.56) 0.000 0.49 (0.44,0.55) 0.000

Neurosurgery 0.90 (0.83,0.98) 0.019 0.89 (0.82,0.97) 0.010

Ophthalmology 0.21 (0.17,0.27) 0.000 0.22 (0.17,0.28) 0.000

Neurology 1.01 (0.93,1.11) 0.765 0.99 (0.90,1.09) 0.844

General Surgery 0.81 (0.72,0.91) 0.000 0.80 (0.71,0.89) 0.000

Internal Medicine:

Cardiology

0.78 (0.69,0.88) 0.000 0.76 (0.67,0.86) 0.000

Obstetrics and Gynecology 0.68 (0.58,0.78) 0.000 0.66 (0.57,0.76) 0.000

Un specified Pediatrics 0.53 (0.44,0.63) 0.000 0.68 (0.56,0.84) 0.000

Internal Medicine:

Gastroenterology

0.80 (0.69,0.91) 0.001 0.78 (0.68,0.89) 0.000

Urology 0.82 (0.71,0.95) 0.007 0.82 (0.71,0.94) 0.005

Internal Medicine:

Endocrinology

0.86 (0.75,0.99) 0.042 0.84 (0.73,0.97) 0.019

Internal Medicine:

Nephrology

0.74 (0.62,0.89) 0.001 0.73 (0.61,0.87) 0.001

Not Specified Cases 0.12 (0.07,0.21) 0.000 0.12 (0.07,0.22) 0.000

Un specified Internal

Medicine

0.61 (0.49,0.76) 0.000 0.60 (0.48,0.75) 0.000

Other medical specialties 0.75 (0.69,0.81) 0.000 0.81 (0.75,0.88) 0.000

* Adjusted for age group, gender, travel season and medical specialty by using modified Poisson as a model for analysis ** Significance level p<0.05

41

Table 13. Unadjusted and adjusted incidence rate ratios for the total number of trips seeking

treatment overseas during the study time period.

Independent Variables Unadjusted Adjusted *

IRR 95% CI P-Value** IRR 95% CI P-Value**

Age group

0-4 yrs. old 1.00 - - 1.00 - -

5-12 yrs. old 1.00 (0.92,1.09) 0.983 1.02 (0.94,1.12) 0.634

13-18 yrs. old 0.91 (0.83,1.01) 0.075 0.95 (0.86,1.06) 0.379

19-39 yrs. old 0.89 (0.84,0.95) 0.001 0.92 (0.85,0.99) 0.031

40-54 yrs. old 0.95 (0.88,1.02) 0.175 0.94 (0.87,1.03) 0.170

55-69 yrs. old 0.91 (0.85,0.98) 0.013 0.90 (0.82,0.97) 0.009

70+ yrs. old 0.79 (0.72,0.86) 0.000 0.78 (0.71,0.86) 0.000

Gender

Female 1.00 - - 1.00 - -

Males 0.98 (0.94,1.01) 0.019 0.97 (0.94,1.01) 0.186

Travel Season

Summer 1.00 - - 1.00 - -

Fall 0.97 (0.92,1.02) 0.270 1.00 (0.95,1.06) 0.945

Winter 1.06 (1.00,1.12) 0.033 1.07 (1.02,1.14) 0.006

Spring 1.03 (0.98,1.08) 0.288 1.08 (1.02,1.13) 0.006

Years

Year in the data set 1.09 (1.07,1.10) 0.000 1.09 (1.08,1.09) 0.000

Medical Specialty

Orthopedic Surgery 1.00 - - 1.00 - -

Internal Medicine: Oncology 1.37 (1.27,1.47) 0.000 1.34 (1.24,1.44) 0.000

Neurosurgery 1.06 (0.98,1.15) 0.151 1.07 (0.98,1.16) 0.125

Ophthalmology 1.09 (0.99,1.20) 0.069 1.15 (1.05,1.26) 0.003

Neurology 0.97 (0.88,1.08) 0.599 0.99 (0.90,1.10) 0.898

General Surgery 1.03 (0.93,1.14) 0.551 1.11 (1.01,1.23) 0.039

Internal Medicine:

Cardiology

1.02 (0.92,1.13) 0.678 1.07 (0.96,1.18) 0.221

Obstetrics and Gynecology 0.98 (0.88,1.09) 0.700 1.01 (0.90,1.12) 0.922

Un specified Pediatrics 1.23 (1.10,1.36) 0.000 1.10 (0.97,1.24) 0.123

Internal Medicine:

Gastroenterology

1.01 (0.90,1.14) 0.812 1.06 (0.94,1.19) 0.323

Urology 0.95 (0.84,1.08) 0.448 0.97 (0.85,1.10) 0.625

Internal Medicine:

Endocrinology

0.93 (0.81,1.07) 0.301 0.96 (0.84,1.10) 0.531

Internal Medicine:

Nephrology

0.99 (0.86,1.14) 0.842 0.99 (0.86,1.14) 0.916

Not Specified Cases 1.04 (0.91,1.20) 0.555 1.10 (0.95,1.26) 0.198

Un specified Internal

Medicine

1.06 (0.92,1.22) 0.443 1.09 (0.95,1.25) 0.227

Other medical Specialties 1.10 (1.03,1.18) 0.007 1.05 (0.978,1.13) 0.196

*Adjusted for age group, gender, travel season, years, and medical specialty by using Negative Binomial as a model for analysis **Significance level p<0.05

42

CHAPTER THREE: MANUSCRIPT TWO

Patient Characteristics and the Motivational Factors for Choosing Treatment Destinations among

Patients Treated Overseas from the UAE during 2009 – 2012

43

Introduction

By government law, all UAE nationals are provided healthcare services. Therefore all UAE

nationals, whether or not they reside in Dubai, have free access to Dubai Health Authority primary

and tertiary healthcare facilities. Although the public healthcare sector strives to provide good

healthcare services to its people, there are still a number of people who travel overseas to seek

healthcare. However, the numbers of patients treated overseas are not accurately calculated, and

the reasons that “push” patients from the UAE and that “pull” them towards the treatment

destinations are unknown to the government (Crompton, 1979; Hsu, 2009; Jang, 2002;

Mohammad, 2010; Turnbull & Uysal, 1995; Uysal & Jurowski, 1994). Since the government is

also funding the UAE nationals for their treatment abroad, the government has started to seriously

investigate the reasons why UAE nationals are travelling overseas seeking healthcare instead of

utilizing healthcare services in the Emirate of Dubai and other Emirates in the UAE (Helble, 2011;

Mansfeld, 1992).

In 2009 the Dubai Health Authority took the first step to explore the reasons for overseas

treatment by creating a knowledge, attitudes and perceptions survey in collaboration with the

Dubai Statistics Center to explore people’s perceptions and attitudes related to their treatment

overseas experiences. This study will not only help in understanding the motivational factors and

patients’ preferences when travelling abroad for healthcare services, but also will advance the

government’s understanding about patients’ choices for one destination over another. Enhancing

this understanding is very important since the treatment destinations vary in the costs which the

government is bearing.

44

Methods

Study Aim: Explore patients’ characteristics and the motivational factors for choosing

treatment destinations among the patients treated overseas from the UAE during 2009 – 2012.

Research Question: Are there associations among patients’ characteristics or motivational

factors and the destination of choice for treatment among patients treated overseas in the UAE for

the period 2009 – 2012?

Null Hypothesis: There are no associations among patients’ characteristics or motivational

factors and destinations of choice for treatment among patients treated overseas from the UAE

during 2009 -2012.

Data Source and Study Design

A secondary data analysis was performed from a cross-sectional Knowledge, Attitudes and

Perceptions (KAP) survey related to medical treatment abroad among residents of Dubai that was

conducted in Dubai, United Arab Emirates between June 2012 and July 2012 (Kaliyaperumal,

2004). The survey was conducted among 361 families who were residents of Dubai with at least

one family member who had experienced seeking healthcare overseas. Using the WHO definition

of trading in health services we are referring to the movement of patients to the country providing

healthcare services for diagnosis and treatment, and not the shipment of laboratory samples or

clinical results for diagnosis and/or clinical consultation as second opinions (R. D. Smith, Chanda,

& Tangcharoensathien, 2009). Designing the survey and collecting the data was through a

collaborative effort between the Dubai Health Authority (DHA) and the Dubai Statistical Center

(DSC) with the DHA designing the survey and the DSC collecting the data.

45

The survey was conducted with nonprobability sampling (purposive sampling) as the

methodology of sample selection (Etikan, Musa, & Alkassim, 2016; Farrokhi, 2012). The study

participants were selected through two main approaches. In the first approach the sample was

drawn from the Dubai Health Authority (DHA) medical records; 1678 cases were drawn from the

Dubai Health Authority records who had traveled at the government expense during 2010 - 2012.

There were 452 cases who agreed to participate in the survey. In the second approach the sample

was drawn from the Dubai Statistical Center Household Survey that was conducted in 2009. People

were selected who had travelled during the same year at their own expense. There were 384 cases

selected and 119 cases agreed to participate in the survey.

1678

Cases were drawn from

DHA for patients who

travelled at DHA expense

384

Cases were drawn from

DSC for patients who travelled at their own

expense

452

Cases agreed to participate

in the survey

119

Cases agreed to participate

in the survey

571

Total number of participants

in the survey

Figure 1. Non Probability Purposive Sampling

46

Response Rates of the KAP Survey

Residents Number of families

with overseas treated

patient identified and

intended to survey

Didn’t answer the

phone

Rejected and didn’t

complete the survey

Completed the survey

UAE Nationals 468 (82%) 90 40 338 (72%)

Non-UAE Nationals 103 (18%) 41 39 23 (22%)

Total 571 (100%) 131 79 361 (63%)

The Knowledge, Attitudes and Perceptions (KAP) Survey

The KAP survey was conducted to explore views, perceptions and experiences mainly for

the UAE residents related to treatment abroad for the period 2009 – 2012 (Erler, 2008). The survey

asked the patients (or a family member) about the reasons why the patient travelled abroad in order

to understand the motivations behind seeking healthcare abroad instead of seeking healthcare

services in the UAE. Both UAE nationals and non-UAE nationals were interviewed who sought

healthcare abroad during 2009 – 2012. The data includes people who paid from their own pocket,

and people whose expenses were covered by the government. All the patients who traveled for

healthcare services went for legal healthcare services in both the home country (UAE) and the

destination country. The patients travelled for different levels of treatment, including life

threatening diseases, serious diseases and medically optional conditions (Guy et al., 2015; Henson,

2015). Some patients travelled to high income countries such as Germany, UK and the USA while

others travelled to low-middle income countries such as India and Thailand (I. Glenn Cohen,

2014). The mode of data collection was through in-person and phone interviews with times ranging

from 45 minutes to an hour interview. Patients who were less than 15 years old and patients who

were not available for the interview were replaced by a family member 15 years old or above that

escorted the patient during the treatment abroad and who was eligible to respond to the KAP

survey.

47

The total number of people completing the survey was 361 with a response rate of 63%.

Non-UAE nationals, however, had a low response rate of 22%, so a decision was made to omit

them from this analysis and focus only on the UAE nationals who had a response rate of 72%.

(Appendix Figure 1)

The survey included 9 sections. Section (1) included the basic information about the survey

and the mode of data collection. In cases where the patient who had been through the travel

experience was not available, a family member who either escorted the patient or a family member

who didn’t escort but had enough information about the patient experience, and who was aged 15

years old and above, was eligible to answer the survey. The other 8 sections were the following:

Section (2) included general socio-demographic information about the patient who travelled

abroad. Section (3) included health seeking behavior in the UAE, including patient health status

before travelling abroad for healthcare and questions about the healthcare provider in the UAE and

the degree of satisfaction about the healthcare services received in the UAE.

Section (4) included travel related information about the last trip by the patient, reasons for

travelling abroad, motivational factors and sources of information for choosing the country of

destination, as well as the country selected for their most recent healthcare service. In addition,

this section included what information patients required when choosing the healthcare provider

abroad. Section (5) included treatment related questions such as the type of service the patient had

received, whether the service received was inpatient or outpatient, information sought when

choosing the physician abroad, and inquiries about the physician abroad. Moreover the section

included the patient’s diagnosis abroad, the availability of treatment in the UAE and the financial

coverage of the patient’s overseas treatment. This section also asked about the main reason for

deciding to obtain healthcare outside the UAE. Section (6) included family related information

48

and travel preferences. Section (7) included financial questions related to the refund policy in case

the treatment was not received as planned. Section (8) included questions about the risks of travel

and treatment abroad. The questions in this section were related to unfavorable reactions and

complications during or after the treatment abroad, reporting in case of medical error, and patient

decisions about the treatment destination in case the travel visa was not issued or delayed. Section

(9) included the patient’s satisfaction about the overseas treatment experience and whether the

patient would recommend the overseas treatment experience to others, and what services the

patient wished could be provided in the UAE.

Since the objective of this paper is to explore patient characteristics and motivational

factors for choosing treatment destinations among those patients treated overseas from the UAE

during 2009-2012, only those survey sections and variables were selected that are relevant for the

research question as guided by the study framework and literature review. Variables were used for

descriptive analysis and the study’s regression analysis models. Questions in the survey that were

in the various sections had different instructions regarding answering formats such as: select one

answer only, circle all that apply, respond according to the Likert scale from1 to 5, and rank in

order of importance from least important to most important. Cases with missing responses were

not omitted but included as “unknown.” The study was approved by The Johns Hopkins School of

Public Health Institutional Review Board as non-human subjects research with IRB No: 00007896.

49

Variables & Measures

Demographic Characteristics. Variables measuring demographic characteristics included:

gender, age, marital status for those aged 15+, employment status for those aged 15+, education

level for those aged 15+, household average monthly income, individual answering the survey

(self-reported or a family member reported), and whether the family member reported escorted or

did not escort the patient. (See Table 2 and Appendix Table 2) Gender was a binary variable; males

were used as the reference group. Age was used as a continuous variable. Marital status for those

aged 15+ was used as a binary variable: not married and married. Married was used as a reference

group. Employment status for those aged 15+ was used as a binary variable: not working and

working. Not working was used as a reference group. Education level for those aged 15+ was used

as a categorical variable, with categories that included: illiterate or can’t read and write, up to high

school level, college and above. Illiterate or can’t read and write was used as a reference group.

Household average monthly income was used as a categorical variable10 with categories that

included: low income (≤29,000 AED = ≤7,896.53 USD), middle income (≥30,000 - ≤99,999 AED

= ≥8,168.82 - ≤27,229.14 USD), high income (≥100,000 AED = ≥ 27,229.41 USD) with the lowest

income used as a reference group. With regard to the respondent answering the survey, answering

the survey variable was used as a binary: self-reported by the patient or a family member reported

on behalf of the patient. Self-reported was used as a reference group. A family member reported

variable was used a binary variable: including the categories of a family member who escorted

the person who travelled overseas or a family member who didn’t escort the person who travelled

overseas. The family member who escorted the person overseas was used as the reference group.

10 1 AED = 0.272294 USD / 1 USD = 3.67250 AED

50

Healthcare Seeking Behavior Before Travelling Abroad. Variables describing healthcare

seeking behavior before travelling abroad included: the health situation regarding diagnosis,

consulting a healthcare provider, healthcare provider, and satisfaction with the healthcare services

provided in the UAE. (See Table 2 and Appendix Table 2) The health situation variable was used

as a binary variable with categories that included diagnosed before travel or undiagnosed before

travel. Undiagnosed used as a reference group. Consult with a healthcare provider was used as a

binary variable with the categories of consulted a healthcare provider before travel and did not

consult a healthcare provider before travel. Did not consult a healthcare provider before travel was

used as a reference group. The type of healthcare provider was used as a binary variable including

the categories of government healthcare providers and private healthcare providers, where

government healthcare provider was used as a reference group. The responses regarding

satisfaction with healthcare services provided in the UAE were used to create two categorical

variables: Satisfaction level with 5 categories for the descriptive table (very dissatisfied,

dissatisfied, neither, satisfied, and very satisfied. Very dissatisfied was used as a reference group).

Satisfaction level with 3 categories for the regression model (dissatisfied, neither, satisfied.

Dissatisfied was used as a reference group).

Diagnosed Medical Conditions before Travelling Overseas. The main medical conditions

for those with diagnoses before travelling overseas were categorized as “yes or no” binary

variables. These included: cancer, bone and joint diseases, heart diseases, high blood pressure,

diabetes, gastrointestinal diseases, eye diseases, urinary system diseases, obstetrics and

gynecology, lung and respiratory diseases, trauma, stroke or brain hemorrhage, ear, nose and throat

(ENT) diseases, cosmetic surgery, skin or venereal disease (Table 3A). A categorical variable was

also created in which patients with only one diagnosed condition were assigned to the appropriate

51

diagnosis category, and respondents selecting more than one condition were assigned to a multi-

morbidity category. (Table 3B) Undiagnosed patients and those with unknown medical conditions

(missing values and patients didn’t circle any answer) were also assigned to separate categories.

For this variable cancer was used as a reference group. (Table 3C). Main conditions and diagnosis

stratified by the outcome of going to the Federal Republic of Germany compared to going to other

destinations used as a categorical. Number of comorbidities patients were diagnosed with in the

UAE was used as a categorical variable; the category of two medical conditions was used as a

reference group (Table 3D and appendix for more details).

Country of Destination. Country of destination was coded as a categorical variable in order

to examine the frequency of destinations. (Table 1 and Appendix Table 1) Categories consisted of

the top 8 destinations travelled by residents of Dubai including the Federal Republic of Germany,

Kingdom of Thailand, United Kingdom, Republic of India, United States of America, Republic of

Singapore, Kingdom of Belgium, and Republic of Austria Other countries were also included as

one category. A binary variable was also created for the most frequent travel destination, the

Federal Republic of Germany, compared to all other destinations for the regression model.

Motivational Factors. Variables regarding motivational factors for overseas travel

included: Main reason for travel; Importance of various factors, including had been there before,

vacation aspects, friendly atmosphere, advised by someone, cost of treatment; Source of

information used to travel abroad; Information used to choose the healthcare provider abroad;

Whether inquiries were made about the physician abroad; What kind of information was sought

about the physician abroad; and the Main reason for travelling overseas for treatment. (Table 5)

The main reason for travel was used as a binary variable, including the categories of treatment

52

purposes only and other purposes. Treatment purposes only was used as a reference group.

(Appendix Table 5)

For responses to the questions related to motivational factors in which respondents were

asked to assess the degree of importance in their decision making (such as have been there before,

vacation aspects, friendly atmosphere, advised by someone, and cost of treatment), two categorical

variables were created. Five categories of importance were used for the descriptive analysis (not

important at all, not important, neutral, important, and very important). Three categories were used

for the regression model (not important, neutral, and important). Not important was used as a

reference group.

Sources and Types of Information Utilized. Every variable under sources of information

used to travel abroad was coded as a binary variable (selected as a response/not selected),

including: Word of mouth from family and friends, Internet forums, Magazine/newspaper,

Radio/TV, Brochures and leaflets, Literature, Physician’s recommendations, Provider’s webpage,

Medical travel agency/broker, Government-overseas treatment office. (Table 5)

Types of information utilized to choose the healthcare provider abroad were coded as

binary variables (selected by the respondent/not selected). These included: Different treatment

options; Qualifications and certificates of the doctor; Experience of the doctor; Reputation of the

medical center/hospital; Past success stories; Cost of treatment; Cost of accommodation, air fare,

transport, food, etc. ; Length of stay; Adverse outcome and complications of the desired treatment;

the Refund policy; The probability of having the treating doctor abroad as a visiting doctor in the

UAE for consultations; Available advanced medical and therapeutic technology; and Opinions of

friends and family regarding the best healthcare providers in the city/country.

53

Whether or not the patient/family inquired about the physician abroad was used as a

categorical variable and those who didn’t inquire were used as a reference group. Types of

inquiries about the physician abroad were used as binary variables (selected/not selected).

Respondents were asked whether information was sought for the following: Physician training and

qualifications, Recovery time as inpatient, How soon can travel back home, Pictures of previous

patients, Complications and adverse outcomes, Cost of treatment and follow-up.

Reasons for Travelling Overseas for Healthcare. Main reasons for travelling overseas for

healthcare were treated as binary variables (selected/not selected). Reasons included: cannot

afford the treatment in the UAE, not eligible for the services provided only in the military hospitals,

long waiting time to get an appointment, undesirable treatment outcome from previous personal

experience, undesirable treatment outcome from other previous experience, privacy and

confidentiality reasons, negative attitude from healthcare providers, post treatment rehab/care not

available, expecting adverse treatment outcome that might result from treatment in the UAE.

Medical Conditions Diagnosed Abroad. Medical conditions diagnosed while seeking

medical treatment overseas were treated as binary variables for each of the medical conditions

selected, including: cancer, neurological diseases & neurosurgery, pediatrics diseases, bone & joint

diseases, heart diseases, eye diseases, obstetrics and gynecology diseases, general surgery, kidney

diseases, gastrointestinal diseases, urinary tract system diseases, high blood pressure, skin or

venereal disease, stroke (brain hemorrhage or clot), mental illness, trauma, medical screening

before surgery, oral and dental diseases, lung and respiratory diseases, (ENT) diseases, diabetes,

and routine and medical checkup (Table 6A and Appendix Table 6). A categorical variable was

also created in which patients with only one diagnosed condition were assigned to the appropriate

diagnosis category, and respondents selecting more than one condition were assigned to a multi-

54

morbidity category. Undiagnosed patients and those with unknown medical conditions (missing

values and/or respondents didn’t circle any answer) were also assigned to separate categories. For

this variable used cancer was used as a reference group (Table 6B). Main condition and diagnosis

stratified by the outcome of going to the Federal Republic of Germany compared to other

destinations and this variable is used as a categorical (Table 6C). The number of comorbidities

patients were diagnosed with abroad was treated as a categorical variable. Patients diagnosed with

two medical conditions was used as a reference group (Table 6D).

Variables Related to the Most Recent Overseas Trip. The following travel related variables

were included: Time in months from the last trip to the interview, type of healthcare service(s)

received abroad, treatment availability in the UAE, source of financial coverage for treatment,

refund policy for healthcare service(s) received abroad, satisfaction with the healthcare services

received overseas, whether would recommend overseas experience to others, services would like

to be available in the UAE, unfavorable reactions/complications/outcomes during and after the

treatment abroad, knowledge of where to report medical errors, preferred choice of what to do if

there was a delay in issuing the visa. (Table 7 and Appendix Table 7)

Time in months since the last trip abroad was treated as a continuous variable. Type of

healthcare service(s) received was used as a categorical variable and included the categories of

inpatient, outpatient, and unknown. Inpatient services was used as a reference group. Treatment

availability in the UAE was used as a categorical variable with the categories of treatment

available, treatment not available, and unknown to respondent. Treatment available was used as a

reference group. Financial coverage for treatment was used as a binary variable with the categories

of government coverage and coverage from a nongovernment source (including self).The

government coverage was used as the reference group. Refund policy was used as a binary variable

55

with the categories of whether the respondent did or did not know about the provider’s refund

policy. Knowing about the refund policy used as a reference group. Responses regarding

satisfaction with the healthcare services received overseas were used to create three variables. The

respondent’s satisfaction level with 5 categories was used for the descriptive table (very

dissatisfied, dissatisfied, neither, satisfied, and very satisfied). Very dissatisfied was used as a

reference group). Satisfaction level with 3 categories was used for the regression model

(dissatisfied, neither, satisfied). Dissatisfied was used as a reference group. Recommending

overseas treatment to others was used as a binary variable with the categories of would or would

not recommend the experience to others. Would recommend the experience to others was used as

a reference group. In addition, a third variable for satisfaction was also created as a satisfaction

score about each destination traveled by residents of Dubai. It is a comparison with the satisfaction

level of the healthcare services provided overseas; among the top 5 destinations traveled by

residents of Dubai on their most recent trip during 2009 - 2012 (Table 9).

Aspects of Services Respondent Would Like Available in the UAE. Service aspects that

the respondent wished were available in the UAE was used as a binary variable (selected as a

response/not selected) with the following categories: reasonable waiting time, good healthcare

provider communication, hospitality of facility, education and reading material regarding patient’s

condition, and convenient atmosphere. (Appendix Table 7) Unfavorable

reactions/complications/outcomes during and after treatment was used as a yes/no binary variable.

No was used as a reference group. Knowledge of where to report a medical error was also used as

a yes/no binary variable. Respondents reporting yes were used as a reference group. Where to

report in case of medical error was used as a binary variable (selected as a response/not selected)

with the following categories: UAE embassy, treatment and overseas patient affairs office, police,

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hospital administration/complaint center. Preferred choice of what to do if there was a delay in

issuing the travel visa was used as categorical variable with the categories of waiting further until

the visa was received, looking for another destination abroad, or searching for health providers in

the UAE with waiting until the visa was received used as a reference group.

Travel Preferences and Role of Family. Patient travel preferences and family related

variables included whether the patient preferred to be escorted, travel arrangement preferences,

and family roles in the overseas travel. Preferences for a travel escort was used as a binary variable

with the categories of preferred travelling alone or travelling with someone. Travelling alone was

used as a reference. The respondent’s travel arrangement preference was also used as a binary

variable that included the categories of preferred to arrange the trip on own, or have the trip

arranged by a travel agency. Prefer to arrange trip by the patient used as a reference group.

Responses regarding family roles in the overseas treatment experience were used to construct

binary variables (selected/not selected) for the following: shared bad experiences, provided help

and support, helped seek options in the UAE/other countries, provided financial help, and were

worried about the experience.


Statistical analyses were conducted by using Stata 13 (Stata Corporation, College Station

TX). Quality assurance and quality control of the dataset were performed by running summary

statistics for missingness and inconsistencies in the dataset. Means, standard deviations (SDs), and

student t-tests were used for continuous variables. Frequency distributions, percentages and chi-

square tests were used for binary and categorical variables. The modified Poisson regression was

used since the incidence of having the outcome of traveling to the Federal Republic of Germany

vs other destinations was more than 10% (Zou, 2004). The Akaike information criterion (AIC) test

57

was performed to choose the best fitted model; the model with all significant variables as the

independent variables had the lowest AIC (525.4077) indicating the best model to be selected.

The outcome was defined as the country destination that residents of Dubai travelled to

during the most recent trip before the KAP survey interview. A binary outcome was created to

examine the associations between independent variables and travelling to the Federal Republic of

Germany compared to other country destinations. The independent variables selected for the

models were statistically significant in cross-tabulations, and bivariate analysis based on the push-

pull factor framework relevant for our outcome of interest and research question.

Two steps of regression analyses were built. The first regression analysis was a bivariate

regression where the dependent variable was regressed on each significant independent variable

separately from the cross tabulation. The second regression analysis was the modified Poisson

model. This was the adjusted model, where each independent variable was adjusted for all other

independent variables. Variables used in the final model were the significant variables in the

bivariate analyses and relevant to our framework. Two types of variables were not included in the

final model: variables that were significant in the cross tabulation and in the bivariate analysis but

not directly relevant to our framework (e.g. Unfavorable reactions/complications/outcomes during

and after treatment, High blood pressure diagnosed overseas) and variables that were significant

in the cross tabulation and the bivariate analysis but not significant in the final model (e.g. income

level, type of healthcare services, and financial help under family response towards overseas

treatment).The backward selection method was used to remove variables not statistically

significant from the model. To ensure that there is no collinearity among the variables in the final

model, the variance inflation factor (VIF) was performed. The mean VIF was (1.05) indicating

there is no collinearity in the model. P<0.05 indicated statistical significance.

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Results

There were 336 UAE national families who sought overseas treatment during 2009 – 2012

and were interviewed regarding their most recent trip to explore their knowledge, attitudes and

perceptions. Only (n=125; 37%) from those who experienced medical treatment overseas as

patients answered the survey; whereas the majority of survey respondents were eligible family

members who escorted patients during the overseas treatment experience or family members who

didn’t escort the patient but did have enough information about the patient experience to serve as

survey respondents. The patients treated overseas travelled to 17 destinations. The top destinations

for treatment overseas among residents of Dubai based on the frequencies were: Federal Republic

of Germany (n=152; 45%), followed by the Kingdom of Thailand (n=64; 19%), and United

Kingdom (n=37; 11%). Other less frequent destinations are shown in Table 1.

Half of the patients were male and half female. The patients’ mean age was 40.09 ±22.66;

a higher proportion were married (n=177, 66%), not working (n=178, 66%), with up to a high

school education (n=132, 49%), and lower household income (n=203, 60%). The data on travel

destinations were dichotomized in terms of travelling to the Federal Republic of Germany and to

all other destinations. Patients who travelled to Germany were more likely than those travelling to

other destinations to have mid-level or higher household incomes (P=0.045) shown in Table 2.

Before seeking medical treatment overseas (n=277; 82%) patients were diagnosed

regarding their medical conditions and (n=285; 85%) did consult their healthcare providers before

travelling overseas. There were (n=215; 64%) patients who sought medical treatment overseas and

who received healthcare services in the government/public sector for their healthcare conditions

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before obtaining medical treatment overseas.11 Overall, patients who traveled overseas either to

the Federal Republic of Germany or other destinations had a mean satisfaction rating of 1.88±1.34

which indicates they were neither satisfied nor dissatisfied with the healthcare services they

received in the UAE as shown in Table 3.

The most frequent medical conditions for which people traveled overseas were cancer,

bone and joint diseases, and heart diseases shown in Table 4A. Looking at patients’ medical

conditions (with multiple choices permitted), those who traveled to other destinations were more

likely to have diagnosed eye diseases (p=0.001) while patients who traveled to Germany were

more likely to have diagnosed stroke (brain hemorrhage or clot) (p=0.03) as shown in Table-4A.

When accounting for comorbidities as a separate category; (n=47; 14%) patients were diagnosed

with more than one condition as shown in Table 4B. Cancer, bone and joint diseases and heart

diseases remained the most frequent diagnoses for patients with only one condition. When

comparing patients by the outcome of going to the Federal Republic of Germany or other

destinations there were significant differences, with those going to the Federal Republic of

Germany less likely to have diagnosed eye diseases and obstetrics and gynecology; and more

likely to have urinary system diseases, and stroke. In addition, patients are more likely to have

undiagnosed medical conditions when travelling to the Federal Republic of Germany, compared

to those who traveled to other destinations (p=0.027) as shown in Table 4C.

As noted, 47 patients who travelled abroad had been diagnosed with multiple medical

conditions. These comorbidities included two medical conditions, three medical conditions, four

medical conditions and up to 5 medical conditions as shown in Table 4D. The most frequent

11 These public providers include: Dubai Health Authority inpatient/outpatient services, Abu Dhabi Health Services

Hospitals and PHCs (SEHA), and Ministry of health inpatient/outpatient services

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comorbidities patients travelled overseas for were heart diseases with diabetes as a comorbidity

with two medical conditions, and heart diseases with diabetes with high blood pressure as a

comorbidity with three medical conditions. More details about baseline comorbidities (diagnoses

prior to travel) examined by the outcome of going to the Federal Republic of Germany versus other

destinations can be found in Appendix Tables 4E to 4N.

Almost all of the patients (n=332; 99%) who travelled overseas went for treatment

purposes only. Overall, those patients who travelled overseas to the Federal Republic of Germany

or to other destinations had no differences regarding their motivational factors, including: having

a previous experience in the destination country, vacation aspects, believing the country has a

friendly environment, and following someone’s advice. Of these factors, following someone’s

advice was the most important, with almost two-thirds of the patients citing this factor as important

or very important. Patients who travelled to the Federal Republic of Germany were less likely

than those travelling to other destinations to cite the cost of travel as an important factor in their

decision-making (p=0.002) as shown in Table 5.

When asked about sources of information utilized, (n=181; 54%) patients reported using

a physician’s recommendation as a source of information when travelling overseas, followed by

word of mouth from family and friends (n=176; 52%). Moreover; (n=95; 28%) patients reported

they would look at the physician’s experience first when choosing a healthcare provider for

services abroad, followed by (n=80; 23%) who would look at the reputation of the medical

center/hospital. The majority of patients (n=256; 76%) inquired about the physician at the

treatment destination; in addition, (n=191; 56%) patients inquired about the physician’s training

and qualifications, followed by (n=128; 38%) who inquired about recovery time as an inpatient.

Patients who sought treatment in the Federal Republic of Germany were less likely to ask about

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the costs of treatment and follow-up than patients who travelled to other destinations (p=0.01)

when inquiring about the physician overseas. When asked about their main reason for travelling

overseas, (n=29; 8%) patients stated that long waiting time for an appointment was the main reason

for deciding to obtain healthcare services overseas followed by (n=27; 8%) patients who stated

that privacy and confidently was another main reason to seek healthcare overseas shown in Table

5.

Cancer, bone and joint diseases and heart diseases remained the most frequent conditions

when patients were diagnosed abroad. Looking at patients medical conditions (with multiple

choices permitted), there were still differences between going to the Federal Republic of Germany

over other destinations. Patients travelling to Germany were less likely to be diagnosed with eye

diseases (p=0.04) and high blood pressure (p=0.01). On the other hand patients are more likely to

be diagnosed with stroke (brain hemorrhage or clot) (p=0.03) when travelling to other destinations,

as shown Table-6A. When accounting for comorbidities as a separate category, the number of

patients who were diagnosed with more than one condition increased to (n=92; 27%) compared to

the baseline number of 47 who had multiple diagnoses in the UAE. Cancer remained the most

frequent diagnosis for patients with only one condition (n=58; 17%) and heart diseases became the

second most frequent condition (n=28; 8%), with bone and joint diseases moving to the third most

frequent condition (n=25; 7%) compared to the baseline diagnoses in the UAE as shown in Table

6B). When comparing patients by the outcome of going to the Federal Republic of Germany over

other destinations there were significant differences between the medical conditions diagnosed and

treated in the Federal Republic of Germany compared to other destinations (p=0.032) as shown in

Table 6C.

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As noted, while seeking medical treatment abroad, patients had a higher number of

diagnosed comorbidities compared with the baseline diagnosis in the UAE. Some patients were

diagnosed with two medical conditions, three medical conditions and up to 7 medical conditions

as shown in Table 6D. The most frequent comorbidity with two medical conditions was cancer

with bone and joint disease, whereas the most frequent comorbidity with three medical conditions

was cancer with high blood pressure and diabetes. More details about comorbidities diagnosed

abroad examined by the outcome of going to the Federal Republic of Germany versus other

destinations can be found in Appendix Tables 6E to 6S.

Table 7 examines factors related to the most recent trip abroad for seeking medical care.

The average number of months was 15.66±15.71 from the last trip for healthcare abroad to the

time of being interviewed for the KAP survey. Overall, (n=228; 67%) patients who received

medical services overseas had inpatient treatment (surgical or non-surgical), with patients traveling

to Germany more likely to receive inpatient services than those travelling to other destinations

(p=0.04). More than half (n=187; 55%) stated that their medical treatment was not available in the

UAE, with no significant differences by treatment destination. Overall, the majority (n=265; 78%)

indicated that their expenses of treatment were covered by the government, although those

travelling to Germany were significantly more likely to have government coverage than those

travelling to other destinations (p=<0.001).12 The majority (n=296; 88%) revealed that they didn’t

know about the refund policy the health care provider overseas. Overall, patients who received

overseas medical treatment had a higher mean satisfaction level (3.45±0.94) with the healthcare

received during the last healthcare trip abroad than with the healthcare services they had received

in the UAE. The great majority (n=302; 90%) would recommend their overseas healthcare trip

12 Government of Dubai, or Ministry of health, or Government of Abu-Dhabi

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experience to someone else, with no differences by country of destination. When asked about the

aspects of services the survey respondents would like to have available in the UAE, the top 3 were:

good healthcare provider communication13 (82%), a convenient access and atmosphere14 (64%),

and a reasonable waiting time at the clinic15 (42%).

In addition, although most patients (n=274; 81%) who received medical treatment overseas

did not experience any unfavorable reactions/complication/outcomes during or after treatment

overseas,16 patients travelling to Germany were more likely to experience such events than patients

traveling to other destinations (p=0.002). The majority (n=286; 85%) of the respondents expressed

that they knew where to report in case of a medical error and (n=237; 70%) indicated they would

contact the UAE embassy at the destination country, with no significant differences by country of

destination. In addition, the majority (n=257; 76%)17 expressed that they would wait and still go

to the same destination if they faced a delay in the issuing of a visa of entry to their desired

destination as shown in Table 7. (Council of the European Union, 2015)

With regard to preferences for travelling overseas for treatment and the role of family

members, the great majority (n=326; 97%) of the respondents preferred travelling overseas

escorted by a family member, (n=241; 72%) preferred the trip to be arranged by a travel agency,

and (n=314; 93%) disclosed that their family’s response was to support and help in their decision

13 Treating doctor talked clearly to me about my condition, Treating doctor gave me different treatment options,

Treating doctor explained to me how I can cope; live normal life with my condition, Treating doctor explained what

might happen to me in the future, The medical staff was polite, and courteous, The medical staff was able to respond

to my inquiries efficiently and referred me to the right persons, The treating doctor was listening to me 14Easiness of booking for an appointment “convenient, didn't take long time”, Consultation and Diagnostic work-ups

and treatment were all in the same building, The hospital called to report my results instead of me going to them 15 Reasonable waiting time at the clinic before seeing the doctor 16 Fever/infection after the surgery, allergy from medication, wrong diagnosis, other surgical complications, other

medical complications, results not as explain by the doctor 17 The survey was before the agreement between the European Union and the United Arab Emirates in Brussels on

May 6th 2015 on the short-stay visa waiver were Ireland and the United Kingdom are not part of this agreement

64

about travelling overseas to receive medical treatment. However, financial help from family was

less likely for those travelling to Germany in comparison to those who travelled to other

destinations (p=0.02) as shown in Table 8. Although the top travel destination for treatment

overseas among residents of Dubai was the Federal Republic of Germany, the percentage satisfied

or very satisfied with their experience was 87%, which is lower than the other top destinations

which were: 95% for Thailand, 92% for the United Kingdom, 93% for India, and 92% for the

United States of America as shown in Table 9.

The motivational factors and association with country of destination when seeking healthcare

services overseas

The model examining motivational factors associated with choosing country of destination

when seeking healthcare services overseas. The model was adjusted for the covariates cost of

treatment, and treatment coverage with the medical conditions (eye disease and stroke), associated

with the outcome. Prevalence ratio is shown in Table 10. People diagnosed with eye diseases had

a 66% lower prevalence ratio of choosing the Federal Republic of Germany (PR 0.34, 95%CI:

0.13, 0.87, p=0.03) compared to people with other medical conditions. On the other hand, people

who were diagnosed with stroke (brain hemorrhage or clot) had a 90% higher prevalence ratio to

choose the Federal Republic of Germany compared to people with other medical conditions (PR

1.90, 95% CI: 1.45,2.51, p=<0.001).

People who had the cost of treatment as an important reason to choose the country of

destination for treatment had a 29% lower prevalence ratio of choosing the Federal Republic of

Germany compared to people who had the cost as not important at all (PR 0.71, 95% CI: 0.51,0.10,

p=0.05). People who were not sponsored by the government had a 67% lower prevalence ratio of

65

choosing the federal Republic of Germany compared to people who were sponsored by the

government.

Discussion

Nearly half of the patients from the United Arab Emirates who travelled overseas during

2009-2012 sought medical treatment in the Federal Republic of Germany as a first trip. The

prevalence of travelling to the Federal Republic of Germany was significantly associated with

lower concerns about financial costs and having government coverage for medical expenses in

comparison to travelling to other destinations. Patients who travelled to the Federal Republic of

Germany were more likely to be diagnosed with stroke (brain hemorrhage or clot) and less likely

to be diagnosed with eye diseases. Although receiving advice from someone was not statistically

significantly different between those choosing the Federal Republic of Germany over other

destinations, it had the highest frequency compared to other motivational factors such as having

been there before, vacation aspects, and a perceived friendly atmosphere. Moreover, physician

training, qualifications and experience followed by reputation of the medical center, were

important information that patients inquired about in general when seeking healthcare services

overseas.

Many studies have stated that financial cost plays a vital role in influencing decisions

regarding seeking healthcare services overseas (Culley et al., 2011; Eissler & Casken, 2013; Gan

& Frederick, 2013; Guiry & Vequist, 2011; Guy et al., 2015; Horowitz & Rosensweig, 2007; Khan,

Chelliah, & Haron, 2016; Kozak, 2002; Lee, Han, & Lockyer, 2012; Moghimehfar, 2011; Noree

et al., 2014; Peters, 2011; Kai Ruggeri et al., 2015; Turner, 2011; Yu, 2012). Respondents to this

survey were price sensitive when making the decision between seeking healthcare in the Federal

Republic of Germany compared to other destinations (N. T. Lunt, Russell Mannion, and Mark

66

Exworthy, 2013). Respondents agreed that cost is very important when choosing the destination;

cost was part of their concerns when inquiring about physicians abroad and patients’ families were

more likely to provide financial support when patients make the decision to travel to other

destinations compared to the Federal Republic of Germany. In addition, patients travelling to the

Federal Republic of Germany rather than to other destinations were more likely to have their

medical expenses covered by the government. Therefore lower concern about costs can be

considered a main pull factor that attracted UAE nationals to choose the Federal Republic of

Germany over other destinations. On the other hand; medical conditions were another factor

influencing choice of the country of destination. Patients diagnosed with stroke (brain hemorrhage

or clot) were more likely to choose the Federal Republic of Germany as a treatment destination.

On the contrary, patients diagnosed with eye disease were more likely to choose other destinations

compared to the Federal Republic of Germany. The results in this aim are consistent with our

results from the first aim. We found in aim-1b, compared to orthopedic surgery as a reference

group, patients with Neurosurgery had an 11% lower prevalence ratio for seeking the procedure in

the Federal Republic of Germany over other destinations. Whereas patients with Ophthalmology

had a 78% lower prevalence ratio for seeking the procedure in the Federal Republic of Germany

when using the same reference group of orthopedic surgery.

According to the literature, there are many motivational factors that can push the patients

from the country of residency and pull them towards the treatment destinations. Although the

financial cost was a significant reason for choosing between the Federal Republic of Germany and

other destinations, other factors were also important in seeking healthcare services overseas such

as: being advised by someone, word of mouth from family and friends, a physician’s

recommendation, and long waiting time for treatment in the UAE (V. A. Crooks et al., 2010;

67

Heung, 2010; Turnbull & Uysal, 1995; Yu, 2012). The literature emphasizes the importance of

word of mouth as a source of information when exchanging and looking for feedback about the

treatment destination (E. Yeoh, Othman, K. and Ahmad, H., 2013). In addition, the literature has

stated that people’s expectations are formed as a result of word of mouth and recommendations

either from family and friends or a physician’s referral and recommendations. Quality of care, long

waiting time and unavailability of the treatment in the country of residence are considered

fundamental factors that push people to treatment destinations. People would prefer destinations

that are specialized for the healthcare services related to their health condition. Furthermore,

healthcare providers’ interpersonal aspects, conduct and communication, as well as medical staff

responsiveness are important factors in seeking healthcare services overseas. In our study

respondents expressed that healthcare provider communication from the overseas experience

would be desirable in the UAE.

Although physician reputation and characteristics were not significant variables in

choosing between the different destinations in our study, 76% of the respondents stated that they

would inquire about the physician abroad before seeking healthcare services overseas. When

inquiring about the physician abroad, 57% stated they would inquire about physician training and

qualifications and 38% would inquire about recovery time as an inpatient. Physician characteristics

are one of the important factors when selecting a healthcare provider overseas (Damman,

Spreeuwenberg, Rademakers, & Hendriks, 2012). Physician competence, expertise, training and

qualifications were selected by our respondents in the survey, which is consistent with the literature

(Ejaz et al., 2014; Guy et al., 2015). Moreover, some studies have demonstrated that physician

demographic characteristics such as age, gender, race, religion and marital status are least

important to the patients when making a choice about physicians compared to physicians’

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professional expertise such as being board certified and specializations (Bornstein, Marcus, &

Cassidy, 2000). Hospital reputation, accreditation and characteristics are other important factors,

following physician characteristics when selecting healthcare providers (Beukers et al., 2014).

According to some studies about patients’ hospital choices, in non-emergency cases and when

patients are financially covered, patients will choose hospitals with high quality of care ratings and

shorter waiting times. Furthermore patients’ decisions are more influenced sometimes by family

and friends’ experiences when making a decision about a hospital or a medical center compared

to the key performance indicators of the healthcare provider on its webpage (I. B. De Groot, Otten,

W., Dijs-Elsinga, J., Smeets, H.J., Kievit, J. and Marang-van de Mheen, P.J., 2012; I. B. De Groot,

Otten, W., Smeets, H.J. and Marang-van de Mheen, P.J., 2011).

Acknowledging limitations of the study is very important in order to make suggestions for

future research related to treatment overseas. The sample size was small for this study. Many

motivational factors that were considered significant in the literature were unable to be detected as

significant in this study. Variables that had borderline significance in our study: availability of

treatment in the UAE (p=0.08), satisfaction of the healthcare provided overseas (p=0.06), and

patients diagnosed with Obstetrics and Gynecology diseases before seeking medical treatment

overseas (p=0.06). Therefore to achieve a desired level of precision and a desired margin of error;

a minimum detectable difference is required through a power and sample size calculation to have

a better representative sample in the future. (Ahmad, Amin, Aleng, & Mohamed, 2012). Since the

methodology was through purposive sampling, therefore we have to be careful with generalization

since the participants in the study are not the true representation of the population of the Emirate

of Dubai which would be needed to make statistical inferences. Additionally, the ratio of non-UAE

nationals to UAE nationals was 3:47 (6:94) which is not the true representation of the population

69

of Dubai; therefore the non-UAE nationals were dropped from the sample to reduce the “noise

effect” and to focus on the UAE-nationals only as a priority in this study. It is also worthwhile to

mention that our study is a cross-sectional study; as a result it yields weak evidence of causality

between the predictors and the outcome.

Only 37% of the survey was answered by the patient who had experienced the medical

treatment overseas. On the other hand 63% of the survey was answered by an eligible family

member who escorted the patient during the treatment overseas or a family member who did not

escort the patient overseas but have enough information about the patient experience. This lead to

question the perception and the motivational factors answered in this survey whether it reflects the

true perception of the patient or the family member who answered the survey. In addition since 16

months was the average time from the last trip during which patients and their families obtained

healthcare services overseas before being interviewed for this survey, “re-call bias” may pose a

threat to the internal validity of the survey results. Moreover, the study design did not account for

whether more than one family member experienced travelling overseas with the patient for medical

treatment. Accounting for more than one family member would help ensure that the survey is

capturing the right experiences adjusted for the patient characteristics, treatment destination,

motivational factors and medical condition.

Validity and reliability of the survey can be further improved in the future. Although the

survey was piloted once, it is important to use the survey more than one time on the same

population to test the reliability and consistency of the tool overtime. In addition other reliability

and validity metric tests can be applied to ensure high validity and reliability of the survey (Bland,

1997; Radhakrishna, 2007). Geographical closeness of the destination to the home country is

considered one of the main factors in choosing the destination of treatment in the literature. This

70

question was asked twice in two different sections of the survey once as “geographical closeness

to the UAE” and another time as “travelling to treatment destinations closer to the UAE.” Since

the results of the two questions were inconsistent and different from each other, this variable was

dropped from the analysis for reliability purposes. Quality of healthcare was another question

related to reasons that best explain why the patient did not get healthcare services in the UAE was

dropped because only 6% of the participants answered that question.

In terms of the survey writing format, there is a room for wording improvement. For

example, the question related to medical conditions diagnosed in the UAE (at baseline) compared

to medical conditions diagnosed abroad had inconsistency with the medical condition terms. The

medical conditions were written differently under each question. Another example of a wording

format is the Likert questions. There are two Likert questions; one question was titled as a Likert

question and another question was titled as rank according to the importance. The ranking question

used in the survey is another form of Likert scale since participants are ranking the same item not

ranking different items in terms of importance. Therefore ranking question should be titled as a

Likert question and not as a ranking question (Allen & Seaman, 2007; Boone & Boone, 2012).

As related to the strengths of this study, although there is some literature about medical

tourism and medical travel, there is very limited quantitative research studying the associations

between patients’ characteristics, motivational factors, and medical conditions when it comes to

choosing treatment destinations, and choosing physicians and hospitals in the treatment

destinations. Therefore this research paper will provide good insights and will contribute to the

knowledge base regarding seeking healthcare overseas. This study will have great policy and

strategy implications, not only for the Emirate of Dubai, but also for the UAE in general.

71

Understanding the motivational factors for people who traveled overseas seeking

healthcare will help in creating strategies to improve the healthcare services in the Emirate of

Dubai and in the UAE. Moreover, it will give better insights for having long term planning for

better access with alternative options for patients in the government sector and the private sector

in the emirate of Dubai. That can be achieved through the expansion of the healthcare services

related to the medical conditions patients travelled for and also through collaboration between the

government and private sector by public-private partnership agreements (FASO, 2016; Sharma &

Bindal, 2014).

It is also important for the government to ensure that the patients have enough adequate

information about the services related to their medical condition in the UAE to give patients more

options to choose from and increase patients’ access and utilization of the healthcare services in

Dubai and in the UAE. Identifying the pull and push factors are also important in order to use them

to attract patients to stay in the UAE in order to reduce the risks and complications following

treatment overseas, since patients will be diagnosed and treated locally instead of having treatment

and follow up in two different locations.

Considering that some respondents expressed that long waiting time, as well as privacy

and confidentiality reasons were main motives to travel overseas, the government should work on

reducing waiting time and ensure policies and regulations are in place to protect privacy and

patients’ rights. In addition, it is important to underscore that healthcare provider communication

was one of the service aspects that respondents wished to be available in the UAE. Therefore

physicians, nurses, allied health personal and all the workforce who provide healthcare services or

who are in a direct contact with the patients should be trained for better interpersonal

communication.

72

Conclusion

In conclusion, tracking patients’ experience following treatment overseas is not only

important in order to know patient outcomes after receiving treatment overseas, but also to learn

from patients’ experiences. A closer follow up of patients after returning from the treatment

destinations can set the stage for comparative and cost effectiveness analyses in order to send

patients to destinations of lower cost and high quality patient outcomes in the future. In addition,

measuring patients’ satisfaction levels in depth after the experiences provided overseas can help

the government to learn best practices from destinations with high satisfaction rates and find other

appropriate options for destinations rated with low satisfaction rates by patients.

73

Tables

Table 1. Top 8 travel destinations of residents of Dubai, United Arab Emirates who sought

medical treatment overseas during 2009 – 2012

No. Country of Destination Total Sample N (%)

1 Federal Republic of Germany 152 (45.2)


3 United Kingdom 37 (11.01)

4 Republic of India 27 (8.04)

5 United States of America 13 (3.87)




9 Other countries 17 (5.09)

Total 336 (100.00)

Table 2. Demographic characteristics of residents of Dubai, United Arab Emirates who

sought medical treatment overseas during 2009 – 2012

Variable Total Sample

N (%)

Federal Republic of

Germany

Other Destinations P-value

Gender 1.00

Male 168 (50.00) 76 (50.00) 92 (50.00)

Female 168 (50.00) 76 (50.00) 92 (50.00)

Age (years) * 40.09 ±22.66 38.90±22.91 41.08±22.46 0.38

Marital Status** 0.56

Married 177 (66.04) 75 (64.10) 102 (67.55)

Not Married 91 (33.96) 42 (35.90) 49 (32.45)

Employment Status** 0.85

Not working 178 (66.42) 77 (65.81) 101 (66.89)

Working 90 (33.58) 40 (34.19) 50 (33.11)

Educational Level** 0.89

Illiterate or Can’t

Read & Write

73 (27.24) 32 (27.35) 41 (27.15)

Up to High School 132 (49.25) 56 (47.86) 76 (50.33)

College & Above 63 (23.51) 29 (24.79) 34 (22.52)

Household Income

Categories***

0.045

Low Income 203 (60.42) 81 (53.29) 122 (66.30)

Middle Income 70 (20.83) 39 (25.66) 31 (16.85)

Higher Income 63 (18.75) 32 (21.05) 31 (16.85)

Answering the Survey 0.21

Self-reported 125 (37.20) 51 (33.55) 74 (40.22)

Family member

reported

211 (62.80) 101 (66.45) 110 (59.78)

Family Member

Reported

0.92

74

Escorted 189 (92.20) 92 (92.00) 97 (92.38)

Not Escorted 16 (7.80) 8 (8.00) 8 (7.62)

* mean ± standard deviation

** Only among those who are 15 years and older

***1 AED = 0.272294 USD / 1 USD = 3.67250 AED [low income (≤29,000 AED = ≤7,986.53 USD), middle income (≥30,000 -

≤99,999 AED = ≥8,168.82 - ≤27,229.14 USD), high income (≥100,000 AED = ≥ 27,229.41 USD)]

P-value for chi-square test

Table 3. Residents of Dubai, United Arab Emirates health seeking behavior before

travelling overseas

*SD: Standard Deviation


Variable Total Sample N (%) Federal Republic of

Germany


Health Situation

Undiagnosed 59 (17.56) 25 (16.45) 34 (18.48) 0.63

Diagnosed 277 ( 82.44) 127 ( 83.55) 150 (81.52)

Consult Healthcare Provider

Didn’t Consult 51 (15.18) 20 ( 13.16) 31 (16.85) 0.35

Consult 285 (84.82) 132 (86.84) 153 (83.15)

Healthcare Provider

Government 215 (63.99) 100 (65.79) 115 (62.50) 0.53

Other 121 (36.01) 52 (34.21) 69 (37.50)

Satisfaction of the Healthcare

Services Provided in the UAE

1.00

0=Very dissatisfied 72(21.43) 32 (21.05) 40 (21.74)

1=Dissatisfied 69 (20.54) 31 (20.39) 38 (20.65)

2=Neutral 60 (17.86) 27 (17.76) 33 (17.93)

3=Satisfied 96 (28.57) 45 (29.61) 51 (27.72)

4=Very Satisfied 39 (11.61) 17 (11.18) 22 (11.96)

Mean ±SD* 1.88±1.34 1.89±1.34 1.88±1.35 0.89

75

Table 4A. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

before seeking medical treatment overseas during 2009 – 2012 (more than one choice

permitted)

No. Medical Condition Total Sample N

(%)

Federal Republic of

Germany

Other

Countries

P-value

1 Cancer 47 (17.03) 21 (16.54) 26 (17.45) 0.84

2 Bone and Joint 44 (15.88) 23 (18.11) 21 (14.00) 0.35

3 Heart Diseases 41 (14.80) 17 (13.39) 24 (16.00) 0.54

4 High Blood Pressure 24 (7.14) 7 (4.61) 17 (9.24) 0.10

5 Diabetes 34 (10.12) 12 (7.89) 22 (11.96) 0.22

6 Gastroenterology 22 (6.55) 10 (6.58) 12 (6.52) 0.98

7 Eye Disease 20 (5.95) 3 (1.97) 17 (9.24) 0.01

8 Urinary System 16 (4.76) 9 (5.92) 7 (3.80) 0.36

9 Obstetrics and Gynecology 8 (2.38) 1 (0.66) 7 (3.80) 0.06

10 Lungs and Respiratory 9 (2.68) 3 (1.97) 6 (3.26) 0.467

11 Trauma 8 (2.38) 3 (1.97) 5 (2.72) 0.66

12 Stroke 7 (2.08) 6 (3.95) 1 (0.54) 0.03

13 Ear, nose and throat (ENT)

Diseases

3 (0.89) 2 (1.32) 1 (0.54) 0.454

14 Cosmetic 3 (0.89) 2 (1.32) 1 (0.54) 0.454

15 Skin and Venereal Diseases 2 (0.60) 1 (0.66) 1 (0.54) 0.90

16 Oral and Dental Diseases 1 (0.30) 0 (0) 1 (0.54) 0.36


Table 4B. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

before seeking medical treatment overseas during 2009 – 2012(diagnosis categories include

patients with only one condition; patients with multimorbidity included as a separate

category)

No. Medical Condition Total Sample N (%)

1 Cancer 37 (11.01)

2 Bone & Joint Diseases 29 (8.63)

3 Heart Diseases 28 (8.33)

4 High Blood Pressure 2 (0.60)

5 Diabetes 7 (2.08)

6 Gastrointestinal Diseases 11 (3.27)

7 Eye Diseases 16 (4.76)

8 Urinary System Diseases (Kidney or Bladder) 12 (3.57)


10 Lungs & Respiratory Diseases 8 (2.38)

11 Trauma 7 (2.08)

12 Stroke or Brain Hemorrhage 4 (1.19)

13 Ear, nose and throat (ENT) Diseases 1 (0.30)

14 Cosmetic Surgery 2 (0.60)

15 Skin or Venereal Diseases 1 (0.30)

16 More than one condition 47 (13.99)

17 Unknown Conditions 60 (17.86)

18 Undiagnosed 58 (17.26)

Total 336 (100.00)

76

Table 4C. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

before seeking medical treatment overseas during 2009 – 2012 by country of destination


No. Medical Condition Federal Republic of Germany Other Countries

1 Cancer 16 (10.53) 21 (11.41)

2 Bone and Joint 15 (9.87) 14 (7.61)

3 Heart Diseases 13 (8.55) 15 (8.15

4 High Blood Pressure 0 (0) 2 (1.09)

5 Diabetes 2 (1.32) 5 (2.72)

6 Gastroenterology 6 (3.95) 5 (2.72)

7 Eye Diseases 2 (1.32) 14 (7.61)

8 Urinary System 9 (5.92) 3 (1.63)

9 Obstetrics and Gynecology 0 (0) 6 (3.26)

10 Lungs and Respiratory 3 (1.97) 5 (2.72)

11 Trauma 3 (1.97) 4 (2.17)

12 Stroke 4 (2.63) 0 (0)


Diseases

0 (0) 1 (0.54)

14 Cosmetic 1 (0.66) 1 (0.54 )

15 Skin and Venereal Diseases 0 (0) 1 (0.54)

16 More than one Diagnose 20 (13.16) 27 (14.67)

17 Unknown 25 (16.45) 35 (19.02)

18 Undiagnosed 33 (21.71) 25 (13.59)

Total 152 (100.00) 184 (100.00)

P- Value 0.027

77

Table 4D. Number of comorbidities that residents of Dubai, United Arab Emirates were

diagnosed with before seeking medical treatment overseas during 2009 – 2012 by country

of destination


Number Comorbidities Total sample N (%) Federal Republic of Germany Other Destinations 2 comorbidities 31 ( 65.96) 16 (80.00) 15 ( 55.56)

3 comorbidities 13 ( 27.66) 4 (20.00) 9 ( 33.33)

4 comorbidities 1 (2.13) 0 (0) 1 ( 3.70)

5 comorbidities 2 (4.26) 0 (0) 2 ( 7.41)

Total 47 (100) 20 (100) 27 (100)

P-value 0.261

78

Table 5. Motivational factors among residents of Dubai, United Arab Emirates who sought

medical treatment overseas during 2009 – 2012 by country of destination


Germany


Main Reason for Travel 0.85

Treatment purpose only 332 (98.81) 150 (98.68) 182 (98.91)

Other purposes 4 (1.19) 2 (1.32) 2 (1.09)

Have Been There Before 0.19

Not Important at all 166 (49.40) 74 (48.68) 92 (50.00)

Not Important 56 (16.67) 33 (21.71) 23 (12.50)

Neutral 13 (3.87) 6 (3.95) 7 (3.80)

Important 58 (17.26) 23 (15.13) 35 (19.02)

Very Important 43 (12.80) 16 (10.53) 27 (14.67)

mean±SD* 2.27±1.52 2.17±1.43 2.35± 1.58

Vacation Aspects 0.11


Not Important 66 (19.64) 36 (23.68) 30 (16.30)

Neutral 25 (7.44) 9 (5.92) 16 (8.70)

Important 18 (5.36) 4 (2.63) 14 (7.61)

Very Important 9 (2.68) 3 (1.97) 6 (3.26)

mean±SD* 1.61±1.01 1.51±0.87 1.70±1.11

Friendly Atmosphere 0.24


Not Important 47 (13.99) 25 (16.45) 22 (11.96)

Neutral 22 ( 6.55) 10 (6.58) 12 (6.52)

Important 68 (20.24) 28 (18.42) 40 (21.74)

Very Important 54 (16.07) 18 (11.84) 36 (19.57)

mean±SD* 2.52± 1.58 2.32±1.50 2.68±1.63

Advised by Someone 0.53


Not Important 30 (8.93) 16 (10.53) 14 (7.61)

Neutral 22 (6.55) 12 (7.89) 10 ( 5.43)

Important 81 (24.11) 33 (21.71) 48 (26.09)

Very Important 141 (41.96) 60 (39.47) 81 (44.02)

mean±SD* 3.62±1.54 3.49±1.58 3.73±1.50

Cost of Treatment 0.002


Not Important 54 (16.07) 29 (19.08) 25 (13.59)

Neutral 41 (12.20) 17 (11.18) 24 (13.04)

Important 32 (9.52) 13 (8.55) 19 (10.33)

Very Important 54 (16.07) 12 (7.89) 42 (22.83)

mean±SD* 2.33±1.51 1.99±1.31 2.612±1.62

Sources of Information Used to

Travel Abroad

Word of mouth family and friends 176 (52.38) 74 (48.68) 102 (55.43) 0.22

Internet forums 61 (18.15) 30 (19.74) 31 (16.85) 0.49

Magazine/newspaper 1 (0.30) 1 (0.66) 0 (0) 0.27

Radio/TV 1 (0.30) 0 (0) 1 ( 0.54) 0.36

Brochures and leaflets 1 (0.30) 1 ( 0.66) 0 (0) 0.27

Literature 2 (0.60) 1 (0.66) 1 ( 0.54) 0.89

Physician’s recommendations 181 (53.87) 88 (57.89) 93 (50.54) 0.18

Providers webpage 4 (1.19) 2 (1.32) 2 (1.09) 0.85

79

* SD: Standard Deviation P-value for chi-square test

Medical Travel agency/Broker 2 (0.60) 1 (0.66) 1 (0.54) 0.89

Government (overseas treatment

office)

80 (23.81) 41 (26.97) 39 (21.20) 0.22

Information Would Use to Choose

Healthcare Provider

0.41

Different Treatment Options 27 (8.04) 14 (9.21) 13 (7.07)

Qualifications and certificates of the

doctor

39 (11.61) 19 (12.50) 20 (10.87)

Experience of the doctor 95 (28.27) 36 (23.68) 59 (32.07)

Reputation of the medical

center/hospital

80 (23.81) 36 (23.68) 44 (23.91)

Past success stories 41 (12.20) 19 (12.50) 22 (11.96)

Cost of treatment 6 (1.79) 2 (1.32) 4 (2.17)

Cost of accommodation, air fare,

transport, food, etc.

1 (0.30) 0 (0) 1 (0.54)

Length of stay 1 (0.30) 1 (0.66) 0 (0)

Adverse outcomes and complications

of the desired treatment

2 (0.60) 2 (1.32) 0 (0)

Refund policy 2 (0.60) 0 (0) 2 (1.09)

The probability of having the treating

doctor abroad as visiting doctors in

the UAE for consultations

10 (2.98) 7 (4.61) 3 ( 1.63)

Available advanced medical &

Therapeutic technology

3 (0.89) 1 (0.66) 2 (1.09)

Opinions of friends and family

regarding the best healthcare

providers in the city/country

29 (8.63) 15 (9.87) 14 (7.61)

Inquire About Physician 0.76

Didn’t Inquire 80 (23.81) 35 (23.03) 45 (24.46)

Inquire 256 (76.19) 117 (76.97) 139 (75.54)

Types of Inquiries About the

Physician Abroad

Physician Training & Qualifications 191 (56.85) 86 (56.58) 105 (57.07) 0.93

Recovery Time as inpatient 128 (38.10) 55 (36.18) 73 ( 39.67) 0.51

How soon will travel back home 87 (25.89) 37 (24.34) 50 (27.17) 0.56

Pictures of Previous Patients 59 (17.56) 29 (19.08) 30 (16.30) 0.51

Complications & Adverse outcomes 84 (25.00) 38 (25.00) 46 (25.00) 1.00

Cost of treatment and follow up 35 (10.42) 9 (5.92) 26 (14.13) 0.01

Main reason to travel overseas for

Healthcare

Cannot afford treatment in the UAE 12 (3.57) 6 (3.95) 6 (3.26) 0.74

Not eligible for the service provided

in the UAE

11 (3.27) 5 (3.29) 6 (3.26) 0.99

Long waiting time for an appointment 29 (8.63) 12 (7.89) 17 (9.24) 0.66

Undesirable outcome from previous

personal experience

21 (6.25) 8 (5.26) 13 (7.07) 0.50

Undesirable outcome from other

previous experience

24 (7.14) 8 (5.26) 16 (8.70) 0.22

Privacy and confidently reasons 27 (8.04) 10 (6.58) 17 (9.24) 0.37

Healthcare provider attitude 20 (5.95) 5 (3.29) 15 (8.15) 0.06

Post treatment rehabilitation is not

available

6 (1.79) 3 (1.97) 3 (1.63) 0.81

Expecting adverse treatment outcome

in the UAE

20 (5.95) 7 (4.61) 13 (7.07) 0.34

80

Table 6A. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

while seeking medical treatment overseas during 2009-2012 (more than one choice

permitted)


No. Medical Condition Total sample N

(%)

Federal Republic

of Germany Other Destinations P-value

1 Cancer 108 (32.14) 48 (31.58) 60 (32.61) 0.84

2 Neurological Disease, and

Neurosurgery

18 (5.36) 10 (6.58) 8 (4.35) 0.36

3 Bone & Joint Diseases 50 (14.88) 24 (15.79) 26 (14.13) 0.67

4 Heart Diseases 44 (13.10) 17 (11.18) 27 (14.67) 0.35

5 Eye Diseases 24 (7.14) 6 (3.95) 18 (9.78) 0.04

6 Obstetrics and Gynecology 8 (2.38) 1 (0.66) 7 (3.80) 0.06

7 General Surgery 23 (6.85) 10 (6.58) 13 (7.07) 0.86

8 Kidney Disease 15 (4.46) 6 ( 3.95) 9 (4.89) 0.68

9 Gastro-intestinal Diseases 21 (6.25) 11 (7.24) 10 (5.43) 0.50

10 Urinary System Diseases 15 (4.46) 9 (5.92) 6 (3.26) 0.24

11 High Blood pressure 22 (6.55) 4 (2.63) 18 (9.78) 0.01

12 Skin or Venereal Disease 3 (0.89) 0 (0) 3 (1.63) 0.11

13 Stroke (brain hemorrhage or

clot)

7 (2.08) 6 (3.95) 1 (0.54) 0.03

14 Mental Illness 1 (0.30) 0 (0) 1 (0.54) 0.36

15 Trauma 10 (2.98) 5 (3.29) 5 (2.72) 0.76

16 Medical Screening before

Surgery

1 (0.30) 0 (0) 1 (0.54) 0.36

17 Oral and Dental Diseases 1 (0.30) 0 (0) 1 (0.54) 0.36

18 Lungs & Respiratory

Diseases

10 (2.98) 3 (1.97) 7 (3.80) 0.33


Diseases

4 (1.19) 3 (1.97) 1 (0.54) 0.23

20 Diabetes 29 (8.63) 9 (5.92) 20 (10.87) 0.11

22 Routing medical check-up 5 (1.49) 2 (1.32) 3 ( 1.63) 0.81

81

Table 6B. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

while seeking medical treatment overseas during 2009-2012 (diagnosis categories include

patients with only one condition; patients with multimorbidity included as a separate

category)

No. Medical Condition Total Sample N (%)

Cancer 58 (17.26)

Neurological, Neurosurgery Brain Hemorrhage 16 (4.76)

Bone & Joint Diseases 25 (7.44)

Heart Diseases 28 (8.33)

High Blood pressure 1 (0.30)

Eye Diseases 17 (5.06)

Obstetrics and Gynecology 6 (1.79)

General Surgery 7 (2.08)

Urinary System Diseases 12 (3.57)

Gastro-intestinal Diseases 6 (1.79)

Trauma 8 (2.38)

Oral and Dental Diseases 1 (0.30)

Lungs & Respiratory Diseases 5 (1.49)

Ear, nose and throat (ENT) Diseases 3 (0.89)

Diabetes 4 (1.19)

More than one condition 92 (27.38)

Undiagnosed 47 (13.99)

Total 336 (100.00)

82

Table 6C. Main conditions residents of Dubai, United Arab Emirates were diagnosed with

while seeking medical treatment overseas during 2009-2012 by country of destination


Table 6D. Number of comorbidities that residents of Dubai, United Arab Emirates were

diagnosed with while seeking medical treatment overseas during 2009 – 2012 by country of

destination


No. Medical Condition Total sample N (%) Federal Republic of

Germany Other Destinations

1 Cancer 58 (17.26) 28 (18.42) 30 (16.30)

2 Neurological, Neurosurgery Brain

Hemorrhage

16 (4.76) 12 (7.89) 4 (2.17)

3 Bone & Joint Diseases 25 (7.44) 13 (8.55) 12 (6.52)

4 Heart Diseases 28 (8.33) 13 (8.55) 15 (8.15)

5 High Blood pressure 1 (0.30) 0 (0) 1 (0.54)

6 Eye Diseases 17 (5.06) 2 (1.32) 15 (8.15)

7 Obstetrics and Gynecology 6 (1.79) 0 (0 6 (3.26)

8 General Surgery 7 (2.08) 3 (1.97) 4 (2.17)

9 Urinary System Diseases 12 (3.57) 8 (5.26) 4 (2.17

10 Gastro-intestinal Diseases 6 (1.79) 2 (1.32) 4 (2.17)

11 Trauma 8 (2.38) 4 (2.63) 4 (2.17)

12 Oral and Dental Diseases 1 (0.30) 0 (0) 1 (0.54)

13 Lungs & Respiratory Diseases 5 (1.49) 2 (1.32) 3 (1.63)

14 Ear, nose and throat (ENT) Diseases 3 (0.89) 2 (1.32) 1 (0.54)

15 Diabetes 4 (1.19) 1 (0.66) 3 (1.63)

16 More than one condition 92 (27.38) 36 (23.68) 56 (30.43)

17 Undiagnosed 47 (13.99) 26 (17.11) 21 (11.41)

Total 336 (100.00) 152 (100.00) 184 (100.00)

P-value 0.032

Number Comorbidities Total sample N (%) Federal Republic of

Germany Other Destinations

2 comorbidities 69 (75.00) 26 (72.22) 43 (76.79)

3 comorbidities 14 (15.22) 8 (22.22) 6 (10.71)

4 comorbidities 6 (6.52) 2 (5.56) 4 (7.14)

5 comorbidities 1 (1.09) 0 (0.00) 1 (1.79)

6 comorbidities 1 (1.09) 0 (0.00) 1 (1.79)

7 comorbidities 1 (1.09) 0 (0) 1 (1.79)

Total 92 (100) 36 (100.00) 56.00 (100)

P-value 0.55

83

Table 7. Travel related experiences for residents of Dubai, United Arab Emirates during

their most recent trip overseas, 2009 - 2012


Germany


Months ago was the trip

Mean ±SD*

15.66±15.71 16.53±15.26 14.93±16.09 0.37

Type of Healthcare Services 0.042

Inpatient 228 (67.86) 113 (74.34) 115 (62.50)

Outpatient 102 (30.36) 38 (25.00) 64 (34.78)

Unknown 6 (1.79) 1 (0.66) 5 (2.72)

Treatment Available in the

UAE

0.08

Available 96 (28.57) 40 (26.32) 56 (30.43)

Not Available 187 (55.65) 94 (61.84) 93 (50.54)

I don’t know 53 (15.77) 18 (11.84) 35 (19.02)

Treatment Coverage <0.001

Government Expenses 265 (78.87) 141 (92.76) 124 (67.39)

Other Sources 71 (21.13) 11 (7.24) 60 (32.61)

Refund Policy Healthcare

Abroad

0.71

I know 40 (11.90) 17 (11.18) 23 (12.50)

I don’t know 296 (88.10) 135 (88.82) 161 (87.50)

Satisfaction of the

Healthcare Services

Provided Overseas

0.06

0=Very dissatisfied 12 (3.57) 7 (4.61) 5 (2.72)

1=Dissatisfied 8 (2.38) 7 (4.61) 1 (0.54)

2=Neutral 12 (3.57) 6 (3.95) 6 (3.26)

3=Satisfied 89 (26.49) 44 (28.95) 45 (24.46)

4=Very Satisfied 215 (63.99) 88 (57.89) 127 (69.02)

Mean ±SD 3.45±0.94 3.31±1.06 3.56±0.82

Recommending Overseas

Experience to Others

0.99

Recommend 302 (90.15) 137 (90.13) 165 (90.16)

Don’t Recommend 33 (9.85) 15 (9.87) 18 (9.84)

Aspects of Services Wish to

Be Available in the UAE

0.11

Waiting time 142 (42.26) 57 (37.50) 85 (46.20) 0.11

Healthcare provider

Communication

277 (82.44) 121 (79.61) 156 (84.78) 0.21

Hospitality 89 (26.49) 45 (29.61) 44 (23.91) 0.24

Education & Reading

Material

17 (5.06) 10 (6.58) 7 (3.80) 0.25

Convenient Atmosphere 215 (63.99) 92 (60.53) 123 (66.85) 0.23

Unfavorable Reactions/

Complications/ Outcomes

During and After the

Treatment

0.002

No 274 (81.55) 113 (74.34) 161 (87.50)

Yes 62 (18.45) 39 (25.66) 23 (12.50)

I know where to report

medical error

0.16

84

I don’t Know 50 (14.88) 18 (11.84) 32 (17.39)

I know 286 (85.12) 134 (88.16) 152 (82.61)

Where to Report medical

error

Embassy 237 (70.54) 109 (71.71) 128 (69.57) 0.67

Overseas Patients Affairs

Office

95 (28.27) 47 (30.92) 48 (26.09) 0.33

Police 15 (4.46) 6 (3.95) 9 (4.89) 0.68

Hospital Administration

/complaint center

40 (11.90) 18 (11.84) 22 (11.96) 0.97

Next decision if there was

delay in issuing visa

0.19

Wait for Visa 257 (76.49) 119 (78.29) 138 (75.00)

Look for Another

Destination

54 (16.07) 26 (17.11) 28 (15.22)

Search HCP in UAE 25 (7.44) 7 (4.61) 18 (9.78)

* SD: Standard Deviation P-value for chi-square test

85

Table 8. Preferences and family related questions for residents of Dubai, United Arab

Emirates during their most recent trip overseas, 2009 - 2012 by country of destination


Germany

Other Destinations P-Value

Preference for Travel

Escort

0.76

Alone 10 (2.98) 5 (3.29) 5 (2.72)

Escorted 326 (97.02) 147 (96.71) 179 (97.28)

Arrangement Preferences 0.81

Myself 95 (28.27) 42 (27.63) 53 (28.80)

Travel Agency 241 (71.73) 110 (72.37) 131 (71.20)

Family response towards

overseas treatment

Shared bad

experiences

29 (8.63) 14 (9.21) 15 (8.15) 0.73

Help & Support 314 (93.45) 143 (94.08) 171 (92.93) 0.67

Seek Options in

UAE/Other Countries

39 (11.61) 20 (13.16) 19 (10.33) 0.42

Financial Help 87 (25.89) 30 (19.74) 57 (30.98) 0.02

Worry 47 (13.99) 19 (12.50) 28 (15.22) 0.48


Table 9. Satisfaction levels by top 5 travel destinations for residents of Dubai, United Arab

Emirates who sought medical treatment overseas during 2009 – 2012

No. Country of Destination Total Sample N (%) Satisfaction level*

1 Federal Republic of Germany 152 (45.24) 132 (86.84)

2 Kingdom of Thailand 64 (19.05) 61 (95.31)

3 United Kingdom 37 (11.01) 34 (91.89)

4 Republic of India 27 (8.04) 25 (92.59)

5 United States of America 13 (93.87) 12 (92.31)

Total 336 (100) 336 (100)

P-value 0.55

* Very satisfied and satisfied


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Table 10. Unadjusted and adjusted prevalence ratios for travelling to the Federal Republic

of Germany as a treatment destination among residents of Dubai, United Arab Emirates

during 2009-2012

Dependent Variables Unadjusted Adjusted*

PR 95% CI P-Value PR 95% CI P-Value**

Medical Condition

Other Diseases 1.00 - - 1.00 - -

Eye Diseases 0.31 (0.11,0.91) 0.03 0.34 (0.13,0.870) 0.03

Other Diseases 1.00 _ _ 1.00 _ _

Stroke (brain hemorrhage or clot) 1.93 (1.40,2.68) 0.000 1.90 (1.45,2.51) 0.000

Cost of Treatment

Cost is not Important at all 1.00 - - 1.00 - -

Indifferent about the cost 0.79 (0.54,1.16) 0.23 0.83 (0.57,1.21) 0.34

Cost is very important 0.55 (0.39,0.79) 0.001 0.71 (0.51,1.00) 0.05

Treatment Coverage

Government coverage 1.00 - - 1.00 - -

Non-Government coverage 0.29 (0.17,0.51) 0.000 0.33 (0.19,0.57) 0.000

*Adjusted for medical condition, cost of treatment, treatment coverage

**Significant level p<0.05

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CHAPTER FOUR: MANUSCRIPT THREE

Associations between Patient Characteristics and Preferences for Healthcare Services if the

Treatment is Made Available in the UAE among Patients from the UAE Treated Overseas during

2009 – 2012 for Six Selected Medical Conditions

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Introduction

The main aim for studying patients from the UAE seeking healthcare services overseas is

to understand the medical conditions people travel overseas for, motivational factors for choosing

the treatment destinations and to reduce the cost of spending on this strategy. While it is important

to keep the costs down for the overseas treatment strategy, it is also vital to ensure that patients’

demands are met and channeled appropriately in the UAE (Angela Coulter, 1999). Furthermore,

creating an evidence base in the Emirate of Dubai is within the Dubai Health Authority’s agenda

for reforming the healthcare system. Policy makers in the Emirate have been encouraged to

develop a better evidence base for healthcare policy reform and for better quality of care outcomes

(Eddy, 1988; Krumholz, 2008).

It is important to accommodate patients’ preferences in the services provided and to make

patients’ preferences one of the determinants in designing healthcare services for the successful

implementation of health policy (Akkazieva, Gulacsi, Brandtmuller, Pentek, & Bridges, 2006;

Concannon et al., 2014; Hoffman, Montgomery, Aubry, & Tunis, 2010). Additionally, involving

patients in making choices about healthcare services is important to improve the quality of the

services provided and to understand patients’ needs. There are many factors that may influence

patients’ choices and preferences in healthcare. Sociodemographic characteristics, patient’

personalities, information given to patients, past experiences, disease profiles, and financial factors

are all contributing factors to patients’ preferences (Richards et al., 1995). Therefore it is essential

to use the right framework combined with the right analytical tools to ensure capturing a precise

understanding of patients’ preferences (Bowling & Ebrahim, 2001).

This analysis includes patients with bone and joint diseases, cancer, neurological diseases,

eye diseases, heart disease, and those requiring general surgery who were described in the previous

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chapter that addressed Aim-2. In the KAP survey these patients or their family members were

asked four questions regarding their willingness to be seen for diagnosis and treatment for their

case with a known physician in the UAE and their preferences regarding the waiting time.

Moreover, the patients or family members were asked about their willingness to be seen for

diagnosis and treatment for the same case by a visiting physician to the UAE and their preferences

for the waiting time. This part of the study provides preliminary results to policy makers for long

term planning related to the overseas treatment strategy. Although there are limitations of this

analysis, the study design can be further improved and results validated in the future and used to

create an “economics tool box” for a stated preferences technique for better results and better

predictions.

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Methods

Aim-3: Explore associations between patients’ characteristics and preferences for

healthcare services if the treatment is made available in the UAE for the cases of bone and joint

diseases, cancer, neurological diseases, eye diseases, heart disease and a requirement for general

surgery among patients treated overseas from the UAE during 2009 - 2012. Healthcare services

include: 1a. Willingness to be diagnosed and treated by a known physician in the UAE. 1b.

Willingness to wait to be diagnosed and treated by a known physician in the UAE. 2a. Willingness

to be diagnosed and treated by a visiting physician to the UAE. 2b. Willingness to wait to be

diagnosed and treated by a visiting physician to the UAE.

Research Question: Are there any associations between patients’ characteristics and

preferences for the healthcare services in the UAE for the cases of bone and joint diseases, cancer,

neurological diseases, eye diseases, heart disease and general surgery among patients from the

UAE treated overseas during 2009-2012?

Null Hypothesis: There are no associations between patients’ characteristics and

preferences for the healthcare services in the UAE for the cases of bone and joint diseases, cancer,

neurological diseases, eye diseases, heart disease and general surgery among patients from the

UAE treated overseas during 2009-2012.

Data source and study design

The source of data and study design are similar to chapter three, manuscript two.

Variables and Measures

The independent variables used in this analysis are displayed in Table 1A. Variables

included the demographic characteristics of gender, age, marital status for those 15+, employment

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status for those 15+, educational level for those 15+, and household average monthly income. Also

included was who answered the survey (self-reported by the patient or a family member who

responded on behalf of the patient). Family members serving as respondents were asked if they

did or didn’t escort the patient on the most recent trip overseas.

Gender was used as a binary variable with males used as a reference group. Age was used

as a continuous variable. Marital status 15+ was used as a binary variable: not married and married.

Married was used as a reference group. Employment status 15+ was used as a binary variable: not

working and working. Not working was used as a reference group. Education level 15+ was used

as a categorical variable: illiterate or can’t read and write, up to high school level, college and

above. Illiterate or can’t read and write was used as a reference group. Household average monthly

income18 was used as a categorical variable: low income (≤29,000 AED = ≤7,896.53 USD), middle

income (≥30,000 - ≤99,999 AED = ≥8,168.82 - ≤27,229.14 USD), and high income (≥100,000

AED = ≥ 27,229.41) with the lowest income respondents used as a reference group. Person

answering the survey was used as a binary variable: person who travelled overseas and self-

reported, or a family member who answered the survey on behalf of the patient. The patient who

travelled overseas and answered the survey (self-reported) was used as a reference group. Type of

family member reporting was used as a binary variable indicating whether the family member did

or did not escort the person who travelled overseas for treatment. The family member who escorted

the person overseas was used as the reference group.

Variables related to financial aspects that were significant in chapter three (aim-2) were

also added to the analysis. Financial coverage for treatment was used as a binary variable with the

18 1 AED = 0.272294 USD / 1 USD = 3.67250 AED

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categories of government coverage and coverage from a nongovernment source (including

self).The government coverage was used as the reference group. Perception about the cost of

treatment was created as a three category variable from a Likert scale variable (1-not important at

all and not important were collapsed to not important, 2- neutral, and 3- important with very

important were collapsed to important). Not important was used as a reference group.

For the purposes of this analysis patients were selected who had travelled overseas for

treatment of the most common medical conditions as determined by the first aim and the second

aim of this thesis. These medical conditions were: bone and joint diseases, cancer, neurological

diseases, eye diseases, heart disease and those requiring general surgery.

Preferences for healthcare services were used as outcomes in the analysis. Four outcome

variables were constructed. The willingness to be diagnosed and treated by a known physician in

the UAE variable was originally in a Likert scale format: strongly disagree, disagree, neutral,

agree, and strongly agree. It was converted to a three category variable and a binary variable. The

new binary variable was disagree (strongly disagree, disagree and neutral) and agree (agree and

strongly agree). The new three category variable was disagree (Strongly disagree, disagree),

neutral, and agree (agree, strongly agree).

Willingness to wait to be diagnosed and treated by a known physician in the UAE was

originally an ordinal variable with five time categories: 1 week, 2 weeks, 1 month, 3 months and

6 months. This was converted to a binary variable (Jeong, 2016). The new binary variable was: 1

week and more than one week (2 weeks, 1 month, 3 months and 6 months). The same procedures

were used for the other variables. For the willingness to be diagnosed and treated by a visiting

physician to the UAE, the Likert scale variable was converted to a three category variable:

disagree, neutral and agree. The binary variable was: agree and disagree. The same procedure was

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also repeated for willingness to wait to be diagnosed and treated by a visiting physician to the

UAE. The ordinal variable was converted to a binary variable: one week or more than one week.


Statistical analyses were conducted by using Stata 13 (Stata Corporation, College Station

TX). Quality assurance and quality control of the dataset were performed by running summary

statistics for missingness and inconsistencies of the data since it is the same data-set for aim-2.

Means, standard deviations (SDs), and student t-tests were used for continuous variables.

Frequency distributions, percentages and chi-square tests were used for binary and categorical

variables. The Fisher exact test was used as well because of the small sample sizes analyzed for

this aim with some cells having less than 5 observations (Freeman & Campbell). The binary

logistic regression model was used for the analysis since the outcomes were dichotomous for each

medical condition.

Four binary logistic regression analysis models were constructed for this study for each

medical condition:

The first set of binary logistic regression models were run separately for each medical

condition of interest and the outcome was: agree to be diagnosed and treated by a known

physician in the UAE compared to disagree to be diagnosed and treated by a known

physician in the UAE. Disagree to be diagnosed and treated by a known physician in the

UAE was used as a reference group.

The second set of binary logistic regression models were run separately for each medical

condition of interest and the outcome was: willingness to wait for one week to be diagnosed

and treated by a known physician in the UAE, compared to willingness to wait more than

one week to be diagnosed and treated by a known physician in the UAE. Willingness to

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wait more than one week to be diagnosed and treated by a known physician in the UAE

was used as a reference group.

The third set of binary logistic regression models were run separately for each medical

condition of interest and the outcome was: agree to be diagnosed and treated by a visiting

physician to the UAE, compared to disagree to be diagnosed and treated by a visiting

physician to the UAE. Disagree to be diagnosed and treated by a visiting physician to the

UAE was used as a reference group.

The fourth set of binary logistic regression models were run separately for each medical

condition of interest and the outcome was: willingness to wait for one week only to be

diagnosed and treated by a visiting physician to the UAE, compared to willingness to wait

more than one week to be diagnosed and treated by a visiting physician to the UAE.

Willingness to wait more than one week to be diagnosed and treated by a visiting physician

to the UAE was used as a reference group.

Two significance levels were considered for this analysis, α=0.05 and α=<0.1 with

confidence intervals of 90% considered due to small sample sizes with the rule of: either chi-square

or fisher exact test or both <0.1 for the independent variable in order to consider moving that

independent variable to the final model. The Likelihood test ratio was performed to check

goodness of fit since some variables had marginal significance in the bivariate analysis (α=<0.1).

Therefore three types of variables were not included in the final model: 1- variables with marginal

significance in the final model with a likelihood test ratio >0.05 indicating no difference with or

without adding them to the final model such as the following: a. gender in the case of cancer and

willingness to be diagnosed and treated by a known physician in the UAE; b. treatment coverage

in the case of cancer and willingness to be diagnosed and treated by a visiting physician to the

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UAE; 2- variables with omitted results in the final regression model due to small cell observations

like: a. who answered the survey in the case of neurological diseases and willingness to wait to be

diagnosed and treated by a known physician in the UAE. b. family member answering the survey

in the case of neurological diseases and willingness to wait to be treated and diagnosed by a visiting

physician to the UAE. c. household average monthly income in the case of eye diseases and

willingness to wait to be diagnosed and treated by a known physician in the UAE; 3- variables that

were not significant in the final model >0.1 like: a. education in the case of neurological diseases

and willingness to wait to be diagnosed and treated by a visiting physician to the UAE. b. marital

status and who answered the survey in the case of eye diseases and willingness to be diagnosed

and treated by a known physician. In the final model, both P<0.05 and P<0.10 were used to indicate

statistical significance. A sensitivity analysis was also performed by examining two alpha levels

(0.05, 0.1) and pseudo r2 to help in making decisions about the important independent variables in

the preferences for healthcare services questions.

Results

The initial sample for this aim included the survey respondents with the 225 medical

conditions identified from the analyses of Aims 1 and 2 who answered the questions on preferences

for healthcare services and waiting times in the knowledge attitudes and perceptions survey.

Among the 225 medical conditions the most frequent were the following: 47 had bone and joint

diseases, 66 had cancer, 20 had neurological diseases, 25 had eye diseases, 22 travelled for general

surgery and 45 had heart diseases. Out of 225 medical conditions 187 patients had one medical

condition only, 16 patients had two medical conditions, and 2 patients had three medical conditions

as shown in Table 1 and Table 2.

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Willingness to be diagnosed and treated by a known physician in the UAE across the six medical

conditions.

Among those who were willing to be diagnosed and treated by a known physician in the

UAE, patients with neurological Diseases and patients with eye Diseases had the highest

proportion agreeing to be diagnosed and treated by a known physician in the UAE with (n=12

;60%) and (n=15;60%) patients respectively. (n=25; 55%) patients with heart diseases were in

agreement, followed by (n=24; 51%) patients with bone and joint diseases, and (n=32; 48%)

patients with cancer. Patients who went through general surgery had the least agreement regarding

willingness to be diagnosed and treated by a known physician in the UAE (n=7; 32%). The range

of proportions of willingness to be diagnosed and treated by a known physician in the UAE was

32% - 60%, as shown in Table 3.

Willingness to wait to be diagnosed and treated by a known physician in the UAE across the six

medical conditions.

In general, patients were not willing to wait more than one week to be diagnosed and treated

by a known physician in the UAE. Patients with bone and joint diseases had the highest proportion

willing to wait for more than one week to be diagnosed and treated (n=13, 27%), followed by

patients who required general surgery and those with heart diseases with (n=5; 22%) and (n=10;

22%) respectively. (n=13; 19%) patients with cancer were willing to wait more than one week, as

well as (n=4; 16%) patients with eye diseases. The lowest number of patients who were willing to

wait more than a week were patients with neurological diseases (n=1; 5%). The range in

proportions of willingness to wait to be diagnosed and treated by a known physician in the UAE

was 5% - 27%, as shown in Table 4.

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Willingness to be diagnosed and treated by a visiting physician to the UAE across the six medical

conditions.

There was also variation in preferences to be diagnosed and treated by a visiting physician

to the UAE across the six medical conditions. Patients with eye diseases had the highest proportion

of willingness to be diagnosed and treated by a visiting physician to the UAE (n=18; 72%),

followed by patients with bone and joint diseases (n=33; 70%), then patients with cancer (n=46;

69%), patients with heart diseases (n=31; 68%), and patients with neurological diseases (n=12;

60%). Patients needing general surgery had the lowest proportion willing to be diagnosed and

treated by a visiting physician to the UAE (n=11; 50%). The range of proportions willing to be

diagnosed and treated by a visiting physician to the UAE was 50% - 72%, as shown in Table 5.

Willingness to wait to be diagnosed and treated by a visiting physician to the UAE across the six

medical conditions.

When asked about their willingness to wait to be diagnosed and treated by a visiting

physician to the UAE, the minority of patients were willing to wait more than one week. Patients

with bone and joint diseases had the highest proportion willing to wait more than one week (n=20;

43%), followed by patients with heart diseases (n=15; 33%), patients requiring general surgery

(n=7; 32%), patients with neurological diseases (n=6; 30%), and patients with cancer (n=19; 29%).

Patients with eye diseases were the least willing to wait more than one week (n=7; 28%). The

range of proportions willing to wait to be diagnosed and treated by a visiting physician to the UAE

was 28% - 42% as shown in Table 6.

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Patterns across the six medical conditions:

When looking at the patterns of the proportions across the demographic characteristics, for

gender for example there was a higher proportion of males to females in bone and joint diseases

(57.45: 42.55), neurological diseases (60:40) and heart diseases (51.11:48.89). Whereas there was

a higher proportion of females to males in the cases of cancer (54.55: 45.45), eye diseases (52.00:

48.00) and in general surgery (54.55: 45.45). With regard to age, patients with neurological

diseases were older in age (mean = 49±19.83), followed by patients travelling overseas for general

surgery (mean = 46.14±24.39). Patients diagnosed with bone and joint diseases were the third in

mean age (42.5±22.76); patients with eye diseases were fourth in mean age (41.84±23.48); patients

with cancer were fifth in mean age (38.62±24.64); and the youngest mean age were for the patients

with heart diseases (mean = 34.6± 20.59). For the educational attainment, a large proportion of

patients who travelled overseas for bone and joint diseases, cancer, neurological diseases, eye

diseases and heart diseases had up to high school as an educational attainment. whereas a larger

proportion of patients who travelled overseas for general surgery had illiterate and cannot read and

write as an educational attainment (n = 8; 44%) as shown in Table A – Table X.

Associations between Patient Characteristics and Preferences for Treatment in the UAE for Six

Selected Medical Conditions

When examining the association between patients’ characteristics and the preference for

treatment in the UAE; patients with cancer had a marginal significant difference between males

and females related to the willingness to being diagnosed and treated by a known physician in the

UAE. More males had agreed compared to disagreed (n=18; 56% vs. n=12; 35%), whereas less

females had agreed compared to disagreed (n=144; 4% vs n=22; 65%) (p<0.09). In terms of

treatment coverage for the same cases and the same physician; patients who had treatment

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coverage by the government were less likely to agree compared to disagree (n=23; 72% vs n=31;

91%); whereas patients who were not covered by the government were more likely to agree

compared disagree (n=9; 28% vs n=3; 9%) (p=0.04) as shown in Table E.

Moreover, there was a difference in the willingness to wait to be diagnosed and treated by

a known physician in the UAE for the case of cancer in the income category.19 Patients with lower

income were more willing to wait for more than one week compared to waiting for one week only

(n=11; 85% vs. n=27; 51%); whereas patients in the middle and higher income were less likely to

wait more than one week compared to waiting for one week only (n=2; 15% vs. n= 26; 49%)

(p=0.03) as shown in Table F.

There was a difference found in patients diagnosed with cancer and willingness to be

diagnosed and treated by a visiting physician to the UAE related to cost of treatment and treatment

coverage. In terms of cost of treatment; patients were more likely to agree compared to disagree

when the cost is not important (n=32; 70% vs. n=13; 65%). When the cost is neutral; patients were

less likely to agree compared to disagree (n=3; 7% vs n=5; 25%). When cost is important; patients

were more likely to agree than to disagree (n=11; 24% vs. n=2; 10%) (p=0.07). Related to

treatment coverage; patient who had treatment coverage by the government were less likely to

agree than to disagree (n=35; 76% vs. n=19; 95%). Patients who had cancer and not covered by

the government were more likely to agree than to disagree to be diagnosed and treated by a visiting

physician to the UAE (n= 11; 24% vs n=1; 5%) (p=0.07) as shown in Table G.

When examining the association between patients characteristics and willingness to wait

to be diagnosed and treated by a known physician in the UAE for patients with neurological

19 Middle income collapsed with high income

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diseases; patients who had self-reported were more likely to wait for more than one week compared

to willingness to wait for one week only (n=1; 100% vs n=3; 16%). On the other hand; when a

family member reported on behalf of the patient; there was no willingness to wait for more than

one week compared to the willingness to wait for one week only (n=0; 0% vs. n=16; 84%) (p=0.04)

as shown in Table J.

When exploring the association between patients’ characteristics and willingness to be

diagnosed and treated by a visiting physician for the case of neurological diseases; there was a

marginal significance between males and females. Males were more likely to agree being

diagnosed and treated by a visiting physician to the UAE than to disagree (n=9; 75% vs. n=3;

38%), whereas females were less likely to agree for the same case and the same physician than to

disagree (n=3; 25% vs. n=5; 63%) (p=0.09) as shown in Table K.

When examining the association of patients’ characteristics and willingness to wait to be

diagnosed and treated for the case of neurological diseases by a visiting physician to the UAE;

there was a difference in the educational level 15+, answering the survey and when a family

member reported. When looking at the educational level 15+ patients who were illiterate and can’t

read and write were not willing to wait more than one week compared to patients who were willing

to wait for one week only in the same category (n=0; 0% vs n=6; 50%). Patients with up to high

school were more likely to wait more than one week compared to waiting for a week only (n=5;

83% vs. n=3; 25%). Patients with college and above were less likely to wait more than one week

than waiting for one week only (n=1; 17% vs. n=3; 25%) (p=0.05)

There was also a difference among patients answering the survey. Patients self-reported

were more likely willing to wait for more than one week than willing to wait for one week only

(n=3; 50% vs. n=1; 7%). Whereas when a family member reported on behalf of the patient, there

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was a lower likelihood of willingness to wait more than one week than waiting for one week only

(n=3; 50% vs. n=13; 93%) (p=0.03). Moreover there was a difference as well among family

member who reported on behalf of the patient. A family member who escorted the patient overseas

were less likely to wait more than one week for the diagnosis and treatment of the patient by a

visiting physician to the UAE compared to willing to wait for one week (n=2; 67% vs 13; 100%).

Whereas a family member who did not escort patients overseas were more likely to wait more than

one week to for the diagnosis and the treatment of the patient by a visiting physician to the UAE

than waiting for a one week only (n=1; 33% vs. n=0; 0%) (p=0.03) as shown in Table L.

When examining the association between patients’ characteristics and patients’ preference

in the case of eye diseases, there was a marginal significance in the marital status. Married patients

are more likely to agree than to disagree to being diagnosed and treated by a known physician in

the UAE (n=10; 83% vs. n=5; 50%). Whereas patients who were not married were less likely to

agree than to disagree (n=2; 17% vs. (n=5; 50%) (p=0.1). There was a difference in the treatment

coverage for the same case and the same physician. Patients had government coverage were more

likely to agree than to disagree (n=14; 93% vs. n=6; 60%) to being diagnosed and treated by the

same physician. On the other hand, patients who are not covered by the government were less

likely to agree than to disagree (n=1; 7% vs. 4; 40%) to being diagnosed and treated by a known

physician in the UAE (p=0.04). There was also a marginal significance in answering the survey.

Patients who had eye diseases and self-reported were less likely to agree than to disagree (n=4; 27

vs. n=6; 60%) to being diagnosed and treated by a known physician in the UAE than disagree.

When a family member reporting on behalf the patient; a family member were more likely to agree

than to disagree for the patient to be diagnosed and treated by a known physician in the UAE

(n=11; 73% vs. n=4; 40%) (p=0.1) as shown in Table M.

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When examining the association between patients’ characteristics and patients willingness

to wait to be diagnosed and treated by a known physician in the UAE for the case of eye diseases;

patients with lower income were not willing to wait at all more than one week compared to patients

who were willing to wait for a week only (n=0; 0% vs. n=13; 62%). Patients with the middle

income were more likely to wait more than one week compared to patients who were willing to

wait for one week only (n=2; 50% vs. n=3; 14%) . Patients with higher income y were more willing

to wait for more than one week compared to willingness to wait for a week only (n=2; 50% vs.

n=5; 24%) (p=0.07) as shown in Table N.

When exploring the association between patients’ characteristics and willingness to be

diagnosed and treated by a visiting physician to the UAE; there was a difference in answering the

survey for patients with eye diseases. Patients who were self-reported were less likely to agree

being diagnosed and treated for the same physician than to disagree (n=5; 28% vs. n=5; 71%).

When a family member reported on behalf of the patient; there was higher likelihood of agreeing

than disagreeing for the patient to be diagnosed and treated by a visiting physician to the UAE

(n=13; 72% vs. n=2; 29%) (p=0.05) as shown in Table O.

When looking at the willingness to wait to be diagnosed and treated for the case of eye

diseases by a visiting physician to the UAE; there was a difference in the age. Patients who were

willing to wait for one week only aged 36.44± 23.78 compared to patients who were willing to

wait for more than one week 55.71± 17.06 (p=0.06) as shown in Table P.

Patients required to go through general surgery and who agreed to be diagnosed and treated

by a known physician in the UAE aged 64.29±14.02 compared to patient who disagreed to being

diagnosed and treated by a known physician in the UAE aged 37.66±23.80 (p=0.01) as shown in

Table Q. On the other hand; when examining the association between patients’ characteristics and

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willingness to wait to be diagnosed and treated by a visiting physician to the UAE for patients

needing general surgery; there was a marginal difference in the average monthly income. Patients

with lower income were less likely to wait more than one week (n=3; 43% vs. n=13; 87%)

compared to willing to wait for one week only. Patients with middle and high income20 were more

likely to wait more than a week compared to waiting for a one week only (n=4; 57% vs. n=2;

13%). (p=0.03) as shown in Table T.

When examining the association between patients characteristics and willingness to be

diagnosed and treated by a known physician in the UAE for patients with heart diseases; patients

with lower income were less likely to agree (n=15; 60% vs. n=18; 90%) than to disagree. Patients

with middle and high income were more likely to agree (n=6; 24%) compared to patients who

disagreed (n=2; 10%). Patients with higher income were more likely to agree (n=4; 6%) than to

disagree. (p=0.06) as shown in Table U.

There was a difference in the age between patients who were willing to wait for one week

compared to patients who are willing to wait for more than one week related to the diagnosis and

treatment by a known physician in the UAE in the case of heart diseases. Patients who were willing

to wait for a week only had mean age 37±19.94 years old compared to patients who were willing

to wait for more than one week mean age 23.2± 19.65 (p=0.05) as shown in Table V.

20 Middle income collapsed with high income

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Significant Results from the Binary logistic regression for the Associations between Patient

Characteristics and Preferences for Treatment in the UAE for Six Selected Medical Conditions

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated

for Cancer by a Known Physician in the UAE

When using binary logistic regression to identify factors associated with willingness to be

treated and diagnosed by a known physician in the UAE for patients with cancer, treatment

coverage was the only significant predictor. Gender variable was removed from the final model

because of the marginal significance and Likelihood test ratio >0.05. Patients who were not

covered by the government for treatment expenses abroad were 4.04 times more willing to be

diagnosed and treated by a known physician in the UAE compared to patients covered for their

treatment expenses overseas by the government as a reference group (OR 4.04, 90%CI: 0.98,17.29,

p=0.06) as shown in Table E1.

Associations between Patients’ Characteristics and Willingness to Wait to be Diagnosed and

Treated for Cancer by a Known Physician in the UAE

When using binary logistic regression to identify factors associated with the willingness

to wait to be diagnosed and treated by a known physician in the UAE for patients with cancer,

household average monthly income was the only significant predictor. Patients with middle and

higher income were 5.30 times more willing to wait for one week only to be diagnosed and treated

by a known physician compared to lower income patients (OR 5.30, 90%CI: 1.07, 26.23.57,

p=0.041) as shown in Table F1.

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for Cancer by a Visiting Physician to the UAE

When using binary logistic regression to identify factors associated with the willingness

to be diagnosed and treated by a visiting physician to the UAE for patients with cancer, the cost of

treatment was the only significant predictor. The treatment coverage variable was removed from

the final model because of the marginal significance and Likelihood test ratio >0.05. Patients who

were neutral regarding the costs of treatment were 0.24 times more willing to be diagnosed and

treated by a visiting physician to the UAE compared to the reference group who regarded costs as

not important (OR 0.24, 90%CI: 0.05,1.17, p=0.08) as shown in Table G1.


Treated for Neurological Diseases by a Visiting Physician to the UAE

When using binary logistic regression to identify the factors associated with willingness to

wait to be diagnosed and treated by a visiting physician to the UAE for patients with neurological

diseases; answering the survey was the only predictor. Educational level 15+ variable was removed

from the final model since it was not significant. Family member reported variable was also

removed from the final model since results were omitted in the regression due to small sample

size. Patients who had a family member reported and answered the survey on their behalf were 13

times more willing to wait for one week only to be diagnosed and treated by a visiting physician

to the UAE compared to the reference group patients answering the survey as a self-reported (OR

13, 90%CI: 0.98 - 172.95, p=0.052) as shown in Table L1.

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for Eye Diseases and Known physician in the UAE


be diagnosed and treated by a known physician for patients with eye diseases; treatment coverage

was the only predictor. Marital status and answering the survey variables were removed from the

final model since they were not significant. Patients not covered by the government for treatment

expenses abroad were 0.11 times more willing to be treated and diagnosed with a known physician

in the UAE compared to patients by the government as a reference group (OR 0.11, 90%CI:

0.01,1.17, p=0.07) as shown in Table M1.


for Eye Diseases by a Visiting Physician to the UAE


be diagnosed and treated by a visiting physician to the UAE for patients with eye diseases;

answering the survey was the only predictor. Patients who had a family member reporting and

answering the survey on their behalf were 6.5 times more willing to be diagnosed and treated by a

visiting physician to the UAE compared to the reference group self-reported (OR 6.5, 90%CI:

0.94,45.11, p=0.058 ) as shown in Table O1.


Treated for Eye Diseases by a Visiting Physician to the UAE


wait to be diagnosed and treated by a visiting physician to the UAE for patients with eye diseases;

age was the only predictor. With one year increase in age; patients with the case of eye disease

107

were 0.96 times more willing to wait for one week only to be diagnosed and treated by a visiting

physician (OR 0.96, 90%CI: 0.91,1.01, p=0.082) as shown in Table P1.


for General Surgery by a Known Physician in the UAE


diagnosed by a known physician for patient needing general surgery; age was the only predictor.

in table 5A. With one year increase in age; patients with the case of general surgery were 1.08

times more willing to be treated and diagnosed with a known physician in the UAE (OR 1.08,

90%CI: 1.00 - 1.17, p=0.050) as shown in Table Q1.


Treated to go Through General Surgery by a Visiting Physician to the UAE

When using binary logistic regression to identify factors associated willingness to wait to

be diagnosed and treated by a visiting physician for patients needing general surgery; household

income was the only predictor. Patients with middle and higher income were 0.11 times more

willing to wait for one week only to be diagnosed and treated by a visiting physician to the UAE

compared to the reference group lower income (OR 0.11, 90%CI: 0.01 - 0.95, p=0.005) as shown

in Table T1.

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for Heart Diseases by a Known Physician in the UAE


diagnosed and treated by a known physician in the UAE for patients with heart diseases; household

average monthly income was found to be the only predictor. Patients with middle and higher

income were 6 times more willing to be diagnosed and treated by a known physician in the UAE

compared to the reference group of lower income (OR 6, 90%CI: 1.13,31.73.54, p=0.04) as shown

in Table U1.


Treated for Heart Diseases by a Known Physician in the UAE:


diagnosed and treated by a known physician in the UAE for patients with heart diseases; age was

the only predictor. With one year increase in age; patients with the case of heart disease were 1.04

times more willing to wait for one week only to be diagnosed and treated by a known physician

(OR 1.04, 90%CI: 1.00,1.08, p=0.06) as shown in Table V1.

Sensitivity analysis through alpha level (0.05, 0.1)

Due to the small sample size for each medical condition and the fact that the willingness

to be diagnosed and treated by a known physician in the UAE or a visiting physician had more or

less similar patterns with regard to willingness to wait, a sensitivity analysis was performed to

examine alternative solutions to seeking healthcare overseas. The sensitivity analysis was

performed by looking at two levels of alpha (0.1, 0.05) and pseudo r2 to prioritize the preferences

for healthcare services in the UAE.

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Alpha level of (0.05)

Age was significant for going through general surgery (p=0.05) to be diagnosed and treated

by a known physician in the UAE. Household income was significant for going through general

surgery (0.05) for willingness to wait to be diagnosed and treated by a visiting physician to the

UAE. Treatment coverage was significant for the case of cancer (0.05) to be diagnosed and treated

by a known physician in the UAE. Household income was significant for the case of cancer (0.04)

for willingness to wait to be diagnosed and treated by a known physician in the UAE. Answering

the survey was significant for the case of neurological disease (0.05) for willingness to wait to be

diagnosed and treated by a visiting physician to the UAE. Household income was significant for

the case of heart diseases (0.04) to be diagnosed and treated by a known physician in the UAE as

shown in Table 7.

Alpha level of (0.1)

Perception about cost of treatment was significant for the case of cancer (0.08) to be

diagnosed and treated by a visiting physician to the UAE. Age was significant for the case of heart

diseases (0.06). Treatment coverage was significant for the case of eye diseases (0.07) to be

diagnosed and treated by a known physician in the UAE. Answering the survey was significant for

the case of eye diseases (0.06) to be diagnosed and treated by a visiting physician to the UAE. Age

was significant for the case of eye diseases (0.08) for willingness to wait to be diagnosed and

treated by a visiting physician to the UAE as shown in Table 7.

Sensitivity analysis through pseudo r2

By looking at the pseudo r2, the coefficient of determination which illustrates the proportion

of variance in the outcome variable associated with the predictor, the larger the r2 the more

110

variation is explained. The highest r2 were found in: age as a predictor to go through general

surgery (28%), family member answering on behalf of a patient with neurological diseases (18%),

and household income as a predictor to go through general surgery (16%) as shown in Table 8.

Discussion

Demographic characteristics, medical conditions and financial issues were the main factors

that influenced patient preferences in this study. Associations between patient characteristics and

willingness to be seen in the UAE and to wait to be seen were statistically significant for patients

with cancer, neurological diseases, eye diseases, general surgery and heart diseases. On the

contrary there were no significant associations between patient characteristics and preferences for

patients with bone and joint diseases. Moreover, the patterns of associations with demographic

characteristics and preferences were almost the same across the six medical conditions regarding

marital status, employment status, average monthly income, cost related variables and person

answering the survey related variables. On the other hand, mean age, educational attainment and

gender varied across the six medical conditions. Overall, across the six medical conditions, patients

had higher proportions regarding willingness to be diagnosed and treated by a visiting physician

to the UAE and more willing to wait to be diagnosed and treated by a visiting physician compared

to a known physician in the UAE.

Demographic characteristics are considered important factors that can influence patient

preferences for healthcare services. Several studies have been conducted to understand patient

preferences regarding health services and treatment options; age, educational attainment, income

level, occupation type and other demographic characteristics have been found to have direct

influences on patient preferences (Benbassat, Pilpel, & Tidhar, 1998; Butow, Maclean, Dunn,

Tattersall, & Boyer, 1997). The age variable was one of the significant predictors in our study. The

111

odds of willingness to be diagnosed and treated by a known physician in the UAE increases with

age for the patients travelling overseas who required general surgery as a healthcare service. The

literature explains that in addition to the different behavioral characteristics and attitudes for older

patients compared to younger patients, preferences can vary overtime due to situational

characteristics and age-related diseases (Cassileth, Zupkis, Sutton-Smith, & March, 1980;

Williams, Pham-Kanter, & Leitsch, 2009).

In addition; a family member answering on behalf of the patient might be considered as a

confounder since both the patient and the family member might have different perceptions and

preferences related to healthcare services. In some circumstances patients may have different

perceptions than family members as patients know more about their own health status than family

members. In contrast, a family member might give a valuable input in cases of low cognitive

process of the patient which was reflected in the findings of our study. For example, family

members were more likely than patient respondents to be willing to wait for one week only to be

diagnosed and treated by a visiting physician in the case of neurological diseases. Furthermore,

family member preferences might change depending on if the family member is or is not the

primary care giver of the patient (Keeffe, Chou, & Lamoureux, 2009).

Patient preferences for types of healthcare do vary according to their medical conditions.

Medical condition severity, stage of illness and comorbidity are all significant factors that

influence patient preferences and willingness to wait (Brown, 2000; Hawker et al., 2001). In our

study some patients with the above diagnosed diseases are comorbid and selected other medical

conditions in the survey. For the different medical conditions patients have different perceptions

depending on the perceived end result of the treatment, whether the patient is sensitive to managing

the symptoms of the medical condition, or more sensitive to and placing greater importance on

112

survival from the medical condition (Stanek, Oates, McGhan, Denofrio, & Loh, 2000). In addition,

having enough information about the risks and benefits of each option related to the medical

condition influences patient preferences as well. Patient preferences for healthcare services will

also differ depending on whether the patient is newly diagnosed, the patient is in routine follow

up, or the patient is at a stage where a significant change was found in the health status.

Accordingly, patient satisfaction, willingness to wait for treatment and preferences for type of

treatment are likely to shift over time (Epstein & Peters, 2009; Say & Thomson, 2003).

Financial factors such as income level, treatment coverage and perceptions about the cost

of treatment are important factors that influence patient preferences and choices. As illustrated in

Aim-2 – Chapter 3, financial factors play a vital role when choosing the destination of treatment.

In this analysis of Aim-3 financial factors played a different role regarding whether the patient

preferred to be treated and diagnosed by a known physician in the UAE with its associated waiting

time or the patient preferred to be diagnosed and treated by a visiting physician to the UAE

combined with its waiting time as well. Although there were inconsistencies in the associations

related to the financial factors in agreeing and disagreeing to be diagnosed and treated by both

types of physicians and patients’ willingness to wait for treatment across the different medical

conditions, there are many factors that may influence these findings such as confounders we did

not account for, small sample sizes and small numbers of cell observations; these factors can result

in imprecise predictions.

Giving patients the options to choose between known physicians in the UAE compared to

visiting physicians in the UAE may not be enough information to guide patients to elicit their

preferences. Since the patients have different medical conditions they have different perceptions

towards risks, prognosis, and treatment options considering their different previous experiences

113

(A. Coulter, Peto, & Doll, 1994). Therefore it is important for the patients to be provided with

enough unbiased information to understand benefits and risks associated with each option to make

better decisions related to their willingness and preferences. Moreover, the patient’s cognitive

ability combined with culture and background could influence patient preferences and could differ

for each medical condition.

Although this analysis of preferences for healthcare services in the UAE was prepared to

better understand patients’ preferences for local versus visiting physicians, it has many limitations.

First it would have been better if this part of the survey was rigorously prepared to present discrete

choices in a conjoint analysis exercise that could elicit patient preferences separately for each

medical condition. Since each preference was asked separately and not as a tradeoff, we described

the responses as willingness to be seen for diagnosis and treatment and willingness to wait.

Second, in considering use of the conjoint analysis method with discrete choices, each medical

condition should have its own attributes, level of attributes and hypothetical scenarios under the

assumption that each medical condition has its own outcome and its specific trade-offs to estimate

the utility. Furthermore, weights can be considered for the attributes to determine the relative

contribution of each attribute to the full profile in the conjoint analysis method (Bridges, 2003;

Dwight-Johnson, 2004; M. Ryan, and Jenny Hughes, 1997; M. Ryan & Farrar, 2000; Sculpher et

al., 2004; Szeinbach, 2011).

Third, it is very difficult to draw conclusions from this study since the sample consists of

a large number of medical conditions, but the sample size is very small and confounders exist.

Additionally it is not possible to generalize the results since non-purposive sampling was the

collection method of this survey. All of these factors reduce the precision of our estimates and the

generalizability of the results. Sample size limitations can be overcome in the future by calculating

114

the effective sample size required for this study with setting the alpha level for type I error. Fourth,

the absence of International Classification of Disease diagnoses makes it difficult to link the

specific type of the diseases with the preferences and associated waiting times. Finally, to ensure

having better study outcomes for this research question and to better understand the results, a

qualitative study can be added to understand patients’ and family members’ preferences related to

overseas treatment in more depth since there is a scarcity of empirical research related to patient

preferences in the medical travel and overseas treatment field.

Despite the limitations of the methods in this analysis, the results can provide preliminary

information related to planning for each medical condition the healthcare services in the Emirate

of Dubai. Following the results of the sensitivity analysis based on the alpha level and pseudo r2,

the following recommendations can be suggested: 1. Create service lines and build local capacity

by training local physicians for the common and specific medical conditions patients travelled

overseas for, after specifying the ICD codes, and take into consideration the specific needs of older

patients, patients who are not covered financially by the government for treatment overseas, and

patients with low household income. 2. Continue with the visiting doctor program at the DHA – a

program that is already in existence to a) diagnose and treat patients locally and b) train local

physicians to look after the patients after visiting physicians leave the country. 3) Send patients

with complicated cases for treatment and diagnosis overseas only if the service is not within the

local service line, or if difficult to handle by visiting physicians and if the case can’t afford to wait

for a long time.

Providing the option of treatment in the UAE will reduce the risks and complications of

follow-up care after the overseas experience, since patients will be diagnosed and treated locally

instead of having treatment and follow up in two different locations. The results of the analysis for

115

the research aim will encourage the government of Dubai to start strategically planning and

working in building local capacity. This can be done through training local physicians to specialize

and attracting specialists from overseas to the UAE. This will help to meet the need for specialized

care for the most frequent medical conditions patients travel for in both the government and the

private sectors. The results of this aim give insights about the general patients’ profiles who would

be willing to be diagnosed and treated by a known physician in the UAE combined with its

associated waiting time, and patients who would be willing to be diagnosed and treated by a

visiting physician to the UAE combined with its associated waiting time.

Conclusion

In conclusion, understanding patient preferences for healthcare services is very important

in order to improve the quality of services provided. The partnership of patients in the decision

making process regarding healthcare services not only helps in reforming the healthcare system in

the Emirate of Dubai; it also helps the patients to share the responsibility in the healthcare services

with the healthcare providers about the choices they make (Guadagnoli & Ward, 1998). Many

studies emphasize that offering choices to patients leads to higher levels of satisfaction with the

healthcare provided. Moreover, patients’ involvement in healthcare decisions can increase

patients’ compliance towards treatment, improve patient outcomes, reduce pain and anxiety and

improve recovery. In addition long term results can be reaped by the government with regard to

reducing the costs spent on sending patients for treatment overseas, and ensuring that people’s

demand for healthcare are met and channeled appropriately in the UAE.

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Tables

Table 1: Most common medical conditions diagnosed overseas and answered preferences

for healthcare services: Willingness to wait to be diagnosed by a known physician/visiting

physician and waiting time

Table 2. Comorbidity with most common medical conditions diagnosed overseas and

preferences for healthcare services: Willingness to wait to be diagnosed by a known

physician/visiting physician and waiting time

2 Comorbidity Frequency

1 Bone and Joint Disease + General Surgery 3

2 Cancer + Heart Diseases 3

3 Heart Diseases + Eye Diseases 1

4 Bone and Joint Diseases + Heart Diseases 2

5 Bone and Joint Diseases + Cancer 2

6 Neurological Diseases + General Surgery 1

7 Cancer + General Surgery 1

8 Bone and Joint Diseases + Neurological Diseases 2

9 Bone and Joint Disease + Eye Diseases 1

3 Comorbidity Frequency

1 Bone and Joint Diseases + Neurological Diseases + Eye Diseases 1

2 Bone and Joint Diseases + Cancer + Neurological Disease 1

Medical Conditions N (%)

Cancer 59 (28.78)

Bone and Joint Diseases 35 (17.07)

Heart Diseases 39 (19.02)

General Surgery 17 (8.29)

Neurological Diseases 15 (7.32)

Eye Diseases 22 (10.73)

multimorbity 18 (8.78)

Total 205 (100.00)

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Table 5. Willingness to be diagnosed and treated by a visiting physician to the UAE across the six medical

conditions: Bone & Joint Diseases, Cancer, Neurological Disease, General Surgery, Heart Diseases, and Eye

Diseases

Willingness Bone & Joint

N (%)

Cancer N (%) Neurological

Diseases N (%)

General

Surgery N (%)

Heart Diseases

N (%)

Eye Disease N

(%)

0=Disagree 10 (21.28) 11 (16.67) 7 (35.00) 8 (36.36) 8 (17.78) 6 (24.00)

1=Neutral 4 (8.51) 9 (13.64) 1 (5.00) 3 (13.64) 6 (13.33) 1 (4.00)

2=Agree 33 (70.21) 46 (69.70) 12 (60.00) 11 (50.00) 31 (68.89) 18 (72.00)

Mean ± SD 1.49 ± 0.83 1.53 ± 0.77 1.25 ± 0.97 1.13 ± 0.94 1.51 ± 0.79 1.48 ± 0.87

Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

Table 3. Willingness to be diagnosed and treated by a known physician in the UAE across the six medical


Diseases


N (%)


Diseases N (%)

General

Surgery N (%)

Heart Diseases

N (%)

Eye Disease N

(%)

0=Disagree 13 (27.66) 17 (25.76) 5 (25.00) 10 (45.45) 13 (28.89) 7 (28.00)

1=Neutral 10 (21.28) 17 (25.76) 3 (15.00) 5 (22.73) 7 (15.56) 3 (12.00)

2= Agree 24 (51.06) 32 (48.48) 12 (60.00) 7 (31.82) 25 (55.56) 15 (60.00)

Mean ± SD 1.23 ± 0.87 1.23 ± 0.83 1.35 ± 0.88 0.86 ± 0.89 1.27 ± 0.79 1.32±0.9

Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

Table 6. Willingness to wait to be diagnosed and treated by a visiting physician to UAE across the six medical


Diseases


N (%)


Diseases N (%)

General

Surgery N (%)

Heart Diseases

N (%)

Eye Disease N

(%)

One week 27 (57.45) 47 (71.21) 14 (70.00) 15 (68.18) 30 (66.67) 18 (72.00)

More than one

Week

20 (42.55) 19 (28.79) 6 (30.00) 7 (31.82) 15 (33.33) 7 (28.00)

Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

Table 4. Willingness to wait to be diagnosed and treated by a known physician in the UAE across the six medical


Diseases


N (%)


Diseases N (%)

General

Surgery N (%)

Heart Diseases

N (%)

Eye Disease N

(%)

One week 34 (72.34) 53 (80.30) 19 (95.00) 17 (77.27) 35 (77.78) 21 (84.00)

More than one

Week

13 (27.66) 13 (19.70) 1 (5.00) 5 (22.73) 10 (22.22) 4 (16.00)

Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

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Table 7. Sensitivity Analysis by two alpha levels (0.05 and 0.1)

Alpha Level 0.1 Alpha Level 0.05

Cancer

Willingness to be diagnosed and treated for cancer

by a known physician in the UAE

(Treatment coverage p-value 0.05)

Willingness to wait to be diagnosed and treated for

the case of cancer by a known physician in the UAE

(Household income p-value 0.04)

Willingness to be diagnosed and treated for cancer

by a visiting physician to the UAE

(Cost of treatment p-value 0.08)

Neurological Diseases


neurological diseases by a visiting physician to the

UAE (Answering the survey p-value 0.05)

Eye Diseases

Willingness to be diagnosed and treated for eye

diseases by a known physician in the UAE

(Treatment coverage p-value 0.07)

Willingness to be diagnosed and treated for eye

diseases by a visiting physician in the UAE

(Answering the survey p-value 0.06)

Willingness to wait to be diagnosed and treated eye

diseases a visiting physician to the UAE time

(Age p-value 0.08)

General Surgery

Willingness to be diagnosed and treated to go

through general surgery by a known physician in

the UAE

(Age p-value 0.05)

Willingness to wait to be diagnosed and treated to

go through general surgery by a visiting physician

to the UAE


Heart Diseases


heart diseases by a known physician in the UAE

(Age p-value 0.06)

Willingness to be diagnosed and treated for heart

diseases by a known physician in the UAE


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Table 8. Sensitivity Analysis by Pseudo r2

Outcome of Interest Medical

Condition

Predictor Pseudo R2 Variation

explained

P-value

Alpha Level 0.05 Willingness to wait to be diagnosed

and treated by a known physician in

the UAE

Cancer Household

Income 0.0818 9 0.04

Willingness to be diagnosed and

treated by a known physician in the

UAE

Heart

Disease

Household

income 0.0896 7 0.04



UAE

Cancer Treatment

coverage 0.0467 11 0.05

Willingness to wait to be diagnosed

and treated by a visiting physician to

the UAE

Neurological

Diseases

Answering

the survey 0.1839

2 0.05



UAE

General

Surgery

Age 0.2760

1

0.05



the UAE

General

Surgery

Household

Income 0.1614

3 0.05

Alpha level 0.1 Willingness to be diagnosed and

treated by a visiting physician in the

UAE

Eye

Diseases

Answering

the survey 0.1351 4 0.06


and treated for heart diseases by a

known physician in the UAE

Heart

Diseases

Age 0.0867 8 0.06



UAE

Eye diseases Treatment

coverage 0.1252 6 0.07


treated by a visiting physician to the

UAE

Cancer Cost of

treatment 0.0632 10 0.08



the UAE time

Eye

Diseases

Age 0.1287 5 0.08

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Table E1. Significant results from the binary logistic regression analysis for the case of

cancer: willingness to be diagnosed and treated by a known physician in the UAE

Independent Variable Unadjusted*

OR 90%CI P-value**

Treatment Coverage Government Coverage 1.00 - -

Non-Government Coverage 4.04 (0.98,16.62) 0.05

*Treatment coverage variable was used as the only predictor through bivariate analysis by using Binary Logistic Regression

model


Table F1. Significant results from the binary logistic regression analysis for the case of

cancer: willingness to wait to be diagnosed and treated by a known physician in the UAE


OR 90%CI P-value**

Household Average Monthly Income Lower Income - - -

Middle and Higher Income 5.30 (1.07 - 26.23) 0.04

*Household average monthly income variable was used as the only predictor through bivariate analysis by using Binary Logistic

Regression model


Table G1. Significant results from the binary logistic regression analysis for the case of

cancer: willingness to be diagnosed and treated by a visiting physician to the UAE


OR 90%CI P-value**

Cost of Treatment Not Important 1.00 - -

Neutral 0.24 (0.05 - 1.17) 0.08

Important 2.23 (0.43 - 11.50 0.34

*Cost of treatment variable was used as the only predictor through bivariate analysis by using Binary Logistic Regression model


Table L1 Significant results from the binary logistic regression for the case of neurological

diseases: willingness to wait to be diagnosed and treated by visiting physician to the UAE


OR 90%CI P-value**

Answering the Survey

Self-Reported 1.00 - -

Family Member Reported 13 (0.98 - 172.95) 0.05

* Answering the survey variable was used as the only predictor through the bivariate analysis with using Binary Logistic

Regression model


121

Table M1. Significant results from the binary logistic regression analysis for the case of eye

diseases: willingness to be diagnosed and treated by a known physician in the UAE Independent Variable Unadjusted*

OR 90%CI P-value**

Treatment Coverage Government Coverage 1.00 - -

Non-Government Coverage 0.11 (0.01,1.17) 0.07

*Treatment coverage was used as the only predictor through bivariate analysis with using Binary Logistic Regression model


Table O1. Significant results from the binary logistic regression analysis for the case of eye

diseases: willingness to be diagnosed and treated by a visiting physician in the UAE Independent Variable Unadjusted*

OR 90%CI P-value**

Answering the Survey Self-Reported 1.00 - -

Family Member Reported 6.5 (0.94,45.11) 0.06

*Answering the survey variable was used as the only predictor through the bivariate analysis with using Binary Logistic

Regression model


Table P1. Significant results from the binary logistic regression analysis for the case of eye

diseases: willingness to wait to be diagnosed and treated by a visiting physician to the UAE Independent Variable Unadjusted*

OR 90%CI P-value**

Age Age 0.96 (0.91,1.01) 0.08

*Age variable was used as the only predictor through bivariate analysis with using Binary Logistic Regression model


Table Q1. Significant results from the binary logistic regression analysis for going through

general surgery: willingness to be diagnosed and treated by a known physician in the UAE


OR 90%CI P-value**

Age Age 1.08 (1.00 - 1.17) 0.05

*Age variable was used as the only predictor through bivariate analysis with using Binary Logistic Regression model


Table T1. Significant results from the binary logistic regression analysis for going through

general surgery: willingness to wait be diagnosed and treated by a visiting physician to the

UAE Independent Variable Unadjusted*

OR 90%CI P-value**

Household Average Monthly Income Lower Income 1.00 - -

Middle and High Income 0.11 (0.01 - 0.95) 0.05

*Household average monthly income variable was used as the only predictor through bivariate analysis with using Binary

Logistic Regression model


122

Table U1. Significant results from the binary logistic regression analysis for the case of

heart diseases: willingness to be diagnosed and treated by a known physician in the UAE


OR 90%CI P-value**

Household Average Monthly Income Lower Income 1.00 - -

Middle and High Income 6 (1.13 - 31.73) 0.04

*Household average monthly income variable was used as the only predictor through bivariate analysis with using Binary

Logistic Regression model


Table V1. Significant results from the binary logistic regression analysis for the case of

heart diseases: willingness to wait to be diagnosed and treated by a known physician in the

UAE Independent Variable Unadjusted*

OR 90%CI P-value**

Age Age 1.04 (1.00,1.08) 0.06

*Age variable was used as the only predictor in through bivariate analysis with using Binary Logistic Regression model


123

CHAPTER FIVE: SUMMARY AND CONCLUSIONS

124

This chapter provides a summary of the main findings from the study aims, explores policy

implications for the Emirate of Dubai, and discusses areas for future research.

Summary Findings Manuscript One

Aim 1a. Examine the Factors Associated with Treatment Destinations among Patients Treated

Overseas from the United Arab Emirates Sponsored by DHA during 2009-2016 & Aim-1b.

Determine the Factors Associated with Total Number of Trips among the Patients Treated

Overseas from the United Arab Emirates Sponsored by Dubai Health Authority during 2009-2016.

Results from this study showed associations among age, travelling season and medical

specialty with the country of destination as an outcome. The older the age group the higher the

prevalence ratio of seeking healthcare services in the Federal Republic of Germany. On their first

trips, patients treated overseas had a lower prevalence ratio of seeking healthcare services in the

Federal Republic of Germany when travelling in the winter. The top five medical specialties

patients sought treatment for in the Federal Republic of Germany, in comparison to other countries

of destination, were: Neurosurgery, Internal Medicine: Endocrinology, Urology, General Surgery,

and Internal Medicine Gastroenterology with Orthopedic Surgery used as a reference group.

The total number of trips was associated with age, travel season, number of years present

in the study data base, and the medical specialty for which treatment was sought. The older the

patient, the lower the incidence rate ratio of having a larger number of trips. Patients treated

overseas had a higher incidence rate ratio of expected number of trips for seeking healthcare

services in the Federal Republic of Germany in spring and winter compared to the summer.

Moreover, the longer the overseas treated patients were in the data set (within the 8 years of the

data set), the higher the expected number of trips. Patients seeking care for Internal Medicine:

Oncology, Ophthalmology and General Surgery had higher expected numbers of trips overseas.

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Summary Findings Manuscript Two

Aim 2. Patient Characteristics and the Motivational Factors for Choosing Treatment

Destinations among Patients Treated Overseas from the UAE during 2009 – 2012.

This study showed an association between the medical condition and financial factors when

choosing the treatment destinations. Patients diagnosed with stroke (brain hemorrhage or clot) had

a higher prevalence ratio for choosing the Federal Republic of Germany over other treatment

destinations. On the other hand, patients diagnosed with eye diseases had a higher prevalence ratio

of choosing other destinations than the Federal Republic of Germany. Although the survey

responses were collected through non-random sampling, the results of this aim are consistent with

the administrative data in aim-1 in chapter two.

Financial factors such as perceptions of the cost of treatment in the treatment destination

and treatment coverage influenced patients’ choices regarding treatment destinations. Patients who

perceived cost of treatment as an important factor had a lower prevalence ratio of choosing the

Federal Republic of Germany compared to other destinations. In contrast, patients who were

sponsored by the government had a higher prevalence ratio of choosing the Federal Republic of

Germany as a destination of treatment compared to other destinations. In looking at the descriptive

part of this study, other factors were also important as motivational factors in seeking healthcare

services overseas such as: word of mouth, long waiting times in the UAE, unavailability of

treatment in the UAE, and healthcare providers’ interpersonal communications. Although these

factors had high frequencies among the respondents, there were no significant differences in these

factors between choosing the Federal Republic of Germany and other destinations. It is noteworthy

that patients’ satisfaction levels among the top 5 travel destinations were lower for the Federal

Republic of Germany compared to other destinations such as the Kingdom of Thailand, United

126

Kingdom, Republic of India and United States of America. The differences, however, were not

statistically significant.

Summary Findings Manuscript Three

Aim 3. Explore Associations between Patients’ Characteristics and Preferences for Healthcare

Services if the Treatment is Made Available in the UAE for the Cases of Bone and Joint Diseases,

Cancer, Neurological Diseases, Eye Diseases, Heart Disease and a Requirement for General

Surgery among Patients Treated Overseas from the UAE during 2009 - 2012. Healthcare Services

Include: 1a. Willingness to be Diagnosed and Treated by a Known Physician in the UAE. 1b.

Willingness to Wait to be Diagnosed and Treated by a Known Physician in the UAE. 2a.

Willingness to be Diagnosed and Treated by a Visiting Physician to the UAE. 2b. Willingness to

Wait to be Diagnosed and Treated by a Visiting Physician to the UAE.

This study focused on patients with bone and joint diseases, cancer, neurological diseases,

eye diseases, requirements for general surgery and heart diseases, and examined their preferences

to be diagnosed and treated by a known physician or a visiting physician, as well as the amount of

time they were willing to wait for diagnosis and treatment. Overall, the pattern of the demographic

characteristics was almost the same across the six medical conditions related to marital status,

employment status, average monthly income, cost related variables and person answering the

survey. In contrast, mean age, educational attainment and gender distributions differed across the

six medical conditions. Overall, across the six medical conditions, patients had higher proportions

who were willing to be diagnosed and treated by a visiting physician to the UAE and more willing

to wait to be diagnosed and treated by a visiting physician compared to a known physician in the

UAE.

127

With the alpha level set at 0.05 as a significance level, age was significant for general

surgery, financial factors such as income was significant for the case of cancer and for requirement

to go through general surgery and for heart diseases. Whereas treatment coverage was significant

important for the case of cancer too. A family member answering on behalf of the patients was a

significant predictor when answering on the behalf of patients with neurological diseases. These

covariates seems to me important predictors related to healthcare services preferences for certain

medical conditions. Age was significant for patients seeking general surgery: older patients were

more willing to be diagnosed and treated by a known physician in the UAE. Financial factors

played an important role as well in shaping patients preferences. For patients with heart disease,

the higher the income the more likely to be willing to be diagnosed and treated by a known

physician in the UAE. On the other hand, for patients diagnosed with neurological diseases, those

whose family members answered on their behalf were only willing to wait for one week to be

diagnosed and treated by a visiting physician compared to those patients who self-reported their

preferences.

For patients with cancer, financial factors very much impacted their decisions related to

healthcare services preferences. Patients who were not covered by the government were more

likely to be willing to be diagnosed and treated by a known physician in the UAE. In addition,

cancer patients with higher incomes were more likely to be willing to wait for only one week to

be diagnosed and treated by a known physician in the UAE. Age, financial factors (income and

treatment coverage), and family members answering the survey on behalf of the patient were all

found to be significant covariates in addition to the medical condition when making decisions

related to diagnosis and treatment by a known physician or a visiting physician as well as decisions

regarding willingness to wait for diagnosis and treatment by physicians in the UAE.

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Policy Implications

In the second chapter we examined patient characteristics and medical conditions and the

associations with the treatment destination and the total number of trips. It is important to

understand the profiles of patient who sought healthcare services overseas to better understand

patient needs. Demographic profiles, medical conditions and health expenditures are all important

variables that can enable the government to better understand those travelling overseas seeking

healthcare. By looking at the medical conditions, we will be able to predict how many future trips

are required for follow-ups. Since follow-up is an essential component after seeking healthcare

overseas, it is essential that the government should start planning and strategizing how the follow-

up services can be deployed in the UAE (Andersen, 1995).

After patients return home from the international destinations, the patients must continue

appointments and treatment regimens to reduce the risks associated with obtaining medical

treatment overseas (Baker, Haffer, & Denniston, 2003). This will improve patients’ health

outcomes since the overseas treatment had already resulted in a gap in documentation of the

patients’ medical history. The follow-up care program can be designed as a collaborative work

between the overseas treatment destinations and the healthcare providers in the UAE. Depending

on the medical condition and the international classification of disease (ICD), the service line of

the specific medical condition can be made available in the private or the government sectors.

Accordingly the government can design the follow-up care. In addition, alongside with creating a

follow-up care program, the government should start establishing comparative and cost

effectiveness analyses to measure the outcomes of patients treated overseas and to measure

patients’ health related quality of life outcomes. This will help to decide best treatment destinations

for lower costs and high quality care. Furthermore, creating an overseas treatment registry system

129

with all relevant variables related to overseas treatment with detailed data on all the expenditures

per patient will with no doubt help the government to capture over time all the people who travelled

for medical treatment overseas sponsored by all healthcare governmental entities and help capture

all relevant information (Al-Hinai et al., 2011). The expenditures on overseas treatment need to be

studied together with improving the quality and increasing the efficiency of the healthcare services

delivered in the Emirate of Dubai as part of the strategic goals of the DHA. In addition, knowing

the exact numbers of overseas treated patients with their demographic profiles and diagnostic

codes will assist in creating prediction models in the future regarding the diseases for which people

travel.

In the third chapter we examined the associations among patients’ demographics,

motivational factors and choosing treatment destinations as an outcome. It is very important to

understand the motivational factors to recognize how these factors influence patients’ choices of

treatment destinations, as well as choices of physicians and facilities at the treatment destinations.

Understanding the motivational factors that led the patients to travel overseas seeking healthcare

services will guide the government to focus on three main strategies: 1) Quality of Healthcare; 2)

Access to Healthcare; and 3) Efficiency in Healthcare.

With respect to quality, the government should work on reducing the length of waiting time

for the healthcare services in the Emirate of Dubai. This can be achieved through considering

expansion and improvement of the healthcare services in the current public facilities by

introducing new service lines for the medical conditions that motivated patients to travel overseas.

Moreover, it is important to understand patient concerns related to the privacy and patients’ rights

whether it is from a healthcare provider or from a societal perspective. Training medical staff and

healthcare professionals who are in direct contact with the patients for better interpersonal

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communication is also an important strategy to retain patients in the UAE. All in all, the

government should set performance indicators to measure the quality of healthcare related to the

overseas treatment strategy to insure that patients are getting the healthcare services they need and

getting the desired outcomes, especially with their follow-up care in Dubai.

Regarding access to healthcare, it is important to ensure that patients treated overseas are

following up with their treatments and appointments after their overseas treatment experience.

Providing patients with enough information and different treatment options is essential as well for

the different medical conditions for which patients travelled. This information can guide the

patients to use the healthcare services either in the government sector or by channeling them

through the private sector. This strategy will help to ensure patients’ entry into the healthcare

system in the right site where patients’ needs are served the best.

With respect to efficiency, providing a more timely follow-up to the patients who

experienced treatment overseas is necessary to assess patient outcomes in order to create an

evidence base for the government. The evidence base will provide guidance in order to influence

and promote informed patients’ decisions when making choices related to treatment destinations.

At the same time it will guide policy makers to make decisions related to cost effectiveness

regarding lower costs and better outcomes. Overall, comparative and cost effectiveness analyses

should be implemented to measure whether the resources allocated to the overseas treatment

strategy are being utilized optimally and obtaining the best value for the expenditures.

In the fourth chapter we examined associations between patient characteristics and medical

conditions with preferences regarding healthcare services in the UAE. The preferences for

healthcare services if the treatment was made available in the UAE varied by medical condition

with respect to willingness to be diagnosed and treated by a known physician in the UAE with its

131

associated waiting time or willingness to be diagnosed and treated by a visiting physician to the

UAE with its associated waiting time. The results of this study provide preliminary information

related to planning how each medical condition can be better served in the UAE. In addition, it is

important to keep in mind that some subspecialties will not be available in the UAE and there will

still be a need to send patients overseas. Nevertheless, it is necessary to start creating service lines

and building local capacities by training local physicians and attracting expatriate physicians for

certain subspecialties after specifying the international classification of diseases that can be

managed and treated in the UAE. These service lines can be either in the government sector or in

the private sector. This strategy can be linked with the Dubai Health Authority “Dubai Healthcare

Capacity Planning Study (DHCP)” for analyzing population needs for healthcare services

projections. One of the objectives under the DHCP includes satisfying patients’ needs and

providing specialized care to the UAE population as an alternative option to travelling overseas

seeking healthcare services.

Since there is an existing visiting physician program sponsored by the Dubai Health

Authority, the program schedule should develop priorities based on the most common conditions

for which people travelled overseas. This will reduce the flow of patients seeking healthcare

services overseas, will reduce the expenditure for sending patients overseas with their follow-up

trips and will reduce the risks and complications associated with receiving healthcare services

overseas. A related point to consider is strategizing the visiting program not only to diagnose and

treat patients locally for certain sub-specialties, but also to create policies of collaboration for local

physician training in order to continue with patient care after visiting physicians leave the UAE.

Therefore the strategies and policies related to overseas treated patients should be updated to send

patients abroad with complicated cases if the service is not available within the local service lines,

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and too difficult to be handled by a visiting physician or a trained local physician in the UAE.

Moreover, the overseas strategy should be very explicit for the sensitive cases that can’t afford to

wait for a long time.

Last but not least, since the government is encouraged to create an evidence base to reform the

healthcare system in the Emirate of Dubai to meet patients’ needs and improve the quality of care

outcomes, the government should start by exploring alternative empirical economic models with

the associated frameworks and involve important stakeholders to play active roles in decision

making. This will help the government to understand stakeholders’ perceptions in order to

implement the health policies successfully. Using economic preference studies will also provide

alternative options with calculated risks and benefits for every alternative.

Strengths and limitations

Our study provides baseline evidence to the policy makers in the Emirate of Dubai related

to the overseas treatment strategy. The results of the study will help in revisiting and improving

the reporting system and the breakdown of the expenditure related to the overseas treatment

strategy. In general the study will assist in creating a model for follow-up care for the patients who

have experienced overseas treatment to follow-up their health status as soon as they return home.

In addition, intervention strategies can be created to reduce medical specialties for which patients

travelled overseas. It is worth mentioning that the availability of the data at DHA is considered a

strength since the staff at this governmental entity supported easy access to the data for conducting

this research. Additionally, the data can be further utilized in the future to conduct longitudinal

studies, cross-sectional studies, validity testing and reliability research, and economic studies.

Since there are very few empirical research studies related to medical travel, our study contributes

to the limited empirical research in the field. When looking at the knowledge, attitudes and

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perception survey, it is considered the first of its kind in the UAE with a 60% response rate. Both

the administrative data and the KAP survey data provide insights to the government for long term

planning related to creating services lines and providing specialized care through the visiting

physician program for the medical specialties patients travelled overseas for. This study provides

insights as well for public-private partnerships in the healthcare sector in Dubai to address

improving the healthcare services in the Emirate.

It is important to acknowledge the limitations of this study in order to make suggestions

for further research. For instance, an international classification of disease was not available which

reduced the precision of the medical specialty variable in the study, since we were not sure at

which stage the patients were in the progression of their disease. We have to be careful with

generalizations in this study because of the following: 1) Since the patients examined in chapter

two were sponsored by the DHA, we can’t generalize our results to patients sponsored by other

health authorities. 2) Since non-probability sampling (purposive sampling) was the sampling

method of the KAP survey, we can’t generalize our results to all UAE citizens seeking healthcare

services overseas. Reliability and validity of the KAP survey must be tested since the survey was

piloted and used once and was not compared with other tools to the measure the same concept of

medical travel. Another aspect to be considered is that 63% of the survey respondents were family

members answering on behalf of the patients and 8% of the family members did not escort the

patients in the overseas travel experience. Hence; we should consider that the perceptions and the

motivations cited in the survey could reflect the family member’s perceptions rather than the

perceptions and the motivations of the patient. Moreover, the KAP survey didn’t account for more

than one member in the family of the patient who sought healthcare services overseas. As a result,

perceptions and experiences might be mixed up if there was more than one patient in the household

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who sought medical care overseas. In addition since 16 months was the average time from the last

trip during which patients and their families obtained healthcare services overseas before being

interviewed for this survey, “re-call bias” may pose a threat to the internal validity of the survey

results.

Priorities for future studies

Longitudinal Studies

To better understand the medical conditions and countries of destination of patients who

travelled overseas, continued study over time is needed. Although the data in chapter two (aim-

1a) was presented in a cross-sectional manner and based on the first trip, the data can be utilized

in the future to conduct longitudinal data analysis to understand the patterns of overseas treatment

over time. Three important study aims can be achieved by using these data: 1) Examining the

patterns of treatment destinations among patients treated overseas during 2009 – 2016; 2)

Examining the patterns of medical conditions among overseas treated patients during 2009 – 2016;

3) Predicting time to next trip by medical condition regarding number of repeated visits for follow-

up. These longitudinal studies will help in understanding the sequence of patients’ medical

treatment and countries of destination over time. Hence the government could be able to offer

alternative options to expensive treatment destinations whether locally or to destinations with

lower cost and high quality.

Other longitudinal studies can be considered which are related to patient reported

outcomes. Patient reported outcomes (PRO) and health related quality of life measures play an

important role in assessing patient health status. Therefore, to evaluate patient treatments received

overseas, PROs can be used with high validity and relevance to patients’ medical conditions in

order to obtain valid and reliable results (Garcia et al., 2007). At the same time, the PRO tools

135

utilized to measure patient outcomes after receiving treatment overseas should have a reliable and

valid Arabic translation version to be used on the native speaking population of the UAE. In

addition to utilizing the PROs to measure patient outcomes after receiving treatment overseas,

PROs can be utilized as well to measure the follow-up care programs offered to patients coming

from treatment destinations to measure the efficiency and the effectiveness of the programs

provided to overseas treated patients in Dubai.

Validity and Reliability Testing Research

To ensure that the knowledge, attitudes and perceptions survey is a useful tool to measure

people’s perceptions about their overseas treatment experience, the tool should be tested for

reliability and validity after being piloted in Dubai. For reliability and internal consistency of the

survey, the tool should go through test – retest on the same population. The knowledge, perceptions

and attitudes survey should also go through the different types of validity tests: content, criterion,

discriminant, and construct validity to ensure that all the information related to the overseas

treatment experience can be captured by the tool (Pai et al., 2008). Comparing the knowledge,

attitudes and perceptions survey with other measures that theoretically measure the same

constructs and checking the correlations would be ideal for the KAP survey assessment.

Qualitative and Mixed Method Studies

The mixed methods design can be utilized to better understand patients’ perceptions and

attitudes towards the overseas treatment experience. After calculating the study power and setting

the type I error to have enough sample size for the quantitative study, semi-structured qualitative

interviews can also be used to investigate the motivational factors for choosing the destination of

treatment, as well as the specialty physician and the healthcare facility in the treatment destination.

The purpose of the sequential design is to use the qualitative elements to explain the quantitative

136

results (Jones, Nijman, Ross, Ashman, & Callaghan, 2014). The semi-structured interview

questions can be designed based on: thematic analysis for travelling seeking healthcare as

explained in the framework presented in chapter one, literature review related to medical travel,

and consulting experts in the medical travel field. The qualitative study can focus more specifically

on the overseas treatment experience of the patients at the different time frames (Pre-overseas

treatment /during overseas treatment/ Post overseas treatment). Qualitative studies can be

conducted shortly after the overseas treatment experience to ask participants for more details about

emerging findings and to reduce the recall bias regarding the experience.

Cross Sectional Studies

There are many sections in the KAP survey conducted in Dubai that haven’t yet been

analyzed. The price-quality table, for example, can be utilized to study patient perceptions towards

price and quality for the top 5 most frequent countries of destination among overseas treated

patients from the United Arab Emirates during 2009 – 2012: Federal Republic of Germany, United

Kingdom, United Stated of America, Kingdom of Thailand and the Republic of India. Another

section of the knowledge, attitudes and perceptions survey that can be utilized is the preference

table which measures patient preferences regarding different countries of destination when the cost

of treatment overseas is covered by different sponsors, including out of pocket payment, covered

by health insurance, and covered by the government.

Another cross-sectional dataset that can be utilized and that can add value related to

overseas treatment is the Dubai Household Survey. The survey is a collaborative effort between

the Dubai Health Authority and the Dubai Statistics Center. The survey is collected through a

complex stratified (geographic area) design, with multistage probability sampling and is conducted

every 4 years to describe the health status of the population, including mortality, health

137

expenditures, access to health services, health-related behaviors, etc. The design and methodology

of the survey were adapted from those used in the World Bank’s Living Standards Measurement

Surveys (LSMS), the World Health Organization’s World Health Surveys (WHS) and the US

Centers for Disease Control’s National Health Interview Surveys (NHIS). The Dubai Household

Survey 2014 can be utilized to examine the satisfaction levels with the healthcare services

utilization in the Emirate of Dubai among those who received healthcare services overseas

compared to patients who received healthcare domestically by using advanced statistical methods

to adjust for the different service lines in Dubai (Hussin, 2015).

Economic Studies with Larger Sample Sizes

There are many economic studies that can be conducted related to seeking healthcare

services overseas (Ijzerman, van Til, & Bridges, 2012). Willingness to pay (WTP) is one of the

exercises that can be conducted (Gafni, 1991; Hollinghurst, 2016). Since WTP questions were part

of the KAP survey, this part of the survey can be utilized to examine how much patients who

sought healthcare overseas are willing to pay if the treatment was made available in the UAE in

the private sector. The price offered in this exercise is related to the medical conditions patients

were diagnosed with and in UAE currency (AED). The price includes: consultation, investigation,

admission and medicine but not including travel and accommodation. The average prices used in

this exercise were extracted from the claiming system in the funding Department at the DHA.

A second economics exercise that can be conducted related to the same topic is the conjoint

analysis technique. The survey data analyzed in chapter four (aim-3) can be further improved and

developed to conduct a discrete choice conjoint analysis to understand patients’ preferences related

to being diagnosed and treated by a known physician in the UAE or a visiting physician to the

UAE and their associated waiting times. A third economics research approach that can be

138

conducted is a cost effectiveness analysis for costly subspecialties sent overseas to compare

between alternative procedures and alternative destinations (using UAE currency) to look at the

incremental cost-effectiveness ratio to decide which have better outcomes for procedures, as well

as the lower cost destinations with high quality outcomes.

139

APPENDICES

140

Appendix for Manuscript One

Figure-4. Analytical data set selection flow chart

15,138 Total trips

234 trips with more than one medical

specialty removed

Complete case analysis 1 sex missing and

36 age missing

581 trips of UAE citizens in the UAE

removed

2693 trips of Non-UAE citizens removed

4788 second trips onward for all

individuals excluded

6557 first trips of unique individuals used

as an analytical dataset

141

Table 14. Medical Specialty variable used in the study converted from Admin-Original to

ABMS-final

ABMS-final Admin-original

Internal Medicine: Oncology Oncology, Oncology (Breast), Ncology(Colon), Oncology

(Haematology), Oncology Endo, Oncology(Gastro),

Oncology(Uorology), Oncology(Brain),

Onconlogy(Pulmonary)), Oncology (Maxillofacial),

Oncology (Opthalmology)), Oncology(Mandible),

Oncology(Bone), Oncology(Uterus), Oncology

(Neurosurgery)

Internal Medicine: Cardiology Cardiology

Internal Medicine: Rheumatology Rheumatology, Lupus

Internal Medicine: Gastroenterology Gastrology, Liver, Digestive Disease, Hepatology

Internal Medicine: Nephrology Nephrology

Internal Medicine: Endocrinology Endocrinology, Diabetic, Thyroid

Internal Medicine: Hematology Haematology, Thalassemia, Stem Cell Therapy, Bone

Marrow

Internal Medicine: Pulmonology Pulmonary, Respiratory

Internal Medicine: Infectious Diseases Infectious Diseases, Medical (T. B.)

Internal Medicine Medical

Pediatrics: Oncology Paediatric Oncology

Pediatrics: Cardiology Paediatric Cardiology

Pediatrics: Surgery Paediatric Surgery, Pead. &Amp; P.Surg

Pediatrics: Neurosurgery Paediatric Neuro. Surgery

Pediatrics: Rheumatology Pediatric Rheumatology

Pediatrics: Neurology Peadiatric Neurology, Pediatric Neurology

Pediatrics: Gastroenterology Paediatric Gastrology

Pediatrics: Nephrology Pediatric Nephrology, Paeddiatric Nephrology

Pediatrics: Hematology Pediatric Hematology, Pediatrie Thalassemiai

Pediatrics: Endocrinology Pediatric Dibetic, Paediateic Endocrinology

Pediatrics: Neonatology Neonatology

Pediatrics: Pulmonology Pediatric Respiratory

Un specified Pediatrics Paediatric

General Surgery Surgery

Neurosurgery Neuro. Surgery, Neuro. Surgery(Spine), Neurosurgery

&Amp; Gastrology

Orthopedic Surgery Prosthesis, Ortho. (Trauma), Ortho. (Knee), Orthopaedic,

Ortho, Ortho. (Shoulder), Paediatric Ortho, Hand Surgery

Thoracic Surgery Pediatric Cardio Surgery, Cardio Surgery, Cardiothoraic,

Thoracic Sugeon, Thoracic Surgery

Vascular Surgery Vasc. Surg

Plastic Surgery Burn, Plastic Surg.

Obstetrics and Gynecology Sex!=1 & Genatic Infertility (Pgd), Obst &Amp;Gyn,

Fertility, Infertility, Gynaecology

Dermatology Dermatology

142

Neurology Neurology, Epilepsy

Urology Uorology, Paediatric Uorology, Prostate, (Sex==1 & (Obst

&Amp;Gyn, Fertility, Infertility))

Otolaryngology Ent

Dental Dent (Oral S.)

Genetics Genatic

Ophthalmology Ophthalomology, Paediatric Opthalmology, P.Surgery

&Amp; Opthalmology

Physical Medicine and Rehabilitation Rehabilitation, Physiotherapy

Screening & Check-up General Check Up

Psychiatry Autism, Psycatric, Psychiatry

NOT SPEFCIFID CASES Not Specified, Null

Radiology Pet Scan

Oral & Maxillofacial Surgery Oral-Maxillofacail, Maxillofacial Surgery

Table 15. Demographics and total number of trips among patients treated overseas from the

United Arab Emirates during 2009 – 2016 stratified by age and gender (for total trips in the

data-set)

1 Trip Only 2 Trips Only 3 Trips Only

4 Trips

Only 5 Trips Only

6 Trips and

above

Total

Gender

Males 2,196 (53.02) 1,267 (50.58) 754 (48.77) 427 (44.02) 361 (50.77) 844 (57.38) 5,849 (51.56)

Females 1,946 (46.98) 1,238 (49.42) 792 (51.23) 543 (55.98) 350 (49.23) 627 (42.62) 5,496 (48.44)

Total 4,142 (100) 2,505 (100) 1,546 (100) 970 (100) 711 (100.00) 1,471 (100) 11,345 (100)

Age group

0-4 yrs. 399 (9.63) 271 (10.82) 223 (14.42) 119 (12.27) 111 (15.61) 186 (12.64) 1,309 (11.54)

5-12 yrs. 297 (7.17) 184 (7.35) 142 (9.18) 80 (8.25) 66 (9.28) 162 (11.01) 931 (8.21)

13-18 yrs. 213 (5.14) 138 (5.51) 74 (4.79) 66 (6.80) 47 (6.61) 48 (3.26) 586 (5.17)

19-39 yrs. 1,193 (28.80) 766 (30.58) 400 (25.87) 282 (29.07) 130 (18.28) 377 (25.63) 3,148 (27.75)

40-54 yrs. 815 (19.68) 472 (18.84) 330 (21.35) 217 (22.37) 187 (26.30) 321 (21.82) 2,342 (20.64)

55-69yrs. 805 (19.44) 474 (18.92) 285 (18.43) 169 (17.42) 141 (19.83) 285 (19.37) 19.37 (19.03)

70+ yrs. 420 (10.14) 200 (7.98) 92 (5.95) 37 (3.81) 29 (4.08) 92 (6.25) 870 (7.67)

Total 4,142 (100) 2,505 (100) 1,546 (100) 970 (100) 711 (100) 1,471 (100) 11,345 (100)

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Table 16. Demographics and total number of trips (from 1st Trip to 20th Trip) among patients

treated overseas from the United Arab Emirates during 2009 – 2016 stratified by age and

gender (for total trips in the data-set)

Gender

Trip

Number

1st Trip 2nd

Trip

3rd

Trip

4th trip 5th

Trip

6th

Trip

7th Trip 8th

Trip

9th

Trip

10th

Trip

Total

Males 3,398

(51.82)

1,169

(49.98)

543

(49.54)

285

(50.35)

181

(54.03)

110

(55.84)

67

(62.04)

35

(60.34)

21

(58.33)

13

(65.00)

5,849

(51.56)

Females 3,159 (48.18)

1,170 (50.02)

553 (50.46)

281 (49.65)

154 (45.97)

87 (44.16)

41 (37.96)

23 (39.66)

15 (41.67)

7 (35.00)

5,496 (48.44)

Total 6,557 (100.00)

2,339 (100.00)

1,096 (100.00)

566 (100.00)

335 (100.00)

197 (100.00)

108 (100.00)

58 (100.00)

36 (100.00)

20 (100.00)

11,345 (100.00)

Trip

Number

11th

Trip

12th

Trip

13 Trip 14th

Trip

15th

Trip

16th

Trip

17th Trip 18th

Trip

19th

Trip

20th

Trip

Total

Males 9

(75.00)

5

(83.33)

4

(80.00)

2

(100.00)

2

(100.00)

2

(100.00)

0 (0.00) 1

(100.00)

1

(100.00)

1

(100.00)

5,849

(51.56)

Females 3 (25.00)

1 (16.67)

1 (20.00)

0 (0.00)

0 (0.00) 0 (0.00) 1(100.00) 0 (0.00) 0 (0.00) 0 (0.00) 5,496 (48.44)

Total 12 (100.00)

6 (100.00)

5 (100.00)

2 (100.00)

2 (100.00)

2 (100.00)

1 (100.00)

1 (100.00)

1 (100.00)

1 (100.00

11,345 (100.00)

Age group

Trip

Number

1st Trip 2nd

Trip

3rd

Trip

4th

Trip

5th

Trip

6th

Trip

7th Trip 8th

Trip

9th

Trip

10th

Trip

Total

0-4 yrs. 691

(10.54)

285

(12.18)

152

(13.87)

76

(13.43)

44

(13.13)

23

(11.68)

15

(13.89)

10

(17.24)

5

(13.89)

2

(10.00)

1,309

(11.54)

5-12 yrs. 492

(7.50)

196

(8.38)

99

(9.03)

53

(9.36)

34

(10.15)

21

(10.66)

13

(12.04)

11

(18.97)

6

(16.67)

3

(15.00)

931

(8.21)

13-18

yrs.

343 (5.23)

126 (5.39)

56 (5.11)

32 (5.65)

14 (4.18)

7 (3.55) 4 (3.70) 2 (3.45) 1 (2.78) 1 (5.00) 586 (5.17)

19-39

yrs.

1,873 (28.56)

665 (28.43)

275 (25.09)

140 (24.73)

75 (22.39

50 (25.38)

23 (21.30)

13 (22.41)

9 (25.00)

7 (35.00)

3,148 (27.75)

40-54

yrs.

1,307

(19.93)

484

(20.69)

247

(22.54)

127

(22.44)

79

(23.58)

45

(22.84)

27

(25.00)

9

(15.52)

8

(22.22)

4

(20.00)

2,342

(20.64)

55-

69yrs.

1,265

(19.29)

430

(18.38)

210

(19.16)

109

(19.26)

70

(20.90)

38

(19.29)

20

(18.52)

10

(17.24)

4

(11.11)

2

(10.00)

2,159

(19.03)

70+ yrs. 586

(8.94)

153

(6.54)

57

(5.20)

29

(5.12)

19

(5.67)

13

(6.60)

6 (5.56) 3 (5.17) 3 (8.33) 1 (5.00) 870

(7.67)

Total 6,557

(100.00)

2,339

(100.00)

1,096

(100.00)

566

(100.00)

335

(100.00)

197

(100.00)

108

(100.00)

58 (100) 36

(100.00)

20

(100.00)

11,345

(100.00)

Trip

Number

11th

Trip

12th

Trip

13th

Trip

14th

Trip

15th

Trip

16th

Trip

17th

Trip

18th

Trip

19th

Trip

20th

Trip

Total

0-4 yrs. 1 (8.33) 1 (16.67)

1 (20.00)

1 (50.00)

1 (50.00)

1 (50.00)

0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 1,309 (11.54)

5-12 yrs. 3

(25.00)

0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 931

(8.21)

13-18

yrs.

0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 586

(5.17)

19-39

yrs.

5

(41.67)

3

(50.00)

3

(60.00)

1

(50.00)

1

(50.00)

1

(50.00)

1

(100.00)

1

(100.00) 1

(100.00) 1

(100.00) 3,148

(27.75)

40-45

yrs.

2

(16.67)

2

(33.33)

1

(20.00)

0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 2,342

(20.64)

55-59

yrs.

1 (8.33) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 2,159 (19.03)

70+ yrs. 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 870 (7.67)

Total 12

(100.00)

6

(100.00)

5

(100.00)

2

(100.00)

2

(100.00)

2

(100.00)

1

(100.00)

1

(100.00)

1

(100.00)

1

(100.00)

11,345

(100.00)

144

Table 17. Countries of destination among patients treated overseas from the United Arab

Emirates during 2009 – 2016 (for total trips in the data-set)

Country of Destination N (%)

1 Federal Republic of Germany 5,137 (45.28)

2 United Kingdom 2,159 (19.03)

3 Kingdom of Thailand 1,638 (14.44)

4 United Stated of America 741 (6.53)


6 Republic of India 389 (3.43)

7 Kingdom of Spain 389 (3.43)




11 Swiss Confederation 36 (0.32)

12 Korea 31 (0.27)

13 People's Republic of China 26 (0.23)

14 Republic of Slovenia 25 (0.22)

15 Kingdom of Saudi Arabia 24 (0.21)

16 Arab Republic of Egypt 22 (0.19)

17 Republic of the Philippines 20 (0.18)

18 The Hashemite Kingdom of Jordan 13 (0.11)

19 Italian Republic 2 (0.02)

20 Kingdom of Sweden 2 (0.02)

21 Czech Republic 1 (0.01)

22 Republic of Indonesia 1 (0.01)

23 Kingdom of Morocco 1 (0.01)

24 Republic of Turkey 1 (0.01) Total 11,345 (100)

145


Emirates during 2009 – 2016 stratified by gender (for total trips in the data-set)

Country of Destination Gender Total

Females Males

1 Kingdom of Thailand 706 (12.85) 932 (15.93) 1,638 (14.44)

2 Kingdom of Belgium 42 (0.76) 41 (0.7) 83 (0.73)

3 People's Republic of China 12 (0.22) 14 (0.24) 26 (0.23)

4 Czech Republic 1 (0.02) 0 (0) 1 (0.01)

5 Arab Republic of Egypt 8 (0.15) 14 (0.24) 22 (0.19)

6 French Republic 27 (0.49) 21 (0.36) 48 (0.42)

7 Swiss Confederation 17 (0.31) 19 (0.32) 36 (0.32)

8 Federal Republic of Germany 2,440 (44.4) 2,697(46.11) 5,137 (45.28)

9 Republic of India 214 (3.89) 175 (2.99) 389 (3.43)

10 Republic of Indonesia 0 (0) 1 (0.02) 1 (0.01)

11 Italian Republic 1 (0.02) 1 (0.02) 2 (0.02)

12 The Hashemite Kingdom 9 (0.16) 4 (0.07) 13 (0.11)

13 Korea 12 (0.22) 19 (0.32) 31 (0.27)

14 Kingdom of Morocco 0 (0) 1 (0.02) 1 (0.01)

15 Republic of the Philippines 5 (0.09) 15 (0.26) 20 (0.18)

16 Kingdom of Saudi Arabia 9 (0.16) 15 (0.26) 24 (0.21)

17 Republic of Singapore 300 (5.46) 151 (2.58) 451 (3.98)

18 Republic of Slovenia 17 (0.31) 8 (0.14) 25 (0.22)

19 Kingdom of Spain 157 (2.86) 232 (3.97) 389 (3.43)

20 Kingdom of Sweden 0 (0) 2 (0.03) 2 (0.02)

21 Republic of Turkey 1 (0.02) 0 (0) 1 (0.01)

22 United Kingdom 1,111 (20.21) 1,048(17.92) 2,159 (19.03)

23 United Stated of America 371 (6.75) 370 (6.33) 741 (6.53)

24 Republic of Austria 36 (0.66) 69 (1.18) 105 (0.93)

Total 5,496 (100) 5,849 (100) 11,345 (100)


Emirates during 2009 – 2016 stratified by age group (for total trips in the data-set)

Country of Destinations Age Group

0-4 yrs 5-12 yrs 13-18 yrs 19-39 yrs 40-54 yrs 55-69 yrs 70+ yrs Total

1 Kingdom of Thailand 65 (4.97) 62 (6.66) 37 (6.31) 371

(11.79)

394

(16.82)

549

(25.43)

160

(18.39)

1,638

(14.44)

2 Kingdom of Belgium 8 (0.61) 3 (0.32) 3 (0.51) 45 (1.43) 12 (0.51) 11 (0.51) 1 (0.11) 83 (0.73)

3 People's Republic of China 5 (0.38) 5 (0.54) 2 (0.34) 5 (0.16) 4 (0.17) 2 (0.09) 3 (0.34) 26 (0.23)

4 Czech Republic 1 (0.08) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.01)

5 Arab Republic of Egypt 0 (0) 0 (0) 1 (0.17) 7 (0.22) 8 (0.34) 4 (0.19) 2 (0.23) 22 (0.19)

6 French Republic 8 (0.61) 5 (0.54) 0 (0) 19 (0.6) 9 (0.38) 5 (0.23) 2 (0.23) 48 (0.42)

7 Swiss Confederation 0 (0) 0 (0) 2 (0.34) 20 (0.64) 9 (0.38) 2 (0.09) 3 (0.34) 36 (0.32)

8 Federal Republic of Germany 468

(35.75)

429

(46.08)

299

(51.02)

1,511 (48) 1,100

(46.97)

917

(42.47)

413

(47.47)

5,137

(45.28)

9 Republic of India 31 (2.37) 12 (1.29) 1 (0.17) 95 (3.02) 76

(3.25)

126

(5.84)

48

(5.52)

389 (3.43)

10 Republic of Indonesia 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1

(0.05)

0 (0) 1 (0.01)

11 Italian Republic 0 (0) 0 (0) 0 (0) 1 (0.03) 0 (0) 0 (0) 1 (0.11) 2 (0.02)

12 The Hashemite Kingdom 0 (0) 2 (0.21) 2 (0.34) 2 (0.06) 2 (0.09) 3 (0.14) 2 (0.23) 13 (0.11)

13 Korea 0 (0) 3 (0.32) 0 (0) 4 (0.13) 4 (0.17) 16 (0.74) 4 (0.46) 31 (0.27)

14 Kingdom of Morocco 0 (0) 0 (0) 0 (0) 1 (0.03) 0 (0) 0 (0) 0 (0) 1 (0.01)

15 Republic of the Philippines 0 (0) 0 (0) 0 (0) 4 (0.13) 7 (0.3) 9 (0.42) 0 (0) 20 (0.18)

16 Kingdom of Saudi Arab 2 (0.15) 15 (1.61) 4 (0.68) 2 (0.06) 1 (0.04) 0 (0) 0 (0) 24 (0.21)

17 Republic of Singapore 11 (0.84) 7 (0.75) 5 (0.85) 112 (3.56) 140 (5.98) 123 (5.7) 53 (6.09) 451 (3.98)

146

18 Republic of Slovenia 9 (0.69) 11 (1.18) 0 (0) 1 (0.03) 4 (0.17) 0 (0) 0 (0) 25 (0.22)

19 Kingdom of Spain 37 (2.83) 37 (3.97) 47 (8.02) 141

(4.48)

44 (1.88) 51 (2.36) 32 (3.68) 389 (3.43)

20 Kingdom of Sweden 0 (0) 0 (0) 0 (0) 1 (0.03) 0 (0) 0 (0) 1 (0.11) 2 (0.02)

21 Republic of Turkey 0 (0) 1 (0.11) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.01)

22 United Kingdom 574

(43.85)

247

(26.53)

137

(23.38)

550

(17.47)

319

(13.62)

232

(10.75)

100

(11.49)

2,159

(19.03)

23 United Stated of America 84 (6.42) 85 (9.13) 36 (6.14) 214 (6.8) 183 (7.81) 99 (4.59) 40 (4.6) 741 (6.53)

24 Republic of Austria 6 (0.46) 7 (0.75) 10 (1.71) 42 (1.33) 26 (1.11) 9 (0.42) 5 (0.57) 105 (0.93)

Total 1,309

(100)

931 (100) 586 (100) 3,148

(100)

2,342

(100)

2,159

(100)

870

(100)

11,345

(100)

Top Table 20. Countries of Destinations among patients treated overseas from the United Arab

Emirates during 2009 – 2016 stratified by calendar year (for total trips in the data-set)

year Top 5 Countries of Destinations Total

Others Germany Thailand UK USA India

2009 109 (8.51) 521 (10.14 ) 61 ( 3.72 ) 206 ( 9.54) 40 (5.4) 29 (7.46) 966 (8.51)

2010 110 (8.59) 410 ( 7.98 ) 75 (4.58) 166 (7.69) 44 (5.94) 26 ( 6.68) 831 (7.32)

2011 105 (8.2) 486 (9.46) 227 (13.86 ) 180 (8.34) 49 (6.61) 29 (7.46) 1076 (9.48)

2012 183 (14.29) 604 (11.76 ) 293 (17.89) 207 (9.59) 78 (10.53) 43 (11.05) 1408 (12.41)

2013 188 (14.68) 616 (11.99) 271 (16.54) 332 (15.38) 95 (12.82) 33 ( 8.48) 1535 (13.53)

2014 212 (16.55) 869 (16.92) 204 (12.45) 390 (18.06) 123 (16.6) 66 (16.97) 1864 (16.43)

2015 219 (17.1) 1054 (20.52 ) 267 (16.30 ) 434 (20.10) 171 (23.08) 85 (21.85) 2230 (19.66)

2016 155 (12.1) 577 ( 11.23 ) 240 ( 14.65 ) 244 (11.30) 141 (19.03) 78 (20.05) 1435 (12.65)

Total 1281 (100) 5137 (100) 1638 (100) 2159 (100) 741 (100) 389 (100) 11345 (100)

Table 21. The most frequent medical specialties for which patients from the United Arab

Emirates sought medical treatment overseas during 2009 –2016 (for total trips in the data-set)

Medical Specialty N(%)

1 Internal Medicine: Oncology 1,912 (16.85)

2 Orthopedic Surgery 1,388 (12.23)

3 Neurosurgery 985 (8.68)

4 Ophthalmology 724 (6.38)

5 Neurology 602 (5.31)

6 Internal Medicine: Cardiology 546 (4.81)



9 Un specified Pediatrics 420 (3.70)

10 Internal Medicine: Gastroenterology 368 (3.24)

11 Urology 306 (2.70)

12 NOT SPEFCIFID CASES 266 (2.34)

13 Internal Medicine: Endocrinology 252 (2.22)

14 Internal Medicine: Nephrology 249 (2.19)

15 Otolaryngology 209 (1.84)

16 Internal Medicine 203 (1.79)

17 Pediatrics: Neurology 195 (1.72)

18 Thoracic Surgery 194 (1.71)

19 Pediatrics: Cardiology 184 (1.62)

147

20 Internal Medicine: Hematology 179 (1.58)

21 Internal Medicine: Pulmonology 139 (1.23)

22 Plastic Surgery 115 (1.01)

23 Pediatrics: Surgery 104 (0.92)

24 Internal Medicine: Rheumatology 91 (0.80)

25 Vascular Surgery 91 (0.80)

26 Physical Medicine and Rehabilitation 84 (0.74)

27 Pediatrics: Oncology 83 (0.73)

28 Dermatology 83 (0.73)

29 Pediatrics: Nephrology 79 (0.70)

30 Screening & Check-up 75 (0.66)

31 Pediatrics: Neurosurgery 53 (0.47)

32 Pediatrics: Gastroenterology 49 (0.43)

33 Pediatrics: Hematology 34 (0.30)

34 Pediatrics: Neonatology 24 (0.21)

35 Oral & Maxillofacial Surgery 24 (0.21)

36 Psychiatry 22 (0.19)

37 Pediatrics: Endocrinology 18 (0.16)

38 Dental 16 (0.14)

39 Internal Medicine: Infectious Diseases 14 (0.12)

40 Pediatrics: Rheumatology 8 (0.07)

41 Genetics 4 (0.04)

42 Pediatrics: Pulmonology 3 (0.03)

Total 11,345 (100.00)

148

Table 22. The most frequent medical specialties for which patients from the United Arab Emirates sought

medical treatment overseas during 2009 –2016 stratified by gender (for total trips in the data-set)

Medical Specialty Gender Total

Females N (%) Males N (%)

1 Internal Medicine: Oncology 1,174 (21.36) 738 (12.62) 1,912 (16.85)

2 Internal Medicine: Cardiology 216 (3.93) 330 (5.64) 546 (4.81)

3 Internal Medicine: Rheumatology 74 (1.35) 17 (0.29) 91 (0.8)

4 Internal Medicine: Gastroenterology 153 (2.78) 215 (3.68) 368 (3.24)

5 Internal Medicine: Nephrology 100 (1.82) 149 (2.55) 249 (2.19)

6 Internal Medicine: Endocrinology 170 (3.09) 82 (1.4) 252 (2.22)

7 Internal Medicine: Hematology 61 (1.11) 118 (2.02) 179 (1.58)

8 Internal Medicine: Pulmonology 74 (1.35) 65 (1.11) 139 (1.23)

9 Internal Medicine: Infectious Diseases 4 (0.07) 10 (0.17) 14 (0.12)

10 Internal Medicine 102 (1.86) 101 (1.73) 203 (1.79)

11 Pediatrics: Oncology 43 (0.78) 40 (0.68) 83 (0.73)

12 Pediatrics: Cardiology 83 (1.51) 101 (1.73) 184 (1.62)

13 Pediatrics: Surgery 33 (0.6) 71 (1.21) 104 (0.92)

14 Pediatrics: Neurosurgery 22 (0.4) 31 (0.53) 53 (0.47)

15 Pediatrics: Rheumatology 6 (0.11) 2 (0.03) 8 (0.07)

16 Pediatrics: Neurology 72 (1.31) 123 (2.1) 195 (1.72)

17 Pediatrics: Gastroenterology 26 (0.47) 23 (0.39) 49 (0.43)

18 Pediatrics: Nephrology 15 (0.27) 64 (1.09) 79 (0.7)

19 Pediatrics: Hematology 16 (0.29) 18 (0.31) 34 (0.3)

20 Pediatrics: Endocrinology 11 (0.2) 7 (0.12) 18 (0.16)

21 Pediatrics: Neonatology 11 (0.2) 13 (0.22) 24 (0.21)

22 Pediatrics: Pulmonology 0 (0) 3 (0.05) 3 (0.03)

23 Un specified Pediatrics 192 (3.49) 228 (3.9) 420 (3.7)

24 General Surgery 232 (4.22) 273 (4.67) 505 (4.45)

25 Neurosurgery 436 (7.93) 549 (9.39) 985 (8.68)

26 Orthopedic Surgery 591 (10.75) 797 (13.63) 1,388 (12.23)

27 Thoracic Surgery 62 (1.13) 132 (2.26) 194 (1.71)

28 Vascular Surgery 36 (0.66) 55 (0.94) 91 (0.8)

29 Plastic Surgery 57 (1.04) 58 (0.99) 115 (1.01)

30 Obstetrics and Gynecology 445 (8.1) 0 (0) 445(3.92)

31 Dermatology 33 (0.6) 50 (0.85) 83 (0.73)

32 Neurology 268 (4.88) 334 (5.71) 602 (5.31)

33 Urology 69 (1.26) 237 (4.05) 306 (2.7)

34 Otolaryngology 79 (1.44) 130 (2.22) 209 (1.84)

35 Dental 5 (0.09) 11 (0.19) 16 (0.14)

36 Genetics 2 (0.04) 2 (0.03) 4 (0.04)

37 Ophthalmology 310 (5.64) 414 (7.08) 724 (6.38)

38 Physical Medicine and 27 (0.49) 57 (0.97) 84 (0.74)

39 Screening & Check-up 39 (0.71) 36 (0.62) 75 (0.66)

40 Psychiatry 9 (0.16) 13 (0.22) 22 (0.19)

41 NOT SPEFCIFID CASES 127 (2.31) 139 (2.38) 266 (2.34)

41 Oral & Maxillofacial 11 (0.2) 13 (0.22) 24 (0.21)

Total 5,496 (100) 5,849 (100) 11,345 (100)

149

Table 23. The most frequent medical specialties and total number of trips patients from the

United Arab Emirates sought medical treatment overseas during 2009 –2016 stratified by age

group (for total trips in the data-set)

Medical Specialty

Age Group

0-4 yrs N

(%)

5-12 yrs

N (%)

13-18

yrs N

(%)

19-39

yrs N

(%)

40-54

yrs N

(%)

55-69

yrs N

(%)

70+ yrs

N (%)

Total

1 Internal Medicine: Oncology 15 (1.15) 32 (3.44) 33 (5.63) 456

(14.49)

612

(26.13)

564

(26.12)

200

(22.99)

1,912(16.85)

2 Internal Medicine: Cardiology 11 (0.84) 9 (0.97) 18 (3.07) 87 (2.76) 127

(5.42)

175

(8.11)

119

(13.68)

546 (4.81)

3 Internal Medicine: Rheumatology 0 (0) 3 (0.32) 5 (0.85) 47 (1.49) 25 (1.07) 8 (0.37) 3 (0.34) 91 (0.8)

4 Internal Medicine: Gastroenterology 4 (0.31) 4 (0.43) 14 (2.39) 143

(4.54)

81 (3.46) 94 (4.35) 28 (3.22) 368 (3.24)

5 Internal Medicine: Nephrology 5 (0.38) 13 (1.4) 9 (1.54) 79 (2.51) 64 (2.73) 57 (2.64) 22 (2.53) 249 (2.19)

6 Internal Medicine: Endocrinology 2 (0.15) 4 (0.43) 12 (2.05) 104 (3.3) 74 (3.16) 41 (1.9) 15 (1.72) 252 (2.22)

7 Internal Medicine: Hematology 19 (1.45) 43 (4.62) 26 (4.44) 38 (1.21) 26 (1.11) 18 (0.83) 9 (1.03) 179 (1.58)

8 Internal Medicine: Pulmonology 1 (0.08) 8 (0.86) 16 (2.73) 18 (0.57) 27 (1.15) 46 (2.13) 23 (2.64) 139 (1.23)

9 Internal Medicine: Infectious Diseases 0 (0) 0 (0) 0 (0) 4 (0.13) 8 (0.34) 0 (0) 2 (0.23) 14 (0.12)

10 Internal Medicine 2 (0.15) 5 (0.54) 4 (0.68) 63 (2) 43 (1.84) 58 (2.69) 28 (3.22) 203 (1.79)

11 Pediatrics: Oncology 39 (2.98) 40 (4.3) 4 (0.68) 0 (0) 0 (0) 0 (0) 0 (0) 83 (0.73)

12 Pediatrics: Cardiology 134

(10.24)

44 (4.73) 6 (1.02) 0 (0) 0 (0) 0 (0) 0 (0) 184 (1.62)

13 Pediatrics: Surgery 72 (5.5) 30 (3.22) 1 (0.17) 0 (0) 1 (0.04) 0 (0) 0 (0) 104 (0.92)

14 Pediatrics: Neurosurgery 41 (3.13) 12 (1.29) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 53 (0.47)

15 Pediatrics: Rheumatology 0(0) 7 (0.75) 1 (0.17) 0 (0) 0 (0) 0 (0) 0 (0) 8 (0.07)

16 Pediatrics: Neurology 110 (8.4) 82 (8.81) 3 (0.51) 0 (0) 0 (0) 0 (0) 0 (0) 195 (1.72)

17 Pediatrics: Gastroenterology 32 (2.44) 15 (1.61) 2 (0.34) 0 (0) 0 (0) 0 (0) 0 (0) 49 (0.43)

18 Pediatrics: Nephrology 48 (3.67) 29 (3.11) 2 (0.34) 0 (0) 0 (0) 0 (0) 0 (0) 79 (0.7)

19 Pediatrics: Hematology 20 (1.53) 14 (1.5) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 34 (0.3)

20 Pediatrics: Endocrinology 9 (0.69) 8 (0.86) 1 (0.17) 0 (0) 0 (0) 0 (0) 0 (0) 18 (0.16)

21 Pediatrics: Neonatology 23 (1.76) 0 (0) 0 (0) 0 (0) 1 (0.04) 0 (0) 0 (0) 24 (0.21)

22 Pediatrics: Pulmonology 2 (0.15) 1 (0.11) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 3 (0.03)

23 Un specified Pediatrics 327

(24.98)

84 (9.02) 9 (1.54) 0 (0) 0 (0) 0 (0) 0(0) 420 (3.7)

24 General Surgery 8 (0.61) 15 (1.61) 27 (4.61) 203

(6.45)

132

(5.64)

92 (4.26) 28 (3.22) 505 (4.45)

25 Neurosurgery 25 (1.91) 48 (5.16) 43 (7.34) 313

(9.94)

267

(11.4)

236

(10.93)

53 (6.09) 985 (8.68)

26 Orthopedic Surgery 76 (5.81) 164

(17.62)

131

(22.35)

445

(14.14)

240

(10.25)

238

(11.02)

94 (10.8) 1,388

(12.23)

27 Thoracic Surgery 7 (0.53) 7 (0.75) 7 (1.19) 27 (0.86) 36 (1.54) 65 (3.01) 45 (5.17) 194 (1.71)

28 Vascular Surgery 8 (0.61) 5 (0.54) 0 (0) 21 (0.67) 29 (1.24) 19 (0.88) 9 (1.03) 91 (0.8)

29 Plastic Surgery 27 (2.06) 15 (1.61) 5 (0.85) 52 (1.65) 11 (0.47) 4 (0.19) 1 (0.11) 115 (1.01)

30 Obstetrics and Gynecology 0 (0) 1 (0.11) 8 (1.37) 246

(7.81)

148

(6.32)

35

1.62

7

0.8

445

3.92

31 Dermatology 14 (1.07) 8 (0.86) 8 (1.37) 42 (1.33) 10 (0.43) 1 (0.05) 0 (0) 83 (0.73)

32 Neurology 7 (0.53) 14 (1.5) 42 (7.17) 261

(8.29)

145

(6.19)

92 (4.26) 41 (4.71) 602 (5.31)

33 Urology 30 (2.29) 15 (1.61) 15 (2.56) 92 (2.92) 46 (1.96) 68 (3.15) 40 (4.6) 306 (2.7)

34 Otolaryngology 36 (2.75) 29 (3.11) 30 (5.12) 72 (2.29) 25 (1.07) 12 (0.56) 5 (0.57) 209 (1.84)

35 Dental 0 (0) 3 (0.32) 3 (0.51) 5 (0.16) 3 (0.13) 2 (0.09) 0 (0) 16 (0.14)

36 Genetics 1 (0.08) 1 (0.11) 0 (0) 2 (0.06) 0 (0) 0 (0) 0 (0) 4 (0.04)

37 Ophthalmology 113 (8.63) 83 (8.92) 87

(14.85)

197

(6.26)

76 (3.25) 106

(4.91)

62 (7.13) 724 (6.38)

38 Physical Medicine and 13 (0.99) 14 (1.5) 0 (0) 18 (0.57) 16 (0.68) 8 (0.37) 15 (1.72) 84 (0.74)

39 Screening & Check-up 0 (0) 4 (0.43) 5 (0.85) 22 (0.7) 20 (0.85) 18 (0.83) 6 (0.69) 75 (0.66)

40 Psychiatry 1 (0.08) 5 (0.54) 5 (0.85) 7 (0.22) 3 (0.13) 1 (0.05) 0 (0) 22 (0.19)

41 NOT SPEFCIFID CASES 21 (1.6) 12 (1.29) 3 (0.51) 76 (2.41) 45 (1.92) 95 (4.4) 14 (1.61) 266 (2.34)

42 Oral & Maxillofacial 6 (0.46) 1 (0.11) 1 (0.17) 8 (0.25) 1 (0.04) 6 (0.28) 1 (0.11) 24 (0.21)

Total 1,309

(100)

931

(100)

586

(100)

3,148

(100)

2,342

(100)

2,159

(100)

870

(100)

11,345 (100)

150

Table 24. Top 5 Countries of Destinations among patients treated overseas from the United Arab

Emirates during 2009 – 2016 and Medical Specialties (for total trips in the data-set)

Medical Specialty Top 5 Countries of Destinations Total

Other Destinations Germany Thailand UK USA India

Internal Medicine: Oncology

361 (28.18 ) 638 (12.42) 360 (21.98 ) 255 (11.81)

236 (31.85) 62 (15.94) 1912 (16.85)

Internal Medicine:

Cardiology

14(1.09) 260 (5.06) 109 ( 6.65 ) 121(5.6) 25 (3.37) 17 ( 4.37) 546 (4.81)

Internal Medicine: Rheumatology

0(0.00) 29 (0.56) 11(0.67) 27(1.25) 10 (1.35) 14 ( 3.60) 91 (0.8)

Internal Medicine:

Gastroenterology

32(2.50) 192(3.74) 26 (1.59) 82(3.8) 18 (2.43) 18 (4.63) 368 (3.24)

Internal Medicine: Nephrology

45 (3.51) 107 (2.08) 30 (1.83) 41(1.9) 13 (1.75) 13 ( 3.34) 249 (2.19)

Internal Medicine:

Endocrinology

11(0.86) 141(2.74) 23(1.40 ) 59(2.73) 13 (1.75) 5 ( 1.29) 252 (2.22)

Internal Medicine: Hematology

13 (1.01 ) 66(1.28) 12( 0.73) 64(2.96) 23 (3.1) 1 ( 0.26) 179 (1.58)

Internal Medicine:

Pulmonology

5 (0.39) 67(1.30 ) 17 (1.04 ) 17(0.79) 31 (4.18) 2 (0.51) 139 (1.23)

Internal Medicine: Infectious Disease

2 (0.16) 4 (0.08) 1(0.06) 5(0.23) 2 (0.27 ) 0 (0) 14 (0.12)

Internal Medicine 13 (1.01) 88 (1.71) 58(3.54) 28(1.3) 9 (1.21) 7 (1.80) 203 (1.79)

Pediatrics: Oncology 3(0.23 ) 45(0.88) 10 (0.61)

15(0.69)

9 (1.21) 1 (0.26) 83 (0.73)

Pediatrics: Cardiology 2 (0.16) 51(0.99) 1(0.06) 121(5.6) 9 (1.21) 0 (0) 184 (1.62)

Pediatrics: Surgery 3 (0.23) 54 (1.05) 3 (0.18) 38(1.76)

6 (0.81) 0 (0) 104 (0.92)

Pediatrics:

Neurosurgery

3 (0.23) 17(0.33) 4 (0.24) 24(1.11) 5 (0.67) 0 (0) 53 (0.47)

Pediatrics:

Rheumatology

0 (0) 0 (0) 0 (0) 8( 0.37) 0 (0) 0 (0) 8 (0.07)

Pediatrics: Neurology 13 (1.01 ) 87 (1.69 ) 6 (0.37) 78(3.61) 9 (1.21) 2 (0.51) 195 (1.72)

Pediatrics:

Gastroenterology

5 (0.39) 13 (0.25) 2(0.12) 18(0.83) 9 (1.21) 2 (0.51) 49 (0.43)

Pediatrics:

Nephrology

1 (0.08 ) 29 ( 0.56 ) 4 (0.24) 22(1.02) 20 (2.7) 3 ( 0.77) 79 (0.7)

Pediatrics:

Hematology

2(0.16) 10 ( 0.19) 1( 0.06 ) 16(0.74) 3 (0.4) 2 (0.51) 34 (0.3)

Pediatrics:

Endocrinology

1(0.08) 8(0.16) 3(0.18) 5(0.23) 1 (0.13 ) 0 (0) 18 (0.16)

Pediatrics:

Neonatology

0 (0) 6(0.12 ) 1( 0.06) 15(0.69) 2 (0.27) 0 (0) 24 (0.21)

Pediatrics:

Pulmonology

0 (0) 1 (0.02) 0 (0) 2(0.09) 0 (0) 0 (0) 3 (0.03)

Un specified

Pediatrics

17 (1.33) 146(2.84) 31 (1.89) 178

(8.24)

41 (5.53) 7 (1.80) 420 (3.7)

General Surgery 38 (2.97 ) 268 (5.22) 85 (5.19) 78(3.61) 18 (2.43) 18 ( 4.63) 505 (4.45)

Neurosurgery 50 (3.90 ) 541 (10.53) 248 (15.14) 70 (3.24) 33 (4.45) 43 ( 11.05) 985 (8.68)

Orthopedic Surgery 74 (5.78) 874 ( 17.01) 165( 10.07)

156(7.23)

55 (7.42) 64 (16.45) 1388

(12.23)

Thoracic Surgery 12 (0.94 ) 93(1.81 ) 45 (2.75) 32(1.48) 6 (0.81) 6 (1.54) 194 (1.71)

Vascular Surgery 1 (0.08 ) 67 ( 1.30) 15 ( 0.92) 4(0.19) 4 (0.54) 0 (0) 91 (0.8)

Plastic Surgery 13 (1.01) 80 (1.56) 1 (0.06) 19(0.88) 2 (0.27) 0 (0) 115 (1.01)

Obstetrics and

Gynecology

62 (4.84) 196 (3.82) 38(2.32) 105(4.86) 13 (1.75) 31 (7.97) 445 (3.92)

Dermatology 1(0.08) 41 (0.80) 5 ( 0.31) 17 (0.79) 2 (0.27) 17 (4.37) 83 (0.73)

Neurology 31 ( 2.42) 400 (7.79) 35 ( 2.14) 75(3.47) 43 (5.8) 18 ( 4.63) 602 (5.31)

151


Emirates treated overseas during 2009-2016 stratified by age where 1 represent most frequent

medical specialty and 5 represent less frequent medical specialty (for total trips in the data-set)

Age

Categories

0 - 4 yrs. 5 – 14 yrs. 15 – 39 yrs. 40 – 54 yrs. 55 – 69 yrs. 70 + yrs.

Medical Specialty

Medical

Specialty 1

Un specified

Pediatrics 327

(24.98)

Orthopedic

Surgery 164

(17.62)

Orthopedic Surgery

131 (22.35)

Internal Medicine:

Oncology 456

(14.49)

Internal Medicine:

Oncology 612 (26.13)

Internal Medicine:

Oncology 564

(26.12)

Medical

Specialty 2

Pediatrics:

Cardiology 134

(10.24)

Un specified

Pediatrics 84

(9.02)

Ophthalmology 87

(14.85)

Orthopedic Surgery

445 (14.14)

Neurosurgery 267

(11.40)

Orthopedic

Surgery 238

(11.02)

Medical

Specialty 3

Ophthalmology

113 (8.63)

Ophthalmology

83 (8.92)

Neurosurgery 43

(7.34)

Neurosurgery 313

(9.94)

Orthopedic Surgery 240

(10.25)

Neurosurgery 236

(10.93)

Medical

Specialty 4

Pediatrics:

Neurology 110

(8.40)

Pediatrics:

Neurology 82

(8.81)

Neurology 42

(7.17)

Neurology 261

(8.29)

Obstetrics and

Gynecology 148

(6.32)

Internal Medicine:

Cardiology 175

(8.11)

Medical

Specialty 5

Orthopedic

Surgery 76

(5.81)

Neurosurgery 48

(5.16)

Internal Medicine:

Oncology 33

(5.63)

Obstetrics and

Gynecology 246

(7.81)

Neurology 145 (6.19) Ophthalmology

106 (4.91)

Urology 17 (1.33) 165 (3.21 ) 28 ( 1.71) 65(3.01) 17 (2.29) 14 ( 3.60) 306 (2.7)

Otolaryngology 8 (0.62) 114 ( 2.22) 17 (1.04) 56 (2.59) 10 (1.35) 4 (1.03) 209 (1.84)

Dental 0 (0) 10 ( 0.19) 2 (0.12) 4(0.19) 0 (0) 0 (0) 16 (0.14)

Genetics 0 (0) 0 (0) 0 (0) 4 (0.19) 0 (0) 0 (0) 4 (0.04)

Ophthalmology 393 ( 30.68) 81 ( 1.58) 21(1.28 ) 182 (8.43) 30 (4.05) 17 (4.37) 724 (6.38)

Physical Medicine and 17 (1.33 ) 54 ( 1.05 ) 3 (0.18) 8 (0.37) 1 (0.13) 1 (0.26) 84 (0.74)

Screening & Check-

up

5 (0.39) 58 (1.13) 2 (0.12 ) 8(0.37) 2 (0.27) 0 (0) 75 (0.66)

Psychiatry 5 (0.39) 7 (0.14 ) 0 (0) 5 (0.23) 5 (0.67 ) 0 (0) 22 (0.19)

NOT SPEFCIFID CASES

7 ( 0.55) 18 (0.35) 214 ( 13.06 ) 24(1.11) 3 (0.4) 0 (0) 266 (2.34)

Oral & Maxillofacial 1 (0.08) 11 (0.21) 1 (0.06 ) 8 (0.37) 3 (0.4) 0 ( 0.00) 24 (0.21)

Total 1,281 (100) 5,137 (100) 1,638 (100) 2,159

(100)

741 (100) 389 (100) 11345

(100)

152


Emirates treated overseas during 2009-2016 stratified by gender where 1 represent most

frequent medical specialty and 5 represent least frequent medical specialty (for total trips in the

data-set)

Table27. Calendar year and total number of trips among patients from the United Arab

Emirates treated overseas during 2009-2016 stratified by gender (for total trips in the data-set)

Gender Calendar Year Total N

(%) 2009 N (%) 2010 N (%) 2011 N (%) 2012 N (%) 2013 N (%) 2014 N (%) 2015 N (%) 2016 N (%)

Females 391

(40.48)

387

(46.57)

491

(45.63)

638

(45.31)

763

(49.71)

947

(50.8)

1,154

(51.75)

725

(50.52)

5,496

(48.44)

Males 575

(59.52)

444

(53.43)

585

(54.37)

770

(54.69)

772

(50.29)

917

(49.2)

1,076

(48.25)

710

(49.48)

5,849

(51.56)

Total 966

(100)

831

(100)

1,076

(100)

1,408

(100)

1,535

(100)

1,864

(100)

2,230

(100)

1,435

(100)

11,345

(100)


Medical Specialties

Medical Specialty 1 Orthopedic Surgery 797 (13.63) Internal Medicine: Oncology 1,174 (21.36)

Medical Specialty 2 Internal Medicine: Oncology 738 (12.62) Orthopedic Surgery 591 (10.75)

Medical Specialty 3 Neurosurgery 549 (9.39) Obstetrics and Gynecology 445 (8.10)

Medical Specialty 4 Ophthalmology 414 (7.08) Neurosurgery 436 (7.93)

Medical Specialty 5 Neurology 334 (5.71) Neurology 268 (4.88)

153

Table 28. Calendar year and total number of trips among patients from the United Arab

Emirates treated overseas during 2009-2016 stratified by age group (for total trips in the data-

set)

Age

Group

Calendar Year Total N

(%) 2009 N

(%)

2010 N

(%)

2011 N

(%)

2012 N

(%)

2013 N

(%)

2014 N

(%)

2015 N

(%)

2016 N

(%)

0-4 yrs 119 (12.32)

117 (14.08)

135 (12.55)

139 (9.87)

177 (11.53)

206 (11.05)

273 (12.24)

143 (9.97)

1,309 (11.54)

5-12 yrs 89 (9.21)

70 (8.42)

95 (8.83)

101 (7.17)

113 (7.36)

156 (8.37)

198 (8.88)

109 (7.6)

931 (8.21)

13-18 yrs 54 (5.59)

42 (5.05)

43 (4)

65 (4.62)

77 (5.02)

93 (4.99)

132 (5.92)

80 (5.57)

586 (5.17)

19-39 yrs 261 (27.02)

219 (26.35)

274 (25.46)

388 (27.56)

415 (27.04)

536 (28.76)

645 (28.92)

410 (28.57)

3,148 (27.75)

40-54 yrs 184 (19.05)

154 (18.53)

225 (20.91)

320 (22.73)

337 (21.95)

387 (20.76)

421 (18.88)

314 (21.88)

2,342 (20.64)

55-69 yrs 176 (18.22)

135 (16.25)

212 (19.7)

283 (20.1)

288 (18.76)

361 (19.37)

420 (18.83)

284 (19.79)

2,159 (19.03)

70+ yrs 83 (8.59)

94 (11.31)

92 (8.55)

112 (7.95)

128 (8.34)

125 (6.71)

141 (6.32)

95 (6.62)

870 (7.67)

Total 966 (100)

831 (100)

1,076 (100)

1,408 (100)

1,535 (100)

1,864 (100)

2,230 (100)

1,435 (100)

11,345 (100)

Table 29. Calendar year and total number of trips among patients treated overseas from the

United Arab Emirates during 2009-2016 stratified by medical specialty (for total trips in the

data-set)

Medical Specialty Calendar Year

2009 2010 2011 2012 2013 2014 2015 2016 Total

1 Internal Medicine:

Oncology

179

(18.53)

147

(17.69)

186

(17.29)

246

(17.47)

267

(17.39)

271

(14.54)

304

(13.63)

312

(21.74)

1,912

(16.85)


Cardiology

37 (3.83) 50 (6.02) 69 (6.41) 57 (4.05) 80 (5.21) 82 (4.4) 98 (4.39) 73 (5.09) 546 (4.81)


Rheumatology

7 (0.72) 6 (0.72) 7 (0.65) 5 (0.36) 12 (0.78) 17 (0.91) 21 (0.94) 16 (1.11) 91 (0.8)


Gastroenterology

16 (1.66) 20 (2.41) 27 (2.51) 65 (4.62) 44 (2.87) 64 (3.43) 73 (3.27) 59 (4.11) 368 (3.24)


Nephrology

26 (2.69) 18 (2.17) 21 (1.95) 30 (2.13) 29 (1.89) 52 (2.79) 44 (1.97) 29 (2.02) 249 (2.19)


Endocrinology

21 (2.17) 17 (2.05) 28 (2.6) 28 (1.99) 33 (2.15) 45 (2.41) 56 (2.51) 24 (1.67) 252 (2.22)


Hematology

17 (1.76) 22 (2.65) 13 (1.21) 16 (1.14) 34 (2.21) 20 (1.07) 26 (1.17) 31 (2.16) 179 (1.58)


Pulmonology

12 (1.24) 13 (1.56) 10 (0.93) 19 (1.35) 27 (1.76) 16 (0.86) 31 (1.39) 11 (0.77) 139 (1.23)


Infectious Diseases

0 (0) 0 (0) 1 (0.09) 3 (0.21) 3 (0.2) 3 (0.16) 3 (0.13) 1 (0.07) 14 (0.12)

10 Internal Medicine 18 (1.86) 14 (1.68) 23 (2.14) 18 (1.28) 25 (1.63) 46 (2.47) 34 (1.52) 25 (1.74) 203 (1.79)

11 Pediatrics: Oncology 22 (2.28) 10 (1.2) 10 (0.93) 9 (0.64) 5 (0.33) 10 (0.54) 10 (0.45) 7 (0.49) 83 (0.73)

12 Pediatrics: Cardiology 21 (2.17) 12 (1.44) 25 (2.32) 15 (1.07) 24 (1.56) 38 (2.04) 28 (1.26) 21 (1.46) 184 (1.62)

154

13 Pediatrics: Surgery 17 (1.76) 13 (1.56) 14 (1.3) 6 (0.43) 7 (0.46) 11 (0.59) 27 (1.21) 9 (0.63) 104 (0.92)

14 Pediatrics:

Neurosurgery

4 (0.41) 6 (0.72) 2 (0.19) 7 (0.5) 10 (0.65) 16 (0.86) 8 (0.36) 0 (0) 53 (0.47)

15 Pediatrics:

Rheumatology

1 (0.1) 0 (0) 0 (0) 0 (0) 1 (0.07) 1 (0.05) 1 (0.04) 4 (0.28) 8 (0.07)

16 Pediatrics: Neurology 14 (1.45) 4 (0.48) 25 (2.32) 22 (1.56) 18 (1.17) 42 (2.25) 49 (2.2) 21 (1.46) 195 (1.72)

17 Pediatrics:

Gastroenterology

8 (0.83) 5 (0.6) 4 (0.37) 2 (0.14) 5 (0.33) 8 (0.43) 11 (0.49) 6 (0.42) 49 (0.43)

18 Pediatrics: Nephrology 3 (0.31) 5 (0.6) 11 (1.02) 11 (0.78) 12 (0.78) 14 (0.75) 16 (0.72) 7 (0.49) 79 (0.7)

19 Pediatrics: Hematology 2 (0.21) 3 (0.36) 3 (0.28) 3 (0.21) 4 (0.26) 4 (0.21) 5 (0.22) 10 (0.7) 34 (0.3)

20 Pediatrics:

Endocrinology

2 (0.21) 0 (0) 4 (0.37) 2 (0.14) 1 (0.07) 4 (0.21) 4 (0.18) 1 (0.07) 18 (0.16)

21 Pediatrics: Neonatology 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 6 (0.32) 14 (0.63) 4 (0.28) 24 (0.21)

22 Pediatrics:

Pulmonology

3 (0.31) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (0.03)

23 Un specified Pediatrics 30 (3.11) 61 (7.34) 43 (4) 72 (5.11) 76 (4.95) 55 (2.95) 60 (2.69) 23 (1.6) 420 (3.7)

24 General Surgery 18 (1.86) 23 (2.77) 31 (2.88) 64 (4.55) 64 (4.17) 110 (5.9) 133 (5.96) 62 (4.32 505 (4.45)

25 Neurosurgery 87 (9.01) 68 (8.18) 101 (9.39) 156

(11.08)

147 (9.58) 141 (7.56) 141 (6.32) 144

(10.03)

985 (8.68)

26 Orthopedic Surgery 123

(12.73)

90 (10.83) 141 (13.1) 183 (13) 203

(13.22)

209

(11.21)

278

(12.47)

161

(11.22)

1,388

(12.23)

27 Thoracic Surgery 35 (3.62) 21 (2.53) 19 (1.77) 35 (2.49) 33 (2.15) 29 (1.56) 15 (0.67) 7 (0.49) 194 (1.71)

28 Vascular Surgery 18 (1.86) 10 (1.2) 8 (0.74) 8 (0.57) 9 (0.59) 9 (0.48) 12 (0.54) 17 (1.18) 91 (0.8)

29 Plastic Surgery 14 (1.45) 8 (0.96) 13 (1.21) 9 (0.64) 13 (0.85) 11 (0.59) 25 (1.12) 22 (1.53) 115 (1.01)

30 Obstetrics and

Gynecology

23 (2.38) 23 (2.77) 33 (3.07) 53 (3.76) 76 (4.95) 94 (5.04) 94 (4.22) 49 (3.41) 445 (3.92)

31 Dermatology 5 (0.52) 2 (0.24) 8 (0.74) 10 (0.71) 11 (0.72) 18 (0.97) 21 (0.94) 8

(0.56)

83 (0.73)

32 Neurology 48 (4.97) 47 (5.66) 57 (5.3) 73 (5.18) 78 (5.08) 89 (4.77) 133 (5.96) 77 (5.37) 602 (5.31)

33 Urology 36 (3.73) 20 (2.41) 37 (3.44) 46 (3.27) 33 (2.15) 48 (2.58) 61 (2.74) 25 (1.74) 306 (2.7)

34 Otolaryngology 15 (1.55) 11 (1.32) 32 (2.97) 23 (1.63) 30 (1.95) 40 (2.15) 45 (2.02) 13 (0.91) 209 (1.84)

35 Dental 3 (0.31) 3 (0.36) 0 (0) 1 (0.07) 2 (0.13) 2 (0.11) 3 (0.13) 2 (0.14) 16 (0.14)

36 Genetics 0 (0) 2 (0.24) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (0.14) 4 (0.04)

37 Ophthalmology 42 (4.35) 37 (4.45) 51 (4.74) 57 (4.05) 99 (6.45) 162 (8.69) 168 (7.53) 108 (7.53) 724 (6.38)

38 Physical Medicine and 19 (1.97) 8 (0.96) 12 (1.12) 6 (0.43) 8 (0.52) 8 (0.43) 13 (0.58) 10 (0.7) 84 (0.74)

39 Screening & Check-up 2 (0.21) 6 (0.72) 0 (0) 9 (0.64) 1 (0.07) 32 (1.72) 20 (0.9) 5 (0.35) 75 (0.66)

40 Psychiatry 1 (0.1) 2 (0.24) 4 (0.37) 2 (0.14) 2 (0.13) 5 (0.27) 2 (0.09) 4 (0.28) 22 (0.19)

41 NOT SPEFCIFID

CASES

17 (1.76) 23 (2.77) 2 (0.19) 32 (2.27) 7 (0.46) 26 (1.39) 139

(6.23)

20 (1.39) 266 (2.34)

42 Oral & Maxillofacial 0 (0) 1 (0.12) 1 (0.09) 5 (0.36) 2 (0.13) 6 (0.32) 4 (0.18) 5 (0.35) 24 (0.21)

Total 966 (100) 831 (100) 1,076

(100)

1,408

(100)

1,535

(100)

1,864

(100)

2,230

(100)

1,435

(100)

11,345

(100)

155

To isolate medical travel from medical tourism, the “medical tourism” variable was created with two

categories:

Summer (June/July/August)

Non-summer (January/February/March/April/May/September/October/November/December)

There was no difference to travel to Federal Republic of Germany vs other destinations in the

summer

0=Others, | medical_tourism

1=Germany | summer tr non-summe | Total

-----------+----------------------+----------

Others | 934 2,594 | 3,528

| 52.15 54.43 | 53.81

-----------+----------------------+----------

Germany | 857 2,172 | 3,029

| 47.85 45.57 | 46.19

-----------+----------------------+----------

Total | 1,791 4,766 | 6,557

| 100.00 100.00 | 100.00

Pearson chi2(1) = 2.7168 Pr = 0.099

156

Appendix for Manuscript Two

Figure-1: Analytical data set flow chart

361 residents of Dubai experienced overseas treatment

during 2009-2012 and was interviewed to explore

knowledge, attitude and perception for their last trip

related to medical travel treatment abroad

Complete case analysis:

1 case dropped: gender inconsistency with medical

condition diagnosed abroad (male with obstetrics and

gynecology)

1 case dropped: answered demographic section only

all other sections were missing

336 families were used as analytical data

set

23 non UAE nationals were removed from the data-

set and focusing on UAE nationals only

157

Variable New Variable Old variables

Table 1. Top 8 travelled destinations by residents of Dubai, United Arab Emirates who sought medical treatment overseas

during 2009 – 2012

119. Countries of

Destinations

Categorical

• Federal Republic of Germany

• Kingdom of Thailand

• United Kingdom

• Republic of India

• United States of America

• Republic of Singapore

• Kingdom of Belgium

• Republic of Austria

• Others (The Hashemite Kingdom of

Jordan, Other Asian Countries,

Ireland, The Islamic Republic of Iran,

The French Republic The Islamic

Republic of Afghanistan, The

Republic of Indonesia The Kingdom

of Spain, Other Latin Americas)

Binary

Federal Republic of Germany

Other (Kingdom of Thailand,

United Kingdom, Republic of

India, United States of America,

Republic of Singapore, Kingdom

of Belgium, Republic of Austria,

The Hashemite Kingdom of

Jordan, Other Asian Countries,

Ireland, The Islamic Republic of

Iran, The French Republic, The

Islamic Republic of Afghanistan,

The Republic of Indonesia, The

Kingdom of Spain, Other Latin

Americas)

Categorical


Kingdom of Thailand

United Kingdom

Republic of India

United States of America

Republic of Singapore

Kingdom of Belgium

Republic of Austria

The Hashemite Kingdom of Jordan

Other Asian Countries

Ireland

The Islamic Republic of Iran

The French Republic

The Islamic Republic of Afghanistan

The Republic of Indonesia

The Kingdom of Spain

Other Latin Americas

Table2. Demographic characteristics of residents of Dubai, United Arab Emirates who sought medical treatment overseas

during 2009 – 2012

104. Marital Status 15+ Binary

Not married n(never married,

divorced widowed)

Married

Categorical

Never married,

Divorced

Widowed

Married

105. Employment status 15+ Binary

Not working (unemployed,

retired)

Working ( Government

Employee, Private Employee)

Categorical

Unemployed

Retired

Government Employee

Private Employee

106. Educational level 15+ Ordinal

Illiterate or can’t read and write

Primary/Preparatory, Secondary

Graduate/Post-graduate

Ordinal

Illiterate or can’t read and write

Primary/Preparatory

Secondary

Graduate/Post-graduate

108. Household average

monthly income21

Categorical

Low income (≤29,000 AED =

≤8,168.55USD)

Continuous

Average monthly income

21 According to Dubai Statistic Center definition of Household income

158

Middle income (≥30,000 -

≤99,999 AED = ≥8,168.82 -

≤27,229.14 USD)

High income (≥100,000 AED =

≥ 27,229.41USD)

Table 3. Residents of Dubai, United Arab Emirates health seeking behavior before travelling oversea

109. Health Situation Status

before travelling abroad

Binary

Not Diagnosed (Medical

complaint but didn’t get

diagnosed in the UAE, Healthy,

no symptoms, just do checkup)

Diagnosed (Existing medical

condition diagnosed)

Categorical

Medical complaint but didn’t get

diagnosed in the UAE

Existing medical condition diagnosed

Healthy, no symptoms, just do check

up

113.1 Healthcare Provider in

the UAE

Binary

Government (Dubai Health

Authority Hospitals for in-

patient services, Dubai Health

Authority Hospitals for out-

patient services, Dubai Health

Authority Primary Health Care

Centers, Ministry of Health

Hospitals for in-patient services,

Ministry of Health Hospitals for

out-patient services, Ministry of

Health Primary Health Care

Centers, Abu Dhabi Health

Services Hospitals and PHCs

(SEHA))

Other (Private Sector Hospitals

for in-patient services, Private

Clinics, Private Sector Hospitals

for out-patient services, Home

visits)

Categorical

Dubai Health Authority Hospitals for

in-patient services

Dubai Health Authority Hospitals for

out-patient services

Dubai Health Authority Primary

Health Care Centers

Ministry of Health Hospitals for in-

patient services

Ministry of Health Hospitals for out-

patient services

Ministry of Health Primary Health

Care Centers

Abu Dhabi Health Services Hospitals

and PHCs (SEHA)

Private Sector Hospitals for in-patient

services

Private Clinics

Private Sector Hospitals for out-

patient services

Home Visits/ Government Sector

Services

Home Visits/ Private Sector Services

Traditional Healer

Pharmacy

Others. (Specify)

I never get care in the UAE & always

travel abroad if I need health care

Table 4. Main conditions residents of Dubai, United Arab Emirates were diagnosed with before seeking medical treatment

overseas during 2009 – 2012

112. Main Diagnosis before

travelling abroad

Categorical

Heart disease

High blood pressure

Cancer

Diabetes

Bone and joint Diseases

Gastro-intestinal Diseases

Obstetrics and Gynecology

Diseases

Ear, nose and throat (ENT)

Diseases

Kidney or bladder (urinary

system) Diseases

Skin or venereal Diseases

Categorical

Heart disease

Cancer

High blood pressure

Diabetes

Bone and joint Diseases

Gastro-intestinal Diseases

Obstetrics and Gynecology Diseases

Ear, nose and throat (ENT) Diseases

Kidney or bladder (urinary system)

Diseases

Skin or venereal Diseases

Stroke (brain hemorrhage or clot)

Mental illness

Trauma

159

Stroke (brain hemorrhage or

clot)

Mental illness

Trauma

Cosmetic surgery

Dental Diseases

Lungs and Respiratory Diseases

Eye Diseases

Medical Screening, routing

medical check-up

More than one condition (more

than more medical condition

selected)

Unknown conditions (for

missing values and people didn’t

circle any answer)

Cosmetic surgery

Dental Diseases

Lungs and Respiratory Diseases

Eye Diseases

Medical Screening, routing medical

check-up

Undiagnosed

Others. (Specify)

Table 5. Motivational factors among residents of Dubai, United Arab Emirates who sought medical treatment overseas during

2009 – 2012 by country of destination

118. Main reason of travel Binary

Treatment purposes only (Treatment

for self, Treatment for family

member, Treatment of medical

complications resulting from

treatment in UAE, Medical checkup

and screening)

Other purposes (Tourism, Others)

Categorical

Tourism

Treatment for self

Treatment for family member

Treatment of medical complications

resulting from treatment in UAE

Medical checkup and screening

Others

Table 6. Main conditions residents of Dubai, United Arab Emirates were diagnosed with while seeking medical treatment

overseas during 2009-2012

Categorical

• Cancer

• Neurological Diseases and

Neurosurgery

• Pediatrics diseases

• Bone and joint Diseases

• Heart disease

• Eye Diseases

• Obstetrics and gynecology Diseases

• General Surgery (Amputations,

Thyroidectomy, Removing benign

tumor, removing sebaceous cyst...)

• Kidney Diseases

• Gastro-Intestinal Diseases

• Urinary Tract system

• High Blood Pressure

• Skin or venereal Diseases

• Stroke (brain hemorrhage or clot)

• Mental illness

• Trauma

• Medical Screening before surgery,

• Oral and Dental Diseases

• Lungs and Respiratory Diseases

• Ear, nose and throat (ENT) Diseases

• Diabetes

• routing medical check-up

• More than one condition (more than

more medical condition selected)

• Unknown conditions (for missing

values and people didn’t circle any

answer)

Categorical

• Cancer

• Neurological Diseases and Neurosurgery

• Pediatrics diseases

• Bone and joint Diseases

• Heart disease

• Eye Diseases

• Obstetrics and gynecology Diseases

• General Surgery (Amputations,

Thyroidectomy, Removing benign tumor,

removing sebaceous cyst...)

• Kidney Diseases

• Gastro-Intestinal Diseases

• Urinary Tract system

• High Blood Pressure

• Skin or venereal Diseases

• Stroke (brain hemorrhage or clot)

• Mental illness

• Trauma

• Medical Screening before surgery,

• Oral and Dental Diseases

• Lungs and Respiratory Diseases

• Ear, nose and throat (ENT) Diseases

• Diabetes

• routing medical check-up

• Others. (Specify)

160

Table 7. Travel related experiences for residents of Dubai, United Arab Emirates during their most recent trip overseas, 2009 -

2012

127. Type of Healthcare

Service Provided

Categorical

Inpatient (Inpatient treatment

“hospitalization”- surgical, Inpatient

treatment “hospitalization” non-

surgical)

Outpatient (Outpatient “no

hospitalization” procedure

“therapeutic”, Outpatient “no

hospitalization” consultation)

Unknown (for missing values and

people didn’t circle any answer)

Categorical

Outpatient (no hospitalization) procedure

(therapeutic)

Inpatient treatment (hospitalization)

surgical

Outpatient (no hospitalization)

consultation

Inpatient treatment (hospitalization) non-

surgical

130. Treatment coverage Categorical

Government (Governor's Diwan,

Government of Dubai, Federal

Ministry of Health, HAAD

Other sources (Employer expense,

Own pocket or from your household

budget, Other)

Categorical

Other

Governor's Diwan, Government of Dubai

Federal Ministry of Health

HAAD

Employer expense

Own pocket or from your household

budget

182. Services Wish to Be

Available in the UAE

Categorical

Waiting time (Reasonable

waiting time at the clinic before

seeing the doctor)

Healthcare Provider

Communication (Treating doctor

talked clearly to me about my

condition, Treating doctor gave

me different treatment options,

Treating doctor explained to me

how I can cope, live normal life

with my condition, Treating

doctor explained what might

happen to me in the future, The

medical staff was polite, and

courteous, The medical staff was

able to respond to my inquiries

efficiently and referred me to the

right persons, The treating

doctor was listening to me)

Hospitality (The facility

“hospital, clinic” was clean and

welcoming)

Education & Reading Material

(Availability of reading material

on my condition in Arabic and

English)

Convenient Atmosphere

(Easiness of booking for an

appointment “convenient, didn't

take long time”, Consultation

and Diagnostic work-ups and

treatment were all in the same

building, The hospital called to

report my results instead of me

going to them)

Unknown (for missing values

and people didn’t circle any

answer)

Reasonable waiting time at the clinic

before seeing the doctor

Easiness of booking for an appointment

(convenient, didn't take long time)

Consultation and Diagnostic work-ups and

treatment were all in the same building

Treating doctor talked clearly to me about

my condition

Treating doctor gave me different

treatment options

Treating doctor explained to me how I can

cope, live normal life with my condition

Treating doctor explained what might

happen to me in the future

The medical staff was polite, and

courteous

The hospital called to report my results

instead of me going to them

The medical staff was able to respond to

my inquiries efficiently and referred me to

the right persons

The facility (hospital, clinic) was clean

and welcoming

The treating doctor was listening to me

Availability of reading material on my

condition in Arabic and English

Treating doctor was paying full attention

to me (not distracted by phone or writing)

161

Table 4E. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities before travelling overseas seeking medical treatment during 2009 – 2012

2 comorbidities Frequency

High blood pressure + Diabetes 3

Bone & Joint + Diabetes 2

Bone & Joint + Stroke or Brain Hemorrhage 1

Bone & Joint + High blood pressure 2

Cancer + Diabetes 1

Diabetes + Stroke or Brain Hemorrhage 1

Eye Diseases + Stroke or Brain Hemorrhage 1

Gastrointestinal Diseases + Eye Diseases 1

Bone & Joint Diseases + Eye Diseases 1

Heart disease + Gastrointestinal Diseases 1


Cancer + Gastrointestinal Diseases 1

Cancer + Bone & Joint 2

Heart disease + Diabetes 4



Heart disease + Urinary System Diseases (Kidney or Bladder) 1

High blood pressure + Gastrointestinal Diseases 2


Bone & Joint + Trauma 2

Cancer + Skin or Venereal Diseases 1



Cancer + Ear, nose and throat (ENT) Diseases 1

Bone & Joint + Cosmetic Surgery 1



Cancer + Dental 1

Obstetrics and Gynecology + Ear, nose and throat (ENT) Diseases 1

Bone & Joint + Gastrointestinal Diseases 1


Table 4F. Residents of Dubai, United Arab Emirates who were diagnosed with 3



Cancer + High blood pressure + Diabetes 3

Diabetes + Gastrointestinal Diseases + Urinary System Diseases (Kidney or Bladder) 1

Heart disease + High blood pressure + Diabetes 4

High blood pressure + Diabetes + Obstetrics and Gynecology 1

162




Bone & Joint Diseases + High blood pressure + Diabetes 2

Bone & Joint Diseases + Heart disease + High blood pressure 1

High blood pressure + Diabetes + Urinary System Diseases (Kidney or Bladder) 1




Table 4G. Residents of Dubai, United Arab Emirates who were diagnosed with 4


Table 4H. Residents of Dubai, United Arab Emirates who were diagnosed with 5



High blood pressure + Diabetes + Gastrointestinal Diseases + Eye Diseases + Urinary System

Diseases (Kidney or Bladder)

1

Bone & Joint Diseases + Heart disease + High blood pressure + Diabetes + Gastrointestinal Diseases 1

Table 4I. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities before travelling overseas seeking medical treatment during 2009 – 2012 who

went to Federal Republic of Germany




Diabetes + Stroke or Brain Hemorrhage 1

Gastrointestinal Diseases + Eye Diseases 1

Bone & Joint Diseases +Eye Diseases 1

Heart disease + Gastrointestinal Diseases 1





Heart disease + Urinary System Diseases (Kidney or Bladder) 1


Bone & Joint + Trauma 1

Cancer + Dental 1


High blood pressure + Diabetes + Gastrointestinal Diseases + Lungs & Respiratory Diseases 1

163


Table 4J. Residents of Dubai, United Arab Emirates who were diagnosed with 3





Diabetes + Gastrointestinal Diseases + Urinary System Diseases (Kidney or Bladder) 1


High blood pressure + Diabetes + Obstetrics and Gynecology 1



High blood pressure + Diabetes + Urinary System Diseases (Kidney or Bladder) 1



Table 4K. Residents of Dubai, United Arab Emirates who were diagnosed with 4




High blood pressure + Diabetes + Gastrointestinal Diseases + Lungs & Respiratory Diseases 1

Table 4L. Residents of Dubai, United Arab Emirates who were diagnosed with 5




High blood pressure + Diabetes + Gastrointestinal Diseases + Eye Diseases + Urinary System

Diseases (Kidney or Bladder)

1

Bone & Joint Diseases + Heart disease + High blood pressure + Diabetes + Gastrointestinal Diseases 1

Table 4M. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities before travelling oversea seeking medical treatment during 2009 – 2012 who

went to other countries of destination



Bone & Joint + Stroke or Brain Hemorrhage 1

Cancer + Diabetes 1

Eye Diseases + Stroke or Brain Hemorrhage 1

Cancer + Gastrointestinal Diseases 1


164


Cancer + Skin or Venereal Diseases 1



Cancer + Ear, nose and throat (ENT) Diseases 1

Bone & Joint + Cosmetic Surgery 1



Obstetrics and Gynecology + Ear, nose and throat (ENT) Diseases 1

Bone & Joint + Gastrointestinal Diseases 1

Table 4N. Residents of Dubai, United Arab Emirates who were diagnosed with 3


went to other countries of destination




Bone & Joint Diseases + Heart disease + High blood pressure 1


165

Table 6E. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities overseas seeking medical treatment during 2009 – 2012


Cancer + Lungs and Respiratory Diseases 1

Cancer + heart diseases 5

Surgery + High Blood pressure 1

Skin or venereal Diseases + Mental illness 1


Bone & Joint + Gastro-Intestinal Diseases 3

Cancer + Heart disease 5

Cancer + Gastro-Intestinal Disease 6

Cancer + Kidney Disease 2

Surgery + screening 1

Bone & Joint + Surgery 3

Cancer + Neurological diseases & Neurosurgery 1

Cancer + Bone & Joint Disease 9


Bone & Joint + Routing medical check-up 1

Cancer + Gastro-Intestinal Diseases 6

Stroke “brain hemorrhage or clot + diabetes 1

Bone & Joint + eye disease 1

Heart disease + Kidney Disease 1

Cancer + Kidney Diseases 2

Cancer +Bone & Joint Disease 9

Cancer + surgery 5

Cancer + surgery 5

Cancer + surgery 5

Kidney Diseases + Lungs and Respiratory Diseases 2

Kidney Diseases + Urinary Tract system 2



Kidney Diseases + Lungs and Respiratory Diseases 2

Heart diseases + diabetes 2

Heart diseases + diabetes 2

Cancer + Urinary Tract system 1




Cancer + heart disease 5

Urinary Tract system + routing medical check-up 1


Gastro-Intestinal Diseases + High Blood pressure 1

166

Kidney Diseases + Urinary Tract system 2

Bone & joint + heart diseases 1

Neurological diseases & Neurosurgery + Surgery 1

Neurological diseases & Neurosurgery + Bone and Joint 1

Cancer + eye disease 3


Surgery + diabetes 2

Surgery + diabetes 2

Cancer + urinary tract disease 2

Cancer + surgery 5

Bone & Joint + surgery 3


Cancer + ENT disease 1


Diabetes + routing medical check-up 1


Cancer + high blood pressure 1




obstetrics and gynecology + surgery 1

Cancer + surgery 5

Cancer + Trauma 1

Surgery + Kidney disease 1

Bone & joint + Gastro-Intestinal Diseases 3




Cancer + Skin or venereal Diseases 1


Table 6F. Residents of Dubai, United Arab Emirates who were diagnosed with 3

comorbidities overseas seeking medical treatment overseas during 2009 – 2012



Cancer + Neurological diseases & Neurosurgery +Bone & Joint Disease 1

Bone & Joint + heart disease + Stroke “brain hemorrhage” or clot 1


Cancer + Gastro-Intestinal Diseases + diabetes 1

Cancer + heart disease + Gastro-Intestinal Diseases 1

obstetrics and gynecology + High blood pressure + Diabetes 1


167

Surgery + High blood pressure + Diabetes 1

Bone & joint + High blood pressure + Diabetes 1

Neurological diseases & Neurosurgery +Bone & Joint Disease + eye disease 1



Bone & joint + high blood + diabetes 1

Table 6G. Residents of Dubai, United Arab Emirates who were diagnosed with 4



Cancer + eye + High blood pressure + Diabetes 1

Cancer + Gastro-Intestinal Diseases + diabetes + routing medical check-up 1

Heart disease + High blood pressure + Diabetes + routing medical check-up 1

Heart disease + high blood pressure + Lungs and Respiratory Diseases + Diabetes 1

Cancer + Neurological diseases & Neurosurgery + High blood pressure + Diabetes 1

Gastro-Intestinal Diseases + high blood pressure + Lungs and Respiratory Diseases + diabetes 1

Table 6H. Residents of Dubai, United Arab Emirates who were diagnosed with 5



Eye disease + kidney disease + Gastro-Intestinal Diseases + high blood pressure + Diabetes 1

Table 6I. Residents of Dubai, United Arab Emirates who were diagnosed with 6



Cancer + Neurological diseases & Neurosurgery + Bone + Joint + Kidney disease + high blood

pressure + Skin or venereal Diseases

1

Table 6J. Residents of Dubai, United Arab Emirates who were diagnosed with 7



Cancer + heart disease + kidney disease + urinary tract disease + high blood pressure + Diabetes 1

Table 6K. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the



Cancer + Lungs and Respiratory Diseases 1


Surgery + High blood pressure 1

Skin or venereal Diseases + Mental illness 1

168


Cancer + heart diseases 5


Surgery + Medical Screening before surgery 1

Bone & Joint + surgery 2

Cancer + Neurological diseases & Neurosurgery 1



Bone & Joint + routing medical check-up 1

Stroke “brain hemorrhage or clot” + Diabetes 1

Bone & Joint + eye diseases 1

Heart diseases + kidney diseases 1

Cancer + kidney 1

Cancer + surgery 4

Cancer + surgery 4

Cancer + surgery 4

Kidney diseases + Lungs and Respiratory Diseases 1

Kidney diseases + urinary tract diseases 1



Heart diseases + Diabetes 2

Heart diseases + Diabetes 2

Cancer + urinary tract diseases 1



Urinary tract disease + routing medical check-up 1


Gastro-Intestinal Diseases + High blood pressure 1

Neurological Diseases and Neurosurgery +Bone & Joint Disease 1

Cancer + eye diseases 1

Surgery + diseases 1



Cancer + High blood pressure 1


Cancer + surgery 4


Cancer + Skin or venereal Diseases 1


169

Table 6L. Residents of Dubai, United Arab Emirates who were diagnosed with 3




Cancer + high blood pressure + Diabetes 3


obstetrics and gynecology + high blood pressure + Diabetes 1

Bone & Joint Disease + high blood pressure + Diabetes 1


Heart disease + high blood pressure + Diabetes 1

Table 6M. Residents of Dubai, United Arab Emirates who were diagnosed with 4




Heart disease + high blood pressure + Diabetes + routing medical check-up 1

Heart disease + high blood pressure + Lungs and Respiratory Diseases + Diabetes 1

Cancer + Neurological Diseases and Neurosurgery + high blood pressure + Diabetes 1

Gastro-Intestinal Diseases + high blood pressure + Lungs and Respiratory Diseases + Diabetes 1

Table 6N. Residents of Dubai, United Arab Emirates who were diagnosed with 5




Eye disease + kidney disease + Gastro-Intestinal Diseases + high blood pressure + high blood

pressure + Diabetes

1

Table 6O. Residents of Dubai, United Arab Emirates who were diagnosed with 6




Cancer + Neurological Diseases and Neurosurgery +Bone & Joint Disease + kidney disease +

high blood pressure + Skin or venereal Diseases

1

Table 6P. Residents of Dubai, United Arab Emirates who were diagnosed with 7




Cancer + heart disease + kidney disease + urinary tract disease + high blood pressure + trauma

+diabetes

1

170

Table 6Q. Residents of Dubai, United Arab Emirates who were diagnosed with 2

comorbidities overseas seeking medical treatment during 2009 – 2012 who went to

countries of destinations



Cancer + Kidney disease 1



Kidney disease + Lungs and Respiratory Diseases 1



Kidney disease + urinary tract disease 1

Bone & joint + heart disease 1

Neurological Diseases and Neurosurgery 1


Surgery + Diabetes 2

Cancer + urinary disease 1

Cancer + surgery 1

Bone & joint + surgery 1

Cancer + Ear, nose and throat 1


Diabetes + routing medical check-up 1



Obstetrics and gynecology Diseases + surgery 1

Cancer + trauma 1

Surgery + kidney disease 1

Bone & joint + Gastro-Intestinal Diseases 2



Table 6R. Residents of Dubai, United Arab Emirates who were diagnosed with 3




Cancer + Neurological Diseases and Neurosurgery +Bone & Joint Disease 1

Bone & Joint + heart disease + brain hemorrhage or clot 1

Cancer + Gastro-Intestinal Diseases + Diabetes 1

Cancer + heart disease + Gastro-Intestinal Diseases 1

Heart disease + high blood pressure + Diabetes 1

Surgery + high blood pressure + Diabetes 1

Neurological Diseases and Neurosurgery +Bone & Joint Disease + eye disease 1

171

Bone & joint + High blood pressure + Diabetes 1

Table 6S. Residents of Dubai, United Arab Emirates who were diagnosed with 4




Cancer + eye disease + high blood pressure + Diabetes 1

Cancer + Gastro-Intestinal Diseases + Diabetes + routing medical check-up 1

172

Appendix for Manuscript Three

Table A. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Bone & Joint Diseases by a known

physician in the UAE

Variable Total Sample N (%) Disagree Agree P-value

Gender 0.64

Male 27 (57.45) 14 (60.87) 13 (54.17)

Female 20 (42.55) 9 (39.13) 11 (45.83)

Fisher's exact 0.77

Age m±SD* 42.5± 22.76 39.77± 23.46 45± 22.296 0.44

Marital Status 15+ 0.75

Married 27 (69.23) 12 (66.67) 15 (71.43)

Not Married 12 (30.77) 6 (33.33) 6 (28.57)

Fisher's exact 1.00

Employment Status

15+

0.17

Not Working 26 (66.67) 10 (55.56) 16 (76.19)

Working 13 (33.33) 8 (44.44) 5 (23.81)

Fisher's exact 0.20

Educational Level

15+

0.80

Illiterate or Cannot

read and write

9 (23.08) 4 (22.22) 5 (23.81)

Up to high School 19 (48.72) 8 (44.44) 11 (52.38)

College & Above 11 (28.21) 6 (33.33) 5 (23.81)

Fisher's exact

HH Average Monthly

income

0.65

Lower Income 26 (55.32) 14 (60.87) 12 (50.00)

Middle Income 15 (31.91) 7 (30.43) 8 (33.33)

Higher Income 6 (12.77) 2 (8.70) 4 (16.67)

Fisher's exact 0.72


Not Important 32 (68.09) 16 (69.57) 16 (66.67)

Neutral 4 (8.51) 2 (8.70) 2 (8.33)

Important 11 (23.40) 5 (21.74) 6 (25.00)

Fisher's exact 1.00

Treatment Coverage 0.66

Government 38 (80.85) 18 (78.26) 20 (83.33)

Other 9 (19.15) 5 (21.74) 4 (16.67)

Fisher's exact 0.72

173

*Mean±Standard Deviation

Answering the survey 0.68

Self-reported 15 (31.91) 8 (34.78) 7 (29.17)

Family member

reported

32 (68.09) 15 (65.22) 17 (70.83)

Fisher's exact 0.76

Family Member 0.46

Escorted 27 (90.00) 12 (85.71) 15 (93.75)

Not escorted 3 (10.00) 2 (14.29) 1 (6.25)

Fisher's exact 0.59

174

Table B. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Bone & Joint Diseases by a


Variable Total Sample N (%) One week More than one

week

P-value

Gender 0.33

Male 27 (57.45) 21 (61.76) 6 (46.15)

Female 20 (42.55) 13 (38.24) 7 (53.85)

Fisher's exact 0.51

Age m±SD* 42.5± 22.76 45± 21.66 36.15± 25.10 0.24


Married 27 (69.23) 21 (70.00) 6 (66.67)

Not Married 12 (30.77) 9 (30.00) 3 (33.33)

Fisher's exact 1.00

Employment Status

15+

0.42

Not Working 26 (66.67) 19 (63.33) 7 (77.78)

Working 13 (33.33) 11 (36.67) 2 (22.22)

Fisher's exact 0.69

Educational Level 15+ 0.37

Illiterate or Cannot read

and write

9 (23.08) 7 (23.33) 2 (22.22)

Up to high School 19 (48.72) 13 (43.33) 6 (66.67)

College & Above 11 (28.21) 10 (33.33) 1 (11.11)

Fisher's exact 0.38

HH Average Monthly

income

0.72

Lower Income 26 (55.32) 18 (52.94) 8 (61.54)

Middle Income 15 (31.91) 12 (35.29) 3 (23.08)

Higher Income 6 (12.77) 4 (11.76) 2 (15.38)

Fisher's exact 0.73


Not Important 32 (68.09) 25 (73.53) 7 (53.85)

Neutral 4 (8.51) 2 (5.88) 2 (15.38)

Important 11 (23.40) 7 (20.59) 4 (30.77)

Fisher's exact 0.34


Government 38 (80.85) 28 (82.35) 10 (76.92)

Other 9 (19.15) 6 (17.65) 3 (23.08)

Fisher's exact 0.69

175



Self-reported 15 (31.91) 12 (35.29) 3 (23.08)

Family member reported 32 (68.09) 22 (64.71) 10 (76.92)

Fisher's exact 0.50

Family Member

Reported

1.00

Escorted 27 (90.00) 18 (90.00) 9 (90.00)

Not escorted 3 (10.00) 2 (10.00) 1 (10.00)

Fisher's exact 1.00

176

Table C. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Bone and Joint Diseases by a

visiting physician to the UAE


Gender 0.98

Male 27 (57.45) 8 (57.14) 19 (57.58)

Female 20 (42.55) 6 (42.86) 14 (42.42)

Fisher's exact 1.00

Age m±SD* 42.5± 22.76 39.92± 25.46 39.92± 25.46 0.64


Married 27 (69.23) 8 (80.00) 19 (65.52)

Not Married 12 (30.77) 2 (20.00) 10 (34.48)

Fisher's exact 0.69

Employment Status

15+

0.20

Not Working 26 (66.67) 5 (50.00) 21 (72.41)

Working 13 (33.33) 5 (50.00) 8 (27.59)

Fisher's exact 0.25

Educational Level

15+

0.19


read and write

9 (23.08) 2 (20.00) 7 (24.14)

Up to high School 19 (48.72) 3 (30.00) 16 (55.17)

College & Above 11 (28.21) 5 (50.00) 6 (20.69)

Fisher's exact 0.22

HH Average

Monthly income

0.19

Lower Income 26 (55.32) 8 (57.14) 18 (54.55)

Middle Income 15 (31.91) 6 (42.86) 9 (27.27)

Higher Income 6 (12.77) 0 (0) 6 (18.18)

Fisher's exact 0.24


Not Important 32 (68.09) 10 (71.43) 22 (66.67)

Neutral 4 (8.51) 1 (7.14) 3 (9.09)

Important 11 (23.40) 3 (21.43) 8 (24.24)

Fisher's exact 1.00


Government 38 (80.85) 10 (71.43) 28 (84.85)

Other 9 (19.15) 4 (28.57) 5 (15.15)

Fisher's exact 0.42

Answering the

survey

0.75

Self-reported 15 (31.91) 4 (28.57) 11 (33.33)

177


Family member

reported

32 (68.09) 10 (71.43) 22 (66.67)

Fisher's exact 1.00

1.00

Family Member

Reported

Escorted 27 (90.00) 9 (90.00) 18 (90.00)

Not Escorted 3 (10.00) 1 (10.00) 2 (10.00)

Fisher's exact 1.00

178

Table D. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Bone & Joint Diseases by a visiting

physician to the UAE


week

P-value

Gender 0.37

Male 27 (57.45) 17 (62.96) 10 (50.00)

Female 20 (42.55) 10 (37.04) 10 (50.00)

Fisher's exact 0.55

Age m±SD* 42.5± 22.76 46.38± 22.52 37.45± 22.61 0.19


Married 27 (69.23) 18 (78.26) 9 (56.25)

Not Married 12 (30.77) 5 (21.74) 7 (43.75)

Fisher's exact 0.17

Employment Status

15+

0.82

Not Working 26 (66.67) 15 (65.22) 11 (68.75)

Working 13 (33.33) 8 (34.78) 5 (31.25)

Fisher's exact 1.00

Educational Level 15+


and write

9 (23.08) 6 (26.09) 3 (18.75) 0.73

Up to high School 19 (48.72) 10 (43.48) 9 (56.25)

College & Above 11 (28.21) 7 (30.43) 4 (25.00)

Fisher's exact 0.76

HH Average Monthly

income

0.92

Lower Income 26 (55.32) 15 (55.56) 11 (55.00)

Middle Income 15 (31.91) 9 (33.33) 6 (30.00)

Higher Income 6 (12.77) 3 (11.11) 3 (15.00)

Fisher's exact 1.00


Not Important 32 (68.09) 17 (62.96) 15 (75.00 )

Neutral 4 (8.51) 3 (11.11) 1 (5.00)

Important 11 (23.40) 7 (25.93) 4 (20.00)

Fisher's exact 0.72


Government 38 (80.85) 23 (85.19) 15 (75.00)

Other 9 (19.15 4 (14.81) 5 (25.00)

Fisher's exact 0.47


179


Self-reported 15 (31.91) 8 (29.63) 7 (35.00)


Fisher's exact 0.76

Family Member

Reported

0.80

Escorted 27 (90.00) 16 (88.89) 11 (91.67)

Not escorted 3 (10.00) 2 (11.11) 1 (8.33)

Fisher's exact 1.00

180

Table E. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Cancer by a known physician in the

UAE


Gender 0.09

Male 30 (45.45) 12 (35.29) 18 (56.25)

Female 36 (54.55) 22 (64.71) 14 (43.75)

Fisher’s exact 0.14

Age m±SD* 38.62± 24.64 40.71± 24.18 36.41± 25.32 0.48


Married 33 (70.21) 18 (72.00) 15 (68.18)

Not Married 14 (29.79) 7 (28.00) 7(31.82)


Employment Status

15+

0.28

Not Working 35 (74.47) 17 (68.00) 18 (81.82)

Working 12 (25.53) 8 (32.00) 4 (18.18)


Educational Level

15+

0.46


read and write

12 (25.53) 7 (28.00) 5 (22.73)

Up to high School 28 (59.57) 13 (52.00) 15 (68.18)

College & Above 7 (14.89) 5 (20.00) 2 (9.09)


HH Average

Monthly income

0.72

Lower Income 38 (57.58) 20 (58.82) 18 (56.25)

Middle Income 10 (15.15) 6 (17.65) 4 (12.50)

Higher Income 18 (27.27) 8 (23.53) 10 (31.25)



Not Important 45 (68.18) 24 (70.59) 21 (65.63)

Neutral 8 (12.12) 6 (17.65) 2 (6.25)

Important 13 (19.70) 4 (11.76) 9 (28.13)



Government 54 (81.82) 31 (91.18) 23 (71.88)

Other 12 (18.18) 3 (8.82) 9 (28.13)


181


Answering the

survey

0.86

Self-reported 22 (33.33) 11 (32.35) 11 (34.38)

Family member

reported

44 (66.67) 23 (67.65) 21 (65.63)


Family Member

Reported

0.92

Escorting 41 (95.35) 22 (95.65) 19 (95.00)

Not escorting 2 (4.65) 1 (4.35) 1 (5.00)


182

Table F. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Cancer by a known physician in the

UAE

Variable Total Sample N (%) One week More than a week P-value

Gender 0.19

Male 30 (45.45) 22 (41.51) 8 (61.54)

Female 36 (54.55) 31 (58.49) 5 (38.46)

Fisher's exact 0.22

Age m±SD* 38.62± 24.64 39.56±24.06 34.76± 18.10 0.53


Married 33 (70.21) 26 (66.68) 7 (87.50)

Not Married 14 (29.79) 13 (33.33) 1 (12.50)

Fisher's exact 0.41

Employment Status

15+

0.39

Not Working 35 (74.47) 30 (76.92) 5 (62.50)

Working 12 (25.53) 9 (23.08) 3 (37.50)

Fisher's exact 0.40

Educational Level

15+

0.40


read and write

12 (25.53) 10 (25.64) 2 (25.00)

Up to high School 28 (59.57) 22 (56.41) 6 (75.00)

College & Above 7 (14.89) 7 (17.95) 0 (0)

Fisher's exact 0.56

HH Average

Monthly income

0.03

Lower Income 38 (57.58) 27 (50.94) 11 (84.62)

Middle and High

Income

28 ( 42.42) 26 (49.06) 2(15.38)

Fisher's exact 0.032


Not Important 45 (68.18) 35 (66.04) 10 (76.92)

Neutral 8 (12.12) 7 (13.21) 1 (7.69)

Important 13 (19.70) 11 (20.75) 2 (15.38)

Fisher's exact 0.90


Government 54 (81.82) 42 (79.25) 12 (92.31)

Other 12 (18.18) 11 (20.75) 1 (7.69)

Fisher's exact 0.43

Answering the

survey

0.83

183


Self-reported 22 (33.33) 18 (33.96) 4 (30.77)

Family member

reported

44 (66.67) 35 (66.04) 9 (69.23)

Fisher's exact 1.00

Family Member

Reported

0.30

Escorting 41 (95.35) 33 (97.06) 8 (88.89)

Not escorting 2 (4.65) 1 (2.94) 1 (11.11)

Fisher's exact 0.38

184

Table G. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case Cancer by a visiting physician to the

UAE


Gender 0.26

Male 30 (45.45) 7 (35.00) 23 (50.00)

Female 36 (54.55) 13 (65.00) 23 (50.00)

Fisher's exact 0.29

Age m±SD* 38.62± 24.64 39.65± 23.12 38.17± 25.50 0.83


Married 33 (70.21) 10 (66.67) 23 (71.88)

Not Married 14 (29.79) 5 (33.33) 9 (28.13)

Fisher's exact 0.74

Employment Status

15+

0.40

Not Working 35 (74.47) 10 (66.67) 25 (78.13)

Working 12 (25.53) 5 (33.33) 7 (21.88)

Fisher's exact 0.48

Educational Level

15+

0.98


read and write

12 (25.53) 4 (26.67) 8 (25.00)

Up to high School 28 (59.57) 9 (60.00) 19 (59.38)

College & Above 7 (14.89) 2 (13.33) 5 (15.63)

Fisher's exact 1.00

HH Average

Monthly income

0.66

Lower Income 38 (57.58) 13 (65.00) 25 (54.35)

Middle Income 10 (15.15) 3 (15.00) 7 (15.22)

Higher Income 18 (27.27) 4 (20.00) 14 (30.43)


Not Important 45 (68.18) 13 (65.00) 32 (69.57)

Neutral 8 (12.12) 5 (25.00) 3 (6.52)

Important 13 (19.70) 2 (10.00) 11 (23.91)

Fisher's exact 0.09


Government 54 (81.82) 19 (95.00) 35 (76.09)

Other 12 (18.18) 1 (5.00) 11 (23.91)

Fisher's exact 0.09

Answering the

survey

0.85

185


Person Travelled

Oversea

22 (33.33) 7 (35.00) 15 (32.61)

Treatment Family

Member

44 (66.67) 13 (65.00) 31 (67.39)

Fisher's exact 1.00

Family Member

Reported

0.53

Not Escorting 41 (95.35) 12 (92.31) 29 (96.67)

Escorting 2 (4.65) 1 (7.69) 1 (3.33)

Fisher's exact 0.52

186

Table H. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Cancer by a visiting


Variable Total Sample N (%) One week More than one week P-value

Gender

Male 30 (45.45) 21 (44.68) 9 (47.37) 0.84

Female 36 (54.55) 26 (55.32) 10 (52.63)

Fisher's exact 1.00

Age m±SD* 38.62± 24.64 39.40± 24.04 36.68± 26.64 0.68


Married 33 (70.21) 24 (70.59) 9 (69.23)

Not Married 14 (29.79) 10 (29.41) 4 (30.77)

Fisher's exact 1.00

Employment Status

15+

0.81

Not Working 35 (74.47) 25 (73.53) 10 (76.92)

Working 12 (25.53) 9 (26.47) 3 (23.08)

Fisher's exact 1.00



and write

12 (25.53) 9 (26.47) 3 (23.08)

Up to high School 28 (59.57) 20 (58.82) 8 (61.54)

College & Above 7 (14.89) 5 (14.71) 2 (15.38)

Fisher's exact 1.00

HH Average Monthly

income

0.77

Lower Income 38 (57.58) 26 (55.32) 12 (63.16)

Middle Income 10 (15.15) 7 (14.89) 3 (15.79)

Higher Income 18 (27.27) 14 (29.79) 4 (21.05)

Fisher's exact 0.75


Not Important 45 (68.18) 30 (63.83) 15 (78.95)

Neutral 8 (12.12) 7 (14.89) 1 (5.26)

Important 13 (19.70) 10 (21.28) 3 (15.79)

Fisher's exact 0.59


Government 54 (81.82) 37 (78.72) 17 (89.47)

Other 12 (18.18) 10 (21.28) 2 (10.53)

Fisher's exact 0.48

1-sided Fisher's exact 0.26

187



Self-reported 22 (33.33) 18 (38.30) 4 (21.05)


Fisher's exact 0.25

Family Member

Reported

0.65

Escorting 41 (95.35) 27 (96.43) 14 (93.33)

Not escorting 2 (4.65) 1 (3.57) 1 (6.67)

Fisher's exact 1.00

188

Table I. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Neurological Diseases by a known



Gender 0.46

Male 12 (60.00) 4 (50.00) 8 (66.67)

Female 8 (40.00) 4 (50.00) 4(33.33)

Fisher's exact 0.65

Age m±SD* 49±19.83 53±14.31 46.33± 23.01 0.48


Married 16 (88.89) 7 (87.50) 9 (90.00)

Not Married 2 (11.11) 1 (12.50) 1 (10.00)

Fisher's exact 1.00

Employment Status

15+

0.20

Not Working 13 (72.22) 7 (87.50) 6 (60.00)

Working 5 (27.78) 1 (12.50) 4 (40.00)

Fisher's exact 0.31

Educational Level

15+

0.18


read and write

6 (33.33) 1 (12.50) 5 (50.00)

Up to high School 8 (44.44) 4 (50.00) 4 (40.00)

College & Above 4 (22.22) 3 (37.50) 1 (10.00)

Fisher's exact 0.19

HH Average Monthly

income

0.57

Lower Income 12 (60.00) 4 (50.00) 8 (66.67)

Middle Income 3 (15.00) 2 (25.00) 1 (8.33)

Higher Income 5 (25.00) 2 (25.00) 3 (25.00)

Fisher's exact 0.81


Not Important 13 (65.00) 6 (75.00) 7 (58.33)

Neutral 2 (10.00) 0 (0) 2 (16.67)

Important 5 (25.00) 2 (25.00) 3 (25.00)

Fisher's exact 0.80


Government 17 (85.00) 6 (75.00) 11 (91.67)

Other 3 (15.00) 2 (25.00) 1 ( 8.33)

Fisher's exact 0.54

189



Self-reported 4 (20.00) 3 (37.50) 1 (8.33)

Family member

reported

16 (80.00) 5 (62.50) 11 (91.67)

Fisher's exact 0.26

Family Member

Reported

0.13

Escorted 15 (93.75) 4 (80.00) 11 (100.00)

Not escorted 1 ( 6.25) 1 (20.00) 0 (0)

Fisher's exact 0.31

190

Table J. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to diagnosed and treated for the case of Neurological Diseases by a


Variable Total Sample N (%) One Week More than one week P-value

Gender 0.40

Male 12 (60.00) 11 (57.89) 1 (100.00)

Female 8 (40.00) 8 (42.11) 0 (0)

Fisher's exact 1.00

Age m±SD* 49 49.21± 20.35 45 -


Married 16 (88.89) 15 (88.24) 1 (100.00)

Not Married 2 (11.11) 2 (11.76) 0 (0)

Fisher's exact 1.00

Employment Status

15+

0.10

Not Working 13 (72.22) 13 (76.47) 0 (0)

Working 5 (27.78) 4 (23.53) 1 (100.00)

Fisher's exact 0.28

Educational Level

15+

0.52


read and write

6 (33.33) 6 (35.29) 0 (0)

Up to high School 8 (44.44) 7 (41.18) 1 (100.00)

College & Above 4 (22.22) 4 (23.53) 0 (0)

Fisher's exact 1.00

HH Average

Monthly income

0.70

Lower Income 12 (60.00) 11 (57.89) 1 (100.00)

Middle Income 3 (15.00) 3 (15.79) 0 (0)

Higher Income 5 (25.00) 5 (26.32) 0 (0)

Fisher's exact 1.00


Not Important 13 (65.00) 13 (68.4) 0 (0)

Neutral 2 (10.00) 2 (10.53) 0 (0)

Important 5 (25.00) 4 (21.05) 1 (100.00)

Fisher's exact 0.35


Government 17 (85.00) 16 ( 84.21) 1 (100.00)

Other 3 (15.00) 3 (15.79) 0 (0)

Fisher's exact 1.00

Answering the

survey

0.04

191


Self-reported 4 (20.00) 3 (15.79) 1 (100.00)

Family member

reported

16 (80.00) 16 (84.21) 0 (0)

Fisher's exact 0.20

Family Member

Reported

-

Escorted 15 (93.75) 15 (93.75) -

Not Escorted 1 (6.25) 1 (6.25) -

Fisher's exact -

192

Table K. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Neurological Diseases by a visiting



Gender 0.09

Male 12 (60.00) 3 (37.50) 9 (75.00)

Female 8 (40.00) 5 (62.50) 3 (25.00)

Fisher's exact 0.17

Age m±SD* 49±19.83 51.25±13.55 47.5±23.59 0.69


Married 16 (88.89) 7 (87.50) 9 (90.00)

Not Married 2 (11.11) 1 (12.50) 1 (10.00)

Fisher's exact 1.00

Employment Status

15+

0.81

Not Working 13 (72.22) 6 (75.00) 7 (70.00)

Working 5 (27.78) 2 (25.00) 3 (30.00)

Fisher's exact 1.00

Educational Level

15+

0.25


read and write

6 (33.33) 3 (37.50) 3 (30.00)

Up to high School 8 (44.44) 2 (25.00) 6 (60.00)

College & Above 4 (22.22) 3 (37.50) 1 (10.00)

Fisher's exact 0.29

HH Average

Monthly income

0.57

Lower Income 12 (60.00) 4 (50.00) 8 (66.67)

Middle Income 3 (15.00) 2 (25.00) 1 (8.33)

Higher Income 5 (25.00) 2 (25.00) 3 (25.00)

Fisher's exact 0.81


Not Important 13 (65.00) 6 (75.00) 7 (58.33)

Neutral 2 (10.00) 1 (12.50) 1 (8.33)

Important 5 (25.00) 1 (12.50) 4 (33.33)

Fisher's exact 0.80


Government 17 (85.00) 8 (100.00) 9 (75.00)

Other 3 (15.00) 0 (0) 3 (25.00)

Fisher's exact 0.24

Answering the

survey

0.65

Self-reported 4 (20.00) 2 (25.00) 2 (16.67)

193


Family member

reported

16 (80.00) 6 (75.00) 10 (83.33)

Fisher's exact 1.00

Family Member

Reported

0.42

Escorted 15 (93.75) 6 (100.00) 9 (90.00)

Not Escorted 1 (6.25) 0 (0) 1 (10.00)

Fisher's exact 1.00

194

Table L. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Neurological Diseases by a



week

P-value

Gender 0.16

Male 12 (60.00) 7 (50.00) 5 (83.33)

Female 8 (40.00) 7 (50.00) 1 (16.67)

Fisher's exact 0.33

Age m±SD* 49±19.83 46.36±22.86 55.17±8.42 0.38


Married 16 (88.89) 10 (83.33) 6 (100.00)

Not Married 2 (11.11) 2 (16.67) 0 (0)

Fisher's exact 0.53

Employment Status

15+

0.14

Not Working 13 (72.22) 10 (83.33) 3 (50.00)

Working 5 (27.78) 2 (16.67) 3 (50.00)

Fisher's exact 0.27



and write

6 (33.33) 6 (50.00) 0 (0)

Up to high School 8 (44.44) 3 (25.00) 5 (83.33)

College & Above 4 (22.22) 3 (25.00) 1 ( 16.67 )

Fisher's exact 0.04

HH Average Monthly

income

0.820

Lower Income 12 (60.00) 9 (64.29) 3 (50.00)

Middle Income 3 (15.00) 2 (14.29) 1 (16.67)

Higher Income 5 (25.00) 3 (21.43) 2 (33.33)

Fisher's exact 0.81


Not Important 13 (65.00) 9 (64.29) 4 (66.67)

Neutral 2 (10.00) 2 (14.29) 0 (0)

Important 5 (25.00) 3 (21.43) 2 (33.33)

Fisher's exact 1.00


Government 17 (85.00) 13 (92.86) 4 (66.67)

Other 3 (15.00) 1 (7.14) 2 (33.33)

Fisher's exact 0.20


195


Self-reported 4 (20.00) 1 (7.14) 3 (50.00)


Fisher's exact 0.06

Family Member

Reported

0.03

Escorted 15 ( 93.75) 13 (100.00) 2 (66.67)

Not escorted 1 (6.25) 0 (0) 1 ( 33.33)

Fisher's exact 0.19

196

Table M. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Eye disease by a known physician

in the UAE


Gender 0.87

Male 12 (48.00) 5 (50.00) 7 (46.67)

Female 13 (52.00) 5 (50.00) 8 (53.33)


Age m±SD* 41.84± 23.48 37.4± 17.41 44.8± 29.87 0.45


Married 15 (68.18) 5 (50.00) 10 (83.33)

Not Married 7 (31.82) 5 (50.00) 2 (16.67)


Employment Status

15+

0.48

Not Working 16 (72.73) 8 (80.00) 8 (66.67)

Working 6 (27.27) 2 (20.00) 4 (33.33)


Educational Level

15+

0.35


read and write

2 (9.09) 0 (0) 2 (16.67)

Up to high School 15 (68.18) 8 (80.00) 7 (58.33)

College & Above 5 (22.73) 2 (20.00) 3 (25.00)


HH Average

Monthly income

0.32

Lower Income 13 (52.00) 7 (70.00) 6 (40.00)

Middle Income 5 (20.00) 1 (10.00) 4 (26.67)

Higher Income 7 (28.00) 2 (20.00) 5 (33.33)



Not Important 17 (68.00) 6 (60.00) 11 (73.33)

Neutral 3 (12.00) 2 (20.00) 1 (6.67)

Important 5 (20.00) 2 (20.00) 3 (20.00)



Government 20 (80.00) 6 (60.00) 14 (93.33)

Other 5 (20.00) 4 (40.00) 1 (6.67)


Answering the

survey

0.1

Self-reported 10 (40.00) 6 (60.00) 4 (26.67)

197

Family member

reported

15 (60.00) 4 (40.00) 11 (73.33)


Family Member

Reported

0.93

Escorted 11 (73.33) 3 (75.00) 8 (72.73)

Not escorted 4 (26.67) 1 (25.00) 3 (27.27)



198

Table N. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Eye disease by a known



Gender 0.93

Male 12 (48.00) 10 (47.62) 2 (50.00)

Female 13 (52.00) 11 (52.38) 2 (50.00)


Age m±SD* 41.84± 23.48 40.33± 25.28 49.75± 7.32 0.47


Married 15 (68.18) 11 (61.11) 4 (100.00)

Not Married 7 (31.82) 7 (38.89) 0 (0)


Employment Status

15+

0.26

Not Working 16 (72.73) 14 (77.78) 2 (50.00)

Working 6 (27.27) 4 (22.22) 2 (50.00)


Educational Level

15+

0.78


read and write

2 (9.09) 2 (11.11) 0 (0)

Up to high School 15 (68.18) 12 (66.67) 3 (75.00)

College & Above 5 (22.73) 4 (22.22) 1 (25.00)


HH Average

Monthly income

0.07

Lower Income 13 (52.00) 13 (61.90) 0 (0)

Middle Income 5 (20.00) 3 (14.29) 2 (50.00)

Higher Income 7 (28.00) 5 (23.81) 2 (50.00)



Not Important 17 (68.00) 13 (61.90) 4 (100.00)

Neutral 3 (12.00) 3 (14.29) 0 (0)

Important 5 (20.00 5 (23.81) 0 (0)



Government 20 (80.00) 16 (76.19) 4 (100.00)

Other 5 (20.00) 5 (23.81) 0 (0)


199


Answering the

survey

0.50

Self-reported 10 (40.00) 9 (42.86) 1 (25.00)

Family member

reported

15 (60.00) 12 (57.14) 3 (75.00)


Family Member

Reported

0.77

Escorted 11 (73.33) 9 (75.00) 2 (66.67)

Not escorted 4 (26.67) 3 (25.00) 1 (33.33)


200

Table O. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Eye Disease by a visiting physician

to the UAE


Gender 0.14

Male 12 (48.00) 5 (71.43) 7 (38.89)

Female 13 (52.00) 2 (28.57) 11 (61.11)

Fisher's exact 0.20

Age m±SD* 41.84± 23.48 44.42± 20.65 40.83± 24.98 0.74


Married 15 (68.18) 5 (71.43) 10 (66.67)

Not Married 7 (31.82) 2 (28.57) 5 (33.33)

Fisher's exact 1.00

Employment Status

15+

0.93

Not Working 16 (72.73) 5 (71.43) 11 (73.33)

Working 6 (27.27) 2 (28.57) 4 (26.67)

Fisher's exact 1.00

Educational Level

15+

0.23


read and write

2 (9.09) 0 (0) 2 (13.33)

Up to high School 15 (68.18) 4 (57.14) 11 (73.33)

College & Above 5 (22.73) 3 (42.86) 2 (13.33)

Fisher's exact 0.34

HH Average

Monthly income

0.90

Lower Income 13 (52.00) 4 (57.14) 9 (50.00)

Middle Income 5 (20.00) 1 (14.29) 4 (22.22)

Higher Income 7 (28.00) 2 (28.57) 5 (27.78)

Fisher's exact 1.00


Not important 17 (68.00) 4 (57.14) 13 (72.22)

Neutral 3 (12.00) 2 (28.57) 1 (5.56)

Important 5 (20.00) 1 (14.29) 4 (22.22)

Fisher's exact 0.32


Government 20 (80.00) 5 (71.43) 15 (83.33)

Other 5 (20.00) 2 (28.57) 3 (16.67)

Fisher's exact 0.60

Answering the

survey

0.05

201


Self-reported 10 (40.00) 5 (71.43) 5 (27.78)

Family member

reported

15 (60.00) 2 (28.57) 13 (72.22)

Fisher's exact 0.08

Family Member

Reported

0.36

Escorted 11 (73.33) 2 (100.00) 9 (69.23)

Not escorted 4 (26.67) 0 (0) 4 (30.77)

Fisher's exact 1.00

202

Table P. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Eye Disease by a visiting



Gender 0.75

Male 12 (48.00) 9 (50.00) 3 (42.86)

Female 13 (52.00) 9 (50.00) 4 (57.14)

Fisher's exact 1.00

Age m±SD* 41.84± 23.48 36.44± 23.78 55.71± 17.06 0.06


Married 15 (68.18) 10 (66.67) 5 (71.43)

Not Married 7 (31.82) 5 (33.33) 2 (28.57)

Fisher's exact 1.00

Employment Status

15+

0.93

Not Working 16 (72.73) 11 (73.33) 5 (71.43)

Working 6 (27.27) 4 (26.67) 2 (28.57)

Fisher's exact 1.00

Educational Level

15+

0.21


read and write

2 (9.09) 1 (6.67) 1 (14.29)

Up to high School 15 (68.18) 9 (60.00) 6 (85.71)

College & Above 5 (22.73) 5 (33.33) 0 (0)

Fisher's exact 0.26

HH Average

Monthly income

0.77

Lower Income 13 (52.00) 10 (55.56) 3 (42.86)

Middle Income 5 (20.00) 3 (16.67) 2 (28.57)

Higher Income 7 (28.00) 5 (27.78) 2 (28.57)

Fisher's exact 0.84


Not important 17 (68.00) 12 (66.67) 5 (71.43)

Neutral 3 (12.00) 2 (11.11) 1 (14.29)

Important 5 (20.00) 4 (22.22) 1 (14.29)

Fisher's exact 1.00


Government 20 (80.00) 14 (77.78) 6 (85.71)

Other 5 (20.00) 4 (22.22) 1 (14.29)

Fisher's exact 1.00

Answering the

survey

0.47

203


Self-reported 10 (40.00) 5 (71.43) 5 (27.78)

Family member

reported

15 (60.00) 2 (28.57) 13 (72.22)

Fisher's exact 0.66

Family Member

Reported

0.36

Escorted 11 (73.33) 9 (69.23) 2 (100.00)

Not escorted 4 (26.67) 4 (30.77) 0 (0)

Fisher's exact 1.00

204

Table Q. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of General Surgery by a known



Gender 0.28

Male 10 (45.45) 8 (53.33) 2 (28.57)

Female 12 (54.55) 7 (46.67) 5 (71.43)

Fisher's exact 0.38

Age m±SD* 46.14±24.39 37.66±23.80 64.29±14.02 0.01


Married 12 (66.67) 8 (72.73) 4 (57.14)

Not Married 6 (33.33) 3 (27.27) 3 (42.86)

Fisher's exact 0.63

Employment Status

15+

0.17

Not Working 12 (66.67) 6 (54.55) 6 (85.71)

Working 6 ( 33.33) 5 (45.45) 1 (14.29)

Fisher's exact 0.32

Educational Level

15+

0.56


read and write

8 (44.44) 4 (36.36) 4 (57.14)

Up to high School 5 (27.78) 3 (27.27) 2 (28.57)

College & Above 5 (27.78) 4 (36.36 ) 1 (14.29)

Fisher's exact 0.82

HH Average Monthly

income

0.36

Lower Income 16 (72.73) 12 (80.00) 4 (57.14)

Middle Income 3 (13.64) 1 (6.67) 2 (28.57)

Higher Income 3 (13.64) 2 (13.33) 1 (14.29)

Fisher's exact 0.49


Not Important 15 (68.18) 11 (73.33) 4 (57.14)

Neutral - -

Important 7 (31.82) 4 (26.67) 3 (42.86)

Fisher's exact 0.63


Government 13 ( 59.09) 9 (60.00) 4 (57.14)

Other 9 (40.91) 6 (40.00) 3 (42.86)

Fisher's exact 1.00


205


Self-reported 7 (31.82) 4 (26.67) 3 (42.86)

Family member

reported

15 (68.18) 11 (73.33) 4 (57.14)

Fisher's exact 0.63

Family Member

Reported

0.47

Escorted 12 (85.71) 9 (90.00) 3 (75.00)

Not escorted 2 (14.29) 1 (10.00) 1 (25.00)

Fisher's exact 0.51

206

Table R. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to diagnosed for the case of General Surgery by a known physician and

preference for the waiting time


week

P-value

Gender 0.78

Male 10 (45.45) 8 (47.06) 2 (40.00)

Female 12 (54.55) 9 (52.94) 3 (60.00)

Fisher's exact 1.00

Age m±SD* 46.14±24.39 45.59±24.09 48±28.24 0.85


Married 12 (66.67) 9 (64.29) 3 (75.00)

Not Married 6 (33.33) 5 (35.71) 1 (25.00)

Fisher's exact 1.00

Employment Status

15+

0.42

Not Working 12 (66.67) 10 (71.43) 2 (50.00)

Working 6 (33.33) 4 (28.57) 2 (50.00)

Fisher's exact 0.57



and write

8 (44.44) 7 (50.00) 1 (25.00)

Up to high School 5 (27.78) 4 (28.57) 1 (25.00)

College & Above 5 (27.78) 3 (21.43) 2 (50.00)

Fisher's exact 0.77

HH Average Monthly

income

0.77

Lower Income 16 (72.73) 13 (76.47) 3 (60.00)

Middle Income 3 (13.64) 2 (11.76) 1 (20.00)

Higher Income 3 (13.64) 2 (11.76) 1 (20.00)

Fisher's exact 0.59


Not Important 15 (68.18) 13 (76.47) 2 (40.00)

Neutral - -

Important 7 (31.82) 4 (23.53) 3 (60.00)

Fisher's exact 0.27


Government 13 (59.09) 10 (58.82) 3 (60.00)

Other 9 (40.91) 7 (41.18) 2 (40.00)

Fisher's exact 1.00

207



Self-reported 7 ( 31.82) 5 (29.41) 2 (40.00)


Fisher's exact 1.00

Family Member

Reported

0.53

Escorted 12 (85.71) 10 (83.33) 2 (100.00)

Not escorted 2 (14.29) 2 (16.67) 0 (0)

Fisher's exact 1.00

208

Table S. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of General Surgery by a visiting



Gender 1.00

Male 10 (45.45) 5 (45.45) 5 (45.45)

Female 12 (54.55) 6 (54.55) 6 (54.55)

Fisher's exact 1.00

Age m±SD* 46.136±24.39 38.82±22.40 53.45±26.00 0.16


Married 12 (66.67) 6 (66.67) 6 (66.67)

Not Married 6 (33.33) 3 (33.33) 3 (33.33)

Fisher's exact 1.00

Employment Status

15+

1.00

Not Working 12 (66.67) 6 (66.67) 6 (66.67)

Working 6 (33.33) 3 (33.33) 3 (33.33)

Fisher's exact 1.00

Educational Level

15+

0.82


read and write

8 (44.44) 4 (44.44) 4 ( 44.44)

Up to high School 5 (27.78) 3 (33.33) 2 (22.22)

College & Above 5 (27.78) 2 (22.22) 3 (33.33)

Fisher's exact 1.00

HH Average

Monthly income

0.12

Lower Income 16 (72.73) 10 (90.91) 6 (54.55)

Middle Income 3 (13.64) 0 (0) 3 (27.27)

Higher Income 3 (13.64) 1 (9.09) 2 (18.18)

Fisher's exact 0.19


Not Important 15 (68.18) 8 (72.73) 7 (63.64)

Neutral - - -

Important 7 (31.82) 3 (27.27) 4 (36.36)

Fisher's exact 1.00


Government 13 (59.09) 5 (45.45) 8 (72.73)

Other 9 (40.91) 6 (54.55) 3 (27.27)

Fisher's exact 0.39

Answering the

survey

0.65

Self-reported 7 (31.82) 3 (27.27) 4 (36.36)

209


Family member

reported

15 (68.18) 8 (72.73) 7 (63.64)

Fisher's exact 1.00

Family Member 0.83

Escorted 12 (85.71) 7 (87.50) 5 (83.33)

Not Escorted 2 (14.29) 1 (12.50) 1 (16.67)

Fisher's exact 1.00

210

Table T. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of General Surgery a visiting



week

P-value

Gender 0.28

Male 10 (45.45) 8 (53.33) 2 (28.57)

Female 12 (54.55) 7 (46.67) 5 (71.43)

Fisher's exact 0.38

Age m±SD* 46.14±24.39 42.93±25.04 53±23.20 0.38


Married 12 (66.67) 8 (66.67) 4 (66.67)

Not Married 6 (33.33) 4 (33.33) 2 (33.33)

Fisher's exact 1.00

Employment Status

15+

1.00

Not Working 12 (66.67) 8 ( 66.67) 4 (66.67)

Working 6 (33.33) 4 (33.33) 2 (33.33)

Fisher's exact 1.00



and write

8 (44.44) 5 (41.67) 3 (50.00)

Up to high School 5 (27.78) 5 (41.67) 0 (0)

College & Above 5 (27.78) 2 (16.67) 3 (50.00)

Fisher's exact 0.14

HH Average Monthly

income

0.03

Lower Income 16 (72.73) 13 (86.67) 3 (42.86)

Middle and Higher

Income

6 (27.27) 2 (13.33) 4 (57.14 )

Fisher's exact 0.05


Not Important 15 (68.18) 10 (66.67) 5 (71.43)

Neutral - - -

Important 7 (31.82) 5 (33.33) 2 (28.57)

Fisher's exact 1.00


Government 13 (59.09) 9 (60.00) 4 (57.14)

Other 9 (40.91) 6 (40.00) 3 (42.86)

Fisher's exact 1.00


211


Self-reported 7 (31.82) 4 (26.67) 3 (42.86)

Family member reported 15 (68.18( 11 (73.33) 4 (57.14)

Fisher's exact 0.63

Family Member

Reported

0.43

Escorted 12 (85.71) 9 (81.82) 3 (100.00)

Not escorted 2 (14.29) 2 (18.18) 0 (0)

Fisher's exact 1.00

212

Table U. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Hearth Diseases by a known



Gender 0.89

Male 23 (51.11) 10 (50.00) 13 (52.00)

Female 22 (48.89) 10 (50.00) 12 (48.00)

Fisher's exact 1.00

Age m±SD* 34.6± 20.59 31.55± 20.88 37.04± 20.45 0.38


Married 20 (58.82) 8 (57.14) 12 (60.00)

Not Married 14 (41.18) 6 (42.86) 8 (40.00)

Fisher's exact 1.00

Employment Status

15+

0.50

Not Working 24 (70.59) 9 (64.29) 15 (75.00)

Working 10 (29.41) 5 (35.71) 5 (25.00)

Fisher's exact 0.70

Educational Level

15+

0.62


read and write

9 (26.47) 3 (21.43) 6 (30.00)

Up to high School 16 (47.06) 8 (57.14) 8 (40.00)

College & Above 9 (26.47) 3 (21.43) 6 (30.00)

Fisher's exact 0.74

HH Average Monthly

income

0.02

Lower Income 33 (73.33) 18 (90.00)

15 (60.00)

Middle and Higher

Income

12 (26.67) 2(10.00) 10 (40.00)

Fisher's exact 0.04


Not Important 27 (60.00) 10 (50.00) 17 (68.00)

Neutral 7 (15.56) 3 (15.00) 4 (16.00)

Important 11 (24.44) 7 (35.00) 4 (16.00)

Fisher's exact 0.37


Government 37 (82.22) 15 (75.00) 22 (88.00)

Other 8 (17.78) 5 (25.00) 3 (12.00)

Fisher's exact 0.44

213



Self-reported 22 (48.89) 10 (50.00) 12 (48.00)

Family member

reported

23 (51.11) 10 (50.00) 13 (52.00)

Fisher's exact 1.00

Family Member

Reported

0.35

Escorted 21 (95.45) 10 (100.00) 11 (91.67)

Not escorted 1 (4.55) 0 (0) 1 (8.33)

Fisher's exact 1.00

214

Table V. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Hearth Diseases a known



Gender 0.18

Male 23 (51.11) 16 (45.71) 7 (70.00)

Female 22 (48.89) 19 (54.29) 3 (30.00)

Fisher's exact 0.28

Age m±SD* 34.6± 20.59 37.85± 19.94 23.2± 19.65 0.05


Married 20 (58.82) 17 (58.62) 3 (60.00)

Not Married 14 (41.18) 12 (41.38) 2 (40.00)

Fisher's exact 1.00

Employment Status

15+

0.57

Not Working 24 (70.59) 21 (72.41) 3 (60.00)

Working 10 (29.41) 8 (27.59) 2 (40.00)

Fisher's exact 0.62

Educational Level

15+

0.76


read and write

9 (26.47) 8 (27.59) 1 (20.00)

Up to high School 16 (47.06) 14 (48.28) 2 (40.00)

College & Above 9 (26.47) 7 (24.14) 2 (40.00

Fisher's exact 0.84

HH Average

Monthly income

0.77

Lower Income 33 (73.33) 25 (71.43) 8 (80.00)

Middle Income 8 (17.78) 7 (20.00) 1 (10.00)

Higher Income 4 (8.89) 3 (8.57) 1 (10.00

Fisher's exact 0.85


Not important 27 (60.00) 22 (62.86) 5 (50.00)

Neutral 7 (15.56) 4 (11.43) 3 (30.00)

Important 11 (24.44) 9 (25.71) 2 (20.00

Fisher's exact 0.41


Government 37 (82.22) 29 (82.86) 8 (80.00)

Other 8 (17.78) 6 (17.14) 2 (20.00)

Fisher's exact 1.00

215


Answering the

survey

0.94

Self-reported 22 (48.89) 17 (48.57) 5 (50.00)

Family member

reported

23 (51.11) 18 (51.43) 5 (50.00

Fisher's exact 1.00

Family Member

Reported

0.58

Escorted 21 (95.45) 16 (94.12) 5 (100.00)

Not escorted 1 (4.55) 1 (5.88) 0 (0)

Fisher's exact 1.00

216

Table W. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to be diagnosed and treated for the case of Heart Diseases by a visiting



Gender 0.92

Male 23 (51.11) 7 (50.00) 16 (51.61)

Female 22 (48.89) 7 (50.00) 15 (48.39)

Fisher's exact 1.00

Age m±SD* 34.6± 20.59 33.36± 20.697 35.16± 20.86 0.79


Married 20 (58.82) 6 (60.00) 14 (58.33)

Not Married 14 (41.18) 4 (40.00) 10 (41.67)

Fisher's exact 1.00

Employment Status

15+

0.96

Not Working 24 (70.59) 7 (70.00) 17 (70.83

Working 10 (29.41) 3 (30.00) 7 (29.17)

Fisher's exact 1.00

Educational Level

15+

0.36


read and write

9 (26.47) 3 (30.00) 6 (25.00)

Up to high School 16 (47.06) 6 (60.00) 10 (41.67)

College & Above 9 (26.47) 1 (10.00) 8 (33.33)

Fisher's exact 0.50

HH Average

Monthly income

0.13

Lower Income 33 (73.33) 13 (92.86) 20 (64.52)

Middle Income 8 (17.78) 1 (7.14) 7 (22.58)

Higher Income 4 (8.89) 0 (0) 4 (12.90)

Fisher's exact 0.19


Not important 27 (60.00) 9 (64.29) 18 (58.06)

Neutral 7 (15.56) 0 (0) 7 (22.58)

Important 11 (24.44) 5 (35.71) 6 (19.35)

Fisher's exact 0.12


Government 37 (82.22) 11 (78.57) 26 (83.87)

Other 8 (17.78) 3 (21.43) 5 (16.13)

Fisher's exact 0.69

Answering the

survey

0.24

Self-reported 22 (48.89) 5 (35.71) 17 (54.84)

217

Family member

reported

23 (51.11) 9 (64.29) 14 (45.16)

Fisher's exact 0.34

Family Member

Reported

0.39

Escorted 21 (95.45) 9 (100.00) 12 (92.31)

Not escorted 1 (4.55) 0 (0) 1 (7.69)

Fisher's exact 1.00


218

Table X. Demographical characteristics of residents of Dubai, United Arab Emirates who

were willing to wait to be diagnosed and treated for the case of Heart Diseases a visiting



Gender 0.67

Male 23 (51.11) 16 (53.33) 7 (46.67)

Female 22 (48.89) 14 (46.67) 8 (53.33)

Fisher's exact 0.76

Age m±SD* 34.6± 20.59 33.63± 19.54 36.53± 23.15 0.66


Married 20 (58.82) 14 (58.33) 6 (60.00)

Not Married 14 (41.18 10 (41.67) 4 (40.00)

Fisher's exact 1.00

Employment Status

15+

0.96

Not Working 24 (70.59) 17 (70.83) 7 (70.00)

Working 10 (29.41) 7 (29.17) 3 (30.00)

Fisher's exact 1.00



and write

9 (26.47) 4 (16.67) 5 (50.00)

Up to high School 16 (47.06) 12 (50.00) 4 (40.00)

College & Above 9 (26.47) 8 (33.33) 1 (10.00

Fisher's exact 0.14

HH Average Monthly

income

0.69

Lower Income 33 (73.33) 22 (73.33) 11 (73.33)

Middle Income 8 (17.78) 6 (20.00) 2 (13.33)

Higher Income 4 (8.89) 2 (6.67) 2 (13.33)

Fisher's exact 0.76


Not important 27 (60.00) 19 (63.33) 8 (53.33)

Neutral 7 (15.56) 4 (13.33) 3 (20.00

Important 11 (24.44) 7 (23.33) 4 (26.67)

Fisher's exact 0.74


Government 37 (82.22) 24 (80.00) 13 (86.67)

Other 8 (17.78) 6 (20.00) 2 (13.33)

Fisher's exact 0.70

219


Self-reported 22 (48.89) 14 (46.67) 8 (53.33)


Fisher's exact 0.76

Family Member

Reported

0.13

Escorted 21 (95.45) 15 (100.00) 6 (85.71)

Not escorted 1 (4.55) 0 (0) 1 (14.29)

Fisher's exact 0.32


220

AA. Willingness to be diagnosed and treated for the case of Bone & Joint by a known


Preference Total Sample N (%)

Strongly Disagree 7 (14.89)

Disagree 6 (12.77)

Neutral 10 (21.28)

Agree 20 (42.55)

Strongly Agree 4 (8.51)

Total 47 (100.00)

BB. Willingness to wait to be diagnosed and treated for the case of Bone & Joint by a



1 Week 34 (72.34)

2 Weeks 7 (14.89)

1 Month 5 (10.64)

6 Months 1 (2.13)

Total 47 (100.00)

CC. Willingness to be diagnosed and treated for the case of Bone and Joint Diseases by a




Disagree 4 (8.51)

Neutral 4 (8.51)

Agree 23 (48.94)


Total 47 (100.00)

DD. Willingness to wait to be diagnosed and treated for the case of Bone & Joint Diseases

by a visiting physician to the UAE


1 Week 27 (57.45)

2 Weeks 14 (29.79)

1 Month 5 (10.64)

3 Months 1 (2.13)

Total 47 (100.00)

221

EE. Willingness to be diagnosed and treated for the case of Cancer by a known physician in

the UAE



Disagree 4 (6.06)

Neutral 17 (25.76)

Agree 21 (31.82)


Total 66 (100)

FF. Willingness to wait to be diagnosed and treated for the case of Cancer a known



1 Week 53 (80.30)

2 Weeks 11 (16.67)

1 Month 2 (3.03)

Total 66 (100)

GG. Willingness to be diagnosed and treated for the case of Cancer by a visiting physician

to the UAE



Disagree 1 (1.52)

Neutral 9 (13.64)

Agree 28 (42.42)


Total 66 (100)

HH. Willingness to wait to be diagnosed and treated for the case of Cancer by a visiting



1 Week 47 (71.21)

2 Weeks 14 (21.21)

1 Month 4 (6.06)

6 Months 1 (1.52)

Total 66 (100)

222

II. Willingness to be diagnosed and treated for the case of Neurological Diseases by a




Disagree 2 (10.00)

Neutral 3 (15.00)

Agree 7 (35.00)


Total 20 (100.00)

JJ. Willingness to wait to be diagnosed and treated for the case of Neurological Diseases by

a known physician in the UAE


1 Week 19 (95.00)

2 Weeks 1 (5.00)

Total 20 (100.00)

KK. Willingness to be diagnosed and treated for the case of Neurological Diseases by a




Disagree 2 (10.00)

Neutral 1 (5.00)

Agree 5 (25.00)


Total 20 (100.00)

LL. Willingness to wait be diagnosed and treated for the case of Neurological Diseases by a



1 Week 14 (70.00)

2 Weeks 3 (15.00)

1 Month 2 (10.00)

3 Months 1 (5.00)

Total 20 (100.00)

MM. Willingness to be diagnosed and treated for the case of Eye Diseases by a known




223

Disagree 4 (16.00)

Neutral 3 (12.00 )

Agree 10 (40.00)


Total 25 (100.00)

NN. Willingness to wait to be diagnosed and treated for the case of Eye Diseases by a



1 Week 21 (84.00)

2 Weeks 2 (8.00)

1 Month 1 (4.00)

3 Months 1 (4.00)

Total 25 (100.00)

OO. Willingness to be diagnosed and treated for the case of Eye Diseases by a visiting




Disagree 4 (16.00)

Neutral 1 (4.00)

Agree 9 (36.00)


Total 25 (100.00)

PP Willingness to wait be diagnosed and treated for the case of Eye Diseases by a visiting



1 Week 18 (72.00)

2 Weeks 5 (20.00)

1 Month 1 (4.00)

3 Months 1 (4.00)

Total 25 (100.00)

QQ. Willingness to be diagnosed and treated for the case of General Surgery by a known




Disagree 3 (13.64)

224

Neutral 5 (22.73)

Agree 4 (18.18)


Total 22 (100.00)

RR. Willingness to wait to be diagnosed for the case of General Surgery by a known



1 Week 17 (77.27)

2 Weeks 2 (9.09)

1 Month 2 (9.09)

6 Months 1 (4.55)

Total 22 (100.00)

SS. Willingness to be diagnosed and treated for the case of General Surgery by a visiting




Disagree 3 (13.64)

Neutral 3 (13.64)

Agree 5 (22.73)


Total 22 (100.00)

TT. Willingness to wait to be diagnosed and treated for the case of General Surgery by a



1 Week 15 (68.18)

2 Weeks 2 (9.09)

1 Month 3 (13.64)

6 Months 2 (9.09)

Total 22 (100.00)

UU. Willingness to be diagnosed and treated for the case of Heart Diseases by a visiting




Disagree 5 (11.11)

Neutral 7 (15.56)

225

Agree 20 (44.44)


Total 45 (100.00)

VV. Willingness to wait to be diagnosed and treated for the case of Heart Diseases by a

known physician


1 Week 35 (77.78)

2 Weeks 6 (13.33)

1 Month 4 (8.89)

Total 45 (100.00)

WW. Willingness to be diagnosed and treated for the case of Heart Diseases by a visiting




Disagree 5 (11.11)

Neutral 6 (13.33)

Agree 18 (40.00)


Total 45 (100.00)

XX. Willingness to wait to be diagnosis and treatment for the case of Heart Diseases a

visiting physician to the UAE and preference for the waiting time


1 Week 30 (66.67)

2 Weeks 8 (17.78)

1 Month 5 (11.11)

3 Months 2 (4.44)

Total 45 (100.00)

Copy of the Knowledge, Attitudes and Perceptions Survey

Survey Objective: To explore knowledge, attitude and perception related to Medical Treatment

abroad among residents of Dubai.

226

Information to read to respondents:

Dubai Statistic Center in collaboration with Dubai Health Authority are carrying out a survey on

Medical Treatment Abroad 2011, to examine the knowledge, attitude, and perception of residents of

Dubai who traveled abroad for medical treatment.

We wish to learn about your knowledge, attitude and perception regarding your experience with

treatment abroad. We hope to understand your needs, reasons to why you preferred to travel

abroad for treatment as well as barriers to seeking medical care.

Your answers will not be shared with anyone and will remain confidential. The information you

provide will be used to support decision making and planning in health.

Thank you for your participation and collaboration.

For further inquires, please contact any of us:

Dr Eldaw Sulaiman 0509001405

Wafa Al Nakhi 042194079

Dr Amal Al Halyan 042194109

Dr Amnah Almarashdah 042194097

227

Serial Number: ______________________________________

Section 2 General Demographic Information

101. Gender:

1) Male 2) Female

102. Age: (in full years)

103. Nationality: ______________________

104. Marital Status: 15+

1) Never Married

2) Married

3) Separated 4) Divorced

5) Widowed

105. Employment Status: 15+

1) Government Employee 2) Private Sector Employee

3) Self employed

4) Unemployed looking for a job 5) Unemployed not looking for a job

6) Student 7) Housewife

8) Retired 9) Unable to work (Sick, disabled, old person)

106. Education: 15+

1) Illiterate

2) Can read/ write

3) Primary 4) Preparatory

5) Secondary 6) Above secondary and below university

7) Bachelor

8) Higher Diploma 9) Master

10) PhD

107.1 In the UAE, are you covered by insurance?

a) Yes Continue

b) No Move to Question 108

107.2 Type of Insurance Coverage Circle all responses.

A) Government Health Card (MoH/DHA) B) Government Health Insurance (Enaya,Daman)

228

C) Private Health Insurance (Personal)

D) Others. (Specify) E) None

108. What is the total monthly income (on average) of this household (including monthly salaries, grants,

and pensions received by all members in addition to earnings from other sources), in AED?

______________________________________

Section 3 Health Seeking Behavior in UAE

109. Before you traveled abroad for treatment, what was your general health situation status?

1) I had some medical complaints but did not get diagnosed in UAE continue

2) I had an existing medical condition/diagnosed Move to question 112

3) I was perfectly healthy with no symptoms; I just wanted to do a check-up. Move to question 113

110. Before traveling abroad, what were the symptoms you complained of?

Circle all responses.

A) Abdominal Pain B) Joint(s) problem

C) High Blood Pressure D) Breast Problems

E) Chest Pain

F) Cough G) Diarrhea

H) Constipation I) Ear Problems

J) Eye Problems

K) Genital Problems in Infants L) Genital Problems in Adults

M) Hair Loss N) High Blood Sugar

O) Headaches P) Vision Problems

Q) Hearing Problems

R) Lower Back Pain S) Menstrual Cycle Problems

T) Nausea and Vomiting U) Neck Swelling

V) Pain

W) Bleeding X) Skin Rashes

Y) Tooth Problems Z) Urination Problems

AA) Swelling

BB) Others (specify)

229

111. If you complained of more than one symptom, mention the main symptom?

One answer only

1) Abdominal Pain Move to question 113

2) Joint(s) Problem Move to question 113

3) High Blood Pressure Move to question 113

4) Breast Problems Move to question 113

5) Chest Pain Move to question 113

6) Cough Move to question 113

7) Diarrhea Move to question 113

8) Constipation Move to question 113

9) Ear Problems Move to question 113

10) Eye Problems Move to question 113

11) Genital Problems in Infants Move to question 113

12) Genital Problems in Adults Move to question 113

13) Hair Loss Move to question 113

14) High Blood Sugar Move to question 113

15) Headaches Move to question 113

16) Vision Problems Move to question 113

17) Hearing Problems Move to question 113

18) Lower Back Pain Move to question 113

19) Menstrual Cycle Problems Move to question 113

20) Nausea and Vomiting Move to question 113

21) Neck Swelling Move to question 113

22) Pain Move to question 113

23) Bleeding Move to question 113

24) Skin Rashes Move to question 113

25) Tooth Problems Move to question 113

26) Urination Problems Move to question 113

27) Swelling Move to question 113

28) Others (Specify) Move to question 113

112. Before traveling abroad, what were the main diagnoses or medical conditions you had? Circle all

responses.

A) Heart disease (HD)

B) Cancer C) High blood pressure (HBP)

D) Diabetes

E) Bone and joint Diseases (B&JD) F) Gastro-intestinal Diseases (GI)

G) Obstetrics and Gynecology Diseases (OBGYN) H) Ear, nose and throat (ENT) Diseases (ENT)

I) Kidney or bladder (urinary system) Diseases (KD)

J) Skin or venereal Diseases (Derma) K) Stroke (brain hemorrhage or clot) (Stroke)

L) Mental illness M) Trauma (Trauma)

N) Cosmetic surgery (Cosmetic) O) Dental Diseases (Dental)

P) Lungs and Respiratory Diseases (Respiratory)

230

Q) Eye Diseases (OU)

R) Medical Screening, routing medical check-up (CKU) S) Undiagnosed

X) Others. (Specify)

113.Consultation and source of care for problems in the UAE before travelling abroad

113.1 Do you consult a healthcare provider prior travel abroad for treatment?

1) Yes Continue

2) No Move to Question 114

Read out responses. Circle all responses

113.2 Which of the following healthcare providers was your main source of care for this problem in the

UAE before traveling abroad – i.e. the problem for which you obtained medical care abroad?

a) Dubai Health Authority Hospitals for in-patient services Move to Question 115

b) Dubai Health Authority Hospitals for out-patient services Move to Question 115

c) Dubai Health Authority Primary Health Care Centers Move to Question 115

d) Ministry of Health Hospitals for in-patient services Move to Question 115

e) Ministry of Health Hospitals for out-patient services Move to Question 115

f) Ministry of Health Primary Health Care Centers Move to Question 115

g) Abu Dhabi Health Services Hospitals and PHCs (SEHA) Move to Question 115

h) Private Sector Hospitals for in-patient services Move to Question 115

i) Private Sector Hospitals or Clinics for out-patient services Move to Question 115

j) Home Visits/ Government Sector Services

k) Home Visits/ Private Sector Services Move to Question 115

l) Traditional Healer Move to Question 115

m) Pharmacy n) Others. (Specify) Move to Question 115

114. Which reason(s) best explains why you did not get health care in the UAE?

Do not read responses. Probe by asking “any other reasons” three times.

Circle all responses

A) Cannot afford the service (cost of visit, investigations, medication)

B) Poor quality of service (skills of provider, availability of equipment)

C) Cannot afford the cost of transport D) Cultural/religious/language barriers with provider

E) No access (couldn’t take time off / permission from work, no transport available) F) Tried but there was a long waiting list

G) I thought I was not sick enough

H) I couldn't figure out where to go I) Other. (Specify)

115. What is the main source of information you use when looking for a healthcare provider in the UAE?

Do not read responses. Probe by asking “any other source of information” three times. Circle all responses

231

A) Word of mouth, from family and friends

B) Recommended by my family doctor C) Recommended by my health care co-coordinator/or case manager (my health insurance

company) D) Internet

E) Yellow pages

F) Magazines/ newspaper G) Radio/ TV

H) Brochures and leaflets I) Literature

J) Others (specify)

116. Overall, how satisfied were you with the care you received in the UAE before travelling abroad?

1) Very satisfied 2) Satisfied

3) Neither satisfied nor dissatisfied

4) Dissatisfied 5) Very dissatisfied

Section 4 Travel Related

117. How many months ago was your last overseas trip where you or a family member obtained a health

care service? ____________

118. On this trip, what was the main reason for your travel?

Read out responses. One answer only

1) Tourism

2) Treatment for self 3) Treatment for family member

4) Treatment of medical complications resulting from treatment in UAE 5) Medical checkup and screening

6) Visiting a friend

7) Visiting my family back home 8) Business

9) Others. (Specify)

119. In which country outside the UAE did you last seek healthcare services? ___________________

232

120. Why did you choose this country (For the interviewer: Mention the name of the country)?

Read and circle all responses. Rank according to importance

REASON

RANK (1,2,3,… where 1=most

important)

(1) (2) (3) (4) (5)

A) Geographical closeness to UAE

B) Have been there before

C) My homeland

D) Vacation aspect (resort, spa, shopping malls,

massage, funfair, museums, Weather and climate is

adaptable)

E) Friendly atmosphere (common language of

communication, hospitality, transport, familiar with

food)

F) Advised by someone

G) Cost of treatment is less than UAE

121. What was the source of information you used when you wanted to travel abroad for treatment? Do

not read responses. Probe by asking “any other source of information” three times. Circle all responses

A) Word of mouth (family and friends)

B) Internet forums C) Magazines/ newspaper

D) Radio/ TV E) Brochures and leaflets

F) Literature

G) Physician’s recommendations H) Provider's web page

I) Medical travel agency/Broker J) Government (Overseas treatment office)

X) Others. (Specify)

122. When you decided to obtain healthcare services abroad, what information did you look for in order

to choose a healthcare provider?

Do not read responses. Probe by asking “any other information” three times. Rank top 3 in order of

importance

REASON

First

important

reason

second

important

reason

Third

important

reason

A Different Treatment options

233

B Qualifications and certificates of the doctor

C Experience of the doctor

D Reputation of the medical center/ hospital

E Past success stories

F Cost of treatment

G Cost of accommodation, air fare, transport, food, etc.

H Length of stay

I Reverse outcome and complications of the desired

treatment

J Refund policies

K The probability of having the treating doctor abroad

as visiting doctors in the UAE for consultations

L Available advanced medical & Therapeutic technology

M Opinions of friends and family regarding the best

healthcare providers in the city/country

N Others. (Specify)

Section 5 Treatment Related

123. For how long did you stay abroad on this trip?

Days Months

124. Of this period, on how many days did you?

Service type Number of days

A) Visit outpatient clinic

B) Spend as an inpatient

125. Inquiries for the physicians abroad

125.1 Did you inquire about the physician abroad?

1) Yes Continue

234

2) No Move to question 126

125.2 What were the questions that you inquire about?

Read out responses. Circle all responses

A) Doctor membership training and qualification they hold

B) How much recovery time the procedure will take as inpatient

C) How soon you will travel back home after the operation D) To see before and after pictures of previous patients

E) Procedure complications and reverse outcomes F) Precaution taken prior/during procedure to prevent complications

G) Cost of treatment and follow up

126. What was the disease, illness or condition that was diagnosed abroad?

Circle all responses.

A) Cancer

B) Neurological Diseases and Neurosurgery

C) Pediatrics diseases D) Bone and joint Diseases

E) Heart disease F) Eye Diseases

G) Obstetrics and gynecology Diseases H) General Surgery (Amputations, Thyroidectomy, Removing benign tumor, removing sebaceous

cyst...)

I) Kidney Diseases J) Gastro-Intestinal Diseases

K) Urinary Tract system L) High Blood Pressure

M) Skin or venereal Diseases

N) Stroke (brain hemorrhage or clot) O) Mental illness

P) Trauma Q) Medical Screening before surgery,

R) Oral and Dental Diseases

S) Lungs and Respiratory Diseases T) Ear, nose and throat (ENT) Diseases

U) Diabetes V) routing medical check-up

W) Others. (Specify)

127. What type of healthcare services did you receive during your last overseas trip?

1) Outpatient (no hospitalization) procedure (therapeutic) 2) Inpatient treatment (hospitalization) surgical

3) Outpatient (no hospitalization) consultation

4) Inpatient treatment (hospitalization) non-surgical 5) Others. (Specify)

6) Don’t know

235

128. Is the treatment that you had abroad available in the UAE?

1. Yes Continue

2. No Move to question 130

3. Don't Know Move to question 130

129. What were your main reasons for deciding to obtain healthcare outside the UAE?

Do not read responses. Probe by asking “any other reasons” three times. Circle all responses

A) Can not afford the treatment in the UAE (limited insurance coverage or no coverage) B) Not eligible_ services provided only in the military hospital

C) Long waiting time to get an appointment D) Undesirable treatment outcome from previous personal experience

E) Undesirable treatment outcome from others' previous experience F) Privacy and confidentiality reasons

G) Negative attitude from health care providers

H) The post treatment rehab/care is not available in the UAE I) Expecting reverse treatment outcome that might result from treatment in the UAE

J) Other. (Specify)

130. Who paid for the cost of treatment abroad?

1) Governor's Diwan, Government of Dubai 2) Federal Ministry of Health

3) HAAD

4) Employer expense 5) Insurance Provider (personal/employer)

6) Others (Specify) 7) you own pocket or from your household budget

131. The next question asks about expenditure in your last overseas trip. I would like to ask you about

how much were spent on treatment, accommodation and travel expenses. We want you to remember all

the expenses related in AED.

a. Own Pocket/

Household

b. Government/

Diwan

c. Insurance

Treatment

Accommodation

Travel

236

FOR INTERVIEWER: IF THE ANSWER FOR QUESTION 129 IS (A) "CAN NOT

AFFORD THE TREATMENT"THEN ASK THE FOLLOWING SET OF QUESTIONS (132

TO 151) BASED ON THE DIAGNOSIS OF PATIENT (SEE ANSWERS OF QUESTION

126)

1. Cancer

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF CANCER FOR WHICH THE

RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

READ TO RESPONDENT:

If the current price for cancer treatment package in the UAE on

average (consultation, investigations, admission, medicines) is (8,500

) AED.

READ TO RESPONDENT:

I would like to ask you some questions about your response to

potential changes in the price of this treatment fee. In answering these

questions, please bear in mind the following:

1. Price stated above are in the UAE (travel and accommodation abroad

is not included)

2. Cheaper alternative treatment is available in the UAE

132 Suppose that the price of cancer

treatment increased to (15,000) AED.

Would you go abroad for treatment?

Yes 1

No 2

Don't know 99

Go to 134

Go to 134

133 Suppose that the price of cancer

treatment increased even further - to

(21,000) AED, would you go abroad

for treatment?

Yes 1

No 2

Don't know 99

Go to 135

134 Suppose that the price increase was

less than the previous amount.

Suppose the price of cancer treatment

increased to (12,000) AED. Would you

go abroad for treatment?

Yes 1

No 2

Don't know 99

135 What would be the maximum price you

would be willing to pay for … cancer

treatment abroad?

Amount _________ continue

237

2. Neurologic Diseases and Neurosurgery

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH

THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT


READ TO RESPONDENT:

If the current price for the treatment of Neurological Diseases and

Neurosurgery package in the UAE on average (consultation,

investigations, admission, medicines) is (16,000) AED.

READ TO RESPONDENT:





is not included)


136 Suppose that the price for the

treatment of “Neuro” increased to

(25,000) AED. Would you go abroad

for treatment?

Yes 1

No 2

Don't know 99

Go to 138

Go to 138


treatment of “Neuro” increased even

further - to (35,000) AED, would you


Yes 1

No 2

Don't know 99

Go to 139



Suppose the price for the treatment of

“Neuro” increased to (20,000) AED.


Yes 1

No 2

Don't know 99


would be willing to pay for the

treatment of “Neuro” abroad?

Amount _________ Continue

238

3. Pediatric Diseases:

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF HEART DISEASES FOR WHICH



READ TO RESPONDENT:

If the current price for the treatment of Pediatric disease package in

the UAE on average (consultation, investigations, admission, medicines)

is (10,000) AED.

READ TO RESPONDENT:





is not included)



treatment of Pediatric disease increased

to (19,000) AED. Would you go

abroad for treatment?

Yes 1

No 2

Don't know 99

Go to 142

Go to 142


treatment of Pediatric diseases

increased even further - to (29,000)

AED, would you go abroad for

treatment?

Yes 1

No 2

Don't know 99

Go to 143




Pediatric diseases increased to


for treatment?

Yes 1

No 2

Don't know 99



treatment of Pediatric diseases abroad?


239

4. Bone and Joint Diseases




READ TO RESPONDENT:

If the current price for the treatment of Bone and Joint diseases

package in the UAE on average (consultation, investigations, admission,

medicines) is (9,000) AED.

READ TO RESPONDENT:





is not included)



treatment of Bone and Joint diseases

increased to (13,000) AED. Would you


Yes 1

No 2

Don't know 99

Go to 146

Go to 146



increased even further - to (17,000)

AED, would you go abroad for

treatment?

Yes 1

No 2

Don't know 99

Go to 147




Bone and Joint diseases increased to


for treatment?

Yes 1

No 2

Don't know 99




abroad?


240

5. Hearth Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR

WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT


READ TO RESPONDENT:

If the current price for pediatrics diseases treatment package in the

UAE on average (consultation, investigations, admission, medicines) is

(15,000) AED.

READ TO RESPONDENT:





is not included)



treatment of Heart diseases increased



Yes 1

No 2

Don't know 99

Go to 150

Go to 150


treatment of heart diseases increased

even further - to (45,000) AED, would

you go abroad for treatment?

Yes 1

No 2

Don't know 99

Go to 151




Heart disease increased to (22,000)

AED. Would you go abroad for

treatment?

Yes 1

No 2

Don't know 99



treatment of Heart disease abroad?


241

6. Eye Diseases




READ TO RESPONDENT:



(8,000) AED.

READ TO RESPONDENT:





is not included)



treatment of Eye diseases increased to


for treatment?

Yes 1

No 2

Don't know 99

Go to 154

Go to 154


treatment of Eye diseases increased



Yes 1

No 2

Don't know 99

Go to 155




Eye disease increased to (9,000) AED.


Yes 1

No 2

Don't know 99



treatment of Eye disease abroad?


242

7. Obstetrics and Gynecology Diseases




READ TO RESPONDENT:



(7,000) AED.

READ TO RESPONDENT:





is not included)



treatment of OBGYN diseases increased



Yes 1

No 2

Don't know 99

Go to 158

Go to 158


treatment of OBGYN diseases increased



Yes 1

No 2

Don't know 99

Go to 159




OBGYN diseases increased to (8,000)


treatment?

Yes 1

No 2

Don't know 99



treatment of OBGYN diseases abroad?


243

8. General Surgery




READ TO RESPONDENT:



(5000) AED.

READ TO RESPONDENT:





is not included)



treatment of General Surgery increased

to (7,000) AED. Would you go abroad

for treatment?

Yes 1

No 2

Don't know 99

Go to 162

Go to 162


treatment of General Surgery increased



Yes 1

No 2

Don't know 99

Go to 163




General Surgery increased to (6,000)


treatment?

Yes 1

No 2

Don't know 99



treatment of General Surgery abroad?


244

9. KIDNEY TREATMENT PER SESSION




READ TO RESPONDENT:



(550) AED.

READ TO RESPONDENT:





is not included)



treatment of Kidney per session

increased to (650) AED. Would you go


Yes 1

No 2

Don't know 99

Go to 166

Go to 166


treatment of kidney per session

increased even further - to (700) AED,

would you go abroad for treatment?

Yes 1

No 2

Don't know 99

Go to 167




Kidney per session increased to (600)


treatment?

Yes 1

No 2

Don't know 99



treatment of Kidney diseases per

session abroad?


245

10. Gastro-intestinal Diseases




READ TO RESPONDENT:

If the current price for the treatment of Neurological Diseases and

Neurosurgery package in the UAE on average (consultation,

investigations, admission, medicines) is (2,500) AED.

READ TO RESPONDENT:





is not included)



treatment of GI increased to (4,500)


treatment?

Yes 1

No 2

Don't know 99

Go to 170

Go to 170


treatment of GI increased even further

- to (6,500) AED, would you go abroad

for treatment?

Yes 1

No 2

Don't know 99

Go to 171




GI increased to (3,500) AED. Would


Yes 1

No 2

Don't know 99



treatment of GI abroad?


246

Section 6 Family Related

172. In your opinion, what are your preferences in, travelling abroad for treatment?

172.1 Preference for travel escort.

One answer only

1) Travelling alone

2) Travelling with someone

172.2 Arrangement Preferences

One answer only

1) Arrange the trip by self 2) Arrange the trip by agency (airfare, transport, accommodation, consultation)

172.3 Other Preferences


a) Tourism aspect of the destination

b) Travelling to treatment destinations closer to UAE

c) Others. (Specify)

173. When you decided to travel, what was your family response? (Family in UAE or abroad)


A) They told stories of bad experiences in the desired destination

B) They helped in the arrangements of the trip C) They foresaw bad outcomes that are difficult to be managed abroad

D) They looked for different treatment options in the UAE/other countries E) They provided financial help

F) They expressed worry about lack of family support abroad

G) They suggested an escort H) They encouraged family support abroad

I) Others. (Specify)

Section 7 Economic Related

174. Do you know about the refund policy by the health care provider abroad?

1) Yes Continue


175. Do you know when you can get a refund?


A) In case you changed your mind

B) Operation not done

247

C) You can’t get all the procedure needed

D) Exemption E) Emergency case

Section 8 Risk of Travel & Treatment

176. Unfavorable reactions/complication/outcomes during or after treatment abroad

176.1 Have you experienced any of the unfavorable reactions/complications/outcome, during or after

your treatment abroad,?

1) Yes

2) No

176.2 What unfavorable reactions/complication/outcomes during or after treatment abroad have you

experienced?


A) Fever/ infection after the surgery B) Allergy from medicine

C) Wrong diagnosis D) Other surgical complications

E) Other medical complications

F) Results not as explained by the doctor

177. In case of medical error, do you know whom to report to?

1) Yes Continue


178. If yes, whom would you report to?

Circle all the answers

A) UAE embassy

B) Treatment and Overseas Patient Affairs Office C) Police

D) Hospital administration/complaint center

E) Others, specify

179. Suppose that you faced a delay in issuing of Visa of entry to the desired destination, what would be

your next decision?

1) Wait further till you receive the visa

2) Look for another destination abroad 3) Search for health providers in the UAE

248

Section 9 Satisfaction about Overseas Treatment

180. Overall how satisfied were you with the last healthcare trip overseas?

1) Very satisfied 2) Satisfied

3) Neither satisfied nor dissatisfied 4) Dissatisfied

5) Very dissatisfied

181. Would you recommend your healthcare trip overseas experience to someone else?

1) Yes

2) No

182. What are the factors related to the medical services you find abroad that you wished are here in

hospitals and clinics in the UAE?


A) Reasonable waiting time at the clinic before seeing the doctor B) Easiness of booking for an appointment (convenient, didn't take long time)

C) Consultation and Diagnostic work-ups and treatment were all in the same building D) Treating doctor talked clearly to me about my condition

E) Treating doctor gave me different treatment options

F) Treating doctor explained to me how I can cope, live normal life with my condition G) Treating doctor explained what might happen to me in the future

H) The medical staff was polite, and courteous I) The hospital called to report my results instead of me going to them

J) The medical staff was able to respond to my inquiries efficiently and referred me to the right persons

K) The facility (hospital, clinic) was clean and welcoming

L) The treating doctor was listening to me M) Availability of reading material on my condition in Arabic and English

N) Treating doctor was paying full attention to me (not distracted by phone or writing) O) Others (Specify)

249

We would like to ask you about some scenarios related to your preference when

considering healthcare services in the UAE. We will use a scale from 1 to 5 to record your

preference, where 1 means (least preferred) and 5 means (most preferred)

SDA= Strongly Disagree, DA = Disagree, N = Neutral, A = Agree, SA= Strongly Disagree

183. Preference for Healthcare Services in the UAE and Waiting Time for Cancer

Preferences Preference for diagnosis and treatment for the

case

Preference for the diagnoses for the waiting

time

Choices SDA DA N A SA 1

Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

184. Preference for Healthcare Service in the UAE and Waiting Time for Neurologic Diseases and

Neurosurgery


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

185. Preference for Healthcare Services in the UAE and Waiting Time for Pediatric Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

250

186. Preference for Healthcare Services in the UAE and Waiting Time for Bone and Joint Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

187. Preference for Healthcare Services in the UAE and Waiting Time for Heart Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

188. Preference for Healthcare Services in the UAE and Waiting Time for Eye Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

189. Preference for Healthcare Services in the UAE and Waiting Time Obstetrics and Gynecology Diseases


case


time

251


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

190. Preference for Healthcare Service and Waiting Time for General Surgery


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

191. Preference for Healthcare Service and Waiting Time for Kidney Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

Known Physician

in the UAE

Visiting Physician

192. Preference for Healthcare Service and Waiting Time for Gastro-intestinal Diseases


case


time


Week

2

Weeks

1

Month

3

Months

6

Months

252

Known Physician

in the UAE

Visiting Physician

193. Complete the price-quality table, what do you think of health services in terms of price (High,

medium, low) and quality (high, medium, low). Please tick a response.

(a). Thailand Price

High Medium Low

Quality

High

Medium

Low

(b). India Price

High Medium Low

Quality

High

Medium

Low

(c). Germany Price

High Medium Low

Quality

High

Medium

Low

(d). UK Price

High Medium Low

Quality

High

Medium

Low

253

(e). USA Price

High Medium Low

Quality

High

Medium

Low

194/195/196 Complete the Preference Table (rank your answers from 1 least preferable, to 5 most

preferable)

Preferred

Destination if I have

to pay for care

myself

Preferred

Destination if

insurance will cover

treatment costs but

not travel,

accommodation

Preferred

Destination if the

government will pay

for my care

a) USA 194 195 196

b) UK 194 195 196

c) Germany 194 195 196

d) France 194 195 196

e) Singapore 194 195 196

f) Malaysia 194 195 196

g) Thailand 194 195 196

h) India 194 195 196

i) Jordan 194 195 196

j) Egypt 194 195 196

k) Turkey 194 195 196

254

References

Abu-Dhabi, H. A. (2018). Department of Health Abu Dhabi. Agency, C. I. (Producer). (2018). Middle East: United Arab Emirates. Ahmad, W. M. A. W., Amin, W. A. A. W. M., Aleng, N. A., & Mohamed, N. (2012). Some practical guidelines

for effective sample-size determination in observational studies. Aceh International Journal of Science and Technology, 1(2).

Akkazieva, B., Gulacsi, L., Brandtmuller, A., Pentek, M., & Bridges, J. F. (2006). Patients' preferences for healthcare system reforms in Hungary: a conjoint analysis. Appl Health Econ Health Policy, 5(3), 189-198.

Al-Hinai, S. S., Al-Busaidi, A. S., & Al-Busaidi, I. H. (2011). Medical Tourism Abroad: A new challenge to Oman's health system - Al Dakhilya region experience. Sultan Qaboos Univ Med J, 11(4), 477-484.

Al-Maskari, F., & El-Sadig, M. (2007). Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey. BMC Ophthalmol, 7, 11. doi:10.1186/1471-2415-7-11

Al-Sharhan, G. O. T. M. (1985). Genetic Disorders in the Arab World: United Arab Emirates: Cancers in the United Arab Emirates. Retrieved from

Allen, I. E., & Seaman, C. A. (2007). Likert scales and data analyses. Quality progress, 40(7), 64. Allua, S., & Thompson, C. B. (2009). Hypothesis testing. Air Med J, 28(3), 108-110, 153.

doi:10.1016/j.amj.2009.03.002 Alwan, A., Maclean, D. R., Riley, L. M., d'Espaignet, E. T., Mathers, C. D., Stevens, G. A., & Bettcher, D.

(2010). Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. Lancet, 376(9755), 1861-1868. doi:10.1016/S0140-6736(10)61853-3

Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav, 36(1), 1-10.

Atkins, D. (2007). Creating and synthesizing evidence with decision makers in mind: integrating evidence from clinical trials and other study designs. Med Care, 45(10 Supl 2), S16-22. doi:10.1097/MLR.0b013e3180616c3f

Authority, D. H. (2018). Aw, T. C. (2010). Global public health and the United Arab Emirates. Asia Pac J Public Health, 22(3 Suppl),

19S-24S. doi:10.1177/1010539510372837 Badsha, H., Kong, K. O., & Tak, P. P. (2008). Rheumatoid arthritis in the United Arab Emirates. Clin

Rheumatol, 27(6), 739-742. doi:10.1007/s10067-007-0782-z Baker, F., Haffer, S. C., & Denniston, M. (2003). Health-related quality of life of cancer and noncancer

patients in Medicare managed care. Cancer, 97(3), 674-681. doi:10.1002/cncr.11085 Balaban, V. a. M., C. (2010). Medical tourism research: A systematic review. International Journal of

Infectious Diseases, 14, 135. Beaglehole, R., Ebrahim, S., Reddy, S., Voute, J., Leeder, S., & Chronic Disease Action, G. (2007). Prevention

of chronic diseases: a call to action. Lancet, 370(9605), 2152-2157. doi:10.1016/S0140-6736(07)61700-0

Benbassat, J., Pilpel, D., & Tidhar, M. (1998). Patients' preferences for participation in clinical decision making: a review of published surveys. Behav Med, 24(2), 81-88. doi:10.1080/08964289809596384

Benner, J. S., Morrison, M. R., Karnes, E. K., Kocot, S. L., & McClellan, M. (2010). An evaluation of recent federal spending on comparative effectiveness research: priorities, gaps, and next steps. Health Aff (Millwood), 29(10), 1768-1776. doi:10.1377/hlthaff.2010.0687

Beukers, P. D., Kemp, R. G., & Varkevisser, M. (2014). Patient hospital choice for hip replacement: empirical evidence from the Netherlands. Eur J Health Econ, 15(9), 927-936. doi:10.1007/s10198-013-0535-7

255

Blair, I., & Sharif, A. A. (2012). Population structure and the burden of disease in the United Arab Emirates. J Epidemiol Glob Health, 2(2), 61-71. doi:10.1016/j.jegh.2012.04.002

Bland, J. M., and Douglas G. Altman. (1997). Statistics notes: Cronbach's alpha. BMJ, 314(7080), 572. Boone, H. N., & Boone, D. A. (2012). Analyzing likert data. Journal of extension, 50(2), 1-5. Bornstein, B. H., Marcus, D., & Cassidy, W. (2000). Choosing a doctor: an exploratory study of factors

influencing patients' choice of a primary care doctor. J Eval Clin Pract, 6(3), 255-262. Bowling, A., & Ebrahim, S. (2001). Measuring patients' preferences for treatment and perceptions of risk.

Qual Health Care, 10 Suppl 1, i2-8. Bridges, J. F. (2003). Stated preference methods in health care evaluation: an emerging methodological

paradigm in health economics. Appl Health Econ Health Policy, 2(4), 213-224. Brown, G. C., Melissa M. Brown, and Sanjay Sharma. (2000). Difference between ophthalmologists' and

patients' perceptions of quality of life associated with age-related macular degeneration. Canadian Journal of Ophthalmology, 35(3), 127-133.

Burkett, L. (2007). Medical tourism. Concerns, benefits, and the American legal perspective. J Leg Med, 28(2), 223-245. doi:10.1080/01947640701357763

Butow, P. N., Maclean, M., Dunn, S. M., Tattersall, M. H., & Boyer, M. J. (1997). The dynamics of change: cancer patients' preferences for information, involvement and support. Ann Oncol, 8(9), 857-863.

Carrera, P. M., & Bridges, J. F. (2006). Globalization and healthcare: understanding health and medical tourism. Expert Rev Pharmacoecon Outcomes Res, 6(4), 447-454. doi:10.1586/14737167.6.4.447

Cassileth, B. R., Zupkis, R. V., Sutton-Smith, K., & March, V. (1980). Information and participation preferences among cancer patients. Ann Intern Med, 92(6), 832-836.

Chalkidou, K., Whicher, D., Kary, W., & Tunis, S. (2009). Comparative effectiveness research priorities: identifying critical gaps in evidence for clinical and health policy decision making. Int J Technol Assess Health Care, 25(3), 241-248. doi:10.1017/S0266462309990225

Chanda, R. (Ed.) (2002). Trade in health services (Vol. 80). Clancy, C. M. (2006). Getting to ‘smart’health care. Health Affairs,, 25(6), w589-w592. Cohen, I. G. (2012). How to regulate medical tourism (and why it matters for bioethics). Developing world

bioethics, 12(1), pp.9-20. Cohen, I. G. (2014). Patients with Passports: Medical Tourism, Law and Ethics: Oxford University Press. Concannon, T. W., Fuster, M., Saunders, T., Patel, K., Wong, J. B., Leslie, L. K., & Lau, J. (2014). A systematic

review of stakeholder engagement in comparative effectiveness and patient-centered outcomes research. J Gen Intern Med, 29(12), 1692-1701. doi:10.1007/s11606-014-2878-x

Coulter, A. (1999). Paternalism or partnership?: patients have grown up—and there’s no going back. BMJ: British Medical Journal, 319(7212), 719.

Coulter, A., Peto, V., & Doll, H. (1994). Patients' preferences and general practitioners' decisions in the treatment of menstrual disorders. Fam Pract, 11(1), 67-74.

Council of the European Union, P. o.-G. S. o. t. C. (2015). European Union signs visa waiver agreement with the United Arab Emirates.

Crompton, J. L. (1979). Motivations for pleasure vacation. Annals of tourism research, 6(4), 408-424. Crooks, V. A., et al. (2010). What is known about the patient's experience of medical tourism? A scoping

review. BMC Health Services Research, 10(1), 266. Crooks, V. A., Kingsbury, P., Snyder, J., & Johnston, R. (2010). What is known about the patient's

experience of medical tourism? A scoping review. BMC Health Serv Res, 10, 266. doi:10.1186/1472-6963-10-266

Crooks, V. A., Turner, L., Cohen, I. G., Bristeir, J., Snyder, J., Casey, V., & Whitmore, R. (2013). Ethical and legal implications of the risks of medical tourism for patients: a qualitative study of Canadian health and safety representatives' perspectives. BMJ Open, 3(2). doi:10.1136/bmjopen-2012-002302

256

Culley, L., Hudson, N., Rapport, F., Blyth, E., Norton, W., & Pacey, A. A. (2011). Crossing borders for fertility treatment: motivations, destinations and outcomes of UK fertility travellers. Hum Reprod, 26(9), 2373-2381. doi:10.1093/humrep/der191

Curtis, K., & Youngquist, S. T. (2013). Part 21: categoric analysis: Pearson chi-square test. Air medical journal, 32(4), 179-180.

Damman, O. C., Spreeuwenberg, P., Rademakers, J., & Hendriks, M. (2012). Creating compact comparative health care information: what are the key quality attributes to present for cataract and total hip or knee replacement surgery? Med Decis Making, 32(2), 287-300. doi:10.1177/0272989X11415115

De Groot, I. B., Otten, W., Dijs-Elsinga, J., Smeets, H.J., Kievit, J. and Marang-van de Mheen, P.J. (2012). Choosing between hospitals: the influence of the experiences of other patients. . Medical Decision Making, 32(6), pp.764-778.

De Groot, I. B., Otten, W., Smeets, H.J. and Marang-van de Mheen, P.J. (2011). Is the impact of hospital performance data greater in patients who have compared hospitals? BMC Health Services Research, 11(1), p.214.

Del Giudice, M. E., et al. (2009). Primary care physicians' views of routine follow-up care of cancer survivors. Journal of clinical oncology, 27(20), 3338-3345.

Dubai Health Authority Annual Statistic Books. (2016). Dubai, UAE. Dwight-Johnson, M., Lagomasino, I.T., Aisenberg, E. and Hay, J. (2004). Using conjoint analysis to assess

depression treatment preferences among low-income Latinos. Psychiatric services, 55(8), pp.934-936.

Eddy, D. M., and John Billings. (1988). The quality of medical evidence: implications for quality of care. 7, 1, 19-32.

Eissler, L. A., & Casken, J. (2013). Seeking health care through international medical tourism. J Nurs Scholarsh, 45(2), 177-184. doi:10.1111/jnu.12014

Ejaz, A., Spolverato, G., Bridges, J. F., Amini, N., Kim, Y., & Pawlik, T. M. (2014). Choosing a cancer surgeon: analyzing factors in patient decision making using a best–worst scaling methodology. Annals of surgical oncology, 21(12), 3732-3738.

El Helal, T. A., Abdulbari Bener, and Ibrahim Galadari. (1997). Pattern of cancer in the United Arab Emirates referred to AL-Ain hospital. Annals of Saudi medicine, 17, 506-509.

El Zorkany, B., et al. (2013). Suboptimal management of rheumatoid arthritis in the Middle East and Africa: could the EULAR recommendations be the start of a solution? , 151-159.

Emirates, T. M. o. H. U. A. CANCER INCIDENCE IN UNITED ARAB EMIRATES ANNUAL REPORT OF THE UAE - NATIONAL CANCER REGISTRY - 2014.

Epstein, R. M., & Peters, E. (2009). Beyond information: exploring patients' preferences. JAMA, 302(2), 195-197. doi:10.1001/jama.2009.984

Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1-4.

Farrokhi, F. a. M.-H., A. (2012). Rethinking convenience sampling: Defining quality criteria. . Theory and practice in language studies, 2(4), p.784.

FASO, I. B. (2016). Public Private Partnership. Forgione, D. A., & Smith, P. C. (2007). Medical tourism and its impact on the US health care system. J

Health Care Finance, 34(1), 27-35. Freeman, J. V., & Campbell, M. J. THE ANALYSIS OF CATEGORICAL DATA: FISHER’S EXACT TEST. Gafni, A. (1991). Willingness-to-pay as a measure of benefits. Relevant questions in the context of public

decisionmaking about health care programs. Med Care, 29(12), 1246-1252. Gan, L. L., & Frederick, J. R. (2013). Medical tourists: who goes and what motivates them? Health Mark Q,

30(2), 177-194. doi:10.1080/07359683.2013.787894

257

Garcia, S. F., Cella, D., Clauser, S. B., Flynn, K. E., Lad, T., Lai, J. S., . . . Weinfurt, K. (2007). Standardizing patient-reported outcomes assessment in cancer clinical trials: a patient-reported outcomes measurement information system initiative. J Clin Oncol, 25(32), 5106-5112. doi:10.1200/JCO.2007.12.2341

Gottlieb, S., and Coleen Klasmeier. (2009). Comparative effectiveness research: the need for a uniform standard. American Enterprise Institute for Public Policy Research website.

Guadagnoli, E., & Ward, P. (1998). Patient participation in decision-making. Soc Sci Med, 47(3), 329-339. Guiry, M., & Vequist, D. G. (2011). Traveling abroad for medical care: US medical tourists' expectations

and perceptions of service quality. Health Marketing Quarterly, 28(3), 253-269. Guy, B. S., Henson, J. L. N., & Dotson, M. J. (2015). Characteristics of consumers likely and unlikely to

participate in medical tourism. International Journal of Healthcare Management, 8(2), 68-76. Hajat, C., Harrison, O., & Al Siksek, Z. (2012). Weqaya: a population-wide cardiovascular screening

program in Abu Dhabi, United Arab Emirates. American journal of public health, 102(5), 909-914. Halabi, H., Alarfaj, A., Alawneh, K., Alballa, S., Alsaeid, K., Badsha, H., . . . Dougados, M. (2015). Challenges

and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East. Int J Rheum Dis, 18(3), 268-275. doi:10.1111/1756-185X.12320

Hawker, G. A., Wright, J. G., Coyte, P. C., Williams, J. I., Harvey, B., Glazier, R., . . . Badley, E. M. (2001). Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences. Med Care, 39(3), 206-216.

Helble, M. (2011). The movement of patients across borders: challenges and opportunities for public health. Bull World Health Organ, 89(1), 68-72. doi:10.2471/BLT.10.076612

Henson, J. N., Guy, B.S. and Dotson, M.J. (2015). Should I stay or should I go?: Motivators, decision factors, and information sources influencing those predisposed to medical tourism. International Journal of Healthcare Management, 8(1), pp.4-14.

Heung, V. C., Kucukusta, D. and Song, H. (2010). A conceptual model of medical tourism: Implications for future research. Journal of Travel & Tourism Marketing, 27(3), pp.236-251.

Hoffman, A., Montgomery, R., Aubry, W., & Tunis, S. R. (2010). How best to engage patients, doctors, and other stakeholders in designing comparative effectiveness studies. Health Aff (Millwood), 29(10), 1834-1841. doi:10.1377/hlthaff.2010.0675

Hollinghurst, S., Banks, J., Bigwood, L., Walter, F.M., Hamilton, W. and Peters, T.J. (2016). Using willingness-to-pay to establish patient preferences for cancer testing in primary care. BMC Medical Informatics and Decision Making, 16(1), p.105.

Horowitz, M. D., & Rosensweig, J. A. (2007). Medical tourism--health care in the global economy. Physician Exec, 33(6), 24-26, 28-30.

Horowitz, M. D., Rosensweig, J. A., & Jones, C. A. (2007). Medical tourism: globalization of the healthcare marketplace. MedGenMed, 9(4), 33.

Hsu, T. K., Tsai, Y.F. and Wu, H.H. (2009). The preference analysis for tourist choice of destination: A case study of Taiwan. Tourism Management, 30(2), pp.288-297.

Hussin, A. H., et al. (2015). Tracking access, utilization and health system responsiveness to inform evidence-based health care policy: the case of Qatar. Journal of Local and Global Health Perspectives, 2.

Ijzerman, M. J., van Til, J. A., & Bridges, J. F. (2012). A comparison of analytic hierarchy process and conjoint analysis methods in assessing treatment alternatives for stroke rehabilitation. Patient, 5(1), 45-56. doi:10.2165/11587140-000000000-00000

Jang, S. a. C., L.A. (2002). Travel motivations and destination choice: A study of British outbound market. Journal of Travel & Tourism Marketing, 13(3), pp.111-133.

Jeong, H. J., and W. C. Lee. (2016). The level of collapse we are allowed: Comparison of different response scales in Safety Attitudes Questionnaire. Biometrics & Biostatistics International Journal, 4(4).

258

Johnston, R., Crooks, V. A., Snyder, J., & Kingsbury, P. (2010). What is known about the effects of medical tourism in destination and departure countries? A scoping review. Int J Equity Health, 9, 24. doi:10.1186/1475-9276-9-24

Jones, J., Nijman, H., Ross, J., Ashman, N., & Callaghan, P. (2014). Aggression on haemodialysis units: a mixed method study. J Ren Care, 40(3), 180-193. doi:10.1111/jorc.12068

Kaliyaperumal, K. I. E. C. (2004). Guideline for conducting a knowledge, attitude and practice (KAP) study. AECS Illumination,, 4(1), pp.7-9.

Keeffe, J. E., Chou, S. L., & Lamoureux, E. L. (2009). The cost of care for people with impaired vision in Australia. Arch Ophthalmol, 127(10), 1377-1381. doi:10.1001/archophthalmol.2009.242

Khan, M. J., Chelliah, S., & Haron, M. S. (2016). Medical tourism destination image formation process: A conceptual model. International Journal of Healthcare Management, 9(2), 134-143.

Khoja, T., A. Zahrani, and Tawfik AM Khoja. (2010). Epidemiology of cancer in the Gulf Region. Pan Arab J Oncology, 3(9).

Kozak, M. (2002). Comparative analysis of tourist motivations by nationality and destinations. Tourism Management, 23(3), pp.221-232.

Krumholz, H. M. (2008). Outcomes research: generating evidence for best practice and policies. Circulation, 118(3), 309-318. doi:10.1161/CIRCULATIONAHA.107.690917

Kurbasic, I., Pandza, H., Masic, I., Huseinagic, S., Tandir, S., Alicajic, F., & Toromanovic, S. (2008). The advantages and limitations of international classification of diseases, injuries and causes of death from aspect of existing health care system of bosnia and herzegovina. Acta Inform Med, 16(3), 159-161. doi:10.5455/aim.2008.16.159-161

Lauer, M. S., and Francis S. Collins. (2010). Using science to improve the nation's health system: NIH's commitment to comparative effectiveness research. JAMA, 303(21), 2182-2183.

Lee, M., Han, H., & Lockyer, T. (2012). Medical tourism—attracting Japanese tourists for medical tourism experience. Journal of Travel & Tourism Marketing, 29(1), 69-86.

Loney, T., Aw, T. C., Handysides, D. G., Ali, R., Blair, I., Grivna, M., . . . El-Obaid, Y. (2013). An analysis of the health status of the United Arab Emirates: the 'Big 4' public health issues. Glob Health Action, 6, 20100. doi:10.3402/gha.v6i0.20100

Lunt, N., & Carrera, P. (2010). Medical tourism: assessing the evidence on treatment abroad. Maturitas, 66(1), 27-32. doi:10.1016/j.maturitas.2010.01.017

Lunt, N. T., Russell Mannion, and Mark Exworthy. (2013). A framework for exploring the policy implications of UK medical tourism and international patient flows. Social Policy & Administration, 47(1), 1-25.

Mansfeld, Y. (1992). From motivation to actual travel. Annals of tourism research, 19(3), 399-419. McCallum, B. T. a. J., P.F. (2007). Medical outsourcing: Reducing clients' health care risks. Journal of

Financial Planning, 20(10). Menvielle, L., Menvielle, W. and Tournois, N. (2011). Medical tourism: A decision model in a service

context. Turizam: znanstveno-stručni časopis, 59(1), pp.47-61. Moghimehfar, F. a. N.-E., M.H. (2011). Decisive factors in medical tourism destination choice: A case study

of Isfahan, Iran and fertility treatments. Tourism Management, 32(6), pp.1431-1434. Mohammad, B. A. M. A. H. a. S., A.P.M. (2010). An analysis of push and pull travel motivations of foreign

tourists to Jordan. International Journal of Business and Management, 5(12), p.41. Mokdad, A. H., Jaber, S., Aziz, M. I., AlBuhairan, F., AlGhaithi, A., AlHamad, N. M., . . . Murray, C. J. (2014).

The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet, 383(9914), 309-320. doi:10.1016/S0140-6736(13)62189-3

Noree, T., Hanefeld, J., & Smith, R. (2014). UK medical tourists in Thailand: they are not who you think they are. Global Health, 10, 29. doi:10.1186/1744-8603-10-29

Pai, A. L., Patino-Fernandez, A. M., McSherry, M., Beele, D., Alderfer, M. A., Reilly, A. T., . . . Kazak, A. E. (2008). The Psychosocial Assessment Tool (PAT2.0): psychometric properties of a screener for

259

psychosocial distress in families of children newly diagnosed with cancer. J Pediatr Psychol, 33(1), 50-62. doi:10.1093/jpepsy/jsm053

Peters, C. R. a. S., K.M. (2011). A survey of medical tourism service providers. Journal of Marketing Development and Competitiveness, 5(3), p.117.

Prevention, T. M. o. H. a. (2018). CANCER INCIDENCE IN UNITED ARAB EMIRATES ANNUAL REPORT OF THE UAE - NATIONAL CANCER REGISTRY - 2014 - Statistics and Research Center.

Radhakrishna, R. B. (2007). Tips for developing and testing questionnaires/instruments. Journal of extension, 45(1), 1-4.

Rahim, H. F., Sibai, A., Khader, Y., Hwalla, N., Fadhil, I., Alsiyabi, H., . . . Husseini, A. (2014). Non-communicable diseases in the Arab world. Lancet, 383(9914), 356-367. doi:10.1016/S0140-6736(13)62383-1

Reed, C. M. (2008). Medical tourism. Med Clin North Am, 92(6), 1433-1446, xi. doi:10.1016/j.mcna.2008.08.001

Richards, M. A., Ramirez, A. J., Degner, L. F., Fallowfield, L. J., Maher, E. J., & Neuberger, J. (1995). Offering choice of treatment to patients with cancers. A review based on a symposium held at the 10th annual conference of The British Psychosocial Oncology Group, December 1993. Eur J Cancer, 31A(1), 112-116.

Ruggeri, K., Záliš, L., Meurice, C. R., Hilton, I., Ly, T.-L., Zupan, Z., & Hinrichs, S. (2015). Evidence on global medical travel. Bulletin of the World Health Organization, 93, 785-789.

Ruggeri, K., Zalis, L., Meurice, C. R., Hilton, I., Ly, T. L., Zupan, Z., & Hinrichs, S. (2015). Evidence on global medical travel. Bull World Health Organ, 93(11), 785-789. doi:10.2471/BLT.14.146027

Ryan, M., and Jenny Hughes. (1997). Using conjoint analysis to assess women's preferences for miscarriage management. Health economics, 6(3), 261-273.

Ryan, M., & Farrar, S. (2000). Using conjoint analysis to elicit preferences for health care. BMJ, 320(7248), 1530-1533.

Saadi, H., Carruthers, S. G., Nagelkerke, N., Al-Maskari, F., Afandi, B., Reed, R., . . . Benedict, S. (2007). Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates. Diabetes Res Clin Pract, 78(3), 369-377. doi:10.1016/j.diabres.2007.04.008

Salim, E. I., Moore, M. A., Al-Lawati, J. A., Al-Sayyad, J., Bazawir, A., Bener, A., . . . Sobue, T. (2009). Cancer epidemiology and control in the arab world - past, present and future. Asian Pac J Cancer Prev, 10(1), 3-16.

Say, R. E., & Thomson, R. (2003). The importance of patient preferences in treatment decisions--challenges for doctors. BMJ, 327(7414), 542-545. doi:10.1136/bmj.327.7414.542

Sculpher, M., Bryan, S., Fry, P., de Winter, P., Payne, H., & Emberton, M. (2004). Patients' preferences for the management of non-metastatic prostate cancer: discrete choice experiment. BMJ, 328(7436), 382. doi:10.1136/bmj.37972.497234.44

Sharma, M., & Bindal, A. (2014). Public-Private Partnership. International Journal of Research, 1(7), 1270-1274.

Sheikh-Ismail, L. I., et al. (2009). Prevalence of overweight and obesity among adult females in the United Arab Emirates. International journal of food sciences and nutrition,, 60(sup3), 26-33.

Smith, P. C. a. F., D.A. (2007). Global outsourcing of healthcare: a medical tourism decision model. Journal of Information Technology Case and Application Research, 9(3), pp.19-30.

Smith, R. D., Chanda, R., & Tangcharoensathien, V. (2009). Trade in health-related services. Lancet, 373(9663), 593-601. doi:10.1016/S0140-6736(08)61778-X

Solomon, D. J., et al. (1991). Evaluation and implementation of public health registries. Public health reports, 106(2), 142.

Sox, H. C., & Greenfield, S. (2009). Comparative effectiveness research: a report from the Institute of Medicine. Ann Intern Med, 151(3), 203-205.

260

Stanek, E. J., Oates, M. B., McGhan, W. F., Denofrio, D., & Loh, E. (2000). Preferences for treatment outcomes in patients with heart failure: symptoms versus survival. J Card Fail, 6(3), 225-232. doi:10.1054/jcaf.2000.9503

Szeinbach, S., Harpe, S., Flynn, T., Lloyd, A., Bridges, J. and Muhlbacher, A. (2011). Understanding Conjoint Analysis applications in health. from ISPOR Connections [Online].[cited 2011]

Thompson, C. B. (2009). Descriptive data analysis. Air Med J, 28(2), 56-59. doi:10.1016/j.amj.2008.12.001 Thompson, C. B., & Panacek, E. A. (2008). Data management. Air Med J, 27(4), 156-158.

doi:10.1016/j.amj.2008.05.001 Thorpe Jr, R. J., Gamaldo, A. A., Salas, R. E., Gamaldo, C. E., & Whitfield, K. E. (2016). Relationship between

physical function and sleep quality in African Americans. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 12(10), 1323.

Turnbull, D. R., & Uysal, M. (1995). An exploratory study of German visitors to the Caribbean: Push and pull motivations. Journal of Travel & Tourism Marketing, 4(2), 85-92.

Turner, L. G. (2011). Quality in health care and globalization of health services: accreditation and regulatory oversight of medical tourism companies. Int J Qual Health Care, 23(1), 1-7. doi:10.1093/intqhc/mzq078

Uysal, M., & Jurowski, C. (1994). Testing the push and pull factors. Annals of tourism research, 21(4), 844-846.

Whiting, D. R., Guariguata, L., Weil, C., & Shaw, J. (2011). IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract, 94(3), 311-321. doi:10.1016/j.diabres.2011.10.029

Williams, S. R., Pham-Kanter, G., & Leitsch, S. A. (2009). Measures of chronic conditions and diseases associated with aging in the national social life, health, and aging project. J Gerontol B Psychol Sci Soc Sci, 64 Suppl 1, i67-75. doi:10.1093/geronb/gbn015

Yeoh, E., Khalifah Othman, and Halim Ahmad. (2013). Understanding medical tourists: Word-of-mouth and viral marketing as potent marketing tools. Tourism Management(34), 196-201.

Yeoh, E., Othman, K. and Ahmad, H. (2013). Understanding medical tourists: Word-of-mouth and viral marketing as potent marketing tools. Tourism Management, 34, pp.196-201.

Youngquist, S. T. (2012). Part 19: What is a P value? Air Med J, 31(2), 56-71. doi:10.1016/j.amj.2011.12.007 Yu, J. Y. a. K., T.G. (2012). A cross-cultural study of perceptions of medical tourism among Chinese,

Japanese and Korean tourists in Korea. Tourism Management, 33(1), pp.80-88. Zafar, S., Badsha, H., Mofti, A., Delosantos, A., Altares, J., Matudio, G., & Kong, K. O. (2012). Efforts to

increase public awareness may result in more timely diagnosis of rheumatoid arthritis. J Clin Rheumatol, 18(6), 279-282. doi:10.1097/RHU.0b013e3182676975

Zou, G. (2004). A modified poisson regression approach to prospective studies with binary data. American journal of epidemiology, 159(7), 702-706.

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Curriculum Vitae

Wafa Khamis Alnakhi

Address: Department of Health Policy and Management

624 N Broadway

Baltimore, MD 21205

+12029107527

Objectives:

As a quality oriented professional and passionate to be involved in challenging environment, I am seeking

an opportunity with a dynamic high growth organization/institution that welcomes innovative ideas, and

dedication, where I can practice and apply my skills in health policy, planning, research & strategy.

Education:

Johns Hopkins University, School of Public Health (2013- 2018)

Doctor of Public Health (DrPH) in Health Policy and Management Dept. Healthcare Management and Leadership

with research focus on “Patients from the United Arab Emirates Seeking Healthcare Services Overseas during 2009 –

2016: Characteristics Medical Conditions and Preferences"

Johns Hopkins University, Zanvyl Krieger School of Arts and Science-Advanced Academic

Program (2009 – 2011)

Master Degree in Biotechnology with Concentration in Enterprise

United Arab Emirates University, Faculty of Medicine & Health Sciences (2004 – 2005)

BSc. Degree in Medical Laboratory technology

Higher Colleges of Technology, Sharjah Women's College (2000 – 2004)

Higher Diploma in Medical Laboratory Technology

Work Experience:

JOHNS HOPKINS UNIVERSITY SCHOOL OF PUBLIC HEALTH

Teaching Assistant for the course: Fundamentals of Management for Health Care Organizations

[312.601.01] (2014 – 2016)

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DUBAI HEALTH AUTHORITY

HEALTH POLICY & STRATEGY SECTOR (HPSS)

Senior Policy and Strategy Analyst (2011-2013)

A team member in the strategy development and implementation of Dubai Health Authority Strategy

2011-2013 A coordinator with “Total Alliance Health Partners International” (TAHPI) in conducting “Dubai Clinical

Services Capacity Plan 2020” for Dubai Health Authority, to ensure the health services are well-positioned

to meet the demand for high-quality healthcare services for the citizens and residents of the Emirate of Dubai.

A DHA representative in the data collection from health service providers “Public Sector” in Dubai

A team member in the strategy development of “Overseas Treatment Survey” to explore knowledge, attitude

and perception related to medical treatment abroad among residents of Dubai

Project manager of “Dubai Medical Tourism” initiative to position Dubai as the leading medical tourism

hub of the world because of its well-developed infrastructure and the strategic geographical location between

Europe and South East Asia

Designing and creating departmental policies related to Health Policy and Strategy Sector

Collecting, analyzing and interpreting health quantitative information and data used for Stata Research

Assisting in producing high quality health reports and relevant documentation to be raised to the decision

makers

Undertaking research, analysis, benchmarking, and planning activities for the surveys, strategies and KPIs in

the Health Policy and Strategy Sector

DUBAI CORD BLOOD & RESEARCH CENTER (DCRC)

Medical Laboratory Scientist (2006 – 2009)

Laboratory Safety Identifying and handling specimens

Processing the umbilical cord blood, harvesting stem cells and cryo-save them for transplantation

Human Leukocyte Antigen test at Molecular Base

Performing quality control

Write & review SOPs relevant to DCRC

LATIFA HOSPITAL

Medical Laboratory Scientist (2005- 2006) Hematology, Blood Bank, Molecular Genetics (special and routine tests)

MINISTRY OF HEALTH TAWAM HOSPITAL & ALAIN HOSPITAL Medical Laboratory Scientist (October 2004)

• Training and observing in Biochemistry, Hematology, Histopathology

DUBAI HEALTH AUTHORITY & MINISTRY OF HEALHT

DUBAI HOSPITAL, LATIFA HOSPITAL, ALBARAHA HOSPITAL, ALQASSIMI HOSPITAL,

CENTRAL SHARJAH BLOOD BANK Medical Laboratory Scientist (2003 –2004)

346 hours working on rotation in different clinical laboratories for work placement (for Higher Diploma) in

different hospitals covering the topics ranging from laboratory safety and basic laboratory routine tests to

special tests in:

o Biochemistry

o Hematology

o Blood Bank

o Microbiology

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Voluntary Work:

HOPKINS TOASTMASTERS CLUB Officer (July 2015 – July 2018)

President and Vice President

HAND BY HAND USA NON PROFIT ORGANIZATION GCC Leader Project

A Team Leader (February 2016 – May 2016)

Raising children aged 8 – 12 years awareness about public health behaviors “Eating Healthy Food and Physical

Activity” through fotonovella project: telling a story through photograph and dialogue in Maryland community

schools

SAUDI HEALTH ORGANIZATION Bloomberg School of Public Health

Vice President of External Affairs (2015 – 2016)

ACADEMY HEALTH STUDENT CHAPTER

Vice president of the Chapter in the School of Public Health in Health Policy and Management Department (2015

– 2016) The mission of the chapter is to serve as a networking in Johns Hopkins University and outside Johns Hopkins

University. The chapter is an interdisciplinary platform that links health policy professionals to improve

healthcare delivery enhancing policies through research, leadership, and education

GOVERNMENT SUMMIT Organizer with Ministry of Cabinet Affairs Prime (February 2013)

ALQASSIMI HOSPITAL Medical Laboratory Scientist (July 2003)

240 hours voluntary summer work in different laboratory areas. Duties involved: applying laboratory

safety, handling and processing samples in each department: Biochemistry, Hematology, Blood banking,

Microbiology, Serology & Histopathology , certificate awarded

DUBAI PORT AUTHOROTY-PORT RASHID

PURCHASING DEPARTMENT

Administrative Officer (July 1997)

Voluntary summer work at - Port Rashid in Purchasing Department as an officer, certificate awarded

Research Activities

Abstracts Alnakhi Wafa, Morlock Laura, Thorpe Roland. Total Number of Trips for Patients from the United Arab

Emirates Seeking Medical Treatment Overseas Sponsored By Dubai Health Authority during 2009 – 2016.

[Poster presentation] Academy Health Annual Research Conference. June 2018

Alnakhi Wafa, Hussin AlTijani. The Satisfaction with the Healthcare Services provided in the Emirate of

Dubai among Dubai Residents. Dubai Household Survey -2014: Inpatient Admission. [Speaking

Presentation] STATA Conference. July 2018

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Languages: Arabic: Native speaker

English: Very competent and fluent in all four skills

Spanish: Beginner

patients from the united arab emirates seeking healthcare

Documents