Introduction

The aim of this research is to investigate and further analyse those key factors which affect the buyer behaviour in Arabs and especially as health is the basic need of every human being, considering every aspect of the society never promote any uneven deal in regard to health issues. In this research it will explore and investigate that during in such environment and understanding the cultural, religious etc. of the Arab different societies their choice of health care means when they are coming abroad for advance and equipped treatment, before what factors an Arab patient consider.

Arab culture is basically composed on Islam, and their culture is a full translation of Islam.

Culture is a Latin word “cultura” which means improvement of the soil and total transformation of the nature. The valid and modern meaning of culture is designation of spiritual development and upbringing.

Culture most authentic definition is in most common sense that culture is the spiritual perfection and human development. Culture understanding is mainly concern with sprit and spiritual power.

Culture is the spirit and a valid identity of a nation. Every nation has its own culture and this culture is playing a vital role in the building of a healthy society. Because every society has its own culture that characterises it. Every society has some beliefs and these beliefs are strictly followed by every person of existing society. Arabs are mainly 22 different countries with different culture and different sects and religion, their common language is Arabic with a few other dialects. Arabs are mainly divided like 10 countries in Africa and 12 in Asia, according to UNDP report 1993 its total population is 230 million in 22 different countries, representing in majority Muslim and in minority Christian and Jewish.

Arabs are mainly living in joint family system; every person is more dependent on each and every person. They respect each and every person and especially the elders and give them proper attention due to their age and experience, and always play a vital role in making any decision.

Arabs always consider and never cross the boundaries of Islam, and their belief is very strong in God, it is a strong belief that every happiness and sorrow is from God. A very common and with a strong belief that when any uneven or a good thing happen, it is consider that it is the fortune which born with him and a divine from God.

The key factors which influence the buyer behaviour in Arab are culture, social, personal and psychological factors. In Arab society there is joint family system and an individual person is not free in its decision, because it's all family are more concern about taking in decision and more extent its choice is influenced by the family, culture and personal and psychological factors i.e. its beliefs (religion), perception, motivation and learning.

These are the key factors which influence the consumer buying power, in such a situation how an Arab then goes to select a health service in his country or abroad which satisfy his all factors i.e. its religion, culture and social.

Reason for Choosing this Topic:

Reason for choosing this topic is mainly relevant to my experience in marketing field, being more involved and studied a lot about the history of Arabs and interest in marketing field, also Arab is the new emerging market for business that's why I am optimistic that this theses will enhance my abilities and give a strength to my career in the chosen field. I personally worked in a tobacco company “WTD PAKISTAN” for more than three years and counted as consumer based company because it is mainly based on tobacco selling products. That why it becomes a solid and main reason for choosing this topic. Moreover with my personal experience and after reviewing literature, that different countries have different lifestyle, culture, different approaches in making decisions, different choices and different taste and different level of satisfaction. It seems interesting to me for research and enhance my capability in marketing. This topic is providing a broad/vast analysis to underline the key factors which influence the buyer power of buying because it is thoroughly proved from lot of theories and researches that consumer/ buyer all over the world has certain level of satisfaction, which is disturb by some factors existing in its surrounding environment. To evaluate these influences by considering academic resources, online journals and literature from authentic resources will enhance my knowledge and capabilities to do a better job in my real life.

Literature Review:-

Literature review is playing a vital role in completing of dissertation chosen and moreover will help me in completing my final dissertation has significant importance to complete my dissertation topic and ultimately to help me in completing my final dissertation. So in this context, some introductory literature review has been brought forward which have helped me in finalising my research topic and questions to be investigated. Moreover the essential and sufficient material for my chosen research topic review of literature, journals current articles from the authentic resources (magazines, newspaper) and academic books will give me help me in completing my task.

International marketing:

According to (Burca. D. C, 2004) that international marketing is the process of planning and undertaking transactions across national boundaries that involves exchange.

The above statement gives an idea about the international marketing that it provides a platform for business across the boundaries or between different countries, and these businesses between different countries are under some rules and regulation.

When the transaction takes place across national boundaries then the international marketers are subjected to different set of macro environmental factors and constrain deriving from different political system, legal frame work, cultural norms, and economic circumstances.

Marketing is basically concern with exporting of products or services e.g. it very common that purchasing a chair from IKEA but in reality it will be imported from other countries or it parts will be export from other country but assembled in UK. Same if it is brought under discussion like computer and is accessories so it is clear those materials comes from India and software comes from china or Japan and product assembled in UK or other European countries.

This idea of global import or exchange nourish in the shadow of international marketing, because international marketing introduce such rules and regulation for international marketer like licensing to joint ventures and contracts between two parties.

According to (Sargeant. A, et al, 2002) that marketing is all about marshalling the resources of an organisation to meet the changing needs of customers on whom the organisation depends. Simply it will be quoted as marketing is all about how an organisation addresses its marketers.

Customer's needs are the starting point for marketing activity. Then the marketing manager tries to identify those needs and develop product or service, which satisfy customer needs through an exchange process.

According to chartered institute of marketing that marketing is the management process which identifies, anticipates and supplies customer requirements efficiently and profitability.

According to (Shaughnessy. O. J, 1995) that marketing covers those activities that relate the organisation to those parts of the outside world that use, buy, sell or influence the outputs it produces and the benefits and services it offers.

Simply marketing is the debate in organisation is what to offer, to whom, when, where, how, and for how much.

Concept of marketing:

Globalisation of goods and services created more opportunities for the customers to choose among the products. But customer expectations from the product or service in the available market are higher, because they paid the asked price for the service or product.

It is the main duty of company that before launching any product or service they understand the needs of consumers in the market. When a company understand the expectation and needs of consumer by providing a product or service which meets the need of customer than marketer can develop a successful marketing strategy for the target market.

Customers: A customer is generally understood the person who make the decision to buy a product or service, which pays for it. The product or service purchased by one person but consume by another person. So it is clear that customer and consumer will be same person.

The terminology can imply something about the relationship between a company and its customer. Different customers within a market have different needs, which they seek to satisfy.

To be fully marketing oriented a company needs to provide a product or service in the market which meet the needs of each individual. For this purpose they positioned their product or service in the markets which meet the need of that group.

Needs: It is referred to something deep rooted in an individual personality. The satisfaction of need is conditioned by cultural values of the society from which they belong. In some culture needs for self fulfilment may be satisfied by religious penance, while in other society's needs may be satisfied by creative talent.

According to Maslow's theory that customer are motivated by their desire to satisfy complex needs. It is also recognised that once an individual have satisfied basic physiological needs, then they may be motivated by higher order social and self fulfilment needs.

Value: It is a ratio of perceived benefits to price paid. Customer will evaluate benefits according to the extent to which a product allows their needs to be satisfied. Customers also evaluate the benefits of products compared to the benefits of other products placed competitively in the market.

Consumer places a value on a product or service which is different from the value presumed by supplier. Value can be added by better specifying a product offer in accordance with customer expectation. If the price of a product or service is set higher it will affect its sale. If the price is set low it will increase its sale but affect its profit.

Exchange: it is a way through which goods and services to be acquired. It implies that one party makes some sacrifices to another party in return to receive something of value. Other party expect same something of value.

In market based economies there is a presumption that each party can decide whether or not to enter into an exchange with each other. Each party is also free to choose between a numbers of potential partners.

Basically exchange takes the form of a product being exchanged for money.

Market: the term market has traditionally been used “a place where buyers and sellers gather to exchange goods or services”.

Market simpler and of value definition is that it is the interaction between buyers and sellers.

Marketing Mix:

It is very important for the marketers to consider the marketing mix before launching any product or service. It provides a great deal of knowledge about the operating market and then how, where and to whom the product should be target in the market.

Product: product is the main source by which an organisation satisfy customer or consumer needs. Product offered by an organisation is tangible or intangible in nature must satisfy the needs of potential customer.

The elements of product mix are quality levels, styling, special design features, durability, packaging, range of sizes or options, warranties, after sales service and brand images which is controlled by marketers.

Pricing: it is a critical element and determines the revenue that will be generated.

Setting prices is a difficult part of marketing mix. Prices are determined by the interaction of market forces.

Marketers set prices for individual products on the basis of what they cost to produce, what the competition is charging and what customer are prepared to pay.

Price decision also involve deciding on the relationship between prices charged for different products within a firm's range and decision about the price strategy over time.

Place: it plays a very important role in decision making, Choice of right place for product or service to be launched. Customers mostly prefer to buy the product or service from the nearest distributor.

Organisation right decision of place provides an opportunity to customers to gain access to its products and services easily.

Promotion: promotion is a best source of communication for marketers to highlight or communicate the benefits of their product and service to their target market.

Promotion can be used by different methods like advertising, personal selling, public relation, sales promotion, sponsorship and by direct marketing method.

Promotion method should be not the same in every culture. It will be different according to the requirement of different culture where an organisation operates.

Fundamentals of marketing:

According to (Dwyer. F. R, et al, 1987) states that identification and satisfaction of consumer needs by providing a product or service of value to fulfil the consumer expectation by developing a proper marketing plan or strategy.

It is necessary for marketing managers to understand the position of their organisation. The marketing managers always plan and develop strategies for launching their product or service in market, before they should know about the position of their product or service in the market and factors which makes their product attractive and of value to the consumers.

According to (Kasper, 2001) that it is very important for an organisation to know when, where and how the consumer thinks that their product or service is different from other potential and current competitors in the market.

Porter's strategy of differentiation gives knowledge to an organisation that how they are different from their competitors.

Organisation must identify the customer orientation before developing its marketing strategy.

Benchmarking of customer, organisation and competitors in market are the key function of marketing, such a benchmarking move them to decide a differentiation strategy.

Elements of marketing fundamentals:

Customer orientation: It is very necessary for an organisation to understand in depth its target buyers, then develop or produce a product or service of high or superior value/ quality to fulfil the needs of customers. Customers are the only source who can accept or reject the product value or feedback from consumer is the absolute source for an organisation to know the value and position of their product in the market and among competitors.

Customer orientation requires that a company understand not only the present value to the customer, but also how this is likely to evolve over time.

Competitor Orientation: when an organisation focusing on its customers, so it is also necessary for an organisation to look that how a competitor is satisfying its consumer needs. An organisation needs to understand the short term strengths and weaknesses and long term capabilities and strategies of current and potential competitors in the operated market.

Interfunctional co- ordination: It is very important for marketing managers to develop marketing plan, which not only give promise to customers and marketing staff. But the marketing plans only develop for creating value products and services.

Marketing orientation needs to draw upon and integrate its human and physical resources effectively and adapt them to meet customers' needs.

Customers always pay attention that what an organisation is offering in the market which completely satisfies the expectation of consumers; product or service which satisfies the customer expectation must be of value. And when customer satisfies from the outcome of product or service it directly produces more chances of repeat business and dissatisfaction may lead to failure and negative experience which may limit the business of such an organisation.

Factors influencing buyer behaviour:

According to Usunier (2000) that before purchasing there is no concept of seeing, smelling and touching. This gives an idea about the shape, colour and space during the purchase in some cultures.

In the case of healthcare, when someone is buying healthcare he looks to certain points by knowing that purchasing a product will be not same to purchase a service. In case of healthcare there is no guarantee that an individual will get optimistic benefits.

The healthcare provider must provide in the market of healthcare some reasonable and attractive, competitive and consumer encouraging packages which attract the consumer to buy their packages like price, advance treatment, accommodation and high and quick service. It encourages the consumer that they are receiving the very best and high quality service available in the healthcare market.

Today's world is a hub of marketing and in every sector there is a trend of competition every organisation is trying to capture more market share by launching more consumers attractive packages, to promote and encourage their own product and service.

Devetag's model (1999) of consumer behaviour

This model is basically represent the industrial and corporate change is only brought here under discussion for the process of making decision and influences on the consumer behaviour in case of buying health care.

This model represents the different products or services and provides the grounds to the consumer to choose the product or service.

Devetag's model provides grounds for the consumer to choose between products “A” United Kingdom and products “B” (Home country) or other countries products or services in the market. Product “A” is a superior and expensive quality but product “B” is also compete the market with superior quality.

Devetag's model (1999)

   In the above Devetag's model quality is expressed on y-axis and convenience (price) is expressed on x-axis. In the above diagram product “A” is competing product “B”. And the value of product “A” among the consumer is more than product “B”, the one reason of choosing product “A” of superior quality and high price is because the consumer thinks that “Give something and get something of value” is clear that when consumer decide to purchase a product or service then he expect that the chosen product or service will satisfy his needs. Product “A” has a good reputation in the market due to its quality and price, which makes the minds of consumers, that the product is reliable and meets the requirements of consumers. But in the competition of product “A” and “B” product “C” also exist in the market, shown in the diagram inside the box. Product “C” dominated by “B”, which is inferior to “B” in case of price and quality but still cannot attract more consumer compare product “A”. Product “A” demand among the consumers is due to proper advertisement and reputation in the healthcare market.

It is clear that in case of health care industry consumer always search the market where they can attain quality product or service at reasonable price.

This model is best suitable for decision making and to count the influences on consumer behaviour, because this model highlights psychology of consumer that how consumer choose the product or service among the different available products and services in the market, and how consumer gauge the quality of product or service and underline the importance of chosen product and then purchased it.

According to (Pekkala et al, 1983) that a reliable product needs to be introduce and advertise in the intended market before launching. It means that the product or service needs proper market segmentation, and also advertisement in the relevant business environment. It is compulsory that the marketers appreciate the culture of a country in which he operates.

It is clear from the above statement that culture should be consider when ever providing a service or product in the market of a country. Because culture plays an important role in promoting the product “A” and “B” which attract more consumer all over the world because product “A” is acceptable to the people of a country in which he operates. It clears that before launching or introducing any product or service the cultural values of a country should be considered.

According to Economist (2009) that NHS chief David Nicholson is planning to introduce improvement in the efficiency and productivity of NHS on larger scale. In coming 2013 NHS budget 15% of wealth will be spent on health care services in the UK to fulfil the rising demand with best suitable resources, thus the NHS will be consumer attractive organization in the world market, will play a role model in the health care industry of world.

NHS is from long years a cheap compare to America and other developed European countries. NHS provides a standard service at low cost, and this is happening only due to the effort of General practitioners (GPs). But health care in other countries like Denmark and Netherland is more expensive and physician are act as gatekeeper, means that health buyer never goes for treatment due to high price and low quality.

In the above Devetag's model UK NHS will be awarded as product “A” due to high quality and reasonable price, and planning for the future and spending more money on the health sector will enhance their share in the market, more consumers will attain NHS.

Arabs comes to United Kingdom due to the high quality service like able and experienced doctors, equipped and up to date laboratories and due to recent researches in the medical sciences, on reasonable prices treatment attract more Arabs health consumer to get benefit from the UK health industry.

Due to the proper advertisement and promotion in the market, introduced by the UK health care industry marketers attract more Arabs patients because they are more vulnerable and easily attract towards the available services.

Cultural influences on consumer behaviour:

According to Tylor (1913) that “culture is complex and interrelated set of elements, comprising knowledge, beliefs and values, arts, law, manners and morals and all other kinds of skills and habits acquired by a human being as a member of a particular society”.

It is clear from the above statement of Tylor that culture is not composed on one thing but it is a set of elements already exist in a society, and every society is mainly composed on the beliefs and values (religion) of people living, attitude, habitat, architecture and adopted rules and regulation to survive in the society.

Ralph Linton (1945) describe the culture as it is the configuration of learned behaviour and results of behaviour whose components elements are shared and transmitted by the particular society, furthermore he indicates the limits of the cultural programming which the society can impose on the individual.

Ralph Linton describe the culture more simply that culture is the learning process which result in changes in the behaviour of an individual living in a society, it transmitted from parents to offspring in a very conventional way with its limitation, because every society has cultural limits, compulsory for every individual to obey it.

According to Hofstede (1998) that consumer behaviour is cultural dependant.

These all above definition provides a broader concept of culture that culture is basically name of shared values developed in particular environment, it gives an idea that one culture is not superior to another culture but may be different due to beliefs and values, knowledge, arts, law, manners and morals, habitat and skills.

It is now easier to understand a culture of particular country society, and due to the globalisation of products and services and to provide the equal opportunities to the world population to get benefit from these globalised product or service it necessary to introduce the acceptable marketing and advertising strategies globally. Because one uniform marketing and advertisement strategy is not appropriate as whole, it is evident that marketing and advertisement strategy for West is never works in the Middle East due to their cultural restriction.

According to De Mooji (1997) that products are globalised but people are not globalised, products are accepted in more than one culture due to different and appropriate advertising strategy. Language, concept, number, colour, space and humour are constant among cultures; they are not changeable among cultures.

Communication: According to (Burce. C. D, et al, 2004) that communication plays a vital role in conveying the message among the global marketers, and consider as reflection of a culture. There is a difference between countries verbal communication due to the adapted culture and verbal communication is different from one culture to another, it is not different in term of language but also in term of variables like who, what, how, where, when, and why. Communication may be verbal or non verbal having same importance in conveying the message to the recipient in term when a marketer satisfy a consumer.

According to (Burce. C. D, et al, 2004) that due to cultural differences people are more likely to communicate with each other without any problem and this fluency in the communication is due to hierarchy, status consciousness, behaviour and other factors which plays the role of gatekeepers. The different method of communication and its uses were brought under discussion, how the message is communicated, which channel is used for this communication e.g. spoken or written etc. and it depends on the availability of channels in the cultures and factors are speed, formality, legality and seniority. Another factor is whether message should be communicated, to know the right authority to which the message will be communicated, and also the time schedule for the communication and the meaning and purpose of communication. Body language has different meaning in different cultures, like feet gesture in west society is consider as attention but in Arabs it is an insult and facial gesture is most commonly noticed in the West culture as emotion, happiness and embarrassment but in Arabs culture it is consider as embarrassment and not used for the expression of desire.

According to (Morris, 1997) that non verbal communication is not strange when dealing in different cultures, because this section deals with signals and from these received signals one will understand what the other person is conveying him and then to judge to understand the language of these signals and then make its own assumption to believe or trust on whom.

Non verbal communication deals with body stress signals e.g. perspiration and licking of lips etc. and lower body signals like foot tapping, frequent crossing and uncrossing of knees etc. and body posture signals are used for boredom like body sagging and slumping, body gesture like movements of hands and facial expression are also used for non verbal communication.

Mead (1993) stated that culture and religion is an essential part of lives of the people in every society, and it is compulsory for the health care provider to understand and know the culture and religion of the patient.

According to Galanti (1991) that most cultures shares same beliefs, values and practices, it is necessary for health care provider to treat a patient as a family unit not as individual by creating psychological, spiritual and environment of physical needs.

Sign and symbols: According to (Unsunier, 1993) that interpretation of symbols is strongly culture bound.

The above statement of Unsunier Clearly describe that in every culture they use sign and symbols as a source of communication. This statement provides understanding about the cultural signs and symbols that every culture use very strongly sign and symbols as a source of communication.

According to (Goffman, 1963) that headscarf is a symbol of normative cultural values and social relations of class and power that determine our perception. It communicates the individual and collective motivation of those who adopt it, as much as perception that rejects it.

The symbol of headscarf makes sense as a language of relationship between those who asset their orientation towards values of Islam and those social classes that owe their status to normative values of modernity, such as equality and liberty.

It further argues that stigma refers to individual sign; socially information and individual transmit about himself that disqualifies him and creates an obstacle to being fully accepted by society.

In west colours are more used as sign and symbols like black colour is used for mourning while white colour is used in most of Muslim societies as religious and partially used as mourning colour. Red colour is used as symbol of tragedy and warning. In case of numbers 13 is symbol of bad luck in UK and this number is avoid in any department for numbering purpose e.g. no bed is marked in hospital with 13 etc. in Japan 4, Asia 555 and in china and some other countries 7 is consider bad luck numbers.

In Pakistan crow and black dog is consider as symbol of bad luck, in India owl, UK black cat and in Japan fox is a symbol of bad luck.

It is evident from the above discussion that sign and symbol is a strong source of communication, and always it is necessary for marketers to consider these sign and symbols which rejects by a culture in providing any product or service.

Imagery: Images from very beginning plays a vital role in conveying the messages. In marketing pictures are used as strong source of communication and by this the marketers captured more market shares in the market for their own product.

Marketers use pictures for the advertisement of a product or service, but it will be acceptable in one culture but may bring disaster in other society.

Comparing West culture and Arab, in West culture the advertisement of bra by a naked woman is consider as a routine and essential for advertisement and attract more consumers to buy the product. But in Arabs it will be completely different, it is also true that Arab women are wearing bras but the advertisement strategy for Arabs will be completely different compared to West. It is necessary to have sufficient knowledge about the culture and religion of Arabs.

According to (Keegan et al, 1989) that cultural value always plays a vital role on the consumer behaviour and having defined and always gained a considerable attention in marketing, and also its influences on marketing strategy are well presented.

It is clear from the above theory that culture is always playing a role in influencing the consumer behaviour, because every society is composed on define culture and every culture has its own values, which may need to be considered during any decision making, needs proper attention during choosing any product/service. For marketers to advertise or promote and introduce a product or service in a specified market, they need to consider the cultural values of the country where they operate.

According to (Usunier, 1993) that customer are different in each country, marketers must consider them, and by considering the values, attitudes and tastes between cultures may help in satisfaction of customer.

The above theory states that to avoid the influences on consumer behaviour, it is very compulsory to consider the different customer satisfaction. It is also evident that in every country there are different people are living like in Arabs there are different race and religion background communities are living, they have different cultural values, taste and attitudes. The marketers must consider the cultural values, attitudes and tastes between cultures before making any market strategy for launching any product or service may help in the satisfaction of different customers.

According to (Tse and Worng, 1998) that in marketing the culture values has a strong influences on consumer motivation, life style and product choice.

It is clear from the above statement that from very beginning marketing is influenced by the culture and beliefs. Cultural values has influenced the consumers all aspects like motivation, life style and decision making process about product and service. Kotler (1999) consumer behaviour is culture dependent. It is clear from this statement consumer behaviour is transcending the virtues of its society where he is living.

Kotler Stated that the influences of marketers, political and economic environments are not only influencing buying behaviour but also individual factors which are playing a great role in buyer personality, lifestyle. And also point out that influences on buyer during making a decision, and these constraints of elements are cultural, social, psychological and personal. Hofstede (1980) defined the nature of culture as the “learned belief or pattern of behaviour for coping with recurring experiences” According to (Dubois 1987) that “consumer behaviour has strong universal components, its cultural variation cannot be ignored.”

According Hofstede (1983) that gaining sufficient knowledge about the different culture; it gives more knowledge about the political, sociological and psychological values. Therefore, to know a region's culture is giving more help to measure the consumer/buyer level of satisfaction.

The essential points of influences on consumer behaviour are Hierarchy of needs, cultural based values, institutions which influence consumer behaviour.

According to (Crawford 1997) that there are some exogenous influences on buyer behaviour which are social and cultural in nature like culture, social status, and Reference group (families). On the other side some influences are endogenous on buyer behaviour which are internal to buyer, are psychological in nature and consist on needs and motives, perception, learning, attitudes, personality and self concept.

According to (Hofsted 1998) that the collective mental programming of the people in an environment. Culture is not a characteristic of individual it encompasses a number of people who were conditional by the same education and life experience.

According Shibutani (1995) that culture is the complex of values, ideas, attitudes and other meaningful symbols created by people to shape human behaviour and the artefacts of that behaviour as they are from one generation to the next. According to Money& Gilly and Graham (1998) that one person (buyer) behaviour is different due to cultural differences because one culture is different from other culture, and the practices of one culture will not be giving same results in the different culture.

According to Pucik and Katz (1986) that culture provides the framework for social interactions, service expectations may vary widely from one culture to another.

Key influences on consumer or buyer behaviour in Arabs and their choice for healthcare:

According to (Rita Giacaman, et al, 2006) that Arab, especially Palestinian women are more interested to deliver her first child in house, because it is a strong belief that the first child delivery should be in house in the supervision of trained and experienced women. And it is a culture in Arab countries of home delivery. But in the Israel occupied Palestine this home delivery is completely changed and pregnant women are more likely goes to hospital or local health centre to get on time and proper treatment during giving birth to a child. Majority of Israel occupied Palestine women goes to hospital in case of delivery and about 3.5% stay at home or prefer the trained health professionals.

The above theory gives two different cultures in same people in same area, because in Israel occupied Palestine the woman has more facilities due to social interaction and availability of products in their hospitals, which changed the consumer taste and attitude and make it very easy for them to make a decision about the available service or product. The most common and evident culture in Muslim world is to seek the home based medical treatment in first choice.

According to Hammad (1989) that when Arabs are making decision about the health care, they look to their religion, family and culture. It is necessary for the health care provider to understand/ know the history, beliefs, values and norms of Arabs culture, to successfully and effectively do treatment of an Arab patient.

According to the Oxford advanced learner's Dictionary definition that “the state of being well and freedom from illness in body and mind”.

According to the Robert Hahn's(1995) that in Arabs culture poor health is considering divinity of Allah and people in society look him as shame. This theory more clearly present the factors of buyer society which influence his decision for a particular cure.

According to Usunier (1993) that Arabs gives more importance to Allah in case of each and everything, and the outcome of a task is not the responsibility of a person but it is the well or decision of Allah. This theory applies to the healthcare, business finally to every aspect of life.

According to Hollensen,S (1998) that it is very difficult to understand the culture due its differences, because one culture is very easy to understand but other will be complex to understand. The great problem is to understand the values and attitude of buyer in different countries. Culture encompasses every aspect of a person life. The people who are living in a family life (together) are more influenced by religion, legal, political, economical, technological forces. In different cultures different methods are used for leisure and reward recognitions.

This theory more relates to Arabia because the most population is Muslim are more deep in belief, before making any decision they consider the well of Allah, society and culture virtues.

According to (Burca et al 2004) that sensitivity indicates the differences between different cultures, and understands it objectively that one culture is not right or wrong nor inferior to one another but is different. This can create a long term business relationship. So it is important for international marketing to evaluate cultural assumption.

According to Usunier (2000) that Arabs are not taking responsibility for their work, when something goes wrong they will simply say “inshallah” (if Allah will)and the Arabs employees are passive and they do not care for job related problems.

It is very clear from the above statement the Arabs are not more serious about the daily life issues like work, personal issues and regarding their health issues. They put all the responsibilities of their all mistakes they have done on “God”.

According to (Jain, 1989) that culture impacts the marketing strategy on every dimension.

This statement clearly indicates that applying any market strategy in the Arabs, marketer needs to consider the cultural values, because Arab consumer are more loyal to their cultural and beliefs.

According to (Ricks, 1983) that the cultural influences are mainly impact on the decision process of consumer, that what to purchased, why, how, when, where and by whom.

This theory is more likely fit on consumer, that how influences impacts on the buyer behavior and the process of decision about certain product or service. This journal clearly describes that when consumer feels need about a product or service, first of all he makes a decision what to buy or purchased and what is the nature of service or product, what factors makes him to purchased and make decision about the certain product, and how consumer realize that this service or product will be ideal for him, what are his resources to buy or purchased a certain product, On right time when consumer needs service or product.

The most important step when a consumer takes is to make a decision about the best suitable place or location and to discover about the service provider in the market, and what satisfied the consumer he always look to these points.

Arabs culture and religion are the key factors which influence the buyer behavior. Because it makes the Arab consumer more confuse and makes the situation more complex for him to make any decision about to choose the service or product.

Arabs are more loyal to their religion “Islam” and respect all their cultural values.

According to (Berry et al, 1992) that culture is simply a shared system of socially transmitted behavior that desire, defines and guides people's ways of life.

This journal states that culture is the outcome of shared values in a society, and these shared values are transcending the behavior of individuals living in the society, because it is evident that the people of a society are the main source, who translate the cultural values better than a scholar analysis.

Arab society is basically composed on shared values which show the true and pure Arab culture and one important aspect that Arab religion is playing a vital role in the composition of Arab culture.

According to (Triandis, 1972) that cultural influences on all aspects of our lives, which covers subjective like attitudes, values, beliefs, opinions and behaviors and objectives like clothes, food, utensils and architecture elements.

It is very clear from the above statement that influences on our lives cover both sides subjective and objective. It is very clear that the attitudes of people in a society transcending the values of culture and beliefs.

Arabs are majority Muslim, they belief in one God and last prophet Muhammad (PBUH) and strictly following the sunna and Quran rules and act on it as it is clearly written inside it.

And the objective factors are the life style of people, daily food (eating) routine etc. It is clear that people in every society have their own life style and own traditional food, which translate the true culture of a nation.

Applying the same theory on the Arab, basically Arab religion in majority is Islam, which means belief in one “God” and prophet Muhammad (PBUH). Arabs are more loyal toward their religion.

According to (Tooby and Cosmides, 1992) that culture is not a static entity, that people raised different ways of life, adopted during different time period.

This theory highlights the history of culture, and describe that culture is changing during time to time, and these changes happens due the development in the societies, which brought up changes in the people life style, decision making and their taste etc.

Arab history start from the tribe of “Quaraish” having very dominant cultural values and beliefs, but changes happen due to the development and competition in the Arab market.

According to (Pipher, 1998) that culture exist on multiple level, it enhance the survivals, culture provide rules for living, people interaction and provides a proper system of work etc.

It clearly describes that how culture operates, and its norms. Culture is in every society has multiple existence, means in one society different cultures are nourishing which provide certain rules for living and a unique style of work and relation between the people living in these societies.

Model of buyer behaviour (Sheth, model of industrial buyer behaviour, 1973)

According to (Sheth, 1973 and Webster, 1965) that this organisational model) is developed for industrial buyers to achieve the needs of retail buyers. This model explains in brief the industrial buying process and provides comprehensive thoughts which make it easier to develop some other homogeneous models to fulfil the deficiency in case of decision making about purchasing of certain product or services.

According to (Cardoza and Cagley, 1971) that it very important to do segmentation of industrial market in three different categories to get the proper picture of industrial buying process. The segmentation of industrial market will be on the “size of buying firm”, “position of within the firm of particular buyer responsible”, “and background of individual buyer”.

Sheth model basically represent the knowledge and buyer behaviour and present it into shape of an organisational behaviour model. It is clear from the above statement of Cardoza and Cagley (1971) that the market segmentation makes it easier to understand the market and its buyer and competitors as well. These objectives will be achieved by developing of proper information system, expansion of research on organisational buyer behaviour and also to focus on the new hypotheses for future research.

Sheth model of industrial buyer behaviour describe the elements of individual decision making process in form of a team. In first the model looks a little bit complex due the variables and their relationships among each other. This model provides an idea about the decision making process individually in case of individual team base and collectively in case of joint decision making process for an organisation or individually, and looks best fit for the Arab patient decision making.

This model is basically provides a clear idea about the decision making about the product or service. It will be used in case of Arabs decision making process. Because when an Arab sought for himself an appropriate healthcare abroad (UK) then there are certain process they needs to perform like permission to travel to UK, for this they send their medical documents with proof of funds availibity etc. to the UK embassy in Arabs countries and then the organisation decision process starts. It shows that consumer buyer behaviour is totally depends on the organisation behaviour. An organisation always looks to three main aspects in making any decision, Psychological aspect, joint decision making process and condition.

Psychological aspects: Most commonly this is concerned to the beliefs and values, educational background, reference group (family) and professional goals which plays an important role in the making of decision in case of individually or collectively or for the well of organisation. Specifically in organisation when an opportunity is given to a team to make a joint decision for the well being of an organisation, the team gives the different decision and these individual efforts are put in one model to achieve the given goal.

Conditions: It is very evident among the different countries e.g. in Europe the advertisement strategy will completely different compare to Arabs countries, and also in Asian African countries.

Arabs whenever searching the information about the certain product or services they always look/ consider their cultural values and more essentially to their religion.

It clears that the available information about the specific brand will be different or variable among the team of decision making, confuse the buyer in choosing the appropriate product or service to satisfy his needs.

According to Sheth (1973) that an individual always look for the authentic information about the product or service and then try to compare or fit it with its own experiences and knowledge to satiate its thrust. Every individual has its own idea about a particular product or service, and is gained by the past experience and satisfaction from the product or service. So it is clear that the individual past buyer behaviour about the particular product or service brand will be different because every individual has its own level of condition and satisfaction for the purchasing of a product or service.

Joint decision making process: It provides an idea about the decision making process that decision which are made collectively having less chance of failure and decision made individually having more chances of failure, so that's why Sheth model of industrial behaviour is brought under discussion for Arabs consumer to understand and fit this model in the decision making process. During the decision making in any organisation in prior they develop a system to avoid any favouritism to prevent the organisation from any loss, while choosing a brand or supplier. Joint decision making process mainly take place in the larger organisation due to its size and several other factors to avoids risk and make a good decision for the organisation growth and prosperity. In small organisation they are most likely going for individual or independent decision making process due to its size and low level of risk.

This model is best suited for the Arab consumer, because Arabs are living in joint family system and representing a large family background and also during decision making process there are some endogenous and exogenous factors plays an important role and its is compulsory for the Arab patient to consider these factors to avoid any future influence to his behaviour.

Howard's and sheth's model of consumer buyer behaviour:

This model explain the individual buyer behaviour and under taken decision making process. An individual decision making process can be divide into three stages like Extensive problem solving, Limited problem solving and Routinized response behaviour.

This model further explains individual buyer behaviour. This model also enables marketers to segment the market on bases of individual differences.

This model represents an individual behaviour and exogenous and endogenous influences on it.

Exogenous and endogenous influences are playing an effective role to influence the consumer buying behaviour. It is evident that when consumer bored from one brand then he searches market to find out another brand to satisfy his need. The seeking of other brand to satisfy is key source to the motivation of buyer to purchase.

This motivation of consumer to buy may be commercial or social. Commercial motivation is basically relates to those market activities which attract consumer to buy. The motivation elements will be specific brand price, product, quality, value etc.

The significative stimuli will be in the form of pictorial advertisement e.g. billboard, media, personal, leaflet advertisement.

Motivation of consumer to purchase is depend on the internal state of consumer. The internal state of consumer to buy and then by the consumption of product or service he stores the information about the brand for future use.

Howard and sheth's model also describe the learning process of consumer through the experience with the product. The learning process in the model is described in term of hypothetical construct.

Model clearly describe the process of learning that as an individual learn from experiences, when an individual purchase a product or service for the first time or repeat buying process. This purchasing process and using of the product remain history for the consumer. If the product satisfies the need of consumer he will purchased it again (repeat business) or the product fails to meet the entire needs of consumer will lose its position in the market and no business will take place for that product or service.

Perceptual constructs is mainly describe the process of information. It is necessary to consider the sensitivity of information. When dealing with an individual and especially dealing with Arab patient. Sensitivity of information covers all aspect of the consumer like culture norms and religious. These factors needs to be consider widely by marketers whenever dealing with an Arab patient/ client.

It is very important for the marketers in case of advertisement in Arabs. A woman with underwear is not acceptable and consider as an offence compare to western world.

The relationship between perceptual constructs and learning in term of feedback from consumer and then by the repeat buyer behaviour may enhance the learning and experience about the product or service (subject).

Howard's and Sheth's model clearly describe that exogenous factors are independent and influence endogenous factors like financial status, class and culture etc.

Howard's and Sheth's model gives more importance to the endogenous factors and shows its validity for Arab countries. In Arab cultures financial status is playing a vital role in case of purchasing healthcare.

Simply Howard's and Sheth's model is consider as a best fit model due to experience and information of consumer with the product or service makes him able to make repeat decision about the product or service.

Consumer previous experience with product or service is positive then it will be very easy for the customer to make a repeat buying decision. The environmental stimuli become more meaningful and the buyer then distorts any further information input to suit his own cognitive structure.

Marketers play a very important role in case to make the process simpler for consumer. It helps to make consumer less bored.

Howard's and Sheth's model basically focus on individual buyer. This model works with larger, flexible variables and constructs which influence the individual buyer behaviour, also accommodate the complexities of human behaviour.

Howard's and Sheth's model is more helpful in case of repeat buying decision and extensively when a consumer has no previous experience with product or service and make his own independent decision to buy a product or service.

The focus of Howard's and Sheth's model is basically repeat buying of an individual decision making process. This model is considered as complex and not clearly describes all needs of consumer. Model is also fit for those consumers who are seeking the information for the first time to make a decision about healthcare and about available best location which meet the consumer needs in case of healthcare.

Howard's and Sheth's model is a best fit consumer behaviour model in case of individual decision making and mostly in repeat business.

Arabs society provides knowledge that they are living in joint family system and every family member especially elders of the family influence the decision process of an individual. So that's why this model does not fit in case of decision making but shows its validity in case of repeat business and first time business.

Arab cultural influences on Healthcare:

Arabs are in majority Muslim about (92%) so that's why Arab Muslim cultural influences will be consider to further explore and analyse this topic.

According to Hammad et al (1999) that Islam means submission to Allah. Islam teachings are that almighty Allah is one and utmost owner and power and all practices for him, and prophet Muhammad (PBUH) is the last prophet of Allah. Prophet Muhammad (PBUH) belongs to Nobel tribe of Quaresh from very beginning residing in Arabs continent. Prophet Muhammad (PBUH) was born according to Islamic calendar 12th Rabiulawal 570 BC in holy city of Mecca. He was the true and final messenger from Allah and counts in the line of prophet Ibrahim. Prophet Muhammad brought a universal law for the humanity of all times.

According to Hammad et al (1999) that Muslim believes Islam is the final religion from Allah awarded to Prophet Muhammad (PBUH), and Quran is the revelation from Allah given to Prophet Muhammad (PBUH) by means of Angel Gabriel. Muslim believe in prophet Jesus and mosses they are true messenger of Allah.

According to (Burca. D. Sean, et al, 2004) that there are 1.2 million people in the world, who embrace Islam and Islam is a predominant religion in Saudia Arabia and Malaysia and its impact on the business is much less in past than in the later.

It is more evident that same religion may impact differently in different countries, and there are certain environmental factors which modify the impact of religion.

According to (Hollensen. S, 1998) “that Islam provides the transcultural similarities under shared beliefs, and is of utmost importance in many countries”.

Religion may affect the marketing strategy during religious holidays.

Ramadan:-

According to (Hollensen. S, 1998) that Ramadan is considering in the Muslim world as a holy month, the entire month is a religious holiday for all practices. In Muslim world especially Arabs world during month of Ramadan Muslim fasts from sunrise to sunset.

This religious theory provides an idea that religion plays a vital role in the composition of culture, where religion is consider far superior. In Arab society religion “Islam” is consider more superior which construct their society where Islam play an important role in their everyday life activities. Ramadan is a form of physical and spiritual purification and gives a lesson of patience to the entire humanity, importance of poor people. Fast is not an obligation on sick people, in some cases of pregnancy, women feeding their babies in early days of birth (40 days from birth) and women in menstruation, when they become healthy it is necessary to keep fasts and fulfil the requirement of Ramadan.

Health professional needs to understand the importance of Ramadan and plan before treating any Arab patient; otherwise it will bring a disaster during the treatment or makes the treatment of no value.

Prayer:-

According to (Hollensen. S, 1998) that Muslims pray five times a day, they face toward holy city of Mecca (kabba). The requirements for each prayer are same like “uddu” means wash the face and all secret organs (sexual) and external organs (hands, feet etc.), for mouth brush they used their own religious brush “Miswak” a wooden stick etc. and the other ritual requirements for prayers are clean placed carpets to prevent them from any hurt during prayer. Five times prayer has its own philosophy and methodology in the morning, evening and night they pray loudly by reciting the verses of Quran and prayer verses but in the noon and time between noon and evening they pray quite, involves their whole body while praying.

Islam gives more importance to the pray and on the day of resurrection Allah will first ask about pray, that's why Islam permit an individual while he is on journey allowed to pray only two parts of pray (rakat), for sick he needs to pray the whole pray on sitting in a chair or in bed always looks to comfortability of ill person. During the treatment when an individual is not allowed to wash body parts to prepare his self for pray due to surgery or other treatment Islam permitted “Tayamum” (process of cleaning body parts without water with a clean cloth). It is very important for health care provider to know sufficient about the religion and culture values of Arabs while treating them.

Hajj:-

According to BBC report (2009) that Hajj is the world biggest gathering of Muslim, and every year about two million people from all over the world of every ethnic group, colour, social status, and culture praising Allah in holy city of Mecca in holy place kabba. Its main aim is to strengthen the bond of brotherhood and a symbol of equality that everyone is equal in the eyes of Allah. Hajj is the fifth and final pillar of Islam, and is consider the Sunna e Ibrahim. Hajj is obligated on those people who are physically and financially wealthy. Hajj begins in the twelfth month of Islamic year “lunar” and they move seven times around the kabba, visit to hills of Safa and Marwa to show that we are present in front of Allah wearing simple clothes in open air. Hajj has a big impact on the lives of Muslims all over the world and Muslim stops their all important works and appointment realising the importance of this event.

While dealing with any Arab patient it is important to consider Hajj festival because it may affect the treatment.

Zakat: It is considered as the financial obligation from Allah, purification of wealth.

Zakat is established in Islam only to distribute the wealth equally, philosophy behind the Zakat is that wealth held by human being in trust. Zakat deducts from the wealth of an individual annually depending on his current holding wealth like gold, business, property (land) and his savings. Residential house in which he is living, car of his own use, gold and etc which they use on regular bases are excluded from Zakat.

The payment ratio of Zakat is different in cash it is almost 10% of total in hand wealth, liquidity it is 20% and for crops like wheat, maize, tobacco, dates etc. it is necessary to pay the Zakat according to liquidity formula.

In most of Islamic states banks deducts the Zakat and then it goes to govt account and then the govt distribute it among poor people equally, some people do not prefer by banks and they distribute the Zakat deducted from the wealth personally among needy and poor people.

Prophet Muhammad (PBUH) also encourages the Zakat, because it counts a help without any repayment or voluntary charity.

Iman or Faith:

Faith is the first and most important pillar of Islam, without faith an individual never enters to Islam or called as Muslim.

There is no one almighty but Allah and worthy of worship, prophet Muhammad (PBUH) is the true and last messenger of Allah. This statement is called “Shahadah”. This statement provides the rules and regulation of Muslims life. And the importance of this statement is to serve and obey Allah.

Islamic food:-

According to (Hollensen. S, 1998) that Muslims are not eating those foods which are not slaughter according to the Islamic rules and on the name of “Allah”. In Saudia Arabia and other Muslim countries Pork is restricted to eat.

Role of woman in Islam:-

According to (Hollensen. S, 1998) that the role of woman in the Islamic based society is completely different from the western woman. The economic role of woman is different from culture to culture, considering religious beliefs. The authority of woman in Arabs countries are limited compare to western world, because Islam teaches the lesson of equal rights for women. In Arab world women are only responsible for the in house business, and required to wear ornaments and heavy and wealthy embrioded garments, to prepare her for husband.

Arab History:

Arab world starts from Morocco crossing Northern Africa and touches the Persian Gulf. Arab world is divided in two continents Middle East and North Africa. Arabs dominant religion is Islam and their official language is Quranic language known as “Arabic”. Arab continent is consist on 22 different countries Algeria, Bahrain, the Comoros Islands, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Mauritania, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. Iran and Turkey are not count in the Arab countries.

A common concept about the Arab is that an individual speaks Arabic consider as Arab. Arabs are not homogeneous because they are considered as one nation.

In Arab majority are Muslim about (92%) and other are Christians and Jewish. Muslim population worldwide is 17% and large number of Muslim population is living in Arab world.

According to Hammad (1999) that Arab gives more importance to religion Islam, family and culture when an individual needs health care.

According to Hammad (1999) that Arab gives more importance to religion Islam, family and culture when an individual needs health care.

Arab religion, culture values and norm convey message about the importance of health for an Arab. So that's why it is compulsory for a health care provider to understand the religion and culture values and norm of the Arab before providing their services in the Arab market.

Arabs travel to UK or other countries for the health care because the doctors and nurses etc are not giving the proper attention to the patient during treatment.

Devetag's model (1999) shows the UK position in the market in response to select the appropriate health care service.

Influences on buyer decision making process

To understand the culture of a country that how key factors influence the decision making process.

According to Hofsted (1985) that four values dimension, power distance, uncertainty avoidance, individualism and masculinity are influencing the decision power of an individual or an organisation.

Hofsted this model of four value dimension clearly describe that power distance is basically provide an idea about the unequally distribution of power. When the power is distribute unequally among the people then the power of decision goes in those hands that have more power and less power class is badly suffer from the high power group of people in the society.

Arab society is composed on the same idea, because the power is limit to the only rich people in the country or in Arab family power is limit to the parents or elder member, who can easily influence the decision of an individual about a certain product or service.

Uncertainty avoidance basically looks to the tolerance in the society and search for truth in the society. It is mainly concern that how much the members of a society are comfortable or uncomfortable, which happened due the equally and unequally distribution of power.

Individualism and masculinity are basically more dominant factors in the Arab society. Masculinity is more dominant in the Arab society, because Arab society provides a joint family structure, in which they depend on one another, respect each other opinions and ideas. And decisions are mainly taken by parents or elder members of family. Arabs society provides no idea about individualism.

Problem identification: Problem recognition start when consumer perceives a need and becomes motivated to solve the problem.

According to (Belch. E. G, 1993) that the problem identification initiates the subsequent decision process. It is due to difference between consumer's ideal and actual state. The difference between situation, what the consumer like and what in reality the consumer like, and the goal of consumer to attain the more positive situation.

A patient first recognise that he is sick means first he identified the problem, and then he show a desire/ need to be healthy again, because without healthy life nothing will be achieved. According to Maslow's theory of hierarchy the need to healthy comes in level 5.

Information search: when a patient/consumer recognises the problem, then he goes to purchase a product or service to satisfy his needs. Then he begins to start search for information to get more information's about the available products or services in the global market which satisfy his needs. These searches for information help him in making decision about the product or service.

The first search for information is totally based on scan information stored in memory like past experience, information gained due to repetitive purchased and information or knowledge gained by the experience of using a brand are all considered as best sources of information search and known as internal search.

Then consumer decide to go for external searches like personal sources i.e. friends, friends and co- workers, commercial or marketer control resources like information from advertisement, sales persons and from distributors.

Another source of external source of gathering information about the product or service is public sources like information from newspapers, magazines and from televisions. Personal experience with the product or service is also will be consider in case of information search.

Internet is the most authentic and developed and quick source for information search, because it allows the consumer to address all available products or services in the market by brands and by searching the information about desired product or services choose for him own the most suitable product and helps in making a decision.

Arabs belong to tribal system they mostly prefer to information comes from personal sources, so it is highly impact and having high meaning to the Arabs.

Seeking alternatives: According to (Belch. E. G, 1993) that after searching the information about the product or service the consumer then moves to alternative evaluation, consumer compare the different brands products or services in the market and choose those products or services which satisfy the needs of consumer. The consumer choose alternative by setting up a valid criteria for evaluation of alternative, the criteria can be objective or subjective like before choosing a product or service like buying health care in UK consumer will look to the objective like reliability, price, history and performance in the sector, And the subjective will be like image, styling, quality, and performance etc.

Consumer alternative seeking process is totally based on the evaluation between brands, products and services which satisfy the needs of consumer.

Arabs patient while choosing a product or service look to his culture, subculture and religion and also measure those parameters like while treating his cultural requirements were considered and his treatment will be deliver under the supervision of highly qualified professionals. These are more important to any patient and especially to Arabs they visit UK only for the purpose of healthcare.

Buying decision: During the information search consumer stop searching about the various brands, products and services and make a purchase decision. Without waiting for the outcome of alternative evaluation consumer show the purchase intention to buy a certain product it is also known as predisposition.

Purchased decision is not the same actual purchase decision, when a consumer decides which brand to buy then he implement the decision and make actual decision. A Decision needs more attention in regard, when to buy, where to buy and how much money to spend or invest.

Health is first priority of every human being, and every person he cares for his health according to his own economic position, never compromise on his health and always sought for best available health care.

In case of Arabs patient when they choose a certain product or service or product then they always for destination of value, because due to their tribal mentality they gives importance to the personal sources and take benefits in the future whenever they need.

Post purchased buyer behaviour: when consumer consumes or use the purchased product or service, then consumer compare the level of performance with expectation that either consumer is satisfied or dissatisfied. Satisfaction means consumer satisfactions are met or exceeded, dissatisfaction means that consumer expectation are below the level of needs. These terms of satisfaction and dissatisfaction can be achieved the method of feedback after the consumption or using the product or service.

The negative feedback may damage the reputation of the organisation by losing the customers and may affect its revenues. Positive feedback is a welcoming appraisal from the consumer and may increase the revenues and enhance the reputation of organisation in the market among the competitors.

Agent based model consumer behaviour

According to J. J. Merelo, et al (1998) that agent based model of consumer behaviour which shows two sides one is consumer population (I=1 to N) and other is brand management (K=1 to B) in which how a buyer makes it decision.

It is stated in this model that consumers when purchasing a product or service in the open market they make purchasing decision totally based on the available information. In the market where consumer is purchasing a product or service find out different brands and packages.

If we apply this model on healthcare, it will be noticed that in the open market consumer will find some other organisation that will provide healthcare service in competition to others. Each brand will have a number of brand attributes like price, effectiveness, reputation and profile etc.

Brand is positioned as B=Bs in the brand attribute space and consumer is C=Cs in consumer attribute space.

In case of healthcare when a consumer makes a decision to purchase the service or product he will choose it between different packages and brands available in the market. First of all consumer calculate the perceived value because this is the exact price consumer will pay for the chosen service or product. The choice between different product and services if calculated by price, then it is the universal law that the consumer will go for those product or service which price will be reasonable, if the price for the chosen product is higher than perceived value then consumer will go for bargaining and model for this process is known “Logit model”. The probability for choosing a service or product “S” compare to exp [ Wi (vis - ps) ], where “vis” is the perceived value of the product or service “s”, “i” and “ps” is the price of service or product and weight “Wi” is consumer attribute known as price sensitivity should be positive.

This model describe the whole process of decision making about the certain product or service, that in case of making decision about health care, a consumer search the market about the available product or services to gain sufficient information about the required service, then clearly describe his process of selection that a consumer look for the different brands and available packages in the market and calculate the expenses that are paid by him. Consumers look to the nature of service like experience, reputation, price, accommodation and the history of organisation how they are operating in the market. Consumer satisfied himself on every dimension then he goes to make any decision.

According to (Tse, et al, 1988) that culture also influences problem identification, problem communication and recommendation, which leads an individual to misunderstanding and conflict.

It is clear from the above statement that in case of masculinity, especially in Arab societies may influence the decision power of an individual, which leads an individual in Arab society to comprehend and identify the problem. It is also clear that when a person has less power to influence the decision, it is very hard for an individual to communicate or discuss his problem with his other family member, and recommend for himself the suitable product or service, and these less power to make a decision and selection of service or product may lead an individual to boredom and tension. According to (Alder, 1993) that there are three sources of misunderstanding, first subconscious cultural blunders happen, when culturally based assumption are made about the events, people or behaviour of a country people, particularly when designing an advertising strategy.

Second is lack of knowledge about culture, that how it influences the buyer behaviour.

Third is to understand that other cultures are similar to their culture, which leads to strategic mistakes.

It is clear from the above discussion that during making any decision an organisation or an individual must look to operating country culture, and its hidden values, and making a decision only to look one side of a society and its exist culture will be a blunder by the decision maker. It is also very important to know enough about the culture of the country means enough knowledge about the operating country culture. It is not enough to know about the one culture and start measuring other culture on same scale. It will be blunder because every culture is different from another culture.

This chapter will explain the Arab patient experience after making their decision for UK health care services. This research will also analyse the areas of improvement at UK health care organisations to develop their product and services to overcome and support the cultural issues for Arab patients.

Methodology:

Population:

In this research those Arab patient were included who met the age criteria of over 18 male and female. Who have travelled or currently residing in UK for health care purposes.

Research design:

In Arab continent majority are Muslim countries, to identify the importance of Arab culture only Arabs patient will be invite to participate in this research. The research methodology will be purely qualitative and quantitative. This research will deal with the subjective prospects of patients like personal experience, personality, culture, education and type of illness. It will be a good and authentic source to collect data.

Primary research:

In this research it is highly considered to include complete population. The sampling frame will be hospital admission list from 2009 to 2010.

According to Economist (1997) that figure 30 is more useful rule of thumb for statistical analysis. So that's why systematic sampling selection process was chosen.

According to (Saunders et al, 2003) that when detail data is required and participants were sick and the acquired data, which is used for final research has greater margin of error. This method of selection is very beneficial to select the patients and data collection with full care and more time. It is very easy to store and extract the patient data, and easy to explain to the participants.

Arab world consist of 22 countries and their religious and cultural values and norms are completely different from UK. The information gained from this research will enable UK health care provider to target those Arab community which is ignored by marketers. Data collected from the questionnaire shows that patient from Saudi Arabia, UAE, Qatar and Abu Dhabi are the biggest user of UK health care services but Oman, Kuwait and Mascat patients are in very low numbers. From the rest of Arab world there were no participants noticed during this research. Data collected from the Arab patients will identify the areas to improve by the patient's personal experience with the service.

In case of data collection there are some rules and regulation which is obligatory to be followed. Before distribution of questionnaire it is very compulsory to provide letter of permission from the organisation, which shows the researcher authority to reach the participants and distribute the questionnaire to collect the data. Embassies of target patient were informed in prior. In this regard embassies also play a vital role in collection of data.

After construction of questionnaire it was submitted to the concern supervisor and another expert for comments and suggestion, to meet the research objectives. Suitable changes were introduced in the questionnaire to achieve the research objectives.

Questionnaire testing:

According to Saunders et al, (2003) that “the reliability of the questionnaire is directly proportional to the consistency of response to the questions”.

Questionnaires were distributed in 8 people of different nationalities to identify any deficiency in the questionnaire. The main purpose of questionnaire testing to identify that respondent understands the questions and giving the appropriate answers. Pilot testing will also show the validity of questionnaire for the primary research.

Instruments:

Questionnaire were used for the collection of data, questions were made simple to avoid any error during data collection. Questionnaire was translated into Arabic because most of the Arab community are not educated to standard level. This approach minimise the margin of error in case of collection of data.

The questionnaire consist on

Demographics

Health condition

Cultural and religious issues

Customer satisfaction

Decision process

Brand image

Demographics:

This section covers areas of Arabs are already targeted and those need to be targeted, male and female ratios and ages that were treated by UK health care provider.

Health condition:

This section indicates the seriousness of sickness and the process to get permission to travel UK for treatment.

Cultural and religious issues:

This section covers all cultural and religious issues. In the questionnaire culture related questions are included to identify that how satisfied the Arab patient are from the cultural arrangement.

Arabs are more loyal towards their culture and it is highly recommended for the UK health care provider to do proper cultural arrangement during treatment of Arab patient.

Arab society is completely based on Islam, and religion play an important role in the every aspect of an Arab life. Religion is consider in the first phase for making decision about the treatment and Muslim belief that Allah is almighty and does better for human. Muslim pray five times a day, Ramadan, Zakat and hajj are the basic and most important pillars of Islam.

UK health care provider needs to do proper religious arrangements while treating Arab patient.

In questionnaire religious related question is included to identify that how satisfied are the Arab patient from religious arrangements.

For this purpose to gain accurate data questionnaire were translated in to Arabic due provide every opportunity to the consumer to gain valid and accurate data.

Customer satisfaction:

This section covers mainly most part of the questionnaire. In the questionnaire customer satisfaction is evident to identify that how satisfied are Arab patient from the UK health care provider services, e.g. post buyer behaviour, repeat business etc.

Decision:

This is the most important section of questionnaire; it identifies the influences on Arab patient decision making process and the role of reference group. The influence of reference group is due to joint family system.

Brand:

In the questionnaire it is also included due to the competition in the market, and to identify the position of UK health care in the market. Question is included to identify that UK health care service are placed in the market competitively or not.

Questionnaire design:

According to Robinson (1999) that the consensus of opinion and to measure the quality of service in term of agreement and disagreement. Srevqual model developed by Parasurama et al (1985, 1986) has been widely used in this questionnaire to gain absolute result.

According to Zeithaml et al (1990) that Srevqual is the most often method for measuring service quality. This method compares customer expectation before service encounter and their perception of the actual service delivered.

According to Van Iwaarden et al (2003) has five generic dimensions are stated below:

  1. Tangibles: Physical facilities, equipment and appearance of personnel.
  2. Reliability: Ability to perform the promised service dependably and accurately.
  3. Responsiveness: Willingness to help customers and provide prompt service.
  4. Assurance (including competence, courtesy, credibility and security).Knowledge and courtesy of employees and their ability to inspire trust and confidence.
  5. Empathy: it is concern to the individual care and attention to the customer from an organisation, like communication and understanding the needs of customer.

Questionnaire is design in a brief and simple introductive language explaining the objectives of the research. Questionnaire consists of 25 open and closed questions along with spare space for comments according to the rules of Srevqual.

Questions were put in a sequence and show a meaningful logic which covers an Arab patient journey for UK health care services. The advantage of this was to incorporate the entire experience and then the comparison will be made by using the filter question because every patient journey is individual.

Limitation of the Methodology:

The chosen topic is basically about the UK health care, to get useful information there are lot of constrain at the very beginning of the study e.g. permission from hospital authorities to meet Arab patients etc. these are very compulsory and time consuming.

Arabs patient belong to a society where hospitality is their cultural and traditional. They fully assured and welcoming in completing the questionnaires.

Questionnaire was translated from English into Arabic to fulfil the requirement of those patients, who are not able to understand English. Arab women are more strict about veil or Hijab and do not prefer to meet strangers from outside and also mostly illiterate but due to Islamic teaching they can write, read the Arabic. English style questionnaire was accompanied with Arabic questionnaire to get absolute data.

Findings:

The main purpose of this section is to review the primary research. Primary research is conducted for the UK health care sector to understand the consumer perception and needs, expectation, decision making process and position of their services or product in the global market.

The survey focused on those Arab patients who travelled to UK for health care services. Total numbers of participant in the survey were 40, 82.5% were male and 17.5% were female, 95% of participant showed their desire that they can understand and speak English and only 5% were not able to understand English. All participants were over the age of 18.

It is very clear from the questionnaire that 27.5% from Saudi Arabia, 25% from Abu Dhabi, 20% from UAE, 17.5% from Qatar, 5% from Oman and 2.5% from Kuwait and Mascat consecutively.

From these findings it is very clear that UK health care sector captured sufficient market share in Saudi Arab, Abu Dhabi and UAE compare to Qatar, Oman and Kuwait.

From Devetag's model it is clearly describe that UK is leading the health care service in the global market due the reasonable price and high quality. But to capture more market share UK healthcare sector needs to focus Arabs countries and advertise their health care services properly. In this case embassies and consultant will play an important role. From the questionnaire it is very clear that 47.5% of patient were advised by embassies, 32.5% of patients were advised by their GP (family doctor) and 17.5% of patients were advised by reference group to travel UK for treatment. Embassies, GP's and reference group especially in Arab culture play a vital role in making decision in case of purchasing health care based on previous experience.

UK health care organisation needs to approach to the Arab doctors to introduce their services, packages and available facilities for the patients. Embassies are the most powerful organisation in case of prompting health care, because it is the main source of information for the consumer. Embassies are playing an influential role in decision making process, but they do not hold all the controlling elements. Embassies are almost late payers and always expecting for discount, but in return they provide more business for the organisation. Same the GP also advise patients but his expectation is for commission, and in return then he provides more business to the organisation.

Reference group is slightly different they always consider the satisfaction from the service and post buyer behaviour.

The proper business relation with embassies and GP's will bring more opportunities. But the patient complaint about service to embassy or GP may stop future business; dissatisfaction of consumer of from the previous visit of any family member of the desire consumer may also stop business.

It is a common belief that Arabs are financially strong and spend more money on health care and entertainments. Most of the Arabs are doing their own business and mostly involve in oil based organisation and consider as self employed. From the questionnaire it is clear that 47.5% of Arabs prefer to do their own business rather than work for someone else. Full time employees were only 32.5%, working in multinational organisations on Directors position and earning six figures. The term retired in the questionnaire is used for those who transferred their business to his sons.

It is also evident that 22.5% of Arab patients annual earnings are from £100,000 to £120,000 and 20% are over £120,000.

It is clear from the above findings that Arabs are financially strong and can easily pay for their treatment without any hesitation. From questionnaire it is evident that 45% of Arab patient are fully able to afford their treatment in the UK and 30% of patients welcome 50% to the contribution of their government and the main reason behind this is they are government employees and they think that it will be contribution from the government for what we are doing for the betterment of our country. About 30% of patient thinks that this is our basic right, and it will be fantastic if government contribute for our treatment, 22% are very hopeful for the government contribution, 12.5% of patient are not interested in government contribution due to different reasons.

There is a very famous Arab proverb that the entire process is based on politeness rather than a respect for money.

From the questionnaire it is very clear that 62.5% of Arab patient travelled o UK for treatment due to GP's and about 17.5% of patient by personal recommendation. It is due to the UK GP's expertise and way of treatment. Mostly Arabs are not satisfied from their native doctors' way of treatment, because from the study it quite clear that Arab doctors behaviour are very harsh towards the patients. About 12.5% of patient return to UK for treatment and the main factor for the repeat treatment is satisfaction from treatment.

Overall patients were satisfied from the UK health care in respect to price, quality, Doctors, facilities and value for money.

About 50% of Arab patient were very satisfied, 32% were somewhat satisfied, 5% were neither satisfied nor dissatisfied and 7.5% were very dissatisfied from the UK health care price (expenses of treatment).

From quality 75% of patients were very satisfied, 17.5% were somewhat satisfied and 2.5% consectively neither satisfied nor dissatisfied, somewhat dissatisfied and very dissatisfied.

From Doctors 77.5% of patients were very satisfied, 7.5% were somewhat satisfied, 10% were neither satisfied nor dissatisfied and 2% of patients were very dissatisfied.

In case of facilities 77.5% of patients were very satisfied, 12.5% were somewhat satisfied, 7.5% were neither satisfied nor dissatisfied and 2.5% were very dissatisfied.

In case of value for money 75% of patients were very satisfied, 15% were somewhat satisfied, 7.5% were neither satisfied nor dissatisfied and 2.5% were very dissatisfied.

From the above findings it is very clear that Arab patients are very satisfied from the price, quality of service, expertise of Doctors, facilities during treatment and what they paid for treatment in UK. But the UK health care sector needs to improve their services and reduce the cost of treatment to capture more market share and satisfied Arab consumer. The dissatisfaction of patients was due to non availability of interpreters 24 hours, to some extent cost of treatment, and absenteeism of consultants which affect quality and GP performance.

The main cause of dissatisfaction from quality, consultants and facilities were due to interpreter. It is not clear that the interpreter translated the information was correct or not and can be dangerous to the patients.

Overall 75% of Arab patient were very satisfied with their treatment and 72.5% of patient were very satisfied and 17.5% were somewhat satisfied with UK nurse caring and house keeper during treatment.

Arab patients are more satisfied from the UK treatment compare to their home country treatment. About 67.5% of patients prefer UK treatment over home country treatment due specialized Doctors, equipped laboratories, better quality, advanced treatment and facilities.

According to kotler (1999) that buyer behaviour and decision making process are influenced by cultural issues, previous experience of the product and reference group input.

From the questionnaire it is clear that 70% of Arab patient were very satisfied from the cultural and religious arrangement during treatment and 17.5% were somewhat dissatisfied and a very little amount of patient were hardly dissatisfied from the arrangements.

Muslim prays five times a day and the main source of dissatisfaction is Doctors visit, medication time or due to the incident in the nearby area which affect their religious practice.

Muslim women always hide their face from strangers and during treatment it is very hard to do such cultural arrangements, and doctors and nurse is the key player during treatment and it is impossible to hide or cover the face or your body from them.

From the questionnaire it is clear that 45% of Arab patients were more willing to be accompanied by a family member and 32.5% were somewhat willing to have a family member during treatment. It is due the joint family system and strong relation bond. Mostly Arab women and male aged 55 to 64 and 65 or above were more interested to have a family member during treatment to give them company.

It was gained from the survey that 25% of Arab patient very satisfied, 30% were neither dissatisfied nor satisfied and 22.5% of Arab patient were somewhat dissatisfied and 5% of Arab patient were very dissatisfied from the source of entertainment during treatment.

Entertainment was the core issue for Arab patients during treatment because it was noticed in Royal free hospital Hampstead Heath, Ealing Hospital West Ealing and Central Middlesex Hospital Park Royal that there was less number of Arabic TV channels in operation. It is revealed from the survey that not enough importance was given to the entertainment and communication of Arab patients.

According to Usunier (1993) stated that due to the Arab social and tribal nature food is a source of communication to them.

From the survey it can be seen that 57.5% of Arab patient were very satisfied from the catering facilities (Halal food), 22.5% were somewhat satisfied, 12.5% were neither satisfied and nor dissatisfied, 5% were somewhat dissatisfied and 2.5% of the Arab patient were very dissatisfied from the catering facilities(Halal food) during treatment in UK.

The factor of dissatisfaction from Halal food was less varieties of food in hospitals and is an issue for longer stay patient.

It is discussed thoroughly that Arab patient travel to UK for advanced treatment and after searching the global market they make their own decision. They always consider the best for their own treatment and something of value.

From the survey it is revealed that 75% of Arab patients are strongly agree that they paid for something of value and about 17.5% were somewhat agree, a very few consumer showed their disagreement with the statement due to failure of consultant or nurses on time response. It was due duty changing, Doctor Absenteeism and during emergency.

Arab patients were satisfied from the UK treatment and 72.5% of Arab patient strongly agree that UK treatment fully satisfied their needs and expectation.

It is clear from this question that 50% of Arab patient were strongly agree that UK health service are placed competitively in the market in respect to price and brand, 5% were somewhat agree, 22.5% don't know, 10% were somewhat disagree and 12.5% were very disagree.

It is briefly discussed in the Devetag's model UK health care services are placed in the global market competitively i.e. price and brand.

According to (Pekkala et al 1983) stated that reliable product or service needs proper introduction and advertisement in the desire market before launching. He further argues that services needs proper segmentation, advertisement and it is the responsibility of marketers to consider the cultural values of a country before providing his product or service to the consumer.

In the Devetag's model UK health care services are classed as “A” of superior and expensive quality.

According to NHS chief David Nicholas that in 2013 budget 15% of wealth will be spent on the health care service which will make the UK health care more advance and cheaper and still UK health care is cheaper than Denmark and rest of Europe.

These above theories show that UK health care service is better than other health services in the global market by price and other perspectives.

It is also clear that 72.5% of Arab patient are enough satisfied from the UK treatment and willing to return UK for further treatment if necessary.

This satisfaction is the contribution of GP's and nurses and due the proper use of available facilities. Arab patient treated in UK hospitals are the best source and direct method of advertisement. About 85% of Arab patient showed their willingness that they will advise and recommend UK treatment to other consumer.

In the questionnaire thoroughly it briefly asked in different question about the decision making process.

According to the Howard and Sheth's model (1969) stated in learning constructs, that as we are growing and learning from experiences. The process of learning from experiences makes us able to make a decision to buy on the grounds of our own experience.

It clear from the above model theory “learning constructs” repeat business takes place due to the previous experience with the consumption of a service or product.

In the light of Howard and Sheth's model (1969) when in the market of healthcare a competitor provide its service with increased value and for low price, in this situation embassy buyer behaviour strategy will be adopted.

According to Sheth's model of industrial buyer behaviour (1973) that seeking of information from different sources about a brand will be variable among the decision making group, where there is likely to be a certain amount of perceptual distortion.

A very common perception about Arabs their decisions are mostly influenced by family members taking into account religious and culture are also playing an important role.

On the other hand embassies where they are also playing an important role in decision making process.

Culture and religion are the most evident factors which influenced the buyer decision making process. Culturally reference group is playing its role to influence the decision making ability of an Arab patient. Religious comes next its only stress on the limitation and practices during treatment.

It has been noticed from the research findings that culture and religion practices needs to be put first when satisfying an Arab consumer. UK health care sector needs to further explore Arabs cultural and religious practices to fully satisfy Arab patients. UK health care desire to further target the Arab health care market they need to properly introduce and advertise their product or service in the market before launching. Proper advertisement and marketing of product and service is the only source to literate the Arab community about the brand.

Conclusion

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