Systematic Review of Healthcare Inequalities in Saudi Arabia: A Report

This report presents a systematic review of healthcare inequalities in Saudi Arabia, focusing on the disparities in access to healthcare for women. The methodology employed is a systematic review, chosen for its ability to critically evaluate evidence and address the research question: What are the existing healthcare inequalities among women of Saudi Arabia? The review utilizes electronic databases like Google Scholar, Medline, and CINAHL, with specific inclusion and exclusion criteria to ensure relevance. The research philosophy adopted is positivism, and the FINER formula is applied to refine the research question. The search strategy incorporates keywords, Boolean operators, and the PICO framework. The report includes a PRISMA flow diagram and thematic analysis, leading to recommendations for policymakers to improve healthcare quality and address inequalities within the KSA. The review analyzes the inequalities present within the healthcare system and guide the policy makers to adapt measures in order to alleviate the service quality and improve access to healthcare.

Running head: METHODOLOGY
METHODOLOGY
Name of the Student:
Name of the University:
Author Note:

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Methodology:
The chapter on Methodology forms one of the most important element of a
dissertation or a research thesis. The primary reason being this chapter provides an overview
to the methodology that would be undertaken to conduct the research. The researcher
critically conducts an exhaustive research on the available evidence base in order to choose
an appropriate methodology that is aligned to the research question and the articulated
research objectives (Adams et al., 2017). In order to address the articulated research question
and the devised research objectives, the systematic review research design was chosen as the
most appropriate methodology (Baronoy, 2015). The further sections of this chapter would
present a detailed overview about the rationale for the selection of the research study design,
the undertaken research philosophy and the search strategy in an elaborate manner. The
overall outcome of the research study intends to highlight the inequalities present within the
healthcare system and guide the policy makers to adapt measures in order to alleviate the
service quality and improve access to healthcare.
Rationale for the choice of methodology:
According to Boell & Cecez-Kecmanovic (2014), a systematic review is one of the
most appropriate research design methods that allows the researcher to critically evaluate the
evidence base in order to retrieve the most relevant and reliable information that is stringently
aligned to the research question and research objectives. Research studies further suggest that
while dealing with a social inequality issue, systematic reviews serve as the most appropriate
research design as they offer an insight into the status of the issue over the years (Colquhoun
et al., 2014; Dunne, 2011; Edson et al., 2016). The overall findings can prove to be extremely
effective for current policy makers to revisit the existing policies and introduce reforms. This
accounts for the major reason, why the research design was chosen as a systematic review. It

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can be expected that the systematic review would help in critically evaluating the gamut of
literature contained within the evidence base that deal with inequalities concerning access to
healthcare facilities within KSA.
Strategy for the Systematic Review:
In the words of Faden et al. (2013), the degree to which a systematic review can be
considered authentic is heavily dependent upon the devised search strategy. The search
strategy refers to the set of properties that are used for conducting the search on the electronic
database (Fink, 2019). In this case, the search for the relevant scholarly sources was
conducted on three electronic databases that included, Google Scholar, Medline and
CINAHL. Electronic databases can be defined as a store house of research journals that
provide a vivid insight into what has already been done in the research area of interest.
Knowing what already exists within the evidence base helps to identify the research gap and
accordingly adapt measures to design future research studies. Selection of appropriate
exclusion and inclusion criteria also form an important requisite as it helps to filter the search
and only retrieve the most relevant research materials.
As mentioned by Flick (2019), exclusion criteria are the set of properties that are used
for eliminating research studies that do not address the research question and the devised
objectives appropriately. In this case, the following set of exclusion criteria were followed:
Research articles that were published before 2009
Research articles that were published in foreign languages other than English
Research articles whose full-text versions were not accessible

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On the other hand, inclusion criteria can be explained as the set of properties on the
basis of which research articles are included within a systematic review. In this case, the
following set of inclusion criteria were followed:
Research articles that were published within the ten year time-frame from 2009-2019
Research articles that were published only in English Study
Research studies that were accessible for full-text
Research Philosophy:
As stated by Gray (2013), it has been mentioned that there are three broad categories
of research philosophies which include pragmatism, interpretivism and positivism. Research
studies suggest that while conducting a critical literature review any of the three types of
research philosophies can be integrated (Hughes & Sharrock, 2016; Pandilla-Diaz, 2015).
Research philosophy critically influences every aspect of a research study and that accounts
for the reason why the choice of research philosophy should be appropriate (Knobe &
Nichols, 2013). For addressing this research study the positive research philosophy type was
selected.
Before the choice of the research philosophy was made, the other two types of
research philosophies were duly considered. . Research studies state that the positive research
philosophy is associated with the measurement, observation as well as analysis of the
objective entities with the integration of the statistical and quantitative methodologies
(Saunders et al., 2015; Knobe & Nichols, 2013). On the other hand, the interpretivism
research philosophy is concerned with social construct theories which can be evaluated solely
through qualitative methods (Saunders et al., 2015). Pragmatist approach on the other hand is
outcome oriented and focuses on the original assumptions of the researcher and the degree to

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which the assumptions can be practically integrated to practice and are aligned to the research
question and objectives (Gray, 2013; Hart, 2018).
It can be stated that all the three research philosophies have their individual strengths
and limitations, however, before making the choice, it is integral to assess the strengths and
limitations of the research philosophies by critically aligning the philosophy to the articulated
research topic. Upon integration of the positivism research philosophy reliable and concrete
findings can be acquired (Gray, 2013; Prasad, 2017). On the other hand, upon adaption of the
interpretivism philosophy, a rich in-sight to the research findings can be acquired but this is
directly dependent on the statistical appropriateness (Baronov, 2015; Baronov, 2015).
Therefore, in order to validate the findings of this Critical Review of Literatures, the
Pragmatist Philosophical Orientation was adapted. The chosen philosophy is expected to
yield data triangulation and concrete insights which would help in eliminating the limitations
associated with the positivism or interpretivism research philosophy.
Research Question:
While devising a research question, it is extremely important to critically consider a
few elements that whether or not the devised research question is authentic and credible. It is
integral to ensure that the devised research question is feasible, interesting, novel, ethical and
relevant (Hughes & Sharrock, 2016). The research question was devised with the help of the
FINER formula. In this context, it should be noted that the primary aim of the research study
is to evaluate the existing inequalities in healthcare facilities among women within Saudi
Arabia. Therefore, the research question for the research study can be mentioned as,
What are the existing healthcare inequalities among women of Saudi Arabia?
FINER Formula:

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The FINER formula was used to formulate the research question. As per Edson et al.
(2016), the FINER formulate helps to critically examine the integral constituents of a
research question and accordingly deduce a research question. The FINER Formula
comprises of five components and the table below describes how each of the parameters were
critically satisfied to articulate an appropriate research question.
Component Description Example Achieved
(YES/NO)
Feasible >Devising a suitable
research design in
terms of parameters
such as resource
availability,
manageability and
scope
> It is feasible for
the researcher to
complete the
proposed research
within the deadline
with the use of the
available scholarly
resources
Yes
Interesting >Interests the
reviewer to pursue
the research study
and find relevant
solutions to the
research question
>The research topic
chosen for the
Critical Review of
Literatures interests
the researcher
Yes
Novel >The targeted
research area that is
being investigated
>It is expected that
novel insights would
emerge from the
Yes

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must be novel or
underexplored
conducted Critical
Literature Review
Ethical >Stringent
compliance with the
ethical standards and
guidelines
>This Critical
Literature Review
does not comprise of
data collection
procedure, therefore,
there is no violation
of ethical guidelines
Yes
Relevant >The findings must
inspire future
research and must
present relevant
recommendations
that can be put to
practical use
>This research study
devises
recommendation for
the Ministry of Saudi
Arabia for improved
quality of healthcare
practices
Yes
Search Strategy:
The search strategy for this systematic review was adapted according to the
articulated research objectives. Three research objectives were devised aligned to the research
question, and therefore a three-fold search strategy was employed for the successful
completion of the systematic review (Hart, 2018; Hughes & Sharrock, 2016; Knobe &
Nichols, 2013). Keywords for searching resources were generated according to the
objectives, so that the appropriate and relevant resources could be obtained through the

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search strategy (Boell & Cecez-Kecmanovic, 2014). The search was conducted on the
electronic databases using the specific exclusion and inclusion criteria and the devised key-
terms. In addition to this, the PICO framework was devised which helped to assess the
qualitative and the quantitative scholarly evidences that were gathered within the review
(Kumar, 2019;Lorenzetti et al., 2014) . Apart from these scholarly resources, other
bibliographic aids such as newsletters and government website information was also
considered to be included within the systematic review (McCusker & Gunaydin, 2015;
McGowan et al., 2016). This was done so as to ensure that all important informations are
incorporated within the systematic review.

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PRISMA
Total articles originally retrieved from
two databases 20
Number of duplicates removed (n
= 18)
Full articles retrieved for further
examination (n = 16)
Papers not relevant after review of
title ( n =2 )
Papers retrieved for detailed
examination (n = 18)
Full articles retrieved for further
examination by JBI critical analysis tool
(n=15)
Papers included in the
review (n = 11 )
Papers excluded for not meeting
the inclusion criteria through
abstract review (n =1 )
Papers excluded after the
assessment of quality (n =4)

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PICO Question:
P Population Proportion of female population of KSA
What proportion of female population in KSA
experience poor access to healthcare and are
affected with health inequalities?
I Intervention Access to primary healthcare facilities
What proportion of female population in KSA
have proper access to primary healthcare
facilities?
C Comparison Overall access and quality of healthcare
among the proportion of men in KSA
What is the percentage of healthcare access in
men against women in KSA?
O Outcome Positive health outcome, patient satisfaction
level
What is the current healthcare mortality rate of
women compared to men in KSA?
Data Sources:
It is a critical task to identify and recover the appropriate research studies that must be
incorporated within the systematic review. However, electronic databases can be used to
simplify the work and reduce the time needed by integrating them in a number of

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computerized functions significantly (O’Donnell, 2014; Pandilla-Diaz, 2015). The following
electronic databases were used to conduct this systematic review: first, CINAHL, which
includes a large collection of journal research in the biomedical, pharmacological, nursing,
and medical areas; second, Google Scholar health and medical studies data database; and
third, MEDLINE, which includes research in lifestyle; and (Lorenzetti et al., 2014).
Keywords:
The following keywords that were used to conduct a search on the electronic
databases included the following:
Health inequalities, health disparity, poor health outcome, health status of women, Saudi
Arabia, trends in healthcare, patient outcome, morbidity, mortality of women, access to
healthcare facilities, primary healthcare, healthcare service provision, effective healthcare
intervention
Boolean Operators:
Three Boolean operators (i.e. AND, OR and NOT) as well as the truncation symbol
(i.e. *) were applied to connect keywords in order to refine the search and obtain relevant
results (O'Donnell, 2014). As per, Prasad (2017), Boolean operators are connectors that help
to combine two key words which helps in acquiring the most relevant research studies that
are critically aligned to the articulated research question. Electronic databases are not
equipped with advanced ability to understand long and complex phrases or sentences
(Saunders et al., 2015;Sharif et al., 2013; Smith et al., 2011). This accounts for the main
reason why the Boolean operators are used in combination with the key terms so that the
most relevant paper can be retrieved (Shea et al., 2017; Silverman, 2016). Boolean operators
were used for refining search for example, Health Inequalities OR Health Discrepancy AND

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mortality of women. In the similar manner, the Boolean operators were used in combination
with the different search terms in order to retrieve relevant research results.
Article evaluation strategy:
The first step that was followed while conducting the screening comprised of
eliminating all the duplicates from the retrieved scholarly journals. After the elimination of
the duplicates, the reference lists of all the included research studies were scanned thoroughly
so as to as include any important article that would otherwise be ignored (Supino & Borer,
2012; Vaismoradi et al., 2016; Walliman, 2017). This method of adding important research
articles after the revision of the reference list is known as the Snowball technique. This
technique is important as the electronic databases are continuously updated which might lead
to overlooking certain important data. The third step consisted of a reading of the abstracts of
each other and then excluding any article which did not fulfil either the requirements for
inclusion or exception. Finally, complete texts were collected and examined against
incorporation and exemption requirements for each article which met the aforementioned
requirements (Fink, 2019). The systematic review included those papers that were left at the
end of this phase.
Limitations of search strategy:
The inexperience or absence of in-depth knowledge of the researcher may constitute
as a considerable limit that affected the quality of systematic review, particularly when it
comes to the choice and evaluation of the appropriate documents. Thus, although the current
examiner knows about healthcare management and the current literature on health, it should
be acknowledged that the critics ' absence of expertise in carrying out projects of this nature
is a major restriction of the systematic review. Moreover, the expansive nature of the
materials required for screening and evaluation led to time limits for this systematic review

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(McGowan et al., 2016). Moreover, since several reviewers were unable to finish this
systematic review, it has not been feasible to corroborate search findings as well as critical
assessment and topic analysis and this offers room for research biases. However, these
constraints can be ignored as the researcher made use of the best resources which was
permissible within the stipulated time limit.
Quality Appraisal:
The researcher made use of the JBI critical appraisal checklist in order to evaluate the
quality of the research studies that were included within the Systematic review. Typically, the
appraised research studies comprised of Quantitative, Qualitative and primary observational
and cross sectional studies. The Researchers used the recently developed International
Narrative Systematic Assessment (INSA) instrument to assess critically narrative literature
reviews (NLRs) (Shea et al., 2017). The researcher conducted the private evaluations and
evaluations with the use of remarks and casual notes to classify resources based on perceived
quality, in conjunction with the critique assessment checklist. One of the limitations would
include lack of another independent reviewer to assess or appraise the quality of the research
studies that was included within the systematic review. However, based on the checklists, the
researcher critically appraised each of the research studies that was integrated within the
review and on completion of the critique ranked the research studies in terms of the level of
evidence. The rationale for the same can be explained as the use of a combination of
appraisal schemes to clearly assess the quality of evidence that was integrated within the
systematic review.
Thematic Analysis:
Data assessment for the systematic review can be carried out in a number of respects,
but a so-called thematic literature review was decided for this evaluation. It was the suitable

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choice because it encouraged comfort for the researcher and at the same time, guaranteed a
logical framework while presenting the outcomes of the review and safeguarded the efficient
information synthesis against a sequence of easy descriptions for the included research
(Vaismoradi et al., 2016). Therefore, patterns were recognized and synthesized from
assessment by the reviewers of included research using an organized methodology as theme
assessment to help the thematic literature review.
Ethical Consideration:
A range of ethical factors need to be taken into consideration when study projects
involve human topics. These include the participants ' right to stay anonymous, to withdraw
from the research, and to keep their data confidential. However, since the current systematic
review did not cover human subjects and only previously published research articles collected
data, those specific considerations were not relevant, and the evaluator was not required, in
particular, to uphold the ethical principles of the Health and Social Care Framework for
Research Governance (2005) of the Department of Health (Faden et al., 2013). Consequently,
examiners did not need ethical authorisation from the research ethics committee of the
university to perform the systematic review. Consequently, examiners did not need ethical
authorisation from the research ethics committee of the university to perform the systematic
review majorly because the research design was not primary in nature and did not involve
human subjects.
Potential Outcome:
Therefore, on completion of the systematic review, it is expected that from the
evidence base a detailed statistical interpretation of the data can be retrieved associated with
the overall morbidity and mortality of women within Saudi Arabia on account of drastic
healthcare inequalities. In addition to this, it is also expected that the cumulative findings of

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the research study would also help in discussing in detail the causative reason behind the
existing health inequalities between the men and women of KSA. It would also help to
understand the underlying cause of inequality in the context of political, social as well as
across the physical healthcare domain. Lastly, the systematic review would critically
highlight the efforts that have been undertaken by the KSA government till date to address
the inequalities of healthcare facilities between the men and women within KSA. This would
help to identify the existing gaps within the healthcare system which would help to revisit the
existing healthcare policies and adapt measure to improvise the quality of healthcare delivery.
Conclusion:
Therefore, to conclude, it can be mentioned that this review would critically analyse
the existing healthcare disparity prevailing between the adult male and female population
within KSA. The overall findings would help to identify the existing gaps within the
healthcare system which have contributed to the reduction of access to healthcare facilities
and deterioration of the standard of living status for the women population based at Saudi
Arabia. Therefore, to sum up this systematic review would offer an overview to policy
makers to revisit the existing policies and introduce reforms so as to alleviate the standard of
living and aces to healthcare facilities for the women of Saudi Arabia.

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