Patients from the United Arab Emirates Seeking Healthcare Services Overseas During 2009 – 2016: Characteristics, Motivational Factors and Preferences

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

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

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

iii

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

iv 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.

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 Statistical Analysis ...... 56 Results ...... 58 Discussion ...... 65 Conclusion ...... 72 Tables ...... 73 CHAPTER FOUR: MANUSCRIPT THREE ...... 87 Introduction ...... 88

Methods ...... 90 Data source and study design ...... 90 Variables and Measures ...... 90 Statistical Analysis ...... 93 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

vii

CHAPTER ONE: INTRODUCTION

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

2 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

3 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

4 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

5 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

6 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).

Perceived healthcare need

Finance

Motivation Dissatisfaction

Pre Travel Recreational Research Travel Logistics Travel Obtaining Care Technology

Follow up Post travel Concerns

Advice Reassurance

Future Communications healthcare

Timeline Themes Subthemes

Figure a. Thematic Analysis for Travelling Seeking Healthcare

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

8 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

9 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

10 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

11 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)

Figure b. Motivational Factors Framework to Choose Destination Country:

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.

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

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

16 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?

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

18 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.

19 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%)

20 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.

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

22 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.

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

24 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

25 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

26 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

27 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.

28 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 &

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.

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

4 Trips 6 Trips and Total 1 Trip Only 2 Trips Only 3 Trips Only 5 Trips Only Only above 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)

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

No. Country of Destination N (%) 1 Federal Republic of Germany 928 (47.44) 2 United Kingdom 370 (18.92) 3 Kingdom of Thailand 314 (16.05) 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) 9 Kingdom of Belgium 9 (0.46) 10 French Republic 8 (0.41) 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)

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

No. Country of Destination N (%) 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) 8 General Surgery 60 (3.66)

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

(%) (%) (%) (%) (%) (%) (%)

Unspecified Orthopedic Orthopedic Orthopedic Internal Internal Internal Medical pediatrics Surgery Surgery Surgery Medicine: Medicine: Medicine: Specialty 1 198(28.65) 84(17.07) 77(22.45) 290(15.48) Oncology Oncology Oncology 241(18.44) 268(21.19) 100(17.06)

Medical Pediatrics: Pediatrics: Ophthalmology Neurosurgery Neurosurgery Neurosurgery Internal Specialty 2 Cardiology Neurology 46(13.41) 197(10.52) 172(13.16) 152(12.02) Medicine: 72(10.42) 47(9.55) Cardiology 78(13.31)

Medical Pediatrics: Ophthalmology Neurosurgery Internal Orthopedic Orthopedic Orthopedic Specialty 3 Neurology 46(9.35) 27(7.87) Medicine: Surgery Surgery Surgery 52(8.25) Oncology 157(12.01) 143(11.30) 61(10.41) 189(10.09)

Medical Ophthalmology Unspecified Neurology Obstetrics and General Surgery Internal Neurosurgery Specialty 4 49(7.09) pediatrics 25(7.29) Gynecology 86(6.58) Medicine: 44(7.51) 45(9.15) 173(9.24) Cardiology 104(8.22)

Medical Pediatrics: Pediatrics: Otolaryngology Neurology Obstetrics and General Surgery Neurology Specialty 5 Surgery Cardiology 17(4.96) 151(8.06) Gynecology 67(5.30) 39(6.66) 48(6.95) 28(5.69) 85(6.50)

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 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

(%) (%) (%) (%) (%) (%) (%)

Country of United Kingdom Federal Republic Federal Republic Federal Republic Federal Republic Federal Republic Federal Republic Destination 1 330 (47.76) of Germany 215 of Germany 168 of Germany of Germany 630 of Germany 565 of Germany 296 (43.70) (48.98) 920 (49.12) (48.20) (44.66) (50.51)

Country of Federal Republic United Kingdom United Kingdom United Kingdom Kingdom of Kingdom of Kingdom of Destination 2 of Germany 235 139 (28.25) 87 (25.36) 344 (18.37) Thailand 226 Thailand 312 Thailand 98 ( 34.01) (17.29) (24.66) (16.72)

Country of United Stated of United Stated of Kingdom of Kingdom of United Kingdom United Kingdom United Kingdom Destination 3 America 38 America 39 Thailand 26 Thailand 209 187 (14.31) 128 (10.12) 63 (10.75) (5.50) (7.93) (7.58) (11.16)

Country of Kingdom of Kingdom of Kingdom of United Stated of United Stated of Republic of India Republic of India Destination 4 Thailand 35 Thailand 32 Spain 26 America 104 America 72 77 (6.09) 38 (6.48) (5.07) (6.50) (7.58) (5.55) (5.51)

Country of Kingdom of Kingdom of United Stated of Kingdom of Republic of Republic of Destination 5 Spain 18 Spain 27 America 15 Spain 87 Singapore (63 Singapore 66 Republic of (2.60) (5.49) (4.37) (4.64) 4.82) (5.22) Singapore 30 (5.12)

Table 10. The top 5 most frequent medical specialties among patients from the United Arab Emirates treated overseas during 2009-2016 stratified by gender based on first trip, where 1 represents most frequent medical specialty and 5 represents least frequent medical specialty.

Gender Males Females

Orthopedic Surgery Internal Medicine: Oncology Medical Specialty 1 487(14.33) 516(16.33) Neurosurgery Orthopedic Surgery Medical Specialty 2 344(10.12) 359(11.36)

Internal Medicine: Oncology Obstetrics and Gynecology Medical Specialty 3 309(9.09) 291(9.21)

Ophthalmology Neurosurgery Medical Specialty 4 230(6.77) 285(9.02) Neurology Ophthalmology Medical Specialty 5 211(6.21) 183(5.79)

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

Gender Males Females

Federal Republic of Germany 1,605 Country of Destination 1 Federal Republic of Germany 1,424 (45.08) (47.23)

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)

Figure 1. Distribution of total number of trips among patients treated overseas from the United Arab Emirates during 2009-2016

DISTRIBUTION OF TOTAL NUMBER OF TRIPS AMONG PATIENTS TREATED OVERSEAS FROM THE UAE 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

Figure 2. Total number of trips among patients treated overseas from the United Arab Emirates during 2009-2016, stratified by age groups

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

Total TripsTotal

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

Figure 3. Total number of trips among patients treated overseas from the United Arab Emirates during 2009-2016, stratified by gender

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

Total TripsTotal

Females Males

Table 12. Unadjusted and adjusted prevalence ratios for travelling to the Federal Republic of Germany in comparison to other countries of destination

Unadjusted Adjusted* Independent Variables 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: 0.78 (0.69,0.88) 0.000 0.76 (0.67,0.86) 0.000 Cardiology 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: 0.80 (0.69,0.91) 0.001 0.78 (0.68,0.89) 0.000 Gastroenterology Urology 0.82 (0.71,0.95) 0.007 0.82 (0.71,0.94) 0.005 Internal Medicine: 0.86 (0.75,0.99) 0.042 0.84 (0.73,0.97) 0.019 Endocrinology Internal Medicine: 0.74 (0.62,0.89) 0.001 0.73 (0.61,0.87) 0.001 Nephrology Not Specified Cases 0.12 (0.07,0.21) 0.000 0.12 (0.07,0.22) 0.000 Un specified Internal 0.61 (0.49,0.76) 0.000 0.60 (0.48,0.75) 0.000 Medicine 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

Table 13. Unadjusted and adjusted incidence rate ratios for the total number of trips seeking treatment overseas during the study time period.

Unadjusted Adjusted * Independent Variables 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: 1.02 (0.92,1.13) 0.678 1.07 (0.96,1.18) 0.221 Cardiology 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: 1.01 (0.90,1.14) 0.812 1.06 (0.94,1.19) 0.323 Gastroenterology Urology 0.95 (0.84,1.08) 0.448 0.97 (0.85,1.10) 0.625 Internal Medicine: 0.93 (0.81,1.07) 0.301 0.96 (0.84,1.10) 0.531 Endocrinology Internal Medicine: 0.99 (0.86,1.14) 0.842 0.99 (0.86,1.14) 0.916 Nephrology Not Specified Cases 1.04 (0.91,1.20) 0.555 1.10 (0.95,1.26) 0.198 Un specified Internal 1.06 (0.92,1.22) 0.443 1.09 (0.95,1.25) 0.227 Medicine 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

CHAPTER THREE: MANUSCRIPT TWO

Patient Characteristics and the Motivational Factors for Choosing Treatment Destinations among

Patients Treated Overseas from the UAE during 2009 – 2012

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.

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.

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 452 DHA for patients who Cases agreed to participate travelled at DHA expense in the survey

571 Total number of participants in the survey 384 Cases were drawn from 119 DSC for patients who Cases agreed to participate travelled at their own in the survey expense

Figure 1. Non Probability Purposive Sampling

Response Rates of the KAP Survey

Residents Number of families Didn’t answer the Rejected and didn’t Completed the survey with overseas treated phone complete the survey patient identified and intended to 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.

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

47 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.

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

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

50 diagnosis category, and respondents selecting more than one condition were assigned to a multimorbidity 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

51 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.

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-

53 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

54 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,

55 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 Analysis

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

56 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.

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

58 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

59 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

60 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

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.

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

62 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

63 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

64 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

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;

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’

67 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

68 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

69 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.

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.

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.

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) 2 Kingdom of Thailand 64 (19.05) 3 United Kingdom 37 (11.01) 4 Republic of India 27 (8.04) 5 United States of America 13 (3.87) 6 Republic of Singapore 13 (3.87) 7 Kingdom of Belgium 8 (2.38) 8 Republic of Austria 5 (1.49) 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 Federal Republic of Other Destinations P-value N (%) Germany 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 73 (27.24) 32 (27.35) 41 (27.15) Read & Write 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 0.045 Categories*** 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 211 (62.80) 101 (66.45) 110 (59.78) reported

Family Member 0.92 Reported

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 P-value for chi-square test

Variable Total Sample N (%) Federal Republic of Other Destinations P-value 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 1.00 Services Provided in the UAE 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

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 Other P-value (%) Germany Countries 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) 3 (0.89) 2 (1.32) 1 (0.54) 0.454 Diseases 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 P-value for chi-square test

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) 9 Obstetrics and Gynecology 6 (1.79) 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)

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) 13 Ear, nose and throat (ENT) 0 (0) 1 (0.54) Diseases 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 P-value for chi-square test

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 P-value for chi-square test

Table 5. Motivational factors among residents of Dubai, United Arab Emirates who sought medical treatment overseas during 2009 – 2012 by country of destination

Variable Total Sample N (%) Federal Republic of Other Destinations P-value 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 at all 218 (64.88) 100 (65.79) 118 (64.13) 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 at all 145 (43.15) 71 (46.71) 74 (40.22) 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 at all 62 (18.45) 31 (20.39) 31 (16.85) 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 at all 155 (46.13) 81 (53.29) 74 (40.22) 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

Medical Travel agency/Broker 2 (0.60) 1 (0.66) 1 (0.54) 0.89 Government (overseas treatment 80 (23.81) 41 (26.97) 39 (21.20) 0.22 office)

Information Would Use to Choose 0.41 Healthcare Provider Different Treatment Options 27 (8.04) 14 (9.21) 13 (7.07) Qualifications and certificates of the 39 (11.61) 19 (12.50) 20 (10.87) doctor Experience of the doctor 95 (28.27) 36 (23.68) 59 (32.07) Reputation of the medical 80 (23.81) 36 (23.68) 44 (23.91) center/hospital 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, 1 (0.30) 0 (0) 1 (0.54) transport, food, etc. Length of stay 1 (0.30) 1 (0.66) 0 (0) Adverse outcomes and complications 2 (0.60) 2 (1.32) 0 (0) of the desired treatment Refund policy 2 (0.60) 0 (0) 2 (1.09) The probability of having the treating 10 (2.98) 7 (4.61) 3 ( 1.63) doctor abroad as visiting doctors in the UAE for consultations Available advanced medical & 3 (0.89) 1 (0.66) 2 (1.09) Therapeutic technology Opinions of friends and family 29 (8.63) 15 (9.87) 14 (7.61) regarding the best healthcare providers in the city/country

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 11 (3.27) 5 (3.29) 6 (3.26) 0.99 in the UAE Long waiting time for an appointment 29 (8.63) 12 (7.89) 17 (9.24) 0.66 Undesirable outcome from previous 21 (6.25) 8 (5.26) 13 (7.07) 0.50 personal experience Undesirable outcome from other 24 (7.14) 8 (5.26) 16 (8.70) 0.22 previous experience 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 6 (1.79) 3 (1.97) 3 (1.63) 0.81 available Expecting adverse treatment outcome 20 (5.95) 7 (4.61) 13 (7.07) 0.34 in the UAE * SD: Standard Deviation P-value for chi-square test

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 Other Destinations P-value (%) of Germany 1 Cancer 108 (32.14) 48 (31.58) 60 (32.61) 0.84 2 Neurological Disease, and 18 (5.36) 10 (6.58) 8 (4.35) 0.36 Neurosurgery 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 7 (2.08) 6 (3.95) 1 (0.54) 0.03 clot) 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 1 (0.30) 0 (0) 1 (0.54) 0.36 Surgery 17 Oral and Dental Diseases 1 (0.30) 0 (0) 1 (0.54) 0.36 18 Lungs & Respiratory 10 (2.98) 3 (1.97) 7 (3.80) 0.33 Diseases 19 Ear, nose and throat (ENT) 4 (1.19) 3 (1.97) 1 (0.54) 0.23 Diseases 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 P-value for chi-square test

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)

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

No. Medical Condition Total sample N (%) Federal Republic of Other Destinations Germany 1 Cancer 58 (17.26) 28 (18.42) 30 (16.30) 2 Neurological, Neurosurgery Brain 16 (4.76) 12 (7.89) 4 (2.17) Hemorrhage 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 P-value for chi-square test

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

Number Comorbidities Total sample N (%) Federal Republic of Other Destinations Germany 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 P-value for chi-square test

Table 7. Travel related experiences for residents of Dubai, United Arab Emirates during their most recent trip overseas, 2009 - 2012

Variable Total Sample N (%) Federal Republic of Other Destinations P-value Germany Months ago was the trip 15.66±15.71 16.53±15.26 14.93±16.09 0.37 Mean ±SD* 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 0.08 UAE 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 0.71 Abroad 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 0.06 Healthcare Services Provided Overseas 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 0.99 Experience to Others 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 0.11 Be Available in the UAE Waiting time 142 (42.26) 57 (37.50) 85 (46.20) 0.11 Healthcare provider 277 (82.44) 121 (79.61) 156 (84.78) 0.21 Communication Hospitality 89 (26.49) 45 (29.61) 44 (23.91) 0.24 Education & Reading 17 (5.06) 10 (6.58) 7 (3.80) 0.25 Material Convenient Atmosphere 215 (63.99) 92 (60.53) 123 (66.85) 0.23

Unfavorable Reactions/ 0.002 Complications/ Outcomes During and After the Treatment 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 0.16 medical error

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 95 (28.27) 47 (30.92) 48 (26.09) 0.33 Office Police 15 (4.46) 6 (3.95) 9 (4.89) 0.68 Hospital Administration 40 (11.90) 18 (11.84) 22 (11.96) 0.97 /complaint center

Next decision if there was 0.19 delay in issuing visa Wait for Visa 257 (76.49) 119 (78.29) 138 (75.00) Look for Another 54 (16.07) 26 (17.11) 28 (15.22) Destination Search HCP in UAE 25 (7.44) 7 (4.61) 18 (9.78) * SD: Standard Deviation P-value for chi-square test

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

Variable Total Sample N (%) Federal Republic of Other Destinations P-Value Germany Preference for Travel 0.76 Escort 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 29 (8.63) 14 (9.21) 15 (8.15) 0.73 experiences Help & Support 314 (93.45) 143 (94.08) 171 (92.93) 0.67 Seek Options in 39 (11.61) 20 (13.16) 19 (10.33) 0.42 UAE/Other Countries 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 P-value for chi-square test 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 P-value for chi-square test

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

Unadjusted Adjusted* Dependent Variables 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

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

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

88 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.

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

90 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

91 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

92 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 Analysis

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

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

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.

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.

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.

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

98 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

99 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

100 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.

101

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

102 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

103

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.

104

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated 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.

Associations between Patients’ Characteristics and Willingness to Wait to be Diagnosed and

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.

105

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated for Eye Diseases and Known physician in the UAE

When using binary logistic regression to identify the factors associated with willingness to 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.

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated for Eye Diseases by a Visiting Physician to the UAE

When using binary logistic regression to identify the factors associated with willingness to 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.

Associations between Patients’ Characteristics and Willingness to Wait to be Diagnosed and

Treated for Eye Diseases by a Visiting Physician to the UAE

106 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.

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated for General Surgery by a Known Physician in the UAE

When using binary logistic regression to identify factors associated with willingness to be 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.

Associations between Patients’ Characteristics and Willingness to Wait to be Diagnosed and

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.

107

Associations between Patients’ Characteristics and Willingness to be Diagnosed and Treated for Heart Diseases by a Known Physician in the UAE

When using binary logistic regression to identify factors associated with willingness to be 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.

Associations between Patients’ Characteristics and Willingness to Wait to be Diagnosed and

Treated for Heart Diseases by a Known Physician in the UAE:

When using binary logistic regression to identify factors associated with willingness to be 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.

108

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

109 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

110 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

111 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

112

(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

113 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

114 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.

115

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

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)

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

116

Table 3. Willingness to be diagnosed and treated by a known physician in the UAE across the six medical conditions: Bone & Joint Diseases, Cancer, Neurological Disease, General Surgery, Heart Diseases, and Eye Diseases

Willingness Bone & Joint Cancer N (%) Neurological General Heart Diseases Eye Disease N N (%) Diseases N (%) Surgery N (%) 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 4. Willingness to wait to be diagnosed and treated by a known physician in the UAE across the six medical conditions: Bone & Joint Diseases, Cancer, Neurological Disease, General Surgery, Heart Diseases, and Eye Diseases

Willingness Bone & Joint Cancer N (%) Neurological General Heart Diseases Eye Disease N N (%) Diseases N (%) Surgery N (%) N (%) (%) One week 34 (72.34) 53 (80.30) 19 (95.00) 17 (77.27) 35 (77.78) 21 (84.00) More than one 13 (27.66) 13 (19.70) 1 (5.00) 5 (22.73) 10 (22.22) 4 (16.00) Week Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

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 Cancer N (%) Neurological General Heart Diseases Eye Disease N N (%) Diseases N (%) Surgery N (%) 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 6. Willingness to wait to be diagnosed and treated by a visiting physician to UAE across the six medical conditions: Bone & Joint Diseases, Cancer, Neurological Disease, General Surgery, Heart Diseases, and Eye Diseases

Willingness Bone & Joint Cancer N (%) Neurological General Heart Diseases Eye Disease N N (%) Diseases N (%) Surgery N (%) N (%) (%) One week 27 (57.45) 47 (71.21) 14 (70.00) 15 (68.18) 30 (66.67) 18 (72.00) More than one 20 (42.55) 19 (28.79) 6 (30.00) 7 (31.82) 15 (33.33) 7 (28.00) Week Total 47 (100.00) 66 (100.00) 20 (100.00) 22 (100.00) 45 (100.00) 25 (100.00)

117

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 Willingness to wait to be diagnosed and treated for 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 (Household income p-value 0.05) Heart Diseases Willingness to wait to be diagnosed and treated for Willingness to be diagnosed and treated for heart heart diseases by a known physician in the UAE diseases by a known physician in the UAE (Age p-value 0.06) (Household income p-value 0.04)

118

Table 8. Sensitivity Analysis by Pseudo r2

Outcome of Interest Medical Predictor Pseudo R2 Variation P-value Condition explained Alpha Level 0.05 Willingness to wait to be diagnosed Cancer Household 0.0818 9 0.04 and treated by a known physician in Income the UAE

Willingness to be diagnosed and Heart Household 0.0896 7 0.04 treated by a known physician in the Disease income UAE

Willingness to be diagnosed and Cancer Treatment 0.0467 11 0.05 treated by a known physician in the coverage UAE

Willingness to wait to be diagnosed Neurological Answering 0.1839 0.05 and treated by a visiting physician to Diseases the survey the UAE 2 Willingness to be diagnosed and General Age 0.2760 0.05 treated by a known physician in the Surgery UAE 1

Willingness to wait to be diagnosed General Household 0.1614 0.05 and treated by a visiting physician to Surgery Income the UAE 3

Alpha level 0.1 Willingness to be diagnosed and Eye Answering 0.1351 4 0.06 treated by a visiting physician in the Diseases the survey UAE

Willingness to wait to be diagnosed Heart Age 0.0867 8 0.06 and treated for heart diseases by a Diseases known physician in the UAE

Willingness to be diagnosed and Eye diseases Treatment 0.1252 6 0.07 treated by a known physician in the coverage UAE

Willingness to be diagnosed and Cancer Cost of 0.0632 10 0.08 treated by a visiting physician to the treatment UAE Willingness to wait to be diagnosed Eye Age 0.1287 5 0.08 and treated by a visiting physician to Diseases the UAE time

119

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 **Significant level p<0.10

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

Independent Variable Unadjusted* 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 **Significant level p<0.10

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

Independent Variable Unadjusted* 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 **Significant level p<0.1

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

Independent Variable Unadjusted* 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 **Significant level p<0.1

120

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 **Significant level p<0.10

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 **Significant level p<0.10

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 **Significant level p<0.10

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

Independent Variable Unadjusted* 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 **Significant level p<0.10

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 **Significant level p<0.10

121

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 Independent Variable Unadjusted* 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 **Significant level p<0.10

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 **Significant level p<0.10

122

CHAPTER FIVE: SUMMARY AND CONCLUSIONS

123

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.

124

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

125

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.

126

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.

127

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

128 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

129 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

130 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,

131 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

132 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

133 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

134 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

135 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

136 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

137 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.

138

APPENDICES

139

Appendix for Manuscript One

Figure-4. Analytical data set selection flow chart

15,138 Total trips

2693 trips of Non-UAE citizens removed

581 trips of UAE citizens in the UAE removed

Complete case analysis 1 sex missing and 36 age missing

234 trips with more than one medical specialty removed

4788 second trips onward for all individuals excluded

6557 first trips of unique individuals used as an analytical dataset

140

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

141

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)

4 Trips 6 Trips and Total 1 Trip Only 2 Trips Only 3 Trips Only 5 Trips Only Only above 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)

142

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 1st Trip 2nd 3rd 4th trip 5th 6th 7th Trip 8th 9th 10th Total Number Trip Trip Trip Trip Trip Trip Trip Males 3,398 1,169 543 285 181 110 67 35 21 13 5,849 (51.82) (49.98) (49.54) (50.35) (54.03) (55.84) (62.04) (60.34) (58.33) (65.00) (51.56) Females 3,159 1,170 553 281 154 87 41 23 15 7 5,496 (48.18) (50.02) (50.46) (49.65) (45.97) (44.16) (37.96) (39.66) (41.67) (35.00) (48.44)

Total 6,557 2,339 1,096 566 335 197 108 58 36 20 11,345 (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00)

Trip 11th 12th 13 Trip 14th 15th 16th 17th Trip 18th 19th 20th Total Number Trip Trip Trip Trip Trip Trip Trip Trip Males 9 5 4 2 2 2 0 (0.00) 1 1 1 5,849 (75.00) (83.33) (80.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (51.56) Females 3 1 1 0 0 (0.00) 0 (0.00) 1(100.00) 0 (0.00) 0 (0.00) 0 (0.00) 5,496 (25.00) (16.67) (20.00) (0.00) (48.44) Total 12 6 5 2 2 2 1 1 1 1 11,345 (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00 (100.00)

Age group Trip 1st Trip 2nd 3rd 4th 5th 6th 7th Trip 8th 9th 10th Total Number Trip Trip Trip Trip Trip Trip Trip Trip 0-4 yrs. 691 285 152 76 44 23 15 10 5 2 1,309 (10.54) (12.18) (13.87) (13.43) (13.13) (11.68) (13.89) (17.24) (13.89) (10.00) (11.54) 5-12 yrs. 492 196 99 53 34 21 13 11 6 3 931 (7.50) (8.38) (9.03) (9.36) (10.15) (10.66) (12.04) (18.97) (16.67) (15.00) (8.21) 13-18 343 126 56 32 14 7 (3.55) 4 (3.70) 2 (3.45) 1 (2.78) 1 (5.00) 586 yrs. (5.23) (5.39) (5.11) (5.65) (4.18) (5.17) 19-39 1,873 665 275 140 75 50 23 13 9 7 3,148 yrs. (28.56) (28.43) (25.09) (24.73) (22.39 (25.38) (21.30) (22.41) (25.00) (35.00) (27.75)

40-54 1,307 484 247 127 79 45 27 9 8 4 2,342 yrs. (19.93) (20.69) (22.54) (22.44) (23.58) (22.84) (25.00) (15.52) (22.22) (20.00) (20.64) 55- 1,265 430 210 109 70 38 20 10 4 2 2,159 69yrs. (19.29) (18.38) (19.16) (19.26) (20.90) (19.29) (18.52) (17.24) (11.11) (10.00) (19.03) 70+ yrs. 586 153 57 29 19 13 6 (5.56) 3 (5.17) 3 (8.33) 1 (5.00) 870 (8.94) (6.54) (5.20) (5.12) (5.67) (6.60) (7.67) Total 6,557 2,339 1,096 566 335 197 108 58 (100) 36 20 11,345 (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) Trip 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th Total Number Trip Trip Trip Trip Trip Trip Trip Trip Trip Trip 0-4 yrs. 1 (8.33) 1 1 1 1 1 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 1,309 (16.67) (20.00) (50.00) (50.00) (50.00) (11.54) 5-12 yrs. 3 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 (25.00) (8.21) 13-18 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 yrs. (5.17) 19-39 5 3 3 1 1 1 1 1 1 1 3,148 yrs. (41.67) (50.00) (60.00) (50.00) (50.00) (50.00) (100.00) (100.00) (100.00) (100.00) (27.75)

40-45 2 2 1 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 2,342 yrs. (16.67) (33.33) (20.00) (20.64) 55-59 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 yrs. (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 6 5 2 2 2 1 1 1 1 11,345 (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00) (100.00)

143

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) 5 Republic of Singapore 451 (3.98) 6 Republic of India 389 (3.43) 7 Kingdom of Spain 389 (3.43) 8 Republic of Austria 105 (0.93) 9 Kingdom of Belgium 83 (0.73) 10 French Republic 48 (0.42) 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)

144

Table 18. Countries of destination among patients treated overseas from the United Arab 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)

Table 19. Countries of destination among patients treated overseas from the United Arab 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) 371 394 549 160 1,638 (11.79) (16.82) (25.43) (18.39) (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 468 429 299 1,511 (48) 1,100 917 413 5,137 (35.75) (46.08) (51.02) (46.97) (42.47) (47.47) (45.28) 9 Republic of India 31 (2.37) 12 (1.29) 1 (0.17) 95 (3.02) 76 126 48 389 (3.43) (3.25) (5.84) (5.52) 10 Republic of Indonesia 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 0 (0) 1 (0.01) (0.05) 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)

145

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 44 (1.88) 51 (2.36) 32 (3.68) 389 (3.43) (4.48) 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 574 247 137 550 319 232 100 2,159 (43.85) (26.53) (23.38) (17.47) (13.62) (10.75) (11.49) (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 1,309 931 (100) 586 (100) 3,148 2,342 2,159 870 11,345 (100) (100) (100) (100) (100) (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) 7 General Surgery 505 (4.45) 8 Obstetrics and Gynecology 445 (3.92) 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)

146

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)

147

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)

148

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 13-18 19-39 40-54 55-69 70+ yrs Total (%) N (%) yrs N yrs N yrs N yrs N N (%) (%) (%) (%) (%) 1 Internal Medicine: Oncology 15 (1.15) 32 (3.44) 33 (5.63) 456 612 564 200 1,912(16.85) (14.49) (26.13) (26.12) (22.99) 2 Internal Medicine: Cardiology 11 (0.84) 9 (0.97) 18 (3.07) 87 (2.76) 127 175 119 546 (4.81) (5.42) (8.11) (13.68) 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 81 (3.46) 94 (4.35) 28 (3.22) 368 (3.24) (4.54) 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 44 (4.73) 6 (1.02) 0 (0) 0 (0) 0 (0) 0 (0) 184 (1.62) (10.24) 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 84 (9.02) 9 (1.54) 0 (0) 0 (0) 0 (0) 0(0) 420 (3.7) (24.98) 24 General Surgery 8 (0.61) 15 (1.61) 27 (4.61) 203 132 92 (4.26) 28 (3.22) 505 (4.45) (6.45) (5.64) 25 Neurosurgery 25 (1.91) 48 (5.16) 43 (7.34) 313 267 236 53 (6.09) 985 (8.68) (9.94) (11.4) (10.93) 26 Orthopedic Surgery 76 (5.81) 164 131 445 240 238 94 (10.8) 1,388 (17.62) (22.35) (14.14) (10.25) (11.02) (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) 246 148 35 7 445 (7.81) (6.32) 1.62 0.8 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) 261 145 92 (4.26) 41 (4.71) 602 (5.31) (8.29) (6.19) 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) 87 197 76 (3.25) 106 62 (7.13) 724 (6.38) (14.85) (6.26) (4.91) 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 1,309 931 586 3,148 2,342 2,159 870 11,345 (100) (100) (100) (100) (100) (100) (100) (100)

149

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: 361 (28.18 ) 638 (12.42) 360 (21.98 ) 255 236 (31.85) 62 (15.94) 1912 Oncology (11.81) (16.85) Internal Medicine: 14(1.09) 260 (5.06) 109 ( 6.65 ) 121(5.6) 25 (3.37) 17 ( 4.37) 546 (4.81) Cardiology Internal Medicine: 0(0.00) 29 (0.56) 11(0.67) 27(1.25) 10 (1.35) 14 ( 3.60) 91 (0.8) Rheumatology Internal Medicine: 32(2.50) 192(3.74) 26 (1.59) 82(3.8) 18 (2.43) 18 (4.63) 368 (3.24) Gastroenterology Internal Medicine: 45 (3.51) 107 (2.08) 30 (1.83) 41(1.9) 13 (1.75) 13 ( 3.34) 249 (2.19) Nephrology Internal Medicine: 11(0.86) 141(2.74) 23(1.40 ) 59(2.73) 13 (1.75) 5 ( 1.29) 252 (2.22) Endocrinology Internal Medicine: 13 (1.01 ) 66(1.28) 12( 0.73) 64(2.96) 23 (3.1) 1 ( 0.26) 179 (1.58) Hematology Internal Medicine: 5 (0.39) 67(1.30 ) 17 (1.04 ) 17(0.79) 31 (4.18) 2 (0.51) 139 (1.23) Pulmonology Internal Medicine: 2 (0.16) 4 (0.08) 1(0.06) 5(0.23) 2 (0.27 ) 0 (0) 14 (0.12) Infectious Disease 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) 9 (1.21) 1 (0.26) 83 (0.73) 15(0.69) 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) 6 (0.81) 0 (0) 104 (0.92) 38(1.76) Pediatrics: 3 (0.23) 17(0.33) 4 (0.24) 24(1.11) 5 (0.67) 0 (0) 53 (0.47) Neurosurgery Pediatrics: 0 (0) 0 (0) 0 (0) 8( 0.37) 0 (0) 0 (0) 8 (0.07) Rheumatology Pediatrics: Neurology 13 (1.01 ) 87 (1.69 ) 6 (0.37) 78(3.61) 9 (1.21) 2 (0.51) 195 (1.72) Pediatrics: 5 (0.39) 13 (0.25) 2(0.12) 18(0.83) 9 (1.21) 2 (0.51) 49 (0.43) Gastroenterology Pediatrics: 1 (0.08 ) 29 ( 0.56 ) 4 (0.24) 22(1.02) 20 (2.7) 3 ( 0.77) 79 (0.7) Nephrology Pediatrics: 2(0.16) 10 ( 0.19) 1( 0.06 ) 16(0.74) 3 (0.4) 2 (0.51) 34 (0.3) Hematology Pediatrics: 1(0.08) 8(0.16) 3(0.18) 5(0.23) 1 (0.13 ) 0 (0) 18 (0.16) Endocrinology Pediatrics: 0 (0) 6(0.12 ) 1( 0.06) 15(0.69) 2 (0.27) 0 (0) 24 (0.21) Neonatology Pediatrics: 0 (0) 1 (0.02) 0 (0) 2(0.09) 0 (0) 0 (0) 3 (0.03) Pulmonology Un specified 17 (1.33) 146(2.84) 31 (1.89) 178 41 (5.53) 7 (1.80) 420 (3.7) Pediatrics (8.24) 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) 55 (7.42) 64 (16.45) 1388 156(7.23) (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 62 (4.84) 196 (3.82) 38(2.32) 105(4.86) 13 (1.75) 31 (7.97) 445 (3.92) Gynecology 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)

150

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- 5 (0.39) 58 (1.13) 2 (0.12 ) 8(0.37) 2 (0.27) 0 (0) 75 (0.66) up Psychiatry 5 (0.39) 7 (0.14 ) 0 (0) 5 (0.23) 5 (0.67 ) 0 (0) 22 (0.19) NOT SPEFCIFID 7 ( 0.55) 18 (0.35) 214 ( 13.06 ) 24(1.11) 3 (0.4) 0 (0) 266 (2.34) CASES 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) 2,159 741 (100) 389 (100) 11345 (100) (100)

Table 25. The top 5 most frequent medical specialties among patients from the United Arab 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 0 - 4 yrs. 5 – 14 yrs. 15 – 39 yrs. 40 – 54 yrs. 55 – 69 yrs. 70 + yrs. Categories

Medical Specialty

Un specified Orthopedic Orthopedic Surgery Internal Medicine: Internal Medicine: Internal Medicine: Medical Pediatrics 327 Surgery 164 131 (22.35) Oncology 456 Oncology 612 (26.13) Oncology 564 Specialty 1 (24.98) (17.62) (14.49) (26.12) Medical Pediatrics: Un specified Ophthalmology 87 Orthopedic Surgery Neurosurgery 267 Orthopedic Specialty 2 Cardiology 134 Pediatrics 84 (14.85) 445 (14.14) (11.40) Surgery 238 (10.24) (9.02) (11.02) Medical Ophthalmology Ophthalmology Neurosurgery 43 Neurosurgery 313 Orthopedic Surgery 240 Neurosurgery 236 Specialty 3 113 (8.63) 83 (8.92) (7.34) (9.94) (10.25) (10.93)

Medical Pediatrics: Pediatrics: Neurology 42 Neurology 261 Obstetrics and Internal Medicine: Specialty 4 Neurology 110 Neurology 82 (7.17) (8.29) Gynecology 148 Cardiology 175 (8.40) (8.81) (6.32) (8.11) Medical Orthopedic Neurosurgery 48 Internal Medicine: Obstetrics and Neurology 145 (6.19) Ophthalmology Specialty 5 Surgery 76 (5.16) Oncology 33 Gynecology 246 106 (4.91) (5.81) (5.63) (7.81)

151

Table 26. The top 5 most frequent medical specialties among patients from the United Arab 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)

Gender Males Females

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)

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 391 387 491 638 763 947 1,154 725 5,496 (40.48) (46.57) (45.63) (45.31) (49.71) (50.8) (51.75) (50.52) (48.44)

Males 575 444 585 770 772 917 1,076 710 5,849 (59.52) (53.43) (54.37) (54.69) (50.29) (49.2) (48.25) (49.48) (51.56)

Total 966 831 1,076 1,408 1,535 1,864 2,230 1,435 11,345 (100) (100) (100) (100) (100) (100) (100) (100) (100)

152

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 Calendar Year Total N Group (%) 2009 N 2010 N 2011 N 2012 N 2013 N 2014 N 2015 N 2016 N (%) (%) (%) (%) (%) (%) (%) (%) 0-4 yrs 119 117 135 139 177 206 273 143 1,309 (12.32) (14.08) (12.55) (9.87) (11.53) (11.05) (12.24) (9.97) (11.54)

5-12 yrs 89 70 95 101 113 156 198 109 931 (9.21) (8.42) (8.83) (7.17) (7.36) (8.37) (8.88) (7.6) (8.21)

13-18 yrs 54 42 43 65 77 93 132 80 586 (5.59) (5.05) (4) (4.62) (5.02) (4.99) (5.92) (5.57) (5.17)

19-39 yrs 261 219 274 388 415 536 645 410 3,148 (27.02) (26.35) (25.46) (27.56) (27.04) (28.76) (28.92) (28.57) (27.75)

40-54 yrs 184 154 225 320 337 387 421 314 2,342 (19.05) (18.53) (20.91) (22.73) (21.95) (20.76) (18.88) (21.88) (20.64)

55-69 yrs 176 135 212 283 288 361 420 284 2,159 (18.22) (16.25) (19.7) (20.1) (18.76) (19.37) (18.83) (19.79) (19.03)

70+ yrs 83 94 92 112 128 125 141 95 870 (8.59) (11.31) (8.55) (7.95) (8.34) (6.71) (6.32) (6.62) (7.67)

Total 966 831 1,076 1,408 1,535 1,864 2,230 1,435 11,345 (100) (100) (100) (100) (100) (100) (100) (100) (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: 179 147 186 246 267 271 304 312 1,912 Oncology (18.53) (17.69) (17.29) (17.47) (17.39) (14.54) (13.63) (21.74) (16.85) 2 Internal Medicine: 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) Cardiology 3 Internal Medicine: 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) Rheumatology 4 Internal Medicine: 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) Gastroenterology 5 Internal Medicine: 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) Nephrology 6 Internal Medicine: 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) Endocrinology 7 Internal Medicine: 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) Hematology 8 Internal Medicine: 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) Pulmonology 9 Internal Medicine: 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) Infectious Diseases 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)

153

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: 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) Neurosurgery 15 Pediatrics: 1 (0.1) 0 (0) 0 (0) 0 (0) 1 (0.07) 1 (0.05) 1 (0.04) 4 (0.28) 8 (0.07) Rheumatology 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: 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) Gastroenterology 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: 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) Endocrinology 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: 3 (0.31) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (0.03) Pulmonology 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) 156 147 (9.58) 141 (7.56) 141 (6.32) 144 985 (8.68) (11.08) (10.03) 26 Orthopedic Surgery 123 90 (10.83) 141 (13.1) 183 (13) 203 209 278 161 1,388 (12.73) (13.22) (11.21) (12.47) (11.22) (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 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) Gynecology 31 Dermatology 5 (0.52) 2 (0.24) 8 (0.74) 10 (0.71) 11 (0.72) 18 (0.97) 21 (0.94) 8 83 (0.73) (0.56) 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 17 (1.76) 23 (2.77) 2 (0.19) 32 (2.27) 7 (0.46) 26 (1.39) 139 20 (1.39) 266 (2.34) CASES (6.23) 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 1,408 1,535 1,864 2,230 1,435 11,345 (100) (100) (100) (100) (100) (100) (100)

154

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

155

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

23 non UAE nationals were removed from the data- set and focusing on UAE nationals only

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

156

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 Categorical Categorical Destinations • Federal Republic of Germany  Federal Republic of Germany • Kingdom of Thailand  Kingdom of Thailand • United Kingdom  United Kingdom • Republic of India  Republic of India • United States of America  United States of America • Republic of Singapore  Republic of Singapore • Kingdom of Belgium  Kingdom of Belgium • Republic of Austria  Republic of Austria • Others (The Hashemite Kingdom of  The Hashemite Kingdom of Jordan Jordan, Other Asian Countries,  Other Asian Countries Ireland, The Islamic Republic of Iran,  Ireland The French Republic The Islamic Republic of Afghanistan, The  The Islamic Republic of Iran Republic of Indonesia The Kingdom  The French Republic of Spain, Other Latin Americas)  The Islamic Republic of Afghanistan  The Republic of Indonesia Binary  The Kingdom of Spain  Federal Republic of Germany  Other Latin Americas  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) Table2. Demographic characteristics of residents of Dubai, United Arab Emirates who sought medical treatment overseas during 2009 – 2012 104. Marital Status 15+ Binary Categorical  Not married n(never married,  Never married, divorced widowed)  Divorced  Married  Widowed  Married 105. Employment status 15+ Binary Categorical  Not working (unemployed,  Unemployed retired)  Retired  Working ( Government  Government Employee Employee, Private Employee)  Private Employee

106. Educational level 15+ Ordinal Ordinal  Illiterate or can’t read and write  Illiterate or can’t read and write  Primary/Preparatory, Secondary  Primary/Preparatory  Graduate/Post-graduate  Secondary  Graduate/Post-graduate 108. Household average Categorical Continuous monthly income21  Low income (≤29,000 AED =  Average monthly income ≤8,168.55USD)

21 According to Dubai Statistic Center definition of Household income

157

 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 Binary Categorical before travelling abroad  Not Diagnosed (Medical  Medical complaint but didn’t get complaint but didn’t get diagnosed in the UAE diagnosed in the UAE, Healthy,  Existing medical condition diagnosed no symptoms, just do checkup)  Healthy, no symptoms, just do check  Diagnosed (Existing medical up condition diagnosed)

113.1 Healthcare Provider in Binary Categorical the UAE  Government (Dubai Health  Dubai Health Authority Hospitals for Authority Hospitals for in- in-patient services patient services, Dubai Health  Dubai Health Authority Hospitals for Authority Hospitals for out- out-patient services patient services, Dubai Health  Dubai Health Authority Primary Authority Primary Health Care Health Care Centers Centers, Ministry of Health  Ministry of Health Hospitals for in- Hospitals for in-patient services, patient services Ministry of Health Hospitals for  Ministry of Health Hospitals for out- out-patient services, Ministry of patient services Health Primary Health Care  Ministry of Health Primary Health Centers, Abu Dhabi Health Care Centers Services Hospitals and PHCs  Abu Dhabi Health Services Hospitals (SEHA)) and PHCs (SEHA)  Other (Private Sector Hospitals  Private Sector Hospitals for in-patient for in-patient services, Private services Clinics, Private Sector Hospitals  Private Clinics for out-patient services, Home  Private Sector Hospitals for out- visits) 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 Categorical Categorical travelling abroad  Heart disease  Heart disease  High blood pressure  Cancer  Cancer  High blood pressure  Diabetes  Diabetes  Bone and joint Diseases  Bone and joint Diseases  Gastro-intestinal Diseases  Gastro-intestinal Diseases  Obstetrics and Gynecology  Obstetrics and Gynecology Diseases Diseases  Ear, nose and throat (ENT) Diseases  Ear, nose and throat (ENT)  Kidney or bladder (urinary system) Diseases Diseases  Kidney or bladder (urinary  Skin or venereal Diseases system) Diseases  Stroke (brain hemorrhage or clot)  Skin or venereal Diseases  Mental illness  Trauma

158

 Stroke (brain hemorrhage or  Cosmetic surgery clot)  Dental Diseases  Mental illness  Lungs and Respiratory Diseases  Trauma  Eye Diseases  Cosmetic surgery  Medical Screening, routing medical  Dental Diseases check-up  Lungs and Respiratory Diseases  Undiagnosed  Eye Diseases  Others. (Specify)  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) 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 Categorical  Treatment purposes only (Treatment  Tourism for self, Treatment for family  Treatment for self member, Treatment of medical  Treatment for family member complications resulting from  Treatment of medical complications treatment in UAE, Medical checkup resulting from treatment in UAE and screening)  Medical checkup and screening  Other purposes (Tourism, Others)  Others

Table 6. Main conditions residents of Dubai, United Arab Emirates were diagnosed with while seeking medical treatment overseas during 2009-2012 Categorical Categorical • Cancer • Cancer • Neurological Diseases and • Neurological Diseases and Neurosurgery Neurosurgery • Pediatrics diseases • Pediatrics diseases • Bone and joint Diseases • Bone and joint Diseases • Heart disease • Heart disease • Eye Diseases • Eye Diseases • Obstetrics and gynecology Diseases • Obstetrics and gynecology Diseases • General Surgery (Amputations, • General Surgery (Amputations, Thyroidectomy, Removing benign tumor, Thyroidectomy, Removing benign removing sebaceous cyst...) tumor, removing sebaceous cyst...) • Kidney Diseases • Kidney Diseases • Gastro-Intestinal Diseases • Gastro-Intestinal Diseases • Urinary Tract system • Urinary Tract system • High Blood Pressure • High Blood Pressure • Skin or venereal Diseases • Skin or venereal Diseases • Stroke (brain hemorrhage or clot) • Stroke (brain hemorrhage or clot) • Mental illness • Mental illness • Trauma • Trauma • Medical Screening before surgery, • Medical Screening before surgery, • Oral and Dental Diseases • Oral and Dental Diseases • Lungs and Respiratory Diseases • Lungs and Respiratory Diseases • Ear, nose and throat (ENT) Diseases • Ear, nose and throat (ENT) Diseases • Diabetes • Diabetes • routing medical check-up • routing medical check-up • Others. (Specify) • More than one condition (more than more medical condition selected) • Unknown conditions (for missing values and people didn’t circle any answer)

159

Table 7. Travel related experiences for residents of Dubai, United Arab Emirates during their most recent trip overseas, 2009 - 2012 127. Type of Healthcare Categorical Categorical Service Provided  Inpatient (Inpatient treatment  Outpatient (no hospitalization) procedure “hospitalization”- surgical, Inpatient (therapeutic) treatment “hospitalization” non-  Inpatient treatment (hospitalization) surgical) surgical  Outpatient (Outpatient “no  Outpatient (no hospitalization) hospitalization” procedure consultation “therapeutic”, Outpatient “no  Inpatient treatment (hospitalization) non- hospitalization” consultation) surgical  Unknown (for missing values and people didn’t circle any answer) 130. Treatment coverage Categorical Categorical  Government (Governor's Diwan,  Other Government of Dubai, Federal  Governor's Diwan, Government of Dubai Ministry of Health, HAAD  Federal Ministry of Health  Other sources (Employer expense,  HAAD Own pocket or from your household  Employer expense budget, Other)  Own pocket or from your household budget 182. Services Wish to Be Categorical  Reasonable waiting time at the clinic Available in the UAE  Waiting time (Reasonable before seeing the doctor waiting time at the clinic before  Easiness of booking for an appointment seeing the doctor) (convenient, didn't take long time)  Healthcare Provider  Consultation and Diagnostic work-ups and Communication (Treating doctor treatment were all in the same building talked clearly to me about my  Treating doctor talked clearly to me about condition, Treating doctor gave my condition me different treatment options,  Treating doctor gave me different Treating doctor explained to me treatment options how I can cope, live normal life  Treating doctor explained to me how I can with my condition, Treating cope, live normal life with my condition doctor explained what might  Treating doctor explained what might happen to me in the future, The happen to me in the future medical staff was polite, and  The medical staff was polite, and courteous, The medical staff was courteous able to respond to my inquiries  The hospital called to report my results efficiently and referred me to the instead of me going to them right persons, The treating  The medical staff was able to respond to doctor was listening to me) my inquiries efficiently and referred me to  Hospitality (The facility the right persons “hospital, clinic” was clean and  The facility (hospital, clinic) was clean welcoming) and welcoming  Education & Reading Material  The treating doctor was listening to me (Availability of reading material  Availability of reading material on my on my condition in Arabic and condition in Arabic and English English)

 Convenient Atmosphere  Treating doctor was paying full attention to me (not distracted by phone or writing) (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)

160

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 High blood pressure + Diabetes 3 Cancer + Gastrointestinal Diseases 1 Cancer + Bone & Joint 2 Heart disease + Diabetes 4 Heart disease + Diabetes 4 Bone & Joint + High blood pressure 2 Heart disease + Urinary System Diseases (Kidney or Bladder) 1 High blood pressure + Gastrointestinal Diseases 2 Heart disease + Diabetes 4 Bone & Joint + Trauma 2 Cancer + Skin or Venereal Diseases 1 Bone & Joint + Diabetes 2 High blood pressure + Diabetes 3 Cancer + Ear, nose and throat (ENT) Diseases 1 Bone & Joint + Cosmetic Surgery 1 Heart disease + Diabetes 4 High blood pressure + Gastrointestinal Diseases 2 Cancer + Dental 1 Obstetrics and Gynecology + Ear, nose and throat (ENT) Diseases 1 Bone & Joint + Gastrointestinal Diseases 1 Cancer + Bone & Joint 2

Table 4F. Residents of Dubai, United Arab Emirates who were diagnosed with 3 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012

3 comorbidities Frequency 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

161

Heart disease + High blood pressure + Diabetes 4 Heart disease + High blood pressure + Diabetes 4 Cancer + High blood pressure + Diabetes 3 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 Cancer + High blood pressure + Diabetes 3 Heart disease + High blood pressure + Diabetes 4 Bone & Joint Diseases + High blood pressure + Diabetes 2

Table 4G. Residents of Dubai, United Arab Emirates who were diagnosed with 4 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012

4 comorbidities Frequency High blood pressure + Diabetes + Gastrointestinal Diseases + Lungs & Respiratory Diseases 1

Table 4H. Residents of Dubai, United Arab Emirates who were diagnosed with 5 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012

5 comorbidities Frequency High blood pressure + Diabetes + Gastrointestinal Diseases + Eye Diseases + Urinary System 1 Diseases (Kidney or Bladder) 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

2 comorbidities Frequency High blood pressure + Diabetes 2 Bone & Joint + High blood pressure 1 Diabetes + Stroke or Brain Hemorrhage 1 Gastrointestinal Diseases + Eye Diseases 1 Bone & Joint Diseases +Eye Diseases 1 Heart disease + Gastrointestinal Diseases 1 High blood pressure + Diabetes 2 Cancer + Bone & Joint 2 Heart disease + Diabetes 2 Heart disease + Diabetes 2 Heart disease + Urinary System Diseases (Kidney or Bladder) 1 High blood pressure + Gastrointestinal Diseases 1 Bone & Joint + Trauma 1 Cancer + Dental 1

162

Cancer + Bone & Joint 2

Table 4J. Residents of Dubai, United Arab Emirates who were diagnosed with 3 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012 who went to Federal Republic of Germany

3 comorbidities Frequency Cancer + High blood pressure + Diabetes 2 Diabetes + Gastrointestinal Diseases + Urinary System Diseases (Kidney or Bladder) 1 Heart disease + High blood pressure + Diabetes 3 High blood pressure + Diabetes + Obstetrics and Gynecology 1 Heart disease + High blood pressure + Diabetes 3 Bone & Joint Diseases + High blood pressure + Diabetes 1 High blood pressure + Diabetes + Urinary System Diseases (Kidney or Bladder) 1 Cancer + High blood pressure + Diabetes 2 Heart disease + High blood pressure + Diabetes 3

Table 4K. Residents of Dubai, United Arab Emirates who were diagnosed with 4 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012 who went to Federal Republic of Germany

4 comorbidities Frequency High blood pressure + Diabetes + Gastrointestinal Diseases + Lungs & Respiratory Diseases 1

Table 4L. Residents of Dubai, United Arab Emirates who were diagnosed with 5 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012 who went to Federal Republic of Germany

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

2 comorbidities Frequency Bone & Joint + Diabetes 3 Bone & Joint + Stroke or Brain Hemorrhage 1 Cancer + Diabetes 1 Eye Diseases + Stroke or Brain Hemorrhage 1 Cancer + Gastrointestinal Diseases 1 Bone & Joint + High blood pressure 1

163

Heart disease + Diabetes 2 Cancer + Skin or Venereal Diseases 1 Bone & Joint + Diabetes 3 High blood pressure + Diabetes 1 Cancer + Ear, nose and throat (ENT) Diseases 1 Bone & Joint + Cosmetic Surgery 1 Heart disease + Diabetes 2 Bone & Joint + Diabetes 3 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 comorbidities before travelling overseas seeking medical treatment during 2009 – 2012 who went to other countries of destination

3 comorbidities Frequency Heart disease + High blood pressure + Diabetes 1 Cancer + High blood pressure + Diabetes 1 Bone & Joint Diseases + Heart disease + High blood pressure 1 Bone & Joint Diseases + High blood pressure + Diabetes 1

164

Table 6E. Residents of Dubai, United Arab Emirates who were diagnosed with 2 comorbidities overseas seeking medical treatment during 2009 – 2012

2 comorbidities Frequency Cancer + Lungs and Respiratory Diseases 1 Cancer + heart diseases 5 Surgery + High Blood pressure 1 Skin or venereal Diseases + Mental illness 1 High blood pressure + Diabetes 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 + Surgery 3 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 Cancer +Bone & Joint Disease 9 Cancer +Bone & Joint Disease 9 Kidney Diseases + Lungs and Respiratory Diseases 2 Heart diseases + diabetes 2 Heart diseases + diabetes 2 Cancer + Urinary Tract system 1 Cancer +Bone & Joint Disease 9 Cancer +Bone & Joint Disease 9 Cancer + Gastro-Intestinal Diseases 6 Cancer + heart disease 5 Urinary Tract system + routing medical check-up 1 Cancer + Gastro-Intestinal Diseases 6 Gastro-Intestinal Diseases + High Blood pressure 1

165

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 Cancer + eye disease 3 Surgery + diabetes 2 Surgery + diabetes 2 Cancer + urinary tract disease 2 Cancer + surgery 5 Bone & Joint + surgery 3 Bone & Joint + Gastro-Intestinal Diseases 3 Cancer + ENT disease 1 Cancer +Bone & Joint Disease 9 Diabetes + routing medical check-up 1 Cancer +Bone & Joint Disease 9 Cancer + high blood pressure 1 Cancer + heart disease 5 Cancer + urinary tract disease 2 Cancer + Gastro-Intestinal Diseases 6 obstetrics and gynecology + surgery 1 Cancer + surgery 5 Cancer + Trauma 1 Surgery + Kidney disease 1 Bone & joint + Gastro-Intestinal Diseases 3 Cancer + Gastro-Intestinal Diseases 6 Cancer + eye disease 3 Cancer +Bone & Joint Disease 9 Cancer + Skin or venereal Diseases 1 Cancer + heart disease 5

Table 6F. Residents of Dubai, United Arab Emirates who were diagnosed with 3 comorbidities overseas seeking medical treatment overseas during 2009 – 2012

3 comorbidities Frequency Cancer + High blood pressure + Diabetes 3 Cancer + Neurological diseases & Neurosurgery +Bone & Joint Disease 1 Bone & Joint + heart disease + Stroke “brain hemorrhage” or clot 1 Cancer + High blood pressure + Diabetes 3 Cancer + Gastro-Intestinal Diseases + diabetes 1 Cancer + heart disease + Gastro-Intestinal Diseases 1 obstetrics and gynecology + High blood pressure + Diabetes 1 Heart disease + High blood pressure + Diabetes 2

166

Surgery + High blood pressure + Diabetes 1 Bone & joint + High blood pressure + Diabetes 1 Neurological diseases & Neurosurgery +Bone & Joint Disease + eye disease 1 Cancer + High blood pressure + Diabetes 3 Heart disease + High blood pressure + Diabetes 2 Bone & joint + high blood + diabetes 1

Table 6G. Residents of Dubai, United Arab Emirates who were diagnosed with 4 comorbidities overseas seeking medical treatment during 2009 – 2012

4 comorbidities Frequency 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 comorbidities overseas seeking medical treatment during 2009 – 2012

5 comorbidities Frequency 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 comorbidities overseas seeking medical treatment during 2009 – 2012

6 comorbidities Frequency Cancer + Neurological diseases & Neurosurgery + Bone + Joint + Kidney disease + high blood 1 pressure + Skin or venereal Diseases

Table 6J. Residents of Dubai, United Arab Emirates who were diagnosed with 7 comorbidities overseas seeking medical treatment during 2009 – 2012

7 comorbidities Frequency 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 Federal Republic of Germany

2 comorbidities Frequency Cancer + Lungs and Respiratory Diseases 1 Cancer + heart disease 5 Surgery + High blood pressure 1 Skin or venereal Diseases + Mental illness 1

167

High blood pressure + Diabetes 1 Cancer + heart diseases 5 Cancer + Gastro-Intestinal Diseases 2 Surgery + Medical Screening before surgery 1 Bone & Joint + surgery 2 Cancer + Neurological diseases & Neurosurgery 1 Cancer +Bone & Joint Disease 6 Bone & Joint + Surgery 2 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 Cancer +Bone & Joint Disease 6 Cancer +Bone & Joint Disease 6 Heart diseases + Diabetes 2 Heart diseases + Diabetes 2 Cancer + urinary tract diseases 1 Cancer +Bone & Joint Disease 6 Cancer + heart disease 5 Urinary tract disease + routing medical check-up 1 Cancer + Gastro-Intestinal Diseases 2 Gastro-Intestinal Diseases + High blood pressure 1 Neurological Diseases and Neurosurgery +Bone & Joint Disease 1 Cancer + eye diseases 1 Surgery + diseases 1 Bone & Joint + Gastro-Intestinal Diseases 1 Cancer +Bone & Joint Disease 6 Cancer + High blood pressure 1 Cancer + heart disease 5 Cancer + surgery 4 Cancer +Bone & Joint Disease 6 Cancer + Skin or venereal Diseases 1 Cancer + heart disease 5

168

Table 6L. Residents of Dubai, United Arab Emirates who were diagnosed with 3 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the Federal Republic of Germany

3 comorbidities Frequency Cancer + high blood pressure + Diabetes 3 Cancer + high blood pressure + Diabetes 3 obstetrics and gynecology + high blood pressure + Diabetes 1 Bone & Joint Disease + high blood pressure + Diabetes 1 Cancer + high blood pressure + Diabetes 3 Heart disease + high blood pressure + Diabetes 1

Table 6M. Residents of Dubai, United Arab Emirates who were diagnosed with 4 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the Federal Republic of Germany

4 comorbidities Frequency 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 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the Federal Republic of Germany

5 comorbidities Frequency Eye disease + kidney disease + Gastro-Intestinal Diseases + high blood pressure + high blood 1 pressure + Diabetes

Table 6O. Residents of Dubai, United Arab Emirates who were diagnosed with 6 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the Federal Republic of Germany

6 comorbidities Frequency Cancer + Neurological Diseases and Neurosurgery +Bone & Joint Disease + kidney disease + 1 high blood pressure + Skin or venereal Diseases

Table 6P. Residents of Dubai, United Arab Emirates who were diagnosed with 7 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to the Federal Republic of Germany

7 comorbidities Frequency Cancer + heart disease + kidney disease + urinary tract disease + high blood pressure + trauma 1 +diabetes

169

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

2 comorbidities Frequency Bone & Joint + Gastro-Intestinal Diseases 2 Cancer + Kidney disease 1 Cancer + Gastro-Intestinal Diseases 4 Cancer +Bone & Joint Disease 3 Kidney disease + Lungs and Respiratory Diseases 1 Cancer +Bone & Joint Disease 3 Cancer + Gastro-Intestinal Diseases 4 Kidney disease + urinary tract disease 1 Bone & joint + heart disease 1 Neurological Diseases and Neurosurgery 1 Cancer + eye disease 2 Surgery + Diabetes 2 Cancer + urinary disease 1 Cancer + surgery 1 Bone & joint + surgery 1 Cancer + Ear, nose and throat 1 Cancer +Bone & Joint Disease 3 Diabetes + routing medical check-up 1 Cancer + urinary tract disease 1 Cancer + Gastro-Intestinal Diseases 4 Obstetrics and gynecology Diseases + surgery 1 Cancer + trauma 1 Surgery + kidney disease 1 Bone & joint + Gastro-Intestinal Diseases 2 Cancer + Gastro-Intestinal Diseases 4 Cancer + eye disease 2

Table 6R. Residents of Dubai, United Arab Emirates who were diagnosed with 3 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to countries of destinations

3 comorbidities Frequency 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

170

Bone & joint + High blood pressure + Diabetes 1

Table 6S. Residents of Dubai, United Arab Emirates who were diagnosed with 4 comorbidities overseas seeking medical treatment during 2009 – 2012 who went to countries of destinations

4 comorbidities Frequency Cancer + eye disease + high blood pressure + Diabetes 1 Cancer + Gastro-Intestinal Diseases + Diabetes + routing medical check-up 1

171

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 0.17 15+ 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 0.80 15+ Illiterate or Cannot 9 (23.08) 4 (22.22) 5 (23.81) read and write

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 0.65 income 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

Cost of Treatment 0.97

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

172

Answering the survey 0.68

Self-reported 15 (31.91) 8 (34.78) 7 (29.17)

Family member 32 (68.09) 15 (65.22) 17 (70.83) reported 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 *Mean±Standard Deviation

173

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 known physician in the UAE

Variable Total Sample N (%) One week More than one P-value week 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

Marital Status 15+ 0.85

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 0.42 15+ 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 9 (23.08) 7 (23.33) 2 (22.22) and write

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 0.72 income 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

Cost of Treatment 0.38

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

Treatment Coverage 0.67

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

174

Answering the survey 0.42

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 1.00 Reported 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 *Mean±Standard Deviation

175

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

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.39

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 0.20 15+ 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 0.19 15+ Illiterate or Cannot 9 (23.08) 2 (20.00) 7 (24.14) read and write

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 0.19 Monthly income 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

Cost of Treatment 0.95

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

Treatment Coverage 0.29

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 0.75 survey Self-reported 15 (31.91) 4 (28.57) 11 (33.33)

176

Family member 32 (68.09) 10 (71.43) 22 (66.67) reported 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 *Mean±Standard Deviation

177

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

Variable Total Sample N (%) One week More than one P-value week 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

Marital Status 15+ 0.14

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 0.82 15+ 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+

Illiterate or Cannot read 9 (23.08) 6 (26.09) 3 (18.75) 0.73 and write

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 0.92 income 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

Cost of Treatment 0.63

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

Treatment Coverage 0.38

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

Answering the survey 0.70

178

Self-reported 15 (31.91) 8 (29.63) 7 (35.00)

Family member reported 32 (68.09) 19 (70.37) 13 (65.00)

Fisher's exact 0.76

Family Member 0.80 Reported 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 *Mean±Standard Deviation

179

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

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.78

Married 33 (70.21) 18 (72.00) 15 (68.18) Not Married 14 (29.79) 7 (28.00) 7(31.82) Fisher’s exact 1.00

Employment Status 0.28 15+ Not Working 35 (74.47) 17 (68.00) 18 (81.82) Working 12 (25.53) 8 (32.00) 4 (18.18) Fisher’s exact 0.33

Educational Level 0.46 15+ Illiterate or Cannot 12 (25.53) 7 (28.00) 5 (22.73) read and write

Up to high School 28 (59.57) 13 (52.00) 15 (68.18) College & Above 7 (14.89) 5 (20.00) 2 (9.09) Fisher’s exact 0.51

HH Average 0.72 Monthly income 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) Fisher’s exact 0.79

Cost of Treatment 0.13

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) Fisher’s exact 0.15

Treatment Coverage 0.04

Government 54 (81.82) 31 (91.18) 23 (71.88) Other 12 (18.18) 3 (8.82) 9 (28.13) Fisher’s exact 0.06

180

Answering the 0.86 survey Self-reported 22 (33.33) 11 (32.35) 11 (34.38)

Family member 44 (66.67) 23 (67.65) 21 (65.63) reported Fisher’s exact 1.00

Family Member 0.92 Reported Escorting 41 (95.35) 22 (95.65) 19 (95.00) Not escorting 2 (4.65) 1 (4.35) 1 (5.00) Fisher’s exact 1.00 *Mean±Standard Deviation

181

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

Marital Status 15+ 0.24

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 0.39 15+ 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 0.40 15+ Illiterate or Cannot 12 (25.53) 10 (25.64) 2 (25.00) read and write

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 0.03 Monthly income Lower Income 38 (57.58) 27 (50.94) 11 (84.62) Middle and High 28 ( 42.42) 26 (49.06) 2(15.38) Income Fisher's exact 0.032

Cost of Treatment 0.74

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

Treatment Coverage 0.27

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 0.83 survey

182

Self-reported 22 (33.33) 18 (33.96) 4 (30.77)

Family member 44 (66.67) 35 (66.04) 9 (69.23) reported Fisher's exact 1.00

Family Member 0.30 Reported 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 *Mean±Standard Deviation

183

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

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.72

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 0.40 15+ 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 0.98 15+ Illiterate or Cannot 12 (25.53) 4 (26.67) 8 (25.00) read and write

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 0.66 Monthly income 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)

Cost of Treatment 0.07

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

Treatment Coverage 0.07

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 0.85 survey

184

Person Travelled 22 (33.33) 7 (35.00) 15 (32.61) Oversea Treatment Family 44 (66.67) 13 (65.00) 31 (67.39) Member Fisher's exact 1.00

Family Member 0.53 Reported 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 *Mean±Standard Deviation

185

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 physician to the UAE

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

Marital Status 15+ 0.93

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 0.81 15+ 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

Educational Level 15+ 0.97

Illiterate or Cannot read 12 (25.53) 9 (26.47) 3 (23.08) and write

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 0.77 income 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

Cost of Treatment 0.43

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

Treatment Coverage 0.31

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

186

Answering the survey 0.18

Self-reported 22 (33.33) 18 (38.30) 4 (21.05)

Family member reported 44 (66.67) 29 (61.70) 15 (78.95)

Fisher's exact 0.25

Family Member 0.65 Reported 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 *Mean±Standard Deviation

187

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 physician in the UAE

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.87

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 0.20 15+ 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 0.18 15+ Illiterate or Cannot 6 (33.33) 1 (12.50) 5 (50.00) read and write

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 0.57 income 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

Cost of Treatment 0.46

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

Treatment Coverage 0.31

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

188

Answering the survey 0.11

Self-reported 4 (20.00) 3 (37.50) 1 (8.33)

Family member 16 (80.00) 5 (62.50) 11 (91.67) reported Fisher's exact 0.26

Family Member 0.13 Reported 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 *Mean±Standard Deviation

189

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 known physician in the UAE

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 -

Marital Status 15+ 0.72

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 0.10 15+ 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 0.52 15+ Illiterate or Cannot 6 (33.33) 6 (35.29) 0 (0) read and write

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 0.70 Monthly income 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

Cost of Treatment 0.21

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

Treatment Coverage 0.67

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 0.04 survey

190

Self-reported 4 (20.00) 3 (15.79) 1 (100.00)

Family member 16 (80.00) 16 (84.21) 0 (0) reported 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 - *Mean±Standard Deviation

191

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 physician to the UAE

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.87

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 0.81 15+ 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 0.25 15+ Illiterate or Cannot 6 (33.33) 3 (37.50) 3 (30.00) read and write

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 0.57 Monthly income 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

Cost of Treatment 0.57

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

Treatment Coverage 0.13

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 0.65 survey Self-reported 4 (20.00) 2 (25.00) 2 (16.67)

192

Family member 16 (80.00) 6 (75.00) 10 (83.33) reported Fisher's exact 1.00

Family Member 0.42 Reported 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 *Mean±Standard Deviation

193

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 visiting physician to the UAE

Variable Total Sample N (%) One week More than one P-value week 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

Marital Status 15+ 0.29

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 0.14 15+ 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

Educational Level 15+ 0.05

Illiterate or Cannot read 6 (33.33) 6 (50.00) 0 (0) and write

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 0.820 income 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

Cost of Treatment 0.58

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

Treatment Coverage 0.13

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

Answering the survey 0.03

194

Self-reported 4 (20.00) 1 (7.14) 3 (50.00)

Family member reported 16 (80.00) 13 (92.86) 3 (50.00)

Fisher's exact 0.06

Family Member 0.03 Reported 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 *Mean±Standard Deviation

195

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

Variable Total Sample N (%) Disagree Agree P-value

Gender 0.87 Male 12 (48.00) 5 (50.00) 7 (46.67) Female 13 (52.00) 5 (50.00) 8 (53.33) Fisher’s exact 1.00

Age m±SD* 41.84± 23.48 37.4± 17.41 44.8± 29.87 0.45

Marital Status 15+ 0.01

Married 15 (68.18) 5 (50.00) 10 (83.33) Not Married 7 (31.82) 5 (50.00) 2 (16.67) Fisher’s exact 0.17

Employment Status 0.48 15+ Not Working 16 (72.73) 8 (80.00) 8 (66.67) Working 6 (27.27) 2 (20.00) 4 (33.33) Fisher’s exact 0.64

Educational Level 0.35 15+ Illiterate or Cannot 2 (9.09) 0 (0) 2 (16.67) read and write

Up to high School 15 (68.18) 8 (80.00) 7 (58.33) College & Above 5 (22.73) 2 (20.00) 3 (25.00) Fisher’s exact 0.64

HH Average 0.32 Monthly income 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) Fisher’s exact 0.36

Cost of Treatment 0.59

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) Fisher’s exact 0.82

Treatment Coverage 0.04

Government 20 (80.00) 6 (60.00) 14 (93.33) Other 5 (20.00) 4 (40.00) 1 (6.67) Fisher’s exact 0.12

Answering the 0.1 survey Self-reported 10 (40.00) 6 (60.00) 4 (26.67)

196

Family member 15 (60.00) 4 (40.00) 11 (73.33) reported Fisher’s exact 0.12

Family Member 0.93 Reported Escorted 11 (73.33) 3 (75.00) 8 (72.73) Not escorted 4 (26.67) 1 (25.00) 3 (27.27) Fisher’s exact 1.00 *Mean±Standard Deviation

197

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 physician in the UAE

Variable Total Sample N (%) One week More than one week P-value

Gender 0.93 Male 12 (48.00) 10 (47.62) 2 (50.00) Female 13 (52.00) 11 (52.38) 2 (50.00) Fisher’s exact 1.00

Age m±SD* 41.84± 23.48 40.33± 25.28 49.75± 7.32 0.47

Marital Status 15+ 0.13

Married 15 (68.18) 11 (61.11) 4 (100.00) Not Married 7 (31.82) 7 (38.89) 0 (0) Fisher’s exact 0.26

Employment Status 0.26 15+ Not Working 16 (72.73) 14 (77.78) 2 (50.00) Working 6 (27.27) 4 (22.22) 2 (50.00) Fisher’s exact 0.29

Educational Level 0.78 15+ Illiterate or Cannot 2 (9.09) 2 (11.11) 0 (0) read and write

Up to high School 15 (68.18) 12 (66.67) 3 (75.00) College & Above 5 (22.73) 4 (22.22) 1 (25.00) Fisher’s exact 1.00

HH Average 0.07 Monthly income 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) Fisher’s exact 0.05

Cost of Treatment 0.33

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) Fisher’s exact 0.73

Treatment Coverage 0.28

Government 20 (80.00) 16 (76.19) 4 (100.00) Other 5 (20.00) 5 (23.81) 0 (0) Fisher’s exact 0.55

198

Answering the 0.50 survey Self-reported 10 (40.00) 9 (42.86) 1 (25.00)

Family member 15 (60.00) 12 (57.14) 3 (75.00) reported Fisher’s exact 0.63

Family Member 0.77 Reported Escorted 11 (73.33) 9 (75.00) 2 (66.67) Not escorted 4 (26.67) 3 (25.00) 1 (33.33) Fisher’s exact 1.00 *Mean±Standard Deviation

199

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

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.82

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 0.93 15+ 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 0.23 15+ Illiterate or Cannot 2 (9.09) 0 (0) 2 (13.33) read and write

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 0.90 Monthly income 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

Cost of Treatment 0.28

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

Treatment Coverage 0.50

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 0.05 survey

200

Self-reported 10 (40.00) 5 (71.43) 5 (27.78)

Family member 15 (60.00) 2 (28.57) 13 (72.22) reported Fisher's exact 0.08

Family Member 0.36 Reported 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 *Mean±Standard Deviation

201

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 physician to the UAE

Variable Total Sample N (%) One week More than one week P-value

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

Marital Status 15+ 0.82

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 0.93 15+ 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 0.21 15+ Illiterate or Cannot 2 (9.09) 1 (6.67) 1 (14.29) read and write

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 0.77 Monthly income 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

Cost of Treatment 0.90

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

Treatment Coverage 0.66

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 0.47 survey

202

Self-reported 10 (40.00) 5 (71.43) 5 (27.78)

Family member 15 (60.00) 2 (28.57) 13 (72.22) reported Fisher's exact 0.66

Family Member 0.36 Reported 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 *Mean±Standard Deviation

203

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 physician in the UAE

Variable Total Sample N (%) Disagree Agree 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 37.66±23.80 64.29±14.02 0.01

Marital Status 15+ 0.49

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 0.17 15+ 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 0.56 15+ Illiterate or Cannot 8 (44.44) 4 (36.36) 4 (57.14) read and write

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 0.36 income 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

Cost of Treatment 0.45

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

Treatment Coverage 0.90

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

Answering the survey 0.45

204

Self-reported 7 (31.82) 4 (26.67) 3 (42.86)

Family member 15 (68.18) 11 (73.33) 4 (57.14) reported Fisher's exact 0.63

Family Member 0.47 Reported 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 *Mean±Standard Deviation

205

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

Variable Total Sample N (%) One week More than one P-value week 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

Marital Status 15+ 0.69

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 0.42 15+ 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

Educational Level 15+ 0.51

Illiterate or Cannot read 8 (44.44) 7 (50.00) 1 (25.00) and write

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 0.77 income 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

Cost of Treatment 0.12

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

Treatment Coverage 0.96

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

206

Answering the survey 0.66

Self-reported 7 ( 31.82) 5 (29.41) 2 (40.00)

Family member reported 15 (68.18) 12 (70.59) 3 (60.00)

Fisher's exact 1.00

Family Member 0.53 Reported 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 *Mean±Standard Deviation

207

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 physician to the UAE

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 1.00

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 1.00 15+ 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 0.82 15+ Illiterate or Cannot 8 (44.44) 4 (44.44) 4 ( 44.44) read and write

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 0.12 Monthly income 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

Cost of Treatment 0.65

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

Treatment Coverage 0.19

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 0.65 survey Self-reported 7 (31.82) 3 (27.27) 4 (36.36)

208

Family member 15 (68.18) 8 (72.73) 7 (63.64) reported 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 *Mean±Standard Deviation

209

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 physician to the UAE

Variable Total Sample N (%) One week More than one P-value week 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

Marital Status 15+ 1.00

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 1.00 15+ 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

Educational Level 15+ 0.13

Illiterate or Cannot read 8 (44.44) 5 (41.67) 3 (50.00) and write

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 0.03 income Lower Income 16 (72.73) 13 (86.67) 3 (42.86) Middle and Higher 6 (27.27) 2 (13.33) 4 (57.14 ) Income Fisher's exact 0.05

Cost of Treatment 0.82

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

Treatment Coverage 0.90

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

Answering the survey 0.45

210

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 0.43 Reported 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 *Mean±Standard Deviation

211

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 physician in the UAE

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.87

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 0.50 15+ 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 0.62 15+ Illiterate or Cannot 9 (26.47) 3 (21.43) 6 (30.00) read and write

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 0.02 income Lower Income 33 (73.33) 18 (90.00) 15 (60.00)

Middle and Higher 12 (26.67) 2(10.00) 10 (40.00) Income Fisher's exact 0.04

Cost of Treatment 0.33

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

Treatment Coverage 0.26

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

212

Answering the survey 0.89

Self-reported 22 (48.89) 10 (50.00) 12 (48.00)

Family member 23 (51.11) 10 (50.00) 13 (52.00) reported Fisher's exact 1.00

Family Member 0.35 Reported 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 *Mean±Standard Deviation

213

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 physician in the UAE

Variable Total Sample N (%) One week More than a week P-value

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

Marital Status 15+ 1.00

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 0.57 15+ 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 0.76 15+ Illiterate or Cannot 9 (26.47) 8 (27.59) 1 (20.00) read and write

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 0.77 Monthly income 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

Cost of Treatment 0.36

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

Treatment Coverage 0.84

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

214

Answering the 0.94 survey Self-reported 22 (48.89) 17 (48.57) 5 (50.00)

Family member 23 (51.11) 18 (51.43) 5 (50.00 reported Fisher's exact 1.00

Family Member 0.58 Reported 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 *Mean±Standard Deviation

215

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 physician to the UAE

Variable Total Sample N (%) Disagree Agree P-value

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

Marital Status 15+ 0.93

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 0.96 15+ 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 0.36 15+ Illiterate or Cannot 9 (26.47) 3 (30.00) 6 (25.00) read and write

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 0.13 Monthly income 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

Cost of Treatment 0.12

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

Treatment Coverage 0.67

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 0.24 survey Self-reported 22 (48.89) 5 (35.71) 17 (54.84)

216

Family member 23 (51.11) 9 (64.29) 14 (45.16) reported Fisher's exact 0.34

Family Member 0.39 Reported 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 *Mean±Standard Deviation

217

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 physician to the UAE

Variable Total Sample N (%) One week More than a week P-value

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

Marital Status 15+ 0.93

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 0.96 15+ 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

Educational Level 15+ 0.10

Illiterate or Cannot read 9 (26.47) 4 (16.67) 5 (50.00) and write

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 0.69 income 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

Cost of Treatment 0.78

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

Treatment Coverage 0.58

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

218

Answering the survey 0.67

Self-reported 22 (48.89) 14 (46.67) 8 (53.33)

Family member reported 23 (51.11) 16 (53.33) 7 (46.67)

Fisher's exact 0.76

Family Member 0.13 Reported 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 *Mean±Standard Deviation

219

AA. Willingness to be diagnosed and treated for the case of Bone & Joint by a known physician in the UAE

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 known physician in the UAE Preference Total Sample N (%) 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 visiting physician to the UAE

Preference Total Sample N (%) Strongly Disagree 6 (12.77) Disagree 4 (8.51) Neutral 4 (8.51) Agree 23 (48.94) Strongly Agree 10 (21.28) 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

Preference Total Sample N (%) 1 Week 27 (57.45) 2 Weeks 14 (29.79) 1 Month 5 (10.64) 3 Months 1 (2.13) Total 47 (100.00)

220

EE. Willingness to be diagnosed and treated for the case of Cancer by a known physician in the UAE

Preference Total Sample N (%) Strongly Disagree 13 (19.70) Disagree 4 (6.06) Neutral 17 (25.76) Agree 21 (31.82) Strongly Agree 11 (16.67) Total 66 (100)

FF. Willingness to wait to be diagnosed and treated for the case of Cancer a known physician in the UAE

Preference Total Sample N (%) 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

Preference Total Sample N (%) Strongly Disagree 10 (15.15) Disagree 1 (1.52) Neutral 9 (13.64) Agree 28 (42.42) Strongly Agree 18 (27.27) Total 66 (100)

HH. Willingness to wait to be diagnosed and treated for the case of Cancer by a visiting physician to the UAE

Preference Total Sample N (%) 1 Week 47 (71.21) 2 Weeks 14 (21.21) 1 Month 4 (6.06) 6 Months 1 (1.52) Total 66 (100)

221

II. Willingness to be diagnosed and treated for the case of Neurological Diseases by a known physician in the UAE

Preference Total Sample N (%) Strongly Disagree 3 (15.00) Disagree 2 (10.00) Neutral 3 (15.00) Agree 7 (35.00) Strongly Agree 5 (25.00) 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 Preference Total Sample N (%) 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 visiting physician to the UAE

Preference Total Sample N (%) Strongly Disagree 5 (25.00) Disagree 2 (10.00) Neutral 1 (5.00) Agree 5 (25.00) Strongly Agree 7 (35.00) Total 20 (100.00)

LL. Willingness to wait be diagnosed and treated for the case of Neurological Diseases by a visiting physician to the UAE

Preference Total Sample N (%) 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 physician in the UAE

Preference Total Sample N (%) Strongly Disagree 3 (12.00)

222

Disagree 4 (16.00) Neutral 3 (12.00 ) Agree 10 (40.00) Strongly Agree 5 (20.00) Total 25 (100.00)

NN. Willingness to wait to be diagnosed and treated for the case of Eye Diseases by a known physician in the UAE

Preference Total Sample N (%) 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 physician to the UAE

Preference Total Sample N (%) Strongly Disagree 2 (8.00) Disagree 4 (16.00) Neutral 1 (4.00) Agree 9 (36.00) Strongly 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 physician to the UAE

Preference Total Sample N (%) 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 physician in the UAE

Preference Total Sample N (%) Strongly Disagree 7 (31.82) Disagree 3 (13.64)

223

Neutral 5 (22.73) Agree 4 (18.18) Strongly Agree 3 (13.64) Total 22 (100.00)

RR. Willingness to wait to be diagnosed for the case of General Surgery by a known physician in the UAE

Preference Total Sample N (%) 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 physician to the UAE

Preference Total Sample N (%) Strongly Disagree 5 (22.73) Disagree 3 (13.64) Neutral 3 (13.64) Agree 5 (22.73) Strongly Agree 6 (27.27) Total 22 (100.00)

TT. Willingness to wait to be diagnosed and treated for the case of General Surgery by a visiting physician to the UAE

Preference Total Sample N (%) 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 physician to the UAE

Preference Total Sample N (%) Strongly Disagree 8 (17.78) Disagree 5 (11.11) Neutral 7 (15.56)

224

Agree 20 (44.44) Strongly Agree 5 (11.11) Total 45 (100.00)

VV. Willingness to wait to be diagnosed and treated for the case of Heart Diseases by a known physician

Preference Total Sample N (%) 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 physician to the UAE

Preference Total Sample N (%) Strongly Disagree 3 (6.67) Disagree 5 (11.11) Neutral 6 (13.33) Agree 18 (40.00) Strongly Agree 13 (28.89) 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 Preference Total Sample N (%) 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.

225

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

226

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)

227

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)

228

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)

229

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

230

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? ______

231

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

RANK (1,2,3,… where 1=most REASON important) (1) (2) (3) (4) (5)

A) Geographical closeness to UAE

B) Have been there before

C) My homeland

Vacation aspect (resort, spa, shopping malls, D) massage, funfair, museums, Weather and climate is adaptable)

Friendly atmosphere (common language of E) 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

First second Third REASON important important important reason reason reason

A Different Treatment options

232

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

233

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

234

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/ b. Government/ c. Insurance Household Diwan

Treatment

Accommodation

Travel

235

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 Yes 1 treatment increased to (15,000) AED. Would you go abroad for treatment? No 2 Go to 134

Don't know 99 Go to 134

133 Suppose that the price of cancer Yes 1 Go to 135 treatment increased even further - to No 2 (21,000) AED, would you go abroad

for treatment? Don't know 99

134 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price of cancer treatment

increased to (12,000) AED. Would you Don't know 99 go abroad for treatment?

135 What would be the maximum price you Amount ______continue would be willing to pay for … cancer treatment abroad?

236

2. Neurologic Diseases and Neurosurgery

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

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:

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

136 Suppose that the price for the Yes 1 treatment of “Neuro” increased to (25,000) AED. Would you go abroad No 2 Go to 138 for treatment? Don't know 99 Go to 138

137 Suppose that the price for the Yes 1 Go to 139 treatment of “Neuro” increased even No 2 further - to (35,000) AED, would you go abroad for treatment? Don't know 99

138 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of “Neuro” increased to (20,000) AED. Don't know 99 Would you go abroad for treatment?

139 What would be the maximum price you Amount ______Continue

would be willing to pay for the treatment of “Neuro” abroad?

237

3. Pediatric Diseases:

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF HEART DISEASES FOR WHICH

THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

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:

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

140 Suppose that the price for the Yes 1 treatment of Pediatric disease increased No 2 Go to 142 to (19,000) AED. Would you go

abroad for treatment? Don't know 99 Go to 142

141 Suppose that the price for the Yes 1 Go to 143 treatment of Pediatric diseases No 2 increased even further - to (29,000)

AED, would you go abroad for Don't know 99 treatment?

142 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of Pediatric diseases increased to Don't know 99 (14,000) AED. Would you go abroad for treatment?

143 What would be the maximum price you Amount ______Continue would be willing to pay for the

treatment of Pediatric diseases abroad?

238

4. Bone and Joint Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

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:

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

144 Suppose that the price for the Yes 1 treatment of Bone and Joint diseases No 2 Go to 146 increased to (13,000) AED. Would you

go abroad for treatment? Don't know 99 Go to 146

145 Suppose that the price for the Yes 1 Go to 147 treatment of Bone and Joint diseases No 2 increased even further - to (17,000)

AED, would you go abroad for Don't know 99 treatment?

146 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of Bone and Joint diseases increased to Don't know 99 (11,000) AED. Would you go abroad for treatment?

147 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of Bone and Joint diseases abroad?

239

5. Hearth Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

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:

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

148 Suppose that the price for the Yes 1 treatment of Heart diseases increased No 2 Go to 150 to (30,000) AED. Would you go

abroad for treatment? Don't know 99 Go to 150

149 Suppose that the price for the Yes 1 Go to 151 treatment of heart diseases increased No 2 even further - to (45,000) AED, would

you go abroad for treatment? Don't know 99

150 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of Heart disease increased to (22,000) Don't know 99 AED. Would you go abroad for treatment?

151 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of Heart disease abroad?

240

6. Eye Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

READ TO RESPONDENT:

If the current price for pediatrics diseases treatment package in the UAE on average (consultation, investigations, admission, medicines) is (8,000) 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

152 Suppose that the price for the Yes 1 treatment of Eye diseases increased to No 2 Go to 154 (11,000) AED. Would you go abroad for treatment? Don't know 99 Go to 154

153 Suppose that the price for the Yes 1 Go to 155 treatment of Eye diseases increased No 2 even further - to (15,000) AED, would you go abroad for treatment? Don't know 99

154 Suppose that the price increase was Yes 1 less than the previous amount. Suppose the price for the treatment of No 2 Eye disease increased to (9,000) AED. Don't know 99 Would you go abroad for treatment?

155 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of Eye disease abroad?

241

7. Obstetrics and Gynecology Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

READ TO RESPONDENT:

If the current price for pediatrics diseases treatment package in the UAE on average (consultation, investigations, admission, medicines) is (7,000) 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

156 Suppose that the price for the Yes 1 treatment of OBGYN diseases increased No 2 Go to 158 to (10,000) AED. Would you go abroad for treatment? Don't know 99 Go to 158

157 Suppose that the price for the Yes 1 Go to 159 treatment of OBGYN diseases increased No 2 even further - to (13,000) AED, would you go abroad for treatment? Don't know 99

158 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of OBGYN diseases increased to (8,000) Don't know 99 AED. Would you go abroad for treatment?

159 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of OBGYN diseases abroad?

242

8. General Surgery

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

READ TO RESPONDENT:

If the current price for pediatrics diseases treatment package in the UAE on average (consultation, investigations, admission, medicines) is (5000) 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

160 Suppose that the price for the Yes 1 treatment of General Surgery increased No 2 Go to 162 to (7,000) AED. Would you go abroad for treatment? Don't know 99 Go to 162

161 Suppose that the price for the Yes 1 Go to 163 treatment of General Surgery increased No 2 even further - to (9,000) AED, would you go abroad for treatment? Don't know 99

162 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of General Surgery increased to (6,000) Don't know 99 AED. Would you go abroad for treatment?

163 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of General Surgery abroad?

243

9. KIDNEY TREATMENT PER SESSION

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF PEDIATRICS DISEASES FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

READ TO RESPONDENT:

If the current price for pediatrics diseases treatment package in the UAE on average (consultation, investigations, admission, medicines) is (550) 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

164 Suppose that the price for the Yes 1 treatment of Kidney per session No 2 Go to 166 increased to (650) AED. Would you go abroad for treatment? Don't know 99 Go to 166

165 Suppose that the price for the Yes 1 Go to 167 treatment of kidney per session No 2 increased even further - to (700) AED, would you go abroad for treatment? Don't know 99

166 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of Kidney per session increased to (600) Don't know 99 AED. Would you go abroad for treatment?

167 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of Kidney diseases per session abroad?

244

10. Gastro-intestinal Diseases

FOR INTERVIEWER: PLEASE TICK ON THE TYPE OF NEUROSURGERY FOR WHICH THE RESPONDENT TRAVELLED ABROAD FOR TREATMENT

Q. QUESTION RESPONSE CODE SKIP

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:

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

168 Suppose that the price for the Yes 1 treatment of GI increased to (4,500) No 2 Go to 170 AED. Would you go abroad for treatment? Don't know 99 Go to 170

169 Suppose that the price for the Yes 1 Go to 171 treatment of GI increased even further No 2 - to (6,500) AED, would you go abroad for treatment? Don't know 99

170 Suppose that the price increase was Yes 1 less than the previous amount. No 2 Suppose the price for the treatment of GI increased to (3,500) AED. Would Don't know 99 you go abroad for treatment?

171 What would be the maximum price you Amount ______Continue would be willing to pay for the treatment of GI abroad?

245

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

Circle all responses

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)

Do not read responses. Probe by asking “any other reasons” three times. Circle all responses

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 2) No Move to question 176

175. Do you know when you can get a refund?

Circle all responses

A) In case you changed your mind B) Operation not done

246

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?

Do not read responses. Probe by asking “any other reasons” three times. Circle all responses

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 2) No Move to question 179

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

247

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?

Do not read responses. Probe by asking “any other reasons” three times. Circle all responses

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)

248

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 Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

184. Preference for Healthcare Service in the UAE and Waiting Time for Neurologic Diseases and Neurosurgery

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

185. Preference for Healthcare Services in the UAE and Waiting Time for Pediatric Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

249

186. Preference for Healthcare Services in the UAE and Waiting Time for Bone and Joint Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

187. Preference for Healthcare Services in the UAE and Waiting Time for Heart Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

188. Preference for Healthcare Services in the UAE and Waiting Time for Eye Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

189. Preference for Healthcare Services in the UAE and Waiting Time Obstetrics and Gynecology Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

250

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

190. Preference for Healthcare Service and Waiting Time for General Surgery

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

191. Preference for Healthcare Service and Waiting Time for Kidney Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

Known Physician in the UAE

Visiting Physician

192. Preference for Healthcare Service and Waiting Time for Gastro-intestinal Diseases

Preferences Preference for diagnosis and treatment for the Preference for the diagnoses for the waiting case time

Choices SDA DA N A SA 1 2 1 3 6 Week Weeks Month Months Months

251

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.

Price (a). Thailand High Medium Low

High

Quality Medium

Low

Price (b). India High Medium Low

High

Quality Medium

Low

Price (c). Germany High Medium Low

High

Quality Medium

Low

Price (d). UK High Medium Low

High

Quality Medium

Low

252

Price (e). USA High Medium Low

High

Quality Medium

Low

194/195/196 Complete the Preference Table (rank your answers from 1 least preferable, to 5 most preferable)

Preferred Preferred Preferred Destination if I have Destination if Destination if the to pay for care insurance will cover government will pay myself treatment costs but for my care not travel, accommodation

194 195 196 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

253

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

254

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

255

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

256

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).

257

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

258

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.

259

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.

260

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)

261

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

262

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

263

Languages:  Arabic: Native speaker  English: Very competent and fluent in all four skills  Spanish: Beginner

264