INTERNATIONAL AccOUNTINg STANDARDS bOARD

The literature has shown that the meaning of health has been somewhat marginalised in the literature. It is not surprising therefore that no study was found to examine the meaning of health specifically from the perspective of hospital nurses and patients in Jordan. By reviewing the related research in the Middle East, the search found only one study that has included some Arab participant (Hjelm et al, 2005). This was striking as the investigation of the meaning of health among lay people, as well as health professions, is crucial for establishing health promotion as well as delivering holistic health care services (Bowling, 2005). This is of significance to Jordanian hospitals, as according to Mahasneh (2001) they need to offer the Jordanian community a high level of evidence-based health care.

Hjelm et al’s (2005) has exclusively focused on diabetes health care management and the meaning of health among different ethnic groups in Sweden. Whilst the study did not include participants from Jordan, some findings are of importance to the current research as they were elicited from Middle Eastern participants. Moreover, the method utilised i.e. focus group discussions is one of those methods used in this study, which could offer some insights into their usefulness when it comes to the investigation of health related issues. The study’s implications, together with critique, are addressed below.

Swedish researchers have attempted to uncover the health belief of men with

diabetes who were from different cultural backgrounds and living in Sweden. Hjelm et al (2005) suggested that diabetic patients’ belief might affect self-care and care seeking behaviour and health promotion in general (Hjelm et al, 2005).

A purposive sampling procedure was used and once again, as in previous studies (Paxston, et al, 1995, Yoho and Ezeobele, 2002,), the possibility of selection bias cannot be ruled out. In fact, such a possibility in this study is likely to be high as the sample was recruited by a female nurse who knew some of the participants.

Focus group discussions were held with 35 men with diabetes aged between 39 and 78 years. The sample was comprised of 14 who were born in Arabic countries [Iraq=9 Palestine=2, Lebanon= 2 and Egypt =1]. Other participants (n=10) were from former Yugoslavia and 11 were born in Sweden. The specific number of the group discussions held is not given, but Hjelm et al, (2005) stated that the number was “determined by the principle of saturation in data analysis” (p: 40). Yet from the findings it appears that no further themes have emerged from the discussion at any time. This is by no means unusual in qualitative research using group discussions, which usually generate further knowledge at the time of interaction with the participants (Morgan, 1997). Therefore, the benefits of “principle of saturation of data” in Hjelm et al’s, (2005) study are questioned in terms of in-depth exploration of data.

A specialised diabetic nurse not involved in the management of the patients, undertook the facilitation of focus group discussions. Each discussion has included either three or four participants in order to “minimise the need for interpretations”. However, whilst the sample used could be more manageable, it is argued that each focus group discussion needs to include a range of 5-12 participants to allow

adequate interaction (Morgan, 1998) and thus the sample of three or four raises some concerns about achieving such an objective. Hjelm et al, (2005) acknowledged this limitation but surprisingly they have made a somewhat inaccurate claim by stating that:

“ The small sample size [of participants] are recommended when the prime objective is to obtain the maximum amount of information] (p: 57).

The above statement contradicts the fact that the larger sample size (5-12) is likely to generate more information than, for example a sample of three participants, of course if the discussions are well moderated. The discussions were about the meaning of health, health behaviours and illness causation and no further information was given about how the discussions were moderated. For example, to avoid leading questions and interpret non-verbal communications and thus it would not be possible to

examine the validity of obtained data. To add to the problem, the actual purpose of the discussion is surrounded by significant vagueness. The study was explorative which implies gaining in-depth lay insights regarding the meaning of health related issues from the participants. A reported statement by Hjelm et al, (2005) would indicate that the purpose was likely to be “educative” rather than “explorative”. The following quotation illuminates this:

“ Many respondents particularly, Arabs, expressed positive experience after the interaction and said that they have not only been interviewed but also have gained knowledge about diabetes and its management” (p:57).

Therefore, it can be argued that the diabetes-educated nurse who moderated the discussions perhaps did not control her role as an educator throughout the research. All the discussions were audio recorded and then transcribed independently by two researchers. The independent analysis has shown a high level of agreement.

However, due to the limited details about the study’s context, the transferability of results and thus trustworthiness is indeed in doubt. The health belief model was used to inform the categorisation phase of factors, which could affect diabetic patients’ health. Using this model during the analysis process raises some questions about its effectiveness in exploring related themes to the meaning of health. Its views of health are rooted in the medical model (Bunton and Macdonald, 2002) as discussed earlier in this chapter; such views of health treat people like machines that need to be fixed. The health belief model has been increasingly criticised because of its exclusive focus on preventive health (Tones and Green, 2004).

Indeed, throughout the study Hjelm et al (2005) have an assumption that the health belief model’s components (e.g. perceived seriousness of illness) have an impact on making decisions about following certain health behaviour. However, this is not often the case. Many scholars have found that following certain health behaviours can be determined by other factors such as motivation (Pender, 1996, Tones and Tilford, 2002). Indeed, research has shown that there is a modest link between the health belief model and people’s behaviour (Bunton and Macdonald, 2002). On this basis, the effectiveness of using the health belief model in Hjelm et al’s (2005) work as an analysis guideline is called into question.

Nevertheless, despite the difficulties, there are some key findings that have emerged from the study which are of interest to the current research. Swedish men have focused on healthy lifestyle such as avoiding smoking. In contrast, Arabic and Yugoslavian men paid significant attention to economic factors and the cost of medical treatment. Arab men have shown a more active information seeking behaviour than both Swedish and Yugoslavian men. The meaning of health among Arab men, as well as Swedish was around the notion of the free from illness status. What is more, Arab men emphasised the ability to fulfil their roles in society “bringing up children and being a breadwinner”.

Religion was considered to be of importance for all except one of the Arabic group. They described praying in terms of giving relaxation and mental peace. These results are similar to the earlier reviewed work by Yoho and Ezeobele (2002 study). Despite the differences between Hispanic women’s culture and Arabic culture, praying was deemed as an important dimension of health. This indicates that the link between health and praying is fundamental in people’s health despite the differences in cultures and religions. With regard to social health, Arabs have expressed strong concerns about the importance of social life to their health status. For example, during Ramadan they meet each other and eat together. An interesting finding which emerged was that Arabs were more motivated to gain knowledge about health related issues than Swedish and Yugoslavian men. Although this finding might not be

generalisable due to the small sample size (n=14), it is indicative that Arabs are willing perhaps to get involved in health promotion activities.

Hjelm et al (2005) argue that teaching needs of diabetic patients should be individualised yet such a health education approach has a limited focus on the individual, which often marginalises other related factors such as economical status of individuals. This approach is widely charged as victim blaming as explained in the following chapter.

In conclusion, Hjelm et al’s (2005) inductive study proffers some valuable findings about the diverse views of health among ethnic groups in Sweden. This could help in establishing cultural care and thus health promotion activities. However, the study’s findings should be taken cautiously given the drawbacks outlined above. Indeed, the study has focused only on men and thus the findings are possibly not applicable to women.

As Arabs had been living for a long time in Sweden perhaps the findings might be different if the study had been replicated with a sample from Middle Eastern participants. The dissimilarities between the Swedish and Middle Eastern

environments as well as the quality of life could have resulted in some changes in immigrated Arabs’ understanding of health. Nevertheless, it is worth noting that Arab cultures are similar but not identical and each Arabic country has its own traditions and principles of living ( Brewer, 2004). Because of the absence of Jordanian participants in the Hjelm et al’s (2005) study, the qualitative findings applicability to Jordanian population is questioned. There is therefore a need for up to date research addressing the meaning of health from a Jordanian perspective.