quality - ct 7

RESEARCH ARTICLE Open Access

Access and utilisation of primary health care services comparing urban and rural areas of Riyadh Providence, Kingdom of Saudi Arabia Ghadah Alfaqeeh1, Erica J. Cook2*, Gurch Randhawa3 and Nasreen Ali3

Abstract

Background: The Kingdom of Saudi Arabia (KSA) has seen an increase in chronic diseases. International evidence suggests that early intervention is the best approach to reduce the burden of chronic disease. However, the limited research available suggests that health care access remains unequal, with rural populations having the poorest access to and utilisation of primary health care centres and, consequently, the poorest health outcomes. This study aimed to examine the factors influencing the access to and utilisation of primary health care centres in urban and rural areas of Riyadh province of the KSA.

Methods: A questionnaire survey was carried out to identify the barriers and enablers to accessing PHCS in rural (n = 5) and urban (n = 5) areas of Riyadh province, selected on the classification of the population density of the governorates. An adapted version of the NHS National Survey Programme was administered that included 50 questions over 11 sections that assessed a wide range of factors related to respondent’s access and experience of the PHCS. A total of 935 responses were obtained with 52.9% (n = 495) from urban areas and the remaining 47.1% (n = 440) from rural areas of Riyadh province.

Results: This study highlights that there are high levels of satisfaction among patients among all PHCS. In relation to differences between urban and rural respondents, the findings indicated that there were significant variations in relation to: education level, monthly income, medical investigations, receiving blood tests on time, extra opening hours, distance, cleanliness and health prevention. Core barriers for rural patients related to the distance to reach PHCS, cleanliness of the PHCS, receiving health prevention and promotion services, which should serve to improve health outcomes.

Conclusions: This study highlighted important differences in access to and utilisation of PHCS between urban and rural populations in Riyadh province in the KSA. These findings have implications for policy and planning of PHCCs and reducing inequalities in health care between rural and urban populations and contributing to a reduction in the chronic disease burden in Riyadh province.

Keywords: Health service access, Primary health care, Rurality, Demography

* Correspondence: [email protected] 2Department of Psychology, University of Bedfordshire, Park Square, Luton, UK Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 DOI 10.1186/s12913-017-1983-z

Background One of the core aims of the Sustainable Development Goals (SDG’s) is to provide all people throughout the world with equal, unbiased access to and ensure mea- sures are in place to enable utilisation of basic Primary Health Care Services (PHCS) [1]. International evi- dence continues to demonstrate the fundamental role PHCS plays in improving population health through the reduction of morbidity and all-cause mortality [2, 3]. The impact of globalisation alongside the progres- sion of developing and middle-income countries demo- graphic and epidemiological transition has resulted in a rise in chronic disease [4]. It is reported that the Middle East and North African regions are now shown to have the highest regional prevalence of chronic diseases for 2011, (after age standardisation to the world popula- tion) [5, 6]. Consequently, tackling the rising chronic disease burden alongside the associated cost to the na- tional health care systems [7, 8] represents a central agenda for policymakers when addressing changes to PHCS [9]. The Kingdom of Saudi Arabia (KSA) represents a mid-

dle Eastern country which has seen an increased chronic disease burden [10]. Current evidence has indicated that KSA has the 7th highest rate of Diabetes Mellitus (DM) in the world [11, 12] alongside markedly increased rates of hypertension and coronary heart disease [13, 14]. This has, consequently, led to increased health costs to the government. For example, the current cost of diabetes in estimated at 17 billion Riyals [10] which is expected to increase to 43 billion Riyals [11]. The existing evidence base (the majority of which is

based on evidence from the developed world) shows that early intervention has proven to be an effective strategy for reducing the incidence of chronic diseases and the difficulties, including the costs, associated with treat- ment of such diseases at the later stages of the condi- tions [15, 16]. Internationally, research suggests that access to and utilisation of PHCS can been unequal in countries between urban and rural (and nomadic) popu- lations, with the latter having the poorest access to and utilisation of PHCS [10]. Rural (and nomadic) popula- tions are also the most deprived groups within the KSA population [17, 18]. There is a paucity of evidence in comparing access to

and utilisation of PHCS between urban and rural popu- lations. By understanding the barriers and enablers to accessing PHCS in rural and urban areas in Riyadh prov- ince, KSA, this study will contribute towards reducing inequalities in access to and utilisation of PHCS. The ob- jective of this study was to identify barriers and enablers in relation to access to and utilisation of PHCS among a sample of patients attending PHCS in rural and urban areas of Riyadh province.

Methods Setting The Riyadh province of Saudi Arabia was selected as the location for this study. The Riyadh province consists of twenty governorates (areas, districts or city). The twenty governorates in Riyadh province are not classified as ei- ther urban or rural based on any officially published sta- tistics/record. Hence, it was proposed that the top quartile governorates will be classified as urban and the lower quartile as rural based on the population density [19] for the purposes of this study. The population dens- ity of each governorate was calculated by dividing the total population by the area of the corresponding gover- norate and the governorates were then arranged in a de- scending order of catchment population density to identify the ‘urban’ (top quartile) and the ‘rural’ (bottom quartile) governorates. Table 1 below presents the fig- ures for the catchment population density for the twenty governorates in the Riyadh province. Five rural and five urban Primary Health Care Centres

(PHCC) in the Riyadh province were selected based on the classification of the population density of the gover- norates as discussed above (see Table 1). The selection of the PHCCs in these selected rural and urban gover- norates for the purpose of this study (data collection sites) was based on the Ministry of Health classification of services provided by the PHCCs. The Ministry of Health classifies its PHCCs based on the range of ser- vices provided. MOH classifies PHCCs that have a la- boratory, dentistry and residential facilities for the GP and a nurse working at the PHCC with the identifier B3. After reviewing the Ministry of Health classifications for the PHCCs, it was observed that the most numerous categories of PHCSs were B3. To ensure like to like comparison (in terms of services offered) between rural and urban governorates, the B3 PHCCs serving the lar- gest population in each governorate were identified as the PHC sites for inclusion in this study (Table 2).

Participants and methods Participants were eligible to take part in the present study if they were aged 18 years or older, attended one of the recruiting PHCCs, were a Saudi resident and could consent. The sample size was calculated by using the following formulae (1)n = Z2α P(1-P)/d

2, where n = required sample size, Zα = 1.96 (standard normal devi- ation), P = proportion of patients having access to and utilising the PHC and d = precision of estimate. Consid- ering that 50% of patients have access to and are utilis- ing their PHCCs both at urban and rural regions of Riyadh province, with a precision of ±5% and at 5% level of significance, 384 patients each were required at urban and rural PHCCs. The calculated sample size was 384 (n = (1.96)2 × (0.50 (1–0.50) / (0.05)2 = 384.16). With an

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 2 of 13

anticipated 15% non-response and incomplete responses from the patients, the required sample size increased by 56. This represented a final target sample size of 440 from each urban and rural PHCCs, a total of 880 pa- tients from the selected urban and rural PHCCs of Riyadh province (88 patients from each PHCC).

Data collection A questionnaire survey was carried out to identify the bar- riers and enablers to accessing PHCS in rural and urban areas of Riyadh province. An adapted version of the NHS

National Survey Programme: Primary Care Trust Question bank 2008 v6 dated 27th November 2007 was used. Per- mission to use and adapt the questionnaire was obtained from the Care Quality Commission in the UK [20–25]. The original questionnaire was a validated measuring in- strument and included 123 questions in 15 sections cover- ing information on local PHCS in the UK. The adapted final questionnaire used for this study included 50 ques- tions over 11 sections. These sections included: (1) making an appointment, (2) visiting the PHCC, (3) seeing a doctor, (4) medicines, (5) tests, (6) referrals, (7) seeing another pro- fessional from a PHCC, (8) satisfaction of PHCC, (9) dental care and (10) health promotion alongside (11) personal socio-demographic information (see Additional file 1). An Arabic version of the questionnaire, information

sheet and consent form were developed. These were back translated by the lead researcher (GA) from UK English to Arabic and were piloted for interpretation and accuracy with Saudi postgraduate students studying at the University of Bedfordshire (N = 20). Minimal changes were needed. Modifications mostly related to formatting, i.e. increase of font size and improved pres- entation of information. In some cases, the Arabic trans- lation used a very high level of Arabic grammar and pilot participants suggested that more ‘every day’ Arabic would be more appropriate to ensure that respondents fully understood the questionnaire.

Table 1 Catchment population density of Riyadh province of Saudi Arabia (MOI)

Governorate Area/km2 Population Catchment population density/km2 Rural/Urban

Alriyad 1800 5188286 2882.38 Urban

Al-Deri’yya 2020 73668 36.47

Al-Kharj 19790 376325 19.02

Al-Zulfi 5540 69294 12.51

Dharma 2060 24429 11.86

Al-Muzahmeya 3580 39865 11.14 Semi urban

Hraymla 1480 15324 10.35

Shaqra 4110 40541 9.86

Al-Dwadmy 30580 217305 7.11

HotatBaniTameem 7350 43300 5.89

Al-Ghat 2690 14642 5.44

Al-Majma’ah 30000 133285 4.44

Thadig 5600 17165 3.07

Afeef 26810 77978 2.91

Al-Quway’iyah 50580 126161 2.49

Al-Hareeq 6790 14750 2.17 Rural

Wadi Al-Dawaser 48900 106152 2.17

Rammah 15900 28055 1.76

Al-Aflaj 54120 68201 1.26

Al-Saleel 42420 36383 0.86

Table 2 The PHCCs selected for the study (data collection sites) showing population density

Region Name of PHCC Population density Governorate Category

Rural H 3980 Alaflaj B3

F 2599 Alhareeq B3

G 11495 WadiAldawasir B3

I 6614 Alsaleel B3

C 1033 Rimah B3

Urban A 2077 Darmaa B3

E 10536 Alzulfi B3

B 6065 Al-Deri’yya B3

D 8000 Riyadh B3

J 11368 Al-Kharj B3

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 3 of 13

All patients were recruited at each of the PHCC’s. To facilitate recruitment, practice managers at each of the PHCCs were sent a letter from the Ministry of Health, introducing the study. This was followed up by a phone call from a male research assistant with a date and time to set up a face-to-face meeting with the PHCC practice managers to discuss the research, enlist support to ac- cess patients and complete the questionnaire survey. There were two phases of data collection. Phase one

took place across a 3-month period (1 January 2014–31 March, 2014). In phase one PHCC nurses administered the questionnaires through 1–1 interviews with the pa- tients in Arabic. The lead researcher (GA) with the support of a male

researcher provided a training support session with each PHCC practice team, which included practice managers and nursing staff who would administer the question- naire. During this session, the lead researcher (GA) gave the team a protocol and recruitment packs that provided information on the patient eligibility criteria and the re- cruitment process. The questionnaires were discussed in detail alongside information on how they should be completed and what support nursing staff should pro- vide. During the recruitment phase, a male research as- sistant communicated with the PHCC weekly to ascertain recruitment and engagement. Concerns were quickly identified that related to the resources needed for nurses to administer the questionnaires, with only 438 questionnaires completed during this period. As such, a second phase was built in to the data col-

lection process to facilitate higher recruitment. This phase was conducted across a 2-month period (1st May 2014–1st July 2014). The lead researcher (GS) and a male research assistant, who both had extensive experi- ence in interviewing and administering questionnaires, visited each PHCC to recruit participants. The same

recruitment protocol was applied with all questionnaires administered via 1–1 interviews in Arabic. This phase led to the collection of an additional 538 questionnaires. Overall, there were a total of 935 questionnaires col- lected from both recruitment phases. Table 3 provides the number of questionnaires handed out at each of the phases of the data collection, returned, excluded and the response rate for each PHCC.

Statistical analysis Categorical variables for all explanatory variables were calculated. Chi-square Goodness of Fit analyses were completed for frequencies with adjusted standardised re- siduals (ASR)’s that were calculated to indicate the im- portance of the cell to the ultimate chi-square value, which considers the overall sample size. This was par- ticularly important given the varying counts by uptake rate across groups. Therefore, when reporting the re- sults, the ASR values were used to indicate significance, i.e. ASR values of 3.09 (p < .001), 2.6 (p < .01) and 2 (p < .05) will signify significance, with anything below 2 deemed non-significant (p > .05). All statistical tests were completed using IBM SPSS for Windows, Version 22 [26]; two-tailed significance was assumed at p < 0.05.

Ethics, consent and permissions Ethical approval for this study was obtained from the University of Bedfordshire ethics committee and the KSA Ministry of Health.

Results A total of 935 responses were obtained with 52.9% of pa- tient respondents from urban areas and the remaining 47.1% from rural areas. Results are presented in Table 4.

Table 3 Number of questionnaire collected in the two phases of data collection with response rates by PHCC

PHCC Name

Classification (Urban/Rural)

Questionnaires collected (N) (phase one)

Questionnaires collected (N) (phase one)

Total Questionnaires

Questionnaires excluded (N)

Non- Response (N)

Questionnaires completed (N)

Response rate

(E) Urban 22 78 109 6 3 94 86.24%

(A) Urban 70 36 110 0 4 106 96.36%

(C) Rural 75 25 105 3 2 97 92.38%

(D) Urban 7 79 91 5 0 81 89.01%

(B) Urban 45 70 125 7 3 108 86.40%

(J) Urban 40 64 108 2 2 102 94.44%

(F) Rural 40 55 106 10 1 85 80.19%

(H) Rural 0 84 84 0 0 84 100.00%

(I) Rural 62 22 89 5 0 79 88.76%

(G) Rural 77 25 105 3 0 99 94.29%

Total —————— 438 538 1032 41 15 935 90.60%

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 4 of 13

Table 4 Chi-square comparison of respondents by urban and rural location

Rural Urban

N % ASR N % ASR X2 Sig

Socio-demographic characteristics

Gender Male 208 47.3 2.4 195 39.4 −2.4 5.9 **

Female 232 52.7 −2.4 300 60.6 2.4

Age <20 25 5.7 0.6 24 4.8 −0.6 10.66 *

21-30 141 32 −1.6 184 37.2 1.6

31-40 127 28.9 0.8 131 26.5 −0.8

41-50 95 21.6 1.5 87 17.6 −1.5

51-60 38 8.6 0.8 36 7.3 −1.5

60 year.+ 14 3.2 −2.4 33 6.7 2.4

Education level 0-16 years. 77 17.5 1.7 67 13.5 −1.7 13.26 **

17-18 years. 106 24.1 −3.2 166 33.5 3.2

19 years+ 222 50.5 2.3 213 43 −2.3

Still in education 35 8 −1 49 9.9 1

Current monthly income SAR 3,000 or less 168 38.2 −3.9 252 50.9 3.9 18.64 ***

SAR 3–8,000 240 54.5 2.7 226 45.7 −2.7

SAR 8–15,000 32 7.3 2.6 17 3.4 −2.6

Health status

Perceived health status Excellent 58 13.2 0 65 13.1 0 1.84 NS

Very good 233 53 −0.4 269 54.3 0.4

Good 145 33 0.7 152 30.7 −0.7

Fair 4 0.9 −1.2 9 1.8 1.2

Prescribed medication Yes 209 47.5 0.4 229 46.3 −0.4 0.14 NS

No 231 52.5 −0.4 266 53.7 0.4

Use of services

Made apt. with doctor Yes 0 0 −0.9 1 0.2 0.9 0.89 NS

No 440 100 0.9 494 99.8 0.9

Referral to specialist Yes 265 60.2 1.8 270 54.5 −1.8 3.07 NS

No 175 39.8 −1.8 225 45.5 1.8

Medical investigations No response 196 44.5 −6.1 319 64.4 6.1 64.69 ***

Yes 119 27 0.2 131 26.5 −0.2

No 116 26.4 7.4 41 8.3 −7.4

Do not remember 9 2 1.6 4 0.8 −1.6

Organisational factors

See doctor on time at apt. Not at all 440 100 0.9 494 0.2 −0.9 0.89 NS

Seen without apt. 0 0 −0.9 1 99.8 0.9

Received blood results on time No response 321 73 −0.2 364 73.5 0.2 6.33 NS

Yes on time 84 19.1 −1 107 21.6 1

Later expected 34 7.7 2.3 21 4.2 −2.3

Still waiting 1 0.2 −0.9 3 0.6 0.9

Opening hours Yes often 30 6.8 0 34 6.9 0 0.66 NS

Yes sometimes 125 28.4 0.8 129 26.1 −0.8

No 285 64.8 −0.7 332 67.1 0.7

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 5 of 13

Table 4 Chi-square comparison of respondents by urban and rural location (Continued)

Extra opening times No extra hours 234 53.2 3.3 210 42.4 −3.3 28.75 ***

Early mornings 11 2.5 0.5 10 2 −0.5

Evenings 103 23.4 −4.7 187 37.8 4.7

Saturdays 90 20.5 1.4 84 17 −1.4

Fridays 2 0.5 1.5 0 0 −1.5

No response 0 0 −1.9 4 0.8 1.9

Extra opening days No response 0 0 −1.9 4 0.8 1.9 17.67 ***

One day per week 124 28.2 −1.8 166 33.5 1.8

2-3 days per week 126 28.6 −0.3 146 29.5 0.3

4-5 days per week 57 13 3.6 30 6.1 −3.6

Don’t know 133 30.2 0 149 30.1 0

Distance to PCC Yes 123 28 5.7 64 12.9 −5.7 32.87 ***

No 317 72 −5.7 431 87.1 5.7

Cleanliness of PCC Very clean 245 55.7 −4 339 68.5 4 42.43 ***

Fairly clean 157 35.7 1.5 153 30.9 −1.5

Not very clean 24 5.5 4.4 3 0.6 −4.4

Not at all clean 12 2.7 3.7 0 0 −3.7

Unable to say 2 0.5 1.5 0 0 −1.5

Mobility within PCC Very easy 408 92.7 −3.1 481 97.2 3.1 12.16 **

Fairly easy 31 7 3.2 13 2.6 −3.2

Not at all easy 0 0 −0.9 1 0.2 0.9

Unable to say 1 0.2 1.1 0 0 −1.1

Help understanding Arabic No response 1 0.2 −1.2 4 0.8 1.2 1.48 NS

Yes 1 0.2 0.1 1 0.2 −0.1

No 438 99.5 1 490 99 −1

Financial factors

Pay for prescribed medicine/s Yes 14 3.2 −1.1 23 4.6 1.1 1.31 NS

No 426 96.8 1.1 472 95.4 −1.1

Doctor patient communication

Doctor listened carefully Definitely 394 89.5 1.7 425 85.9 −1.7 2.91 NS

To some extent 46 10.5 −1.7 70 14.1 1.7

Enough time to discuss health Definitely 385 87.5 1.5 416 84 −1.5 2.36 NS

To some extent 50 11.4 −1.5 73 14.7 1.5

No 5 1.1 −0.1 6 1.2 0.1

Treated with dignity and respect Yes all of the time 440 100 2.3 489 98.8 −2.3 5.37 **

Some of the time 0 0 −2.3 6 1.2 2.3

Provided answers for questions Yes definitely 370 84.1 0.8 406 82 −0.8 6.69 NS

Yes to some extent 51 11.6 −1.5 74 14.9 1.5

No 4 0.9 0.2 4 0.8 −0.2

Did not need to 11 2.5 0.3 11 2.2 −0.3

No opportunity 4 0.9 2.1 0 −2.1

Treatment explained & understood Yes definitely 332 75.5 −0.8 384 77.6 0.8 18.5 ***

Yes to some extent 35 8 −2.5 64 12.9 2.5

No 3 0.7 −0.8 6 1.2 0.8

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 6 of 13

Socio-demographic characteristics Gender and age There was a total of 43.1% male and 56.1% female re- spondents. Chi-square analysis revealed that distribution was not equally distributed across the total sample by gender and region (X2 = (2, N = 935) = 5.90, p < .01). Findings confirmed there were significantly more males from regions identified as ‘rural’ (ASR 2.4; p < .05) with significantly more females from regions identified as ‘urban’ (ASR 2.4; p < .05). In relation to age distribution, chi-square analysis re-

vealed that the distribution of age of respondents was not equally represented across both urban and rural re- gions (X2 = (6, N = 935) = 10.66, p < .05). There were sig- nificantly fewer ‘older’ respondents (60 years+) from rural regions (ASR −2.4; p < .05) compared to urban.

Education and income Respondents from rural regions were more likely to have a higher level of education compared to those from urban regions (X2 = (4, N = 935) = 13.26, p < .01). Specif- ically, those residing in urban areas were significantly more likely to have left education at 17–18 years old (ASR 3.2; p < .001) compared to rural areas where re- spondents were more likely to have left education at

19 years and older (ASR 2.3; p < .05). Furthermore, those from rural areas were significantly more likely to earn more income compared to those from urban areas (X2

= (3, N = 935) = 18.64, p < .001). Chi square analysis re- vealed that those residing in rural areas were signifi- cantly more likely to earn SAR 3000–15,000 (p < .01) compared to those from urban areas who were signifi- cantly more likely to earn SAR 3000 or less (ASR 3.9; p < .001).

Health status There was no association by region (urban vs. rural) and health status (X2 = (4, N = 935) = 1.84, p > .05). The ma- jority of respondents rated their health as either very good (rural; 53%, urban; 54.3%) or good (rural; 33%, urban; 30.7%) with only a minority rating their health as poor.

Use of services There was no significant relationship between the region someone resides in (urban vs. rural) and seeing a doctor (X2 = (2, N = 935) = 0.89, p > .05) with most respondents stating that they have not had an appointment with their doctor in the past 12 months (rural; 100%, urban; 99.8%). Likewise, there was no significant relationship

Table 4 Chi-square comparison of respondents by urban and rural location (Continued)

Did not want 32 7.3 3 15 3 −3

Not needed 38 8.6 2 26 5.3 −2

Results explained & understood Yes definitely 112 25.5 0.1 124 25.1 −0.1 4.95 NS

Yes to some extent 7 1.6 1.1 4 0.8 −1.1

No response 321 73 −0.2 3 0.6 0.2

Still waiting 0 0 −1.6 364 7.35 1.6

Health prevention and promotion

Blood sugars checked at PCC Yes 308 70 2.8 303 61.2 −2.8 7.96 **

No 129 29.3 −2.8 188 38 2.8

Not sure 3 0.7 −0.2 4 0.8 0.2

Received advice (weight) Yes lose weight 207 47 −1.1 250 50.5 1.1 5.05 NS

Yes stay the same 79 18 0.5 83 16.8 −0.5

Yes gain weight 21 4.8 −1 31 6.3 1

No like advice 71 16.1 2 58 11.7 −2

No advice wanted 62 14.1 −0.3 73 14.7 0.3

Received advice (healthy eating) Yes definitely 143 32.5 −2.1 193 39 2.1 21.82 ***

Yes to some extent 94 21.4 1 93 18.8 −1

Would like advice 131 29.8 4 92 18.6 −4

No advice wanted 72 16.4 −2.8 117 23.6 2.8

Satisfaction

Satisfaction of using PCC Yes completely 388 88.2 0.8 428 86,5 −0.8 2.98 NS

Yes to some extent 52 11.8 −0.5 64 12.9 0.5

No 0 0 −1.6 3 0.6 1.6

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 7 of 13

between the region someone resides in (urban vs. rural) and being referred to a specialist (X2 = (2, N = 935) = 3.07, p > .05) with all respondents stating that they have not been referred to a specialist in the past 12 months. In relation to medical investigations, there was a signifi- cant relationship between the region someone resides in (urban vs. rural) and having a blood test (X2 = (3, N = 935) = 7.96, p > .01). The findings confirmed that respon- dents from rural regions were significantly more likely to have a blood test (ASR 2.8; p < .01) compared to those from urban regions (ASR −2.8; p < .01).

Organisational factors There was no significant relationship between the region someone resides in (urban vs. rural) and seeing their GP on time (X2 = (2, N = 935) = 0.89, p > .05) with nearly all the respondents stating that they did not have to wait at all to see their doctor. Moreover, there was no significant relationship between the region someone resides in (urban vs. rural) and receiving blood test results on time (X2 = (4, N = 935) = 6.33, p > .05). There was no significant relationship between the re-

gion someone resides in (urban vs. rural) and if clinic hours negatively impacted on respondents seeing their doctor (X2 = (3, N = 935) = 0.66, p > .05), with most re- spondents stating that opening hours was not an issue. There was a significant relationship between the region someone resides in (urban vs. rural) and wanting extra opening days (X2 = (5, N = 935) = 17.67, p < .001) and times (X2 = (6, N = 935) = 28.75, p < .001). The findings confirmed that respondents from urban regions were significantly more likely to want the centre to open early mornings (ASR 4.7; p < .001), with those from rural re- gions most likely to want the centre to open for extra days (ASR 3.6, p < .001). In relation to the distance from patients’ residence to

the primary care centre, there was a significant relation- ship between the region someone resides in (urban vs. rural) and distance posing an issue for attending the pri- mary care centre (X2 = (2, N = 935) = 32.87, p < .001). These findings suggested that distance was significantly more likely to present a problem to those residing in rural regions (ASR 5.7, p < .001) compared to those from urban regions (ASR −5.7, p < .001). There was a significant relationship between the re-

gion someone resides in (urban vs. rural) and the cleanli- ness of the PCC (X2 = (5, N = 935) = 42.43, p < .001) and ease of moving around with mobility (X2 = (4, N = 935) = 12.16, p < .01). Respondents from rural regions were significantly more likely to state that the PCC was not very clean (ASR 4.4, p < .001) and not at all clean (ASR 3.7, p < .001) compared to those from urban regions who were significantly more likely to state the PCC is very clean (ASR 4, p < .001). Mobility appeared to be an issue

for those who resided in a rural region. For example, sig- nificantly more people from urban regions stating it is very easy to get around (ASR 3.1, p < .001) compared to those from regions areas who were more likely to state it was only ‘fairly easy’ (ASR 3.1, p < .001). There was no significant relationship between the re-

gion someone resides in (urban vs. rural) and help un- derstanding Arabic (X2 = (3, N = 935) = 1.48, p > .05), with most respondents stating that understanding Arabic was not an issue.

Financial Respondents were asked if they have had to pay for pre- scribed medicines in the past 12 months. Findings con- firmed there was no significant relationship between the region someone resides in (urban vs. rural) and payment for prescriptions (X2 = (2, N = 935) = 1.31, p > .05), with many respondents stating that they have not had to pay for medicines.

Service provider-patient communication There was no significant relationship between the region someone resides in (urban vs. rural) and whether the re- spondent’s doctor listened carefully (X2 = (2, N = 935) = 2.91, p > .05), provided enough time to discuss health is- sues (X2 = (3, N = 935) = 2.36, p > .05) and provided an- swers for questions (X2 = (2, N = 935) = 6.69, p > .05) and satisfactorily explained investigative test results (X2 = (4, N = 935) = 4.95, p > .05). Most respondents viewed the doctor favourably across all factors. However, there were significant differences noted for

‘being treated with dignity and respect’ (X2 = (2, N = 935) = 5.37, p < .001) and ‘treatment explained and understood’ (X2 = (5, N = 935) = 18.5, p < .01). For ex- ample, respondents from rural areas felt that their doc- tor treated them with dignity and respect ‘all of the time’ (ASR 2.3; p < .01) compared with urban respondents who were significantly more likely to state ‘only some of the time’ (ASR 2.3; p < .01). However, in relation to com- munication relating to treatment, urban respondents were more significantly likely to state treatment was ex- plained well and was well understood (ASR 2.5 p < .01) compared to those from the rural areas.

Service provision There was no significant relationship between the region someone resides in (urban vs. rural) and receiving advice related to weight (X2 = (2, N = 935) = 5.05, p > .05). How- ever, there were significant differences found for blood sugars being checked (X2 = (3, N = 935) = 7.96, p < .01) and receiving advice relating to healthy eating (X2 = (4, N = 935) = 21.82, p < .001). The findings confirmed re- spondents from rural regions were more likely to have their blood sugars checked (ASR 2.8, p < .01). However,

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 8 of 13

respondents from urban regions were significantly more likely to ‘definitely’ receive advice relating to healthy eat- ing (ASR 2.1; p < .05), with those from rural regions less likely to receive advice but significantly more likely to want advice (ASR 4; p < .001).

Overall satisfaction Respondents were asked to rate their level of satisfaction of using the PCC. There was no significant relationship between the region someone resides in (urban vs. rural) and satisfaction (X2 = (3, N = 935) = 2.98, p > .05), with the majority of respondents completely satisfied.

Discussion Socio-demographic characteristics There was higher female participation compared to males, which could be reflective of more general pat- terns of health care utilisation [27, 28]. However, re- search that has explored health service use in Islamic societies has shown that often females have lower rates of healthcare utilisation [29]. This is often because they remain dependent on men to make decisions about healthcare, with women not normally allowed out to visit a health facility or health care provider alone [30]. The higher participation of females in non-Islamic soci- eties may also be related to the presence of a female ad- ministering the questionnaire during recruitment; an essential consideration when conducting research with women in the Saudi Traditional Islamic segregated con- text [31, 32]. Socio-economic factors, such as income, education

and employment, are key enabling characteristics for accessing health care, particularly in terms of the ability to pay for health insurance [33–35]. The monthly in- come of patient respondents ranged from less than 3000–15,000 Riyals per month, with highest income rates shown for 8000 Riyals and less. This is representa- tive of the average monthly incomes in the KSA [36]. Interestingly, respondents from rural regions earned significantly more (3–15,000 Riyals) compared to urban regions (<3000 Riyals). Furthermore, respondents from rural regions were more likely to have a higher level of education and to have left education later compared to those from urban regions. Traditionally, urban regions and cities were viewed as focal points of economic growth, employment and innovation, all factors shown to be indicative of good general health and wellbeing [37]. However, it is now strongly argued that the pro- portion of urban poor in developing countries world- wide is increasing faster that of the overall rate of urban population growth [38]. For example, 30% of the urban population of the Middle East and North Africa live in Slums [39].

Health Status The majority of respondents from both urban and rural locations rated their health as good and very good irre- spective of what region they were from. This is an inter- esting finding given that 47.5% (n = 209) of rural and 46.3% (n = 229) of urban patients are taking prescribed medication. Health care research has shown that beliefs and understandings surrounding a patient’s illness in culturally diverse groups are not only a core facilitator of health service uptake [40, 41] but also medication adher- ence [42]. Consequently, future research should examine the illness beliefs of patients in relation to their health status, co-morbidities and medication to determine what processes are related to help-seeking behaviour and, consequently, access.

Use of services The majority of respondents from both urban and rural regions stated that they have not made an appointment with a doctor in the past 12 months. Whilst this may re- late to recall bias, this does not correspond with other findings. For example, many patients were referred to a specialist and likewise had medical investigations during the same period. Patients from rural areas were signifi- cantly less likely to have had a medical investigation in the past 12 months. Further, whilst the majority of re- spondents from urban areas who had a medical investi- gation stated they received test results on time, for rural participants this was significantly later than expected. International evidence has suggested that provision of medical care is poorer in rural communities [43] par- ticularly those in developing countries, which often is re- lated to lower proportions of healthcare professions [44] and reduced access to medical resources [45].

Organisational factors Whilst it may have been hypothesized that rural patients would want extra opening hours compared to their urban counterparts, this finding was not supported. For example, urban respondents were shown to want in- creased opening hours particularly in the evenings, with rural respondents significantly more likely to state that they did not want extra opening hours. This may be re- lated to the economic growth and the increased levels of employment found in the more urbanised provinces of KSA [46]. Further, this finding may be related to the international legislative commitments that have centred on women’s welfare and increasing their societal and economic role [47, 48]. For example, recent evidence has shown that the number of women in employment in Saudi Arabia quadrupled, from 48,000 in 2009 to over 200,000 in 2012 [48]. Differences are found in urban and rural communities, with rural mothers less likely to be employed and more likely to engage in household chores

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 9 of 13

and parental activities [49, 50]. Inconvenient clinic times for PHCC remains a core barrier to accessing health ser- vices [51–54], more flexible opening times for urban re- spondents should serve to improve health outcomes and increase levels of patient satisfaction. Distance from the patients’ residence was viewed as a

barrier to accessing PHCCs for participants residing in rural areas but not from those residing in urban areas. There is an extensive evidence base that continues to suggest that distance from health facilities, often referred to as the ‘distance decay’ effect, has a detrimental impact on health care utilisation [55–57]. It is widely reported that the KSA population is reluctant to travel long dis- tances to PHCCs because of the hot climate found in the summer months [56, 58]. Households within KSA have high rates of car ownership, so the availability of transportation to the PHCC was not considered an im- portant factor that may intersect with distance from resi- dence as a barrier to accessing the PHCC [59]. The majority of respondents stated it was very easy for

them to move around inside the PHCC. This is particu- larly important in a segregated society like the KSA be- cause, without clearly defined (and resourced) spaces for women and men, access to the PHCC would be a major barrier to accessing and utilising the PHCCs [60]. How- ever, in relation to cleanliness, there were marked differ- ences. For example, rural respondents were significantly more likely to state that the cleanliness was ‘not at all clean’ and ‘not very clean,’ with urban respondents sig- nificantly more likely to state their PHCC was ‘very clean’. This has been found in other rural areas of mid- dle income countries where standards are not always consistent [61]. A recent review by the World Health Organisation stated that primary health care centres have significantly lower water, sanitation and hygiene in middle income countries, although this is viewed as problematic for rural residents as often this is the only point of contact [62]. As such, national planning should remain key in improving services and sanitation to im- prove the delivery of routine services and to prevent and control infections. However, it is also important to note that the rural

sample was characterised by higher levels of income and education. Further, there were more men; therefore, this finding could be related to increased levels of expecta- tions, particularly within in a society with a strong gen- der hierarchy among wealthier and better-educated men. Research has highlighted that acceptability and levels of satisfaction towards health services, particularly in Mid- dle Eastern countries is higher among disadvantaged groups (women and the poor) compared to men and those with higher levels of income [63]. This, therefore, suggests that satisfaction of services may be variable and is dependent on the local context [64].

Doctor patient communication This study found that there was good overall communi- cation between the doctor and patient respondents. The majority of patient respondents said that their doctor lis- tened carefully, had enough time to discuss their medical problem and, if they had questions to ask the doctor, they got the answers and were treated with respect and dignity. These are some of the ideal features patients re- port as being important to creating positive relationships between the doctor (and other health care professionals) and patient [65–67]. However, there were significant dif- ferences found between patient respondents in urban and rural areas in relation to understanding the treat- ment or action that was explained, with fewer rural pa- tient participants feeling that doctors explained reasons for any treatments. This may be related to levels of ex- pectations as previously reported. All the GPs included in this study were a non-Saudi na-

tional, which is the norm in KSA [68] (Egyptian, Pakistani, Sudanese and Tunisian), but spoke Arabic and were Muslim, which may be one reason for positive patient re- sponses about seeing the doctor. None of the respondents said they needed help speaking Arabic. We can surmise, therefore, that having doctors who are able to communi- cate in the vernacular was an enabler for patients acces- sing and utilising the PHCC. The cultural competency of non-Saudi health professionals has been argued as impact- ing on patient satisfaction with HCS in the context of KSA, with calls for increased cultural awareness training for non-Saudi health care professional [68].

Health prevention and promotion All patient respondents said that they had their blood sugar levels measured and were given advice on weight and advice on healthy eating. Results also showed that patient respondents attending PHCC in urban areas were being given more advice on eating a healthy diet compared to patient respondents attending rural PHCCs. It is clear that the PHCCs are monitoring and addressing the health education needs of their patients related to chronic diseases, but increasing prevalence rates of chronic diseases in the KSA and in the Riyadh province suggest that more health education is needed to stem the epidemic of chronic disease in the KSA [69–72].

Overall satisfaction with the PHCCs Patient satisfaction has been used as an indication/meas- ure of quality of care. Overall, patient participants were positive about their PHCCs and the majority said they went to the PHCC because the PHCC dealt with them in a satisfactory way. This research highlighted that pa- tients had high levels of satisfaction with this finding consistently for both urban and rural patients. This find- ing supports existing evidence, which has reported high

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 10 of 13

levels of patient satisfaction with PHCC’s in the KSA [71, 73, 74].

Strengths and limitations This study has provided some important information on the barriers and enablers to the access and utilisation of PHCS in the Riyadh province in the KSA. Nonetheless, there are several limitations to the study that are note- worthy. The lead researcher (GA) was working in a gender-segregated society where women are not permit- ted to access male spaces. The gender bureaucracy in the KSA meant that the success of this study, therefore, was heavily dependent on the support of a mahram who acted as the research assistant (mahram). Consequently, GA was dependent on her mahram to support and ne- gotiate access to research sites, practice managers and accessing male patients. A further limitation related to the patient question-

naire. On some occasions, it was unclear if there was no answer because the question was not applicable or if this was a true missing variable. For example, section E (Test) and section K (Dental care) (see Additional file 1) did not ask patients if they had the relevant facilities in their PHCC. Therefore, if this section was missing, it may have been that the PHCC did not have the facility rather than a true missing variable. This may have im- pacted the validity of the findings.

Conclusions Our study demonstrated that there are important differ- ences in access to and utilisation of PHCS between urban and rural populations. Further studies evaluating patient access, utilisation and experiences in other areas of the KSA will assist policy makers and service pro- viders and provide insight into the required service provision. Our study highlights that there are high levels of satisfaction among patients regarding PHCS. How- ever, distance to reach PHCS and extended opening hours are key issues to consider when commissioning PHCS for rural residents.

Additional file

Additional file 1: Primary Health Care services questionnaire. (DOC 104 kb)

Abbreviations ASR: Adjusted standardised residual; DM: Diabetes mellitus; KSA: Kingdom of Saudi Arabia; PHCC: Primary Health Care Centres; PHCS: Primary Health Care Services

Acknowledgements None.

Funding This research was funded by the Ministry of Health, Kingdom of Saudi Arabia.

Availability of data and materials The data from this study will not be made publically available as it contains personal identifiable data.

Authors’ contributions GA, GR, EC, and NA were involved in conception and design of the study. GA collected all data. All authors contributed to interpretation and prioritisation of findings. GA and EC conducted the statistical analysis. GA drafted the paper. GR is the guarantor. GA, GR, EC, and NA read and approved the final manuscript.

Competing interests The authors declare that they have no competing interests.

Consent for publication Not applicable.

Ethics approval and consent to participate Ethical approval for this study was obtained from the University of Bedfordshire ethics committee and the KSA Ministry of Health. All participants were provided with an information sheet available in English and Arabic. The translation was checked and validated by the research team using backward and forward translation. Consent was obtained verbally by the research team prior to the completion of the questionnaire.

Author details 1Ministry of Health, Riyadh, Kingdom of Saudi Arabia. 2Department of Psychology, University of Bedfordshire, Park Square, Luton, UK. 3Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton, UK.

Received: 3 May 2016 Accepted: 4 January 2017

References 1. Griggs D, Stafford-Smith M, Gaffney O, Rockstrom J, Ohman MC,

Shyamsundar P, Steffen W, Glaser G, Kanie N, Noble I. Policy: sustainable development goals for people and planet. Nature. 2013;495(7441):305–7.

2. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res. 2003;38(3):831–65.

3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.

4. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104(22):2746–53.

5. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311–21.

6. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367(9524):1747–57.

7. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4–14.

8. Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, Nichols G. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(3):293–301.

9. Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004; 291(21):2616–22.

10. Almalki M, FitzGerald G, Clark M. Health care system in Saudi Arabia: an overview/Aperçu du système de santé en Arabie saoudite. East Mediterr Health J. 2011;17(10):784.

11. Mokdad AH, Tuffaha M, Hanlon M, El Bcheraoui C, Daoud F, Al Saeedi M, Alrasheedy AA, Al Hussein MA, Memish ZA, Basulaiman M. Cost of Diabetes in the Kingdom of Saudi Arabia, 2014. J Diabetes Metab. 2015;6:575. doi:10. 4172/2155-6156.1000575.

12. Robert AA, Al Dawish AM, Braham R, Musallam AM, Al Hayek AA, Al Kahtany HN. Type 2 Diabetes Mellitus in Saudi Arabia: Major Challenges and Possible Solutions. Curr Diabetes Rev. 2017;13(1):59–64.

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 11 of 13

13. El Bcheraoui C, Memish ZA, Tuffaha M, Daoud F, Robinson M, Jaber S, Mikhitarian S, Al Saeedi M, AlMazroa MA, Mokdad AH, Al Rabeeah AA. Hypertension and Its Associated Risk Factors in the Kingdom of Saudi Arabia, 2013: a National Survey. Int J Hypertens. 2014;2014. https://www. hindawi.com/journals/ijhy/2014/564679/abs/.

14. Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, Al- Maatouq MA, Al-Marzouki K, Al-Khadra A, Nouh MS, et al. Hypertension in Saudi Arabia. Saudi Med J. 2007;28(1):77–84.

15. Beaglehole R, Ebrahim S, Reddy S, Voute J, Leeder S. Prevention of chronic diseases: a call to action. Lancet. 2008;370(9605):2152–7.

16. Kahn R, Robertson RM, Smith R, Eddy D. The impact of prevention on reducing the burden of cardiovascular disease. Diabetes Care. 2008;31(8): 1686–96.

17. Qureshi NA. Strategies for enhancing the use of primary health care services by nomads and rural communities in Saudi Arabia. 1996.

18. Al Yousuf M, Akerele T, Al Mazrou Y. Organization of the Saudi health system. 2002.

19. Bakhashwain AS. Acceptance and utilisation of primary health care in Jeddah City, Saudi Arabia. Hull: University of Hull; 1995.

20. Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C, Stradling J. A shorter form health survey: Can the SF-12 replicate results from the SF- 36 in longitudinal studies? J Public Health. 1997;19:179–86.

21. Jenkinson C, Coulter A, Bruster S, Richards N, Chandola T. Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care. 2002;11(4):335–9.

22. Brazier JE, Harper R, Jones N, O’cathain A, Thomas K, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992;305(6846):160–4.

23. McHorney CA, Tarlov AR. Individual-patient monitoring in clinical practice: are available health status surveys adequate? Qual Life Res. 1995;4(4): 293–307.

24. Rosenthal GE, Shannon SE. The use of patient perceptions in the evaluation of health-care delivery systems. Med Care. 1997;35(11):NS58–68.

25. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485–91.

26. IBM. IBM SPSS Statistics for Windows, Version 22.0. Armonk: IBM Corp; 2012. 27. El Bcheraoui C, Tuffaha M, Daoud F, Kravitz H, AlMazroa MA, Al Saeedi M,

Memish ZA, Basulaiman M, Al Rabeeah AA, Mokdad AH. Access and barriers to healthcare in the Kingdom of Saudi Arabia, 2013: findings from a national multistage survey. BMJ Open. 2015;5(6):e007801.

28. Ojanuga DN, Gilbert C. Women’s access to health care in developing countries. Soc Sci Med. 1992;35(4):613–7.

29. Ahmed SM, Adams AM, Chowdhury M, Bhuiya A. Gender, socioeconomic development and health seeking behavior in Bangladesh. Soc Sci Med. 2000;51:361–71.

30. Shaikh B, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health. 2005;27(1):49–54.

31. Ryan L, Kofman E, Aaron P. Insiders and outsiders: working with peer researchers in researching Muslim communities. Int J Soc Res Methodol. 2011;14(1):49–60.

32. Egharevba I. Researching an-‘other’ minority ethnic community: Reflections of a black female researcher on the intersections of race, gender and other power positions on the research process. Int J Soc Res Methodol. 2001;4(3): 225–41.

33. Kuo RN, Lai M-S. The influence of socio-economic status and multimorbidity patterns on healthcare costs: a six-year follow-up under a universal healthcare system. Int J Equity Health. 2013;12(1):69.

34. Frenk J. Leading the way towards universal health coverage: a call to action. Lancet. 2015;385(9975):1352–8.

35. James CD, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, Kirunga C, Knippenberg R, Meessen B, Morris SS. To retain or remove user fees? Appl Health Econ Health Policy. 2006;5(3):137–53.

36. Ramady M. The Saudi Arabian economy: policies, achievements, and challengs. 2nd ed. Saudi Arabia: Springer; 2010.

37. Cohen B. Urbanization in developing countries: Current trends, future projections, and key challenges for sustainability. Technol Soc. 2006;28(1–2): 63–80.

38. United nations human settlements programme (UN-HABITAT). The state of the world’s cities 2004/2005: globalization and urban culture. London: Earthscan; 2004.

39. United nations human settlements programme (UN-HABITAT). The challenge of slums: global report on human settlements. London: Earthscan; 2003.

40. Kirscht JP. The health belief model and illness behavior. In: Becker MH, editor. The health belief model and personal health behavior. Thorofare: Charles B Slack INC; 1974.

41. Kar S, Kramer J, Skinner J, Zambrana RE. Panel VI: ethnic minorities, health care systems, and behavior. Health Psychol. 1995;14(7):641–6.

42. Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding Patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the necessity-concerns framework. PLoS One. 2013;8(12):e80633.

43. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976–93.

44. Grobler L, Marais BJ, Mabunda SA, Marindi PN, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. The Cochrane Library. 2009;(1): CD005314. doi:10.1002/14651858.CD005314.pub2.

45. Hall JJ, Taylor R. Health for all beyond 2000: the demise of the Alma-Ata declaration and primary health care in developing countries. Med J Aust. 2003;178(1):17–20.

46. Al-Rasheed M. A history of Saudi Arabia. New York: Cambridge University Press; 2010.

47. Moghadam VM. Women, work and family in the Arab region: Toward economic citizenship. DIFI Family Research and Proceedings. 2015:7. http:// www.qscience.com/doi/full/10.5339/difi.2013.arabfamily.7.

48. Saqib N, Aggarwal P, Rashid M. Women Empowerment and Economic Growth: Empirical Evidence from Saudi Arabia. Adv Manag Appl Econ. 2016; 6(5):79–92.

49. Hossain M, Bose ML, Ahmad A. Nature and impact of women’s participation in economic activities in rural Bangladesh: insights from household surveys. Working Papers. Department of Economics, Lund University. 2004(20). https://www.mysciencework.com/publication/show/ d2506abc8130a7dcb8bee4def18f977d.

50. Hossain Z, Juhari R. Fathers across Arab and Non-Arab Islamic societies. Fathers across cultures: the importance, roles, and diverse practices of dads: the importance, roles, and diverse practices of dads. 2015. p. 368.

51. Kontopantelis E, Roland M, Reeves D. Patient experience of access to primary care: identification of predictors in a national patient survey. BMC Fam Pract. 2010;11:1–15.

52. Beckman A, Anell A. Changes in health care utilisation following a reform involving choice and privatisation in Swedish primary care: a five-year follow-up of GP-visits. BMC Health Serv Res. 2013;13(1):452.

53. Scheppers E, Dongen E, Dekker J, Geertzen J, Dekker J. Potential barriers to the use of health services among ethnic minorities: a review. Fam Pract. 2006;23(3):325–48.

54. Ahmed SM, Adams AM, Chowdhury M, Bhuiya A. Gender, socioeconomic development and health-seeking behaviour in Bangladesh. Social science & medicine. 2000;51(3):361–71.

55. Arcury TA, Gesler WM, Preisser JS, Sherman J, Spencer J, Perin J. The effects of geography and spatial behavior on health care utilization among the residents of a rural region. Health Serv Res. 2005;40(1):135–56.

56. Al-Shahrani H. The accessibility and utilization of primary health care services in Riyadh, Kingdom of Saudi Arabia. Norwich: University of East Anglia; 2004.

57. McLaren ZM, Ardington C, Leibbrandt M. Distance decay and persistent health care disparities in South Africa. BMC Health Serv Res. 2014;14(1):1.

58. el Shabrawy AM. A study of patient satisfaction as an evaluation parameter for utilization of primary health care services. J R Soc Health. 1992;112(2):64–7.

59. Al-Sahili K, Aboul-Ella M. Accessibility of public services in Irbid, Jordan. J Urban Plann Dev. 1992;118(1):1–12.

60. al-Qatari G, Haran D. Determinants of users’ satisfaction with primary health care settings and services in Saudi Arabia. Int J Qual Health Care. 1999;11(6): 523–31.

61. Abodunrin O, Adeomi A, Adeoye OA. Clients’ satisfaction with quality of healthcare received: Study among mothers attending infant welfare clinics in a semi-urban community in South-western Nigeria. Sky Journal of Medicine and Medical Sciences. 2015;2(7):45–51.

62. World Health Organization. Water, sanitation and hygiene in health care facilities Status in low- and middle-income countries and way forward. Geneva: World Health Organization; 2015.

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 12 of 13

63. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136(1):161–71.

64. Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G. A balanced scorecard for health services in Afghanistan. Bull World Health Organ. 2007; 85(2):146–51.

65. Bendapudi NM, Berry LL, Frey KA, Parish JT, Rayburn WL. Patients’ perspectives on ideal physician behaviors. In: Mayo Clinic Proceedings: 2006. Elsevier; 2006;81:338–344.

66. Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Ann Fam Med. 2005;3(4):331–8.

67. Walsh K, Kowanko I. Nurses’ and patients’ perceptions of dignity. Int J Nurs Pract. 2002;8(3):143–51.

68. al-Shahri MZ. Culturally sensitive caring for Saudi patients. J Transcult Nurs. 2002;13(2):133–8.

69. Al-Eissa EI. The morbidity pattern among adolescents visiting primary health care centers. Saudi Med J. 2000;21(10):934–7.

70. Alnaif MS, Alghanim SA. Patients’ knowledge and attitudes towards health education: implications for primary health care services in Saudi Arabia. J Family Community Med. 2009;16(1):27.

71. Al-Faris E, Al Taweel A. Audit of prescribing patterns in Saudi primary health care: what lessons can be learned? Ann Saudi Med. 1998;19(4):317–21.

72. Khan AR, Lateef ZNA-A, Al Aithan MA, Bu-Khamseen MA, Al Ibrahim I, Khan SA. Factors contributing to non-compliance among diabetics attending primary health centers in the Al Hasa district of Saudi Arabia. J Family Community Med. 2012;19(1):26.

73. Ali MES. A study of patient satisfaction as an evaluation parameter for utilization of primary health care services. J R Soc Promot Health. 1992; 112(2):64–7.

74. Almoajel A, Fetohi E, Alshamrani A. Patient satisfaction with primary health care in Jubail City, Saudi Arabia. World J Med Sci. 2014;11(2):255–64.

• We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research

Submit your manuscript at www.biomedcentral.com/submit

Submit your next manuscript to BioMed Central and we will help you at every step:

Alfaqeeh et al. BMC Health Services Research (2017) 17:106 Page 13 of 13