Health Science

Communication

Biosci. Biotech. Res. Comm. 9(4): 587-595 (2016)

Association between demographic characteristics

and health status of uninsured expatriate workers

in Saudi Arabia

Abdulwahab A. Alkhamis

and Shaima S. Ali Miraj

Supervisor Public Health Department and University Branches Department of Public Health,College of

Health Sciences, Saudi Electronic University, PO Box 93499 Riyadh,11673 Saudi Arabia

Assistant Professor, Department of Public Health, College of Health Sciences, Saudi Electronic University,

PO Box 93499 Riyadh, 11673 Saudi Arabia

ABSTRACT

Health insurance in Saudi Arabia is characterized by serious reforms, as the country has undergone major expan-

sion of its healthcare system. Despite enormous positive developments like introduction of compulsory health bene t

scheme for all, healthcare is still in its nascent stage in the Kingdom and little is known about user demographics

of the uninsured expatriate workers and its association with their health status. The present study has attempted to

highlight the impact of certain key demographic factors such as age, educational level, nationality and language

pro ciency on the health status of non-insured expatriates working in Saudi Arabia. A cross-sectional survey with

a multi-stage strati ed cluster sampling technique was used with veri ed questionnaires. Our  ndings indicate that

important characteristics such as age, education, nationality and language, are associated with an individual’s health

status. The analysis of these demographic factors impacting health insurance of expatriates will help in determining

successful and bene cial working of health insurance and its accessibility with regard to ever increasing expatriate

participation in future.

KEY WORDS: DEMOGRAPHIC, CHARACTERISTICS, UNINSURED, EXPATRIATES, SAUDI ARABIA

587

ARTICLE INFORMATION:

*Corresponding Author: s.miraj@seu.edu.sa

Received 28

Nov, 2016

Accepted after revision 27

Dec, 2016

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2015: 3.48 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

588 DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Abdulwahab and Ali Miraj

INTRODUCTION

Not long ago, the World Bank supported the extension

of role of private health insurance in many developing

countries. As a result, some employers in these coun-

tries provide health insurance as a tool to attract profes-

sional workers. Saudi Arabia attracts a large number of

additional expatriates, both skilled and unskilled, in the

hope of seeking employment for  nancial security. Lit-

erature suggests that expatriates have increased health

risks related to leaving their home countries, (Sekhri and

Savedoff 2005, Sommers et al 2012 and Baicker, 2013).

Of late, there has been a resurgence in the role of pri-

vate health insurance companies in providing better ser-

vices to their clients, as in most high and middle income

countries they are now required to provide supplemen-

tary or complementary coverage to primarily, social or

national health insurance systems, with the exception

of the United States, (Bassett and Kane 2007, Thomson

et al 2009, Levy and Janke 2016, Alkhamis et al 2014,

Alkhamis 2016 and Sa 2016).

In a time when global disease burden is immense,

health insurance provides valuable risk coverage against

expenditure caused by any unforeseen medical emer-

gencies. Having health insurance is important for sev-

eral reasons, though these may vary in both developed

and developing economies. It is the poor and most vul-

nerable who are at greatest risk owing to lack of protec-

tion against the impoverishing effects of illness. People

who are uninsured are more likely to have worse health

outcomes, delayed access to care and are more likely to

receive less medical care than the insured ones. Health

care providers do not care about the uninsured people

due to  nancial implications (Bassett and Kane, 2007and

Thomson et al 2009).

The role of private health insurance in access to

healthcare varies among developing and developed

countries, and has been deliberated in different sur-

roundings (Thomson et al 2009; Schoen et al 2010. Dor-

herty 2011, Berkhout and Oostingh, 2008; Drechsler and

Jütting 2005; Islam 2007 and Smith, 2007).

Saudi Arabia shares characteristics of both high and

low-income countries as recently Alkhamis (2012) and

Alkhamis et al (2014) have reported. It has attempted

to seriously reform its private healthcare system and

reduce expatriate access to government resources

through the provision of Compulsory Employment

Based Health Insurance (CEBHI). CEBHI was announced

in 1999; however, it could not be implemented until

2006, when it was carried out in phases according to

company size, similar to the plan used for implementing

compulsory healthcare in Korea (Jeong and Niki, 2012).

Consequently, by November 2008, all companies had to

provide health insurance to their employees regardless

of their company’s size and could not renew their work-

ers residency permit unless they were insured (Cabinet

of Ministers, 1999). Despite widespread adoption of this

policy, employer provided healthcare is still in its nas-

cent stage in the Kingdom, knowledge of controlling

factors becomes vital to determine the successful expan-

sion of employer-provided healthcare and its funding,

(Alkhamis et al 2014, TCCHI 2009, Gallagher 2002,

Alkhamis 2016 and Sa 2016).

As there is no data-based information regarding the

demographic characteristics of uninsured expatriate

workers working in the Kingdom, the present study has

been attempted to identify the important demographic

associations of the uninsured expatriates, in context to

their health status by means of utilization of health ser-

vices by them. Lack of awareness is a major factor of the

low acceptance of health insurance. Thus, an increase in

awareness of the expatriates, with more information on

demographics, would be vital for proper dissemination

of health insurance and its associated bene ts in future.

Earlier studies elsewhere have highlighted the associa-

tion between low health literacy and age, race, language

and education, (Kunter and White 2003, Levy and Janke

2016, McCormack 2009, Paez et al 2014, Quinn et al

2000, Agency for Healthcare Research and Quality 2009,

Short 2004, The Economist 2014, Kenney et al 2010,

Health Insurance Coverage in the United States 2013).

It is pertinent to state that understanding of demo-

graphic characteristics constitutes one of the most

important pillars of any successful healthcare model.

The expatriate population in Saudi Arabia is unique

because not only does this population dominate the

private sector, but expatriates in Saudi Arabia are also

young, have limited education and face more health

problems despite having health insurance because of a

lack of awareness of its proper bene ts

United Nations,

World Population Prospects, 2008; Ministry of Labour

Riyadh, 2009 and Alkhamis et al 2014).

In this paper we present the results of a cross-sec-

tional survey conducted on a representative sample of

uninsured expatriate workers belonging to different

trades in Riyadh, the capital of Saudi Arabia. This inves-

tigation of their health insurance status along with its

associations with demographic factors was conducted

out of public interest and to gain important information

on the lacunae for low penetration of health insurance

in expatriates.

METHODOLOGY

To test the outcomes, veri ed questionnaires were given

to the uninsured expatriate population working in com-

panies representing nine different trades, namely agri-

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS 589

Abdulwahab and Ali Miraj

culture, mining, industry, construction, transportation,

 nancial services, personal services, trade, and elec-

tricity.

All companies that provide healthcare-oriented

services such as hospitals, clinics, eye doctors, and

pharmacies were excluded. Economic sector/industry

classi cation was based on the third revision of the

International Standard Industrial Classi cation (ISIC) of

all economic activities, which has been used to stand-

ardise the collection and reporting of statistics (Ministry

of Labour Riyadh, 2009; Health Insurance Coverage in

the United States, 2013). To determine the sample size, a

multistage strati ed sampling method was used for the

employee population working in the above-mentioned

industrie

s. The study strati cation was based on busi-

ness type, company size and number of employees. The

companies’ size and economic sectors were randomly

selected from the Ministry of Labour database; these

names were concealed and coded. The code of the com-

panies was known only to the Manager of the Statistics

Department of the Ministry of Labour.

The participating companies identi ed from this

database were registered in Riyadh. Riyadh was selected

because it represented more than one third of the expa-

triate population working in Saudi Arabia (Ministry of

Labour Riyadh, 2009). It has a population of over 5.0

million, from which a total of 4,737 participants were

selected. The expatriate workers belonged to countries

from the Asian subcontinent including India, Paki-

stan, Bangladesh, Sri Lanka, and the Philippines; Arab

nations including Egypt, Yemen, and Africa; and West-

ern countries. They were selected randomly, representing

a homogenous group. The present study included only

male expatriates working in the private sector. Female

expatriates, the elderly and children were excluded from

the sample because men dominate the expatriate work-

force in the private sector (98.30% of all expatriates in

the private sector).

The questionnaire was adapted from the Medical

Expenditure Panel Survey (MEPS), and was translated

into six dominant expatriate languages, namely Urdu,

Hindi, Bengali, Malayalam, Arabic and English (Agency

for Healthcare Research and Quality, 2009). The total

sample size was 4,737, out of which 4,575 responded

to the questionnaire prepared, as per standard proto-

col of MEPS. Among the 4,575 respondents, 1,370 were

uninsured and 3,205 were insured. In the current study,

sample size of 1370 uninsured was used. The selected

questionnaire had comparable sections on parameters

representing demographic factors such as age, educa-

tion, nationality, marital status and language pro -

ciency measured for stating difference among the unin-

sured expatriate population across various segments

Similarly outcome measures for health service utiliza-

tion characteristics included Medicare, visit to clinic in

last one year, hospitalization in last one year or above,

reimbursement for payment made and percentage of

reimbursement to evaluate the differences among vari-

ous demographic characteristics of the uninsured sam-

ple population. In the present study, frequencies and

percentages were calculated for the responses collected

from these uninsured respondents. Statistical Package

for the Social Sciences (SPSS) software version 16.0 was

used to analyse the coded data.

RESULTS

The average age of the study population was 36 years.

It was found that an average 22.2 % of the expatriates

were less than 30 years old. The maximum number of

employees found was in age group of 31 to 40 years with

a frequency distribution of 46.3%. It was also observed

that in the age group of 50 years and older, the percent-

age of insured expatriates two times greater than that of

the uninsured (Table 1).

Comparing the categories on basis of educational

quali cation among uninsured individuals from the

sample population, it was found that 74% of the inter-

viewed people were either illiterate, had elementary

level education or had education up to higher secondary

level. In comparison people having technical diploma/

graduation or above were only 26%. The data based on

nationality demonstrated that majority of expatriates

were non-Arabs (69%) maximum being from Bangla-

desh, followed by India and Pakistan. Among the Arab

origin expatriate population, majority of them were

from Egypt, followed by Yemen (Table 1).

On analysing the criteria for language pro ciency, it

was observed that 93% of the sample uninsured popu-

lation was comfortable speaking in Arabic. Comparing

the same for English as a medium of communication,

just 33% were pro cient in it (Table 1). Comparing the

marital status among the uninsured people it was found

that 82% were married, with about 71.3% were living

without their family. The uninsured expatriates were

then compared on the basis of certain outcome meas-

ures based on the utilization of health services. The two

most important criteria among the demographical fac-

tors, age and educational quali cations were compared

to evaluate their in uence on  ve important variables

representing health services utilization namely: medical

care, number of clinical visits in a year, number of hos-

pitalizations in a year, whether reimbursed for expenses

made for hospitalization and percentage of reimburse-

ment made for the same. Interesting observations were

noticed. On comparing the medical care, just 12.2% of

the subjects con rmed of seeking medical care. Among

them, 57.2% belonged to 31 to 45 years of age, followed

590 DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Abdulwahab and Ali Miraj

months, maximum number of visits were observed in 31

to 45 years age group, followed by younger people. Sim-

ilar trends were observed in clinical visits made between

6 to 12 months and > 1 year time period as well (Table2).

Another signi cant observation made was that

among the 1370 sample population, across all age

groups, 28.7% people af rmed on visiting clinic only

after more than one year or more. In comparison, 17.8%

visits were made between 6 to 12 months, followed by

14.3% visits made before 6 months. On evaluating the

outcome of hospitalization, it was found that 32.2%

responded to have sought it. Among them, maximum

people to have undertaken hospitalization were from 31

to 45 years (Table 2).

Similarly when evaluated for reimbursement made

for treatment, a majority of 57.6% people among the

insured sample population con rmed to have been reim-

bursed for payment made, with maximum percentage

(62.8%) being between 31 to 45 years of age. Similarly

on evaluating for percentage of payment, 57% of the

uninsured people received partial payment as compared

to full amount reimbursed for the payment made for

hospitalization/ treatment, (Table 2).

On comparing the outcome measures on the basis of

educational quali cations of the uninsured expatriates,

it was observed that 57.7% people who were hospital-

ized had up to higher secondary educational quali ca-

tions in comparison to 26.3% people hospitalized who

had higher quali cations. Comparing the same on the

basis of reimbursement made for treatment, full reim-

bursement was found in 51.3% having higher quali -

cations. Similarly even among partial reimbursement

made, 47.8% people having higher quali cation fared

better than their counterparts, (Table 3).

DISCUSSION

In the entire Middle East region, comprising of the

major six GCC countries, the evidence related to health

insurance is very scanty because of lack of research in

this area. Our study provides estimates of the impor-

tant demographic characteristics associated with the

health status of expatriates. We have tried to exam-

ine the involvement of age, quali cations, language

and nationality of the uninsured expatriates for seek-

ing health bene ts by utilization of services. Therefore,

the present work contributes signi cantly by providing

relevant information that can be used by health policy

makers. Among the uninsured sample population, the

middle-age group (30 – 50 years) was in majority rep-

resenting 73% of the sample size without having insur-

ance which interestingly was also the one having up

to secondary level (representing nearly 72%). These

lower levels of education level among these respondents

Table 1: Socio-demographic characteristics of uninsured

expatriate employees working in Riyadh, KSA.

Demographic Characteristics Uninsured

Expatriates

n = 1370

Age (in years) No. (In Percentage)

18-30 303(22.2%)

31 – 40 635(46.3%)

40– 50 367(26.8%)

51- 60 58(4.2%)

60+ 7(0.5%)

Education Level

Illiterate 14(1%)

Elementary 463(33.8%)

Up to Secondary /HS schooling 536 (39.1%)

Technical Diploma/Graduate 340 (24.8%)

Post Graduate and Above 17(1.2%)

Nationality (Non-Arab Nations)

India 351(25.6%)

Bangladesh 402(29.3%)

Pakistan 141(10.5%)

Philippines 20(1.4%)

Others 60(4.4%)

Total (In No.) 974

Arab Origin Nations

Egypt 216(15.7%)

Yemen 63(4.6%)

Other Arabs 117(8.5%)

Total (In No.) 396

Language Pro ciency

(Comfortable in conversing)

Arabic 1276 (93%)

English 451 (33%)

Marital Status

Unmarried/ Divorced/Widower 247 (18%)

Married with family in KSA 146 (10.7%)

Married without family in KSA 977 (71.3%)

TOTAL 1370

by 27.1 % people seen from the younger age group of

less than 30 years followed by 16% seen in people with

age group > 45 years (Table 2).

On evaluating frequency of visits to medical clinics in

a year, it was observed that 39% among the uninsured

sample size of 1370, never visited any clinic over one

year or more for treatment in comparison to 61% who

went to clinic to seek treatment. Comparing the same

on the basis of the age group, interesting observations

were seen. When evaluated for clinical visits less than 6

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS 591

Abdulwahab and Ali Miraj

Table 2: Frequency distribution of uninsured expatriates according to age with certain outcome measures.

AGE GROUPS 18-30 31-45 45-60 >60 Total

OUTCOME MEASURES n=1370

Medical care seeked NO (87.8%) 320 (26.5%) 771 (64%) 109

(9.05%)

4 (0.33%) 1204

YES (12.2%) 45 (27.1%) 95 (57.2%) 25

(15.06%)

1 (0.60%) 166

CLINIC VISITS PER YEAR NEVER (39%) 198 (37%) 291 (54.3%) 45 (8.4%) 1 (0.1%) 535

<6 MONTHS(14.3%) 53 (26.9%) 128 (64.9%) 15 (7.6%) 1 (0.5%) 197

6-12 MONTHS (17.8%) 38 (13.93%) 176 (72.13%) 29 (11.8%) 1 (0.4%) 244

>1YEAR (28.9%) 76(19.2%) 271(68.7%) 45(11.4%) 2 (0.5%) 394

HOSPITALIZATION

PER YEAR

NO (67.8%) 274 (29.4%) 562(60.4%) 90 (9.7%) 3(0.3%) 929

YES (32.2%) 91(20.6%) 304 (68.9%) 44(9.9%) 2(0.4%) 441

REIMBURSEMENT NO (42.4%) 31(16.5%) 145(78.05%) 10(5.3%) 2(1%) 188

YES (57.6%) 60(23.7%) 159(62.8%) 34(13.4%) 0 (0%) 253

% OF REIMBURSEMENT FULL (43%) 23(21.1%) 74 (67.8%) 12(11%) 0 (0%) 109

PARTIAL (More than 50%)

(36.3%)

20(21.7%) 58(63%) 14(15.2%) 0 (0%) 92

PARTIAL (Less Than 50%)

(20.7%)

17(32.6%) 27(51.92%) 8 (15.3%) 0 (0%) 52

Table 3: Frequency distribution of uninsured expatriates according to their educational quali cations with outcome

measures.

Educational

Quali cation

Illiterate Elementary Upto HS Diploma/

Graduate &

Above

TOTAL

Outcome Measures n=1370

Medical care NO (87.8%) 10 (0.83%) 399 (33.1%) 476 (39.5%) 319 (26.4%) 1204

YES (12.2%) 4(2.4%) 64(38.5%) 60 (36.1%) 38(22.8%) 166

WENT to CLINIC in LAST

1 YEAR

NEVER (39%) 7(1.3%) 191(35.6%) 204 (38%) 134(25%) 536

<6 MONTHS(14.3%) 1(0.5%) 66(33.6%) 73(37.2%) 56(28.5%) 196

6-12 MONTHS (17.8%) 1(0.4%) 74(30.3%) 110(45.1%) 59(24.2%) 244

>1YEAR (28.9%) 5(1.26%) 132(33.5%) 149(37.8%) 108(27.4%) 394

HOSPITALIZED IN LAST

1 YEAR

NO (67.8%) 12(1.29%) 323(34.7%) 353 (37.9%) 241(25.9%) 929

YES (32.2%) 2(0.5%) 140(31.7%) 183(41.4%) 116(26.3%) 441

REIMBURSEMENT NO (42.4%) 2 (1.06%) 100 (53.19%) 58 (30.85%) 28 (14.8%) 188

YES (57.6%) 0 (0%) 87(34.3%) 94(37.1%) 72(28.4%) 253

% OF REIMBURSEMENT FULL (43%) 0 (0%) 8 (7.3%) 45(41.2%) 56 (51.3%) 109

PARTIAL (More than

50%) (36.3%)

0(0%) 22(23.9%) 26(28.2%) 44(47.8%) 92

PARTIAL (Less Than

50%) (20.7%)

0 (0%) 9 (17.3%) 32(61.5%) 11(21.1%) 52

possibly might have contributed to a reduced awareness

of healthcare options, which in turn led to their greater

percentage of population having no insurance coverage.

This probably draws attention towards two vital

issues representing, issue of health literacy and secondly

the mind-set. The issue of not seeking health insurance

which was among 22% which were less than 30 years

could be highlighted from the fact that probably, since

they been young, feel health insurance is not for them.

However, the same could not be said for the middle aged

respondents, since these people probably, avoided opt-

ing for medical care thinking that there are no issues

Abdulwahab and Ali Miraj

592 DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

with their health, though it may be vice versa. At the

same time, stark differences in health coverage were

observed in the various age groups. In earlier studies it

has been reported that overall health care expenses and

insurance coverage, both increased with age, (Quinn et

al 2000, Short 2004 and The Economist 2014).

However, in our investigation, it was just the reverse.

Among the uninsured, even as age progressed the utili-

zation of health services did not increase. This could be

possibly due to the fact that the large number of expatri-

ates who work in the kingdom had to have sound health

to continue to work. Despite the increasing age, they

might feel no major health issues because of  nancial

reasons or deliberately do not want to report. In our

analysis, it was also found that the younger age group

opted less healthcare in comparison to the middle aged.

This view is consistent with the recent research of

Levy and Janke (2016) and that of McCormack, (2009).

It has been observed that usually, young people would

think and feel to have no health issues as compared to

middle or older age groups. In our study, it was observed

that irrespective of been young, they opted for more

healthcare as compared to the older population. This

may be due to the fact that older age group being in

minority, had low health literacy; and thus probably

would have lacked adequate awareness (McCormack,

2009; Paez et al 2014, United Nations World Population

Prospects 2008).

The existing literature clearly reveals that the insur-

ance status of subjects varies by age. In an earlier study,

it was found that young adults represented the largest

percentage of Americans not covered by a health insur-

ance plan (Kunter and White 2003 and Paez et al 2014).

It was also shown by a 2004 Joint Economic Committee

study, that young adults between the ages of 18 and

24 are about 30% less likely to be insured than the rest

of the population, and the chances of being insured

increase as a person ages (McCormack, 2009)

According to Carper and Beauregard’s MEP survey

conducted in the United States in 2009, age plays a major

factor in whether a worker has health insurance. Young

adults aged between 19 and 23 years old were more at

risk of being uninsured than any other age group. Addi-

tionally, these investigators stated that workers under

the age of 35 were signi cantly more likely than older

workers to be uninsured all year.

Another very strong

aspect which was revealed from our study was that irre-

spective of the age, the education level of a person could

play important in uence on health insurance. The data

of the present study, with regard to educational quali -

cations, showed that70%-80% of the expatriate popula-

tion, irrespective of insurance category had completed

up to higher secondary schooling. The percentage of

illiterate participants was extremely low (<2%).

Carper and Beauregard’s report (Carper and Beaure-

gard 2009), also states that educational attainment has a

substantial impact on worker’s health insurance status.

Lower levels of education were found to be associated

with being uninsured all year in workers 19–64 years of

age or decreased utilization of health services. Workers

who had less than a high school education were about

twice as likely as those who attended at least some col-

lege to be uninsured all year. Earlier studies have found

factors affecting service utilisation ranged from cul-

tural and socio-demographic factors, physical accessi-

bility and disease patterns to perception of quality of

services and con dence in care (The Economist, 2014).

In our study the impact of educational quali cation of

uninsured expatriates was evaluated for healthcare uti-

lisation.On evaluating the data for the

reimbursement

made for treatment/hospitalization, it was found that

the percentages of reimbursement made in highly quali-

 ed uninsured expatriates was signi cantly higher from

those uninsured employees having low quali cation.

Studies have revealed that the insured were more

likely to pay doctor visits when sick and use health

care in community health centres but had less visits per

episode compared with the uninsured who tended to

seek care less frequently (Short 2004 and McCormack

2009). Our study with comprehensive data using a large

number of subjects, is one of its  rst in the Middle East

region to emphasize upon the point that better educa-

tion could signi cantly in uence health insurance reim-

bursements.

The nationality of the expatriates was yet another

distinguishing factor for assessing the impact of demo-

graphic factors on the issue of accessing healthcare. It

was found that out of the total 4,575 expatriate workers

interviewed, a majority of 69% belonged to the South-

east Asian community, comprising Bangladesh (25.3%),

followed by India (24%), and Pakistan (10.9%).

We speculate that when the economy deteriorates,

expatriate in ltration increases. To remain in the earn-

ing country, expatriates are forced to shell out health

premiums regardless of need. It may be mentioned that

the high-quality facilities available, to expatriates in the

Kingdom, are in contrast to the major health disparities

in quality of healthcare, which have been reported to

exist between migrant workers and the local population

elsewhere, (Altijani and Ali, 2010).

In the present study, it was also observed that out of

the 1,370 uninsured respondents a staggering 71% of

non-Arab nationals were found to be uninsured com-

pared with the 33% of Arab-based nationals (i.e., Egypt,

Yemen) seen under insured category. These data show

that there is still need for further development and dis-

tribution of affordable health insurance plans so that

healthcare options are bene cial for both the insured

Abdulwahab and Ali Miraj

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS 593

and the insurer. In the present study, analysis of the lan-

guage pro ciency variable revealed that irrespective of

nationality or insurance status, 89.6%–93% of the sub-

jects had pro ciency in the Arabic language, whereas

among the insured the majority of respondents (61%)

were pro cient in English. Existing literature shows that

effective communication with patients and healthcare

workers is a key part of safe and high-quality healthcare.

Cultural misunderstanding between patients and pre-

dominantly expatriate healthcare providers is another

factor contributing to patient dissatisfaction and poor

quality of care, (Altijani and Ali, 2010 and Kronfoll

2012).

In the present study, it was also observed that because

both native and expatriate subjects had good knowledge

of both the major working languages of the Kingdom,

Arabic and English, there was no reported experience of

a language barrier. Thus, in our study language was not

an issue in selecting healthcare as majority of the expa-

triates had good command of Arabic, the main language

of communication, which is in contrast to the results of

most similar studies, especially in countries that have

a large number of expatriate healthcare workers. These

expatriates faced language problems due to not being

comfortable in the local language.

A recent review concluded that healthcare provid-

ers such as nurses and their patients experience serious

language and communication barriers (Schyye, 2007).

The results of the above-quoted study show a communi-

cation issue between patients and healthcare providers;

however, as there have not yet been studies of the lan-

guage issues between the health insured and the insur-

ers, our study is one of the few reports, where the in u-

ence of language on obtaining health insurance among

expatriates can been seen. The present data demonstrate

that because of the language pro ciency of the subjects,

there were no communication issues when obtaining

health insurance.

On evaluating the demographic factors that could pre-

dominantly in uence decision making among the unin-

sured expatriates for not procuring health insurance, it

was found that a majority (47.3 %) did not have working

permits (iqama) and felt that the only purpose of health

insurance was to renew these permits. This  awed per-

ception, in which there is little value in obtaining health

insurance, alarmingly defeats its purpose, especially in

an expatriate-dominant country.The above  ndings pos-

sibly also re ect the de cient understanding of health

insurance and its bene ts among the interviewed unin-

sured respondents. Thus, when choosing health insur-

ance, expatriates most value employment aspects, such

as renewal of iqama, cost and money-saving, followed

by coverage bene ts, with regard to health awareness,

knowledge and its bene ts.

These data are in conjunction with those of (Altijani

and Ali 2010 and Kronfoll, 2012), who have reported that

the expatriate population in Arab countries faces sig-

ni cant dif culty in accessing health services. Although

access has increased, the quality of the services provided

remains low, mostly owing to expatriates’ view of health

insurance as an unnecessary expenditure. Thus, within

our study sample, age, education and nationality are a

signi cant in uence on whether a person is enrolled

in a health insurance plan. This implies that the young

adults we studied did not generally opt health insurance

because they believed they did not need it possibly due

to their young age and perception of not requiring the

insurance for saving money.In addition, there are other

in uencing factors, such as new health insurance sec-

tors that are still under development, which will provide

expatriates with more choices in the future (Gallagher,

2002; Alkhamis, 2016 and Sa , 2016).

LIMITATIONS OF THE STUDY

This study had some limitations. It represented only male

expatriates and excluded females, the elderly and chil-

dren. The reason for excluding female expatriates was

that their number was limited and represented only 1.7%

of the expatriate population (98.3% are male) (Ministry

of Labour, 2009). Therefore, if female expatriates were to

be included as one of the study variables, it would have

been very dif cult to obtain a suf cient number of par-

ticipants. As the expatriates are not allowed to keep their

parents, the exclusion of the elderly was justi ed. More-

over, since this study is a cross sectional study, which

may have increased bias with respect to time ordering

of events.

CONCLUSION

Providing appropriate healthcare services for a growing

young population, inclusive of locals and expatriates,

is one of the emerging priorities of Saudi Arabia. Exist-

ing disparities between different groups of expatriates

can be addressed using this demographic pro le and its

association with health insurance status. Our  ndings

indicate that expatriates’ health insurance status is con-

siderably impacted by several important demographic

characteristics such as perceived need, perceived value

related to age, sex, education level, socioeconomic sta-

tus, nationality and language. However, as there is great

scope for further development and creation of affordable

health insurance plans bene cial for both the insured

and the insurer, we recommend further, detailed studies,

which might have bearing on the health of expatriates in

light of upcoming health insurance sectors.

Abdulwahab and Ali Miraj

594 DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF UNINSURED EXPATRIATE WORKERS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

This work was supported by the King Abdullah Inter-

national Medical Research Centre under grant number

RC09/084, upon the recommendation of the Research

Committee following the review of the Institutional

Research Board on the ethical aspects of the proposal.

CONFLICT OF INTEREST

The authors do not have any con ict of interest.

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