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Access and barriers to healthcare in the Kingdom of Saudi Arabia, 2013: Findings
from a national multistage survey
Article in BMJ Open · June 2015
DOI: 10.1136/bmjopen-2015-007801
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Charbel El Bcheraoui
University of Washington Seattle
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Marwa Tuffaha
University of Washington Seattle
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Access and barriers to health care in the Kingdom of Saudi Arabia, 2013
Journal: BMJ Open
Manuscript ID: bmjopen-2015-007801
Article Type: Research
Date Submitted by the Author: 28-Jan-2015
Complete List of Authors: El Bcheraoui, Charbel; Institute for Health Metrics and Evaluation, Tuffaha, Marwa; Institute for Health Metrics and Evaluation, Daoud, Farah; Institute for Health Metrics and Evaluation, Kravitz, Hannah; Institute for Health Metrics and Evaluation, AlMazroa, Mohammad; Ministry of Health of the Kingdom of Saudi Arabia, Al Saeedi, Mohammad; Ministry of Health of the Kingdom of Saudi Arabia, Memish, Ziad; Ministry of Health of the Kingdom of Saudi Arabia, Basulaiman, Mohammed; Ministry of Health of the Kingdom of Saudi
Arabia, Al Rabeeah, Abdullah; Ministry of Health of the Kingdom of Saudi Arabia, mokdad, ali; Institute for Health Metrics and Evaluation, University of Washington
<b>Primary Subject Heading</b>:
Global health
Secondary Subject Heading: Health services research, Epidemiology
Keywords: General diabetes < DIABETES & ENDOCRINOLOGY, Hypertension < CARDIOLOGY, Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PRIMARY CARE, PREVENTIVE MEDICINE
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Access and barriers to health care in the Kingdom of Saudi Arabia, 2013: free and
accessible is not enough
Charbel El Bcheraoui, [email protected], Institute for Health Metrics and Evaluation, University
of Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Marwa Tuffaha, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Farah Daoud, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Hannah Kravitz, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Mohammad A. AlMazroa, [email protected], Ministry of Health of the Kingdom of
Saudi Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Mohammad Al Saeedi, [email protected], Ministry of Health of the Kingdom of Saudi
Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Ziad A. Memish, [email protected], Ministry of Health of the Kingdom of Saudi Arabia,
Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Mohammed Basulaiman , [email protected], Ministry of Health of the Kingdom of
Saudi Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Abdullah A. Al Rabeeah, [email protected], Ministry of Health of the Kingdom of Saudi Arabia,
Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
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Ali H. Mokdad, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
†Corresponding Author:
Ali H. Mokdad, PhD
Director, Middle Eastern Initiatives
Professor, Global Health
Institute for Health Metrics and Evaluation
University of Washington
2301 5th Avenue, Suite 600
Seattle, WA 98121
Tel: +1-206-897-2849
Fax: +1-206-897-2899
Keywords: health care, health system, access, barriers, Saudi Arabia
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ABSTRACT
Objectives: We analyzed data from a large household survey to identify barriers to health care in
the Kingdom of Saudi Arabia.
Methods: The Saudi Health Interview Survey (SHIS) is a national multistage survey of
individuals aged 15 years or older. The survey combined a household questionnaire and a
laboratory blood analysis. We used a backward elimination multivariate logistic regression
model to measure association between 1) diagnosis, 2) treatment, and 3) control of hypertension
or diabetes and socio-demographic factors, history of diagnosis with chronic conditions, and type
of, and distance traveled to, the clinic last visited.
Results: Between April and June 2013, a total of 10,735 participants completed SHIS and were
invited to the local health clinics. Hypertensive individuals, women, older individuals, and those
previously diagnosed with diabetes and hypercholesterolemia were more likely to have been
diagnosed with hypertension than their counterparts. Among participants diagnosed with
hypertension, the likelihood of being treated increased with age and education. The likelihood of
having uncontrolled blood pressure despite treatment increased with education and a history of
diagnosis with hypercholesterolemia.
Type of clinic visited and distance traveled to last clinic visit were not associated with diagnosis
or treatment of hypertension or control of blood pressure.
Similar factors were associated with the likelihood of diagnosis and treatment among diabetic
individuals. Having uncontrolled HbA1c levels, despite treatment, was less common among
those who visited governmental clinics other than those of the Ministry of Health, compared to
those who visited Ministry clinics.
Conclusions: Our findings highlight the importance of individual characteristics in health care-
seeking practices rather than system-based potential barriers. Saudis seem to mostly seek health
care when sick. Hence, the Saudi Ministry of Health needs to implement a comprehensive plan
including health education and investigations to understand the barriers and bottlenecks to health
care-seeking behavior.
STRENGTHS AND LIMITATIONS OF THIS STUDY
• First nationally representative study on access and barriers to healthcare in the Kingdom
of Saudi Arabia.
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• Highlights the importance of individual, over environmental and systematic,
characteristics in healthcare seeking behavior among Saudis.
• Calls for in-depth investigations on beliefs and attitudes affecting health care seeking
behavior among Saudis.
• Cross-sectional design that limits assessment of causality.
• Lowered response rate for laboratory testing.
INTRODUCTION
In the Kingdom of Saudi Arabia (KSA), health care is offered for free to Saudi citizens[1]
through more than 2,000 primary health care centers and 420 hospitals.[2] We have previously
reported that Saudis do not make use of periodic health examinations despite their availability for
free.[3] In a more specific example, we have also reported that only a low percentage of women
who should be screened for breast cancer are.[4]
The Saudi Ministry of Health is investing considerable effort and money to prevent disease and
promote health, with a special focus on non-communicable diseases. However, and despite these
efforts, funds, and the free health care system in KSA, more than 1.9 million (15.2%) and 1.7
million (13.4%) Saudis aged 15 years or older are hypertensive and diabetic, respectively.[5,6]
Furthermore, 57.8% and 43.6% of those affected have not been diagnosed with hypertension and
diabetes, respectively, while among those diagnosed, 31.1% and 9.0% are not treated. Among
those treated, 55.0% and 29.1% do not have their condition under control.
Distance to health care settings and types of health care settings have been reported to impact
patients’ health care-seeking behavior.[7–10]
To identify barriers to health care in KSA, we analyzed data from a large household survey on
the relation of distance traveled to health care clinics and type of clinics last visited and
compared these data with diagnosis, treatment, and control of hypertension and diabetes.
METHODS
The Saudi Health Interview Survey (SHIS) is a national multistage survey of individuals aged 15
years or older. Households of Saudi citizens were randomly selected from a national sampling
frame maintained and updated by the Census Bureau. The Ministry of Health divides KSA into
13 health regions, each with its own health department. We divided each region into subregions
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and blocks used by the KSA Department of Statistics. All regions were included, and a
probability proportional to size was used to randomly select subregions and blocks. Households
were randomly selected from each block. A roster of household members was collected, and an
adult aged 15 or older was randomly selected to be surveyed. If the randomly selected adult was
not present, our surveyors made an appointment to return, and a total of three visits were made
before the household was considered as a nonresponse. Blood pressure of the randomly selected
adult was measured at the household by a trained professional.
The survey included questions on socio-demographic characteristics, health care utilization, and
self-reported chronic conditions. These conditions included diabetes, hypercholesterolemia, and
hypertension.
To measure diagnosed hypertension, diabetes, and hypercholesterolemia status, respondents were
asked three separate questions: “Have you ever been told by a doctor, nurse, or other health
professional that you had 1) diabetes mellitus, otherwise known as diabetes, sugar diabetes, high
blood glucose, or high blood sugar; 2) hypercholesterolemia, otherwise known as high or
abnormal blood cholesterol; 3) hypertension, otherwise known as high blood pressure?” Women
diagnosed with diabetes or hypertension during pregnancy were not counted as having these
conditions.
A total of three blood measurements were taken with the participant resting and at five-minute
intervals. We followed National Health and Nutrition Examination Survey (NHANES)
guidelines for determining blood pressure level.[11] Respondents were considered to have
hypertension if they met any of the following criteria: 1) measured diastolic or systolic blood
pressure exceeding 89 or 139 mmHg, respectively, or 2) measured diastolic or systolic blood
pressure not exceeding the appropriate threshold, but the respondent reported taking medications
for hypertension. Hence, respondents who were on drugs for hypertension were considered
hypertensive even if their measured diastolic or systolic blood pressure did not exceed 89 or 139
mmHg, respectively.
Respondents who completed the questionnaire were invited to local primary health care clinics to
provide a blood sample for laboratory analysis. All blood samples were analyzed in a central lab
at the King Fahd Medical City in Riyadh. COBAS INTEGRA400 plus was used to measure
blood levels of HbA1C, or glycated hemoglobin. We followed NHANES guidelines for
determining diabetes status.[11] Respondents were considered to be diabetic if they met any of
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the following criteria: 1) measured HbA1c equaling or exceeding 6.5% (48.5 mmol/mol) or 2)
measured HbA1c not equaling or exceeding 6.5% (48.5 mmol/mol), but the respondent reported
taking medications for diabetes. Hence, the subgroup diabetic includes those with measured
HbA1c equal or above 6.5% or taking medication for diabetes.
To assess use of health care services, participants were asked, “What was the type of the clinic
that you last visited for medical attention for any reason?” and “How far away was the facility
you attended from your home?”
Statistical analysis
We used a backward elimination multivariate logistic regression model to measure association
between 1) diagnosis, 2) treatment, and 3) control of hypertension or diabetes and sex, age,
marital status, education, history of diagnosis with diabetes, hypercholesterolemia, hypertension,
and type of, and distance traveled to, the clinic last visited. The logistic regression eliminated
missing data. Data were weighted to account for the probability of selection and age and sex
post-stratification based on census data for age and sex distribution of the Saudi population.
Weighting methodology
Two sets of sampling weights were generated and incorporated into the dataset for analysis.
First, we created an individual sampling weight for all respondents to account for 1) the
probability of selection of an eligible respondent within a household, 2) the probability of
selection of the household within a stratum, and 3) the post-stratification differences in age and
sex distribution between the sample and the Saudi population.
For individuals who completed the lab-based blood analysis, we computed an additional
sampling weight used in analyzing data from clinic visits to account for 1) the individual
sampling weight described above, 2) the probability of visiting a clinic, 3) socio-demographic,
behavioral, and health differences between respondents who visited the clinic and those who did
not, and 4) the post-stratification differences in age and sex distribution between the respondents
who visited the clinic and the Saudi population. We used SAS 9.3 for the analyses and to account
for the complex sampling design.
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RESULTS
Between April and June 2013, a total of 10,735 participants completed the SHIS — a response rate of 89.4% — and were invited to
the local health clinics. The remaining 1,265 completed part of the household enumeration, or all of it, but the selected adult did not
complete the survey.
An estimated total of 1,957,191 (15.2%) Saudis aged 15 years or older had hypertension (measured or reported taking blood pressure
medication). Of these, 1,119,027 were undiagnosed. Women (adjusted odds ratio [AOR] = 1.87; 95% confidence interval [95% CI]:
1.23 – 2.85), older individuals (AOR = 1.05; 95% CI: 1.03 – 1.07), and those previously diagnosed with diabetes (AOR = 2.38; 95%
CI: 1.60 – 3.53) and hypercholesterolemia (AOR = 2.76; 95% CI: 1.72 – 4.44), were more likely to have been diagnosed with
hypertension than men, younger individuals, and those without such a history of diagnosis (Table 1).
Table 1: Distribution and logistic regression for diagnosis, treatment, and control of hypertension by different factors, hypertensive Saudis aged
15 years or older, Kingdom of Saudi Arabia, 2013
Diagnosis among those hypertensive Treatment among those diagnosed Control among those treated
Socio-demographic
characteristics, health
care access, and
diagnoses of chronic
conditions
N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI)
Sex
Males 492 (54.49; 2.21) REF 417 (53.34; 2.37) REF 165 (49.66; 3.62) REF
Females 459 (45.51; 2.21) 1.87 (1.23 – 2.85) 416 (46.66; 2.37) 1.82 (0.81 – 4.09) 195 (50.34; 3.62) 1.61 (0.85 – 3.08)
Age (years)* 1.05 (1.03 – 1.07) 1.08 (1.05 – 1.12) 1.01 (0.99 – 1.03)
15 – 24 4 (0.65; 0.33) 3 (0.59; 0.34) 1 (0.50; 0.50)
25 – 34 41 (5.06; 0.95) 23 (3.13; 0.84) 13 (4.53; 1.70)
35 – 44 105 (12.10; 1.42) 78 (10.08; 1.35) 40 (11.07; 2.08)
45 – 54 215 (27.42; 2.06) 191 (27.76; 2.21) 79 (28.86; 3.46)
55 – 64 243 (27.92; 2.06) 227 (29.83; 2.25) 106 (30.83; 3.33)
65+ 343 (26.86; 1.82) 311 (28.61; 2.01) 121 (24.21; 2.90)
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Marital status
Currently married 696 (78.40; 1.77) REF 607 (77.83; 1.93) REF 257 (74.25; 3.17) REF
Never married 33 (5.15; 1.16) 0.95 (0.38 – 2.39) 22 (4.41; 1.20) 2.37 (0.58 – 9.75) 11 (5.69; 2.05) 1.73 (0.40 – 7.53)
Separated, divorced, or
widowed 220 (16.45; 1.47) 0.67 (0.39 – 1.17) 202 (17.76; 1.64) 0.66 (0.24 – 1.80) 91 (20.06; 2.74) 1.88 (0.88 – 4.05)
Education
Primary school or less 593 (57.79; 2.18) REF 533 (59.20; 2.32) REF 217 (52.12; 3.62) REF
Elementary or high
school completed 225 (27.48; 2.03) 1.00 (0.63 – 1.58) 195 (27.10; 2.16) 2.86 (1.16 – 7.08) 86 (29.26; 3.48) 2.25 (1.12 – 4.50)
College degree or
higher education 131 (14.73; 1.46) 1.81 (1.06 – 3.09) 104 (13.70; 1.53) 2.78 (1.14 – 6.79) 57 (18.62; 2.77) 4.63 (2.14 – 10.02)
Type of clinic last
visited
Ministry of Health 618 (72.44; 2.23) 548 (71.97; 2.40) 229 (70.65; 3.77)
Other governmental
clinic 70 (8.89; 1.29)
61 (8.66; 1.37)
31 (9.69; 2.11)
Private clinic 112 (18.67; 2.03) 101 (19.37; 2.20) 41 (19.67; 3.52)
Distance travelled to
clinic (km)**
1.01 (0.99 – 1.03)
0 – 2 218 (36.87; 2.66) 189 (36.90; 2.85) 79 (39.24; 4.50)
3 – 5 159 (25.65; 2.46) 138 (24.43; 2.56) 56 (24.82; 4.04)
6 – 10 116 (19.79; 2.22) 107 (20.04; 2.33) 42 (18.68; 3.40)
11 – 35 84 (14.49; 1.97) 78 (15.45; 2.21) 27 (12.14; 2.82)
36 – 100 21 (3.20; 0.86) 19 (3.18; 0.91) 10 (5.12; 1.90)
Diagnosis history of
diabetes
No 484 (51.91; 2.23) REF 406 (48.91; 2.39) REF 168 (47.77; 3.62)
Yes 462 (48.09; 2.23) 2.38 (1.60 – 3.53) 423 (51.09; 2.39) 2.21 (1.05 – 4.62) 188 (52.23; 3.62)
Diagnosis history of
hypercholesterolemia
No 557 (63.01; 2.22) REF 473 (61.06; 2.39) REF 192 (56.85; 3.70) REF
Yes 322 (36.99; 2.22) 2.76 (1.72 – 4.44) 300 (38.94; 2.39) 1.78 (0.82 – 3.84) 143 (43.15; 3.70) 1.89 (1.12 – 3.18)
*AOR for age should be considered as for an increase of 10 years.**AOR for distance should be considered as for an increase of one kilometer.AOR: adjusted
odds ratio; CI: confidence interval; REF: reference.
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Among participants diagnosed with hypertension, 78.9% reported taking medication for their condition. The likelihood of being
treated increased with age (AOR = 1.08; 95% CI: 1.05 – 1.12) and among those who completed elementary or high school (AOR =
2.86; 95% CI: 1.16 – 7.08) or college (AOR = 2.78; 95% CI: 1.14 – 6.79) (Table 1).
About 45% of participants on medication for hypertension had their blood pressure controlled. Hence, about 390,338 adults had
uncontrolled blood pressure. The likelihood of having uncontrolled blood pressure despite treatment increased among those who
completed elementary or high school (AOR = 2.25; 95% CI: 1.12 – 4.50) and college (AOR = 4.63; 95% CI: 2.14 – 10.02) and those
previously diagnosed with hypercholesterolemia (AOR = 1.89; 95% CI: 1.12 – 3.18)
Type of clinic visited, and distance travelled to last clinic visit were not associated with diagnosis or treatment of hypertension or
control of blood pressure.
A total of 5,590 individuals went to the local clinics and provided blood samples for analyses — a response rate of 52.1%. A total of
1,745,532 (13.4%) Saudis aged 15 years or older had diabetes. Among those that our survey identified as diabetic from blood exams,
43.6% were undiagnosed. Older individuals (AOR = 1.05; 95% CI: 1.03 – 1.08) and those previously diagnosed with hypertension
(AOR = 2.39; 95% CI: 1.09 – 5.25) and hypercholesterolemia (AOR = 5.64; 95% CI: 2.37 – 13.44) were more likely to be diagnosed
than younger individuals and those without such a history of diagnosis (Table 1).
Among participants diagnosed with diabetes, 91.0% reported taking medication for their condition. The likelihood of being treated
increased among those with a college degree (AOR = 5.79; 95% CI: 1.57 – 21.32) (Table 2).
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Table 2: Distribution and logistic regression for diagnosis, treatment, and control of diabetes by different factors, diabetic Saudis aged 15 years
or older, Kingdom of Saudi Arabia, 2013
Diagnosis among those with diabetes Treatment among those diagnosed Control among those treated
Socio-demographic
characteristics, health
care access, and
diagnoses of chronic
conditions
N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI)
Sex
Males 392 (61.88; 2.52) 378 (61.40; 2.57) 167 (57.88; 3.92) REF
Females 309 (38.12; 2.52) 302 (38.60; 2.57) 149 (42.12; 3.92) 1.50 (0.76 – 2.97)
Age (years)* 1.05 (1.03 – 1.08) 1.03 (1.00 – 1.07) 1.02 (1.00 – 1.05)
15 – 24 11 (3.01; 1.01) 10 (2.91; 1.01) 7 (2.14; 1.01)
25 – 34 28 (5.59; 1.29) 27 (5.50; 1.30) 32 (14.31; 2.95)
35 – 44 76 (12.43; 1.73) 73 (12.39; 1.77) 82 (29.46; 3.79)
45 – 54 175 (29.90; 2.62) 168 (29.69; 2.66) 76 (28.83; 3.80)
55 – 64 182 (27.80; 2.37) 179 (28.28; 2.43) 114 (22.71; 3.06)
65+ 229 (21.28; 1.95) 223 (21.23; 1.98) 316 (100.00; 0.00)
Marital status
Currently married 535 (82.08; 1.88) 521 (82.31; 1.90) 65 (12.60; 2.08) REF
Never married 27 (5.80; 1.41) 26 (5.76; 1.43) 316 (100.00; 0.00) 0.35 (0.06 – 2.13)
Separated, divorced, or
widowed 138 (12.12; 1.38)
132 (11.94; 1.40)
521 (0.00; 0.00) 0.67 (0.27 – 1.66)
Education
Primary school or less 461 (58.87; 2.62) 445 (58.46; 2.66) REF 32 (13.07; 2.71)
Elementary or high
school completed 172 (29.59; 2.45)
167 (29.75; 2.48) 1.01 (0.34 – 3.00) 316 (100.00; 0.00)
College degree or
higher education 68 (11.53; 1.65)
68 (11.79; 1.69) 5.79 (1.57 – 21.32) 445 (0.00; 0.00)
Type of clinic last
visited
Ministry of Health 469 (79.94; 2.25) REF 454 (79.71; 2.30) REF 225 (86.23; 2.89) REF
Other governmental 48 (8.35; 1.57) 0.44 (0.14 – 1.34) 46 (8.47; 1.61) 4.35 (0.41 – 46.45) 16 (3.96; 1.13) 0.28 (0.10 – 0.79)
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clinic
Private clinic 59 (11.70; 1.77) 0.65 (0.28 – 1.52) 58 (11.82; 1.81) 1.00 (0.17 – 5.75) 21 (9.81; 2.72) 0.54 (0.21 – 1.43)
Distance travelled to
clinic (km)*
0.98 (0.96 – 1.00) 0.97 (0.93 – 1.02) 1.01 (0.98 – 1.04)
0 – 2 167 (46.04; 3.54) 162 (46.24; 3.59) 72 (46.16; 5.36)
3 – 5 113 (19.46; 2.51) 110 (18.92; 2.51) 57 (17.54; 3.09)
6 – 10 83 (20.11; 2.67) 82 (20.23; 2.71) 36 (19.37; 4.23)
11 – 35 52 (11.39; 2.33) 51 (11.55; 2.37) 29 (16.19; 4.24)
36 – 100 6 (3.00; 1.88) 6 (3.05; 1.91) 2 (0.74; 0.56)
Diagnosis history of
hypertension
No 432 (63.73; 2.56) REF 419 (63.96; 2.60) 193 (61.26; 3.95)
Yes 267 (36.27; 2.56) 2.39 (1.09 – 5.25) 259 (36.04; 2.60) 122 (38.74; 3.95)
Diagnosis history of
hypercholesterolemia
No 449 (72.36; 2.39) REF 437 (73.16; 2.42) REF 203 (72.15; 3.56)
Yes 205 (27.64; 2.39) 5.64 (2.37 – 13.44) 196 (26.84; 2.42) 0.54 (0.20 – 1.52) 97 (27.85; 3.56)
*AOR for age should be considered as for an increase of ten years. **AOR for distance should be considered as for an increase of one kilometer. AOR: adjusted
odds ratio; CI: confidence interval; REF: reference.
About 70.9% of participants on medication for diabetes had their diabetes controlled. Hence, about 397,541 adults had uncontrolled
diabetes. The likelihood of having uncontrolled levels of HbA1c despite treatment decreased among those who visited governmental
clinics other than those of the Ministry of Health (AOR = 0.28; 95% CI: 0.10 – 0.79), compared to those who visited the Ministry
clinics (Table 2).
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DISCUSSION
This is the first national study that examines barriers to health care utilization in KSA. Our
findings highlight the importance of individual characteristics in health care-seeking practices,
rather than system-based potential barriers. Our results show that neither distance to nor type of
health care clinic were barriers to diagnosis, treatment, or control of two leading chronic disease
in KSA. Our findings are of great importance as the Ministry continues to invest in building
infrastructure throughout the Kingdom. The 2014 Ministry of Health budget calls for building 34
new hospitals.[12] Therefore, it is crucial to assess the Saudis’ reasons for not seeking care and
address this aspect in order to improve health and reduce burden.
Access to health care is an important determinant of health. Several studies have shown that the
availability of facilities within accessible distance improve health. Therefore, in some countries,
including South Africa, KSA, and Portugal, distance to key populations is considered when
planning on building new health facilities.[13–15] However, in our study, distance was not an
issue, and we didn’t observe any association between type of health care facilities used, or
distance to health care facilities, and health or use of health services in KSA.
Previous small, nonrepresentative studies have examined patient satisfaction with health care
facilities and services in KSA and were focused on the Saudi Ministry of Health primary health
care centers. Most studies showed a high rate of dissatisfaction among users. Of facilities’
characteristics, distance travelled, facilities’ working hours, absence of specialty clinics, waiting
time, waiting area structure, and confidentiality measures were the negative factors most
impacting patients’ satisfaction. Of staff characteristics, surgeons’ services, language barriers
with physicians, and communication about health status were the factors most correlated with
dissatisfaction. As for patients’ characteristics, women and the least educated seem to be more
satisfied than men and more educated patients.[16–18]
Our study has some limitations. First, our data are from a cross-sectional study, and therefore we
cannot assess causality. However, our study is based on a large sample and used a standardized
methodology for all its measures. Second, only 52% of respondents completed the visit to a
health clinic and had their blood drawn for analysis. However, our weighting methodology
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accounted for this bias by applying a post-stratification adjustment using socio-demographic
characteristics, health behaviors, previously diagnosed non-communicable diseases, and
anthropometric measurements of respondents from the household survey.
Despite the density of health facilities and the free health care system in KSA,[1,2] Saudis do not
seem to seek prevention or care until after developing disease symptoms or reaching an advanced
stage of illness. However, the Saudi Ministry of Health invests considerable funds in prevention
and health promotion campaigns.[19] It is crucial for the Ministry to understand why Saudis
abstain from using preventive services, including periodic health examinations and screenings
for preventable diseases. Given the lack of information on this in KSA, formative research
through qualitative research methods is needed, as no assumptions exist regarding the reasons
behind seeking health care, or the lack of care-seeking, among Saudis.
Our findings showed a higher likelihood for women to be diagnosed with chronic conditions,
such as hypertension. However, no difference exists among those diagnosed when it comes to
treatment or control of the condition. Indeed, getting diagnosed requires that one actively seeks
health care. However, getting treated and having one’s condition controlled once diagnosed
relies more on the health care provider’s interaction with the patient and their follow-up. Women
are doing a better job seeking care, but both sexes have a long way to go to improve health and
reduce burden.[5] Diagnosis is the first step toward controlling a condition. Patients have to be
monitored and followed to ensure proper dosage of medication and to reinforce behavioral
changes. Hence, regular checkups have to be scheduled and the patient must be reminded to
come to the clinic.
Our results show the importance of health education and programs to reach the population at
home and in the workplace. Clearly, Saudis are not taking advantage of the free medical services
and medications. The Saudi Ministry of Health could easily implement programs to generate
reminders for visits to clinics, which could help control diseases and reduce burden. Such
systems are available in many countries, where patients are notified about their next scheduled
visits.[20] In KSA, such systems are more likely to be successful, as patients get their
medications refilled for free from health clinics.
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In parallel to understanding individual behavior, the Saudi Ministry of Health needs to assess
specific characteristics in their health care facilities. For instance, a targeted survey can measure
the bottlenecks, including stocks, equipment, and staff, that health care facilities and their users
face. A parallel geographically linked survey, coupled with patient exit interview surveys, could
determine the impact of access and bottlenecks on the health of Saudis.
The Arab culture promotes health and encourages prevention over treatment; an old Arab
proverb says, “Prevention is better than treatment.” However, our findings do not point in this
direction. Saudis seem to mostly seek health care when sick. Free and available health care
services in close proximity are not enough to get Saudis to utilize the care offered. The Saudi
Ministry of Health needs to do more than building additional health care facilities. It needs to
implement a comprehensive plan that includes health education and plans to understand the
barriers and bottlenecks to health care-seeking behavior and access.
Funding
This study was financially supported by a grant from the Ministry of Health of the Kingdom of
Saudi Arabia.
Acknowledgments
We would like to thank Kate Muller at the Institute for Health Metrics and Evaluation for editing
the manuscript.
Competing Interest
The authors declare no conflict of interest
Contributorship Statement
Authors contributed to this study in different ways: AHM and CEB conceived and designed the
study. MB, ZAM, MAS, MAA performed the study. AHM and CEB analyzed the data. CEB,
AHM, FD, MT, HK, MB, ZAM, MAS, MAA and AAR wrote the manuscript. AAR supervised
the study. All co-authors are responsible for the content of this article and have read and
approved the final manuscript.
Data Sharing Statement
The data collected for this study is not publicly available. Any request to access the data needs to
be addressed to the Saudi Ministry of Health.
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REFERENCES
1 M. Clark MA. Health care system in Saudi Arabia: an overview. Eastern Mediterranean
Health Journal 2011;Vol.17.
2 Saudi Arabian Monetary Agency: fourty ninth annual report: Latest economic developments.
http://www.sama.gov.sa/sites/samaen/ReportsStatistics/ReportsStatisticsLib/5600_R_Annual
_En_49_Apx.pdf
3 El Bcheraoui C, Tuffaha M, Daoud F, et al. Low uptake of periodic health examinations in
the Kingdom of Saudi Arabia, 2013. In press
4 El Bcheraoui C, Basulaiman M, Wilson S, et al. Breast cancer screening in Saudi Arabia:
free but almost no takers. In press
5 El Bcheraoui C, Memish ZA, Tuffaha M, et al. Hypertension and its associated risk factors
in the Kingdom of Saudi Arabia, 2013: a national survey. International Journal of
Hypertension Published Online First: In press
2014.http://www.hindawi.com/journals/ijhy/aip/564679/
6 El Bcheraoui C, Basulaiman M, Tuffaha M, et al. Status of the diabetes epidemic in the
Kingdom of Saudi Arabia, 2013. International journal of public health 2014;:1–11.
7 Buzza C, Ono SS, Turvey C, et al. Distance is relative: unpacking a principal barrier in rural
healthcare. J Gen Intern Med 2011;26 Suppl 2:648–54. doi:10.1007/s11606-011-1762-1
8 Ward B, Humphreys J, McGrail M, et al. Which dimensions of access are most important
when rural residents decide to visit a general practitioner for non-emergency care? Aust
Health Rev Published Online First: 22 December 2014. doi:10.1071/AH14030
9 Yamauchi Y, Fujiwara T, Okuyama M. Factors Influencing Time Lag Between Initial
Parental Concern and First Visit to Child Psychiatric Services Among ADHD Children in
Japan. Community Ment Health J Published Online First: 23 December 2014.
doi:10.1007/s10597-014-9803-y
10 Schoeps A, Gabrysch S, Niamba L, et al. The Effect of Distance to Health-Care Facilities on
Childhood Mortality in Rural Burkina Faso. Am J Epidemiol 2011;173:492–8.
doi:10.1093/aje/kwq386
11 Centers for Disease Control and Prevention. National Health and Nutrition Examination
Survey: Health Tech/Blood Pressure Procedures Manual. cdc.gov.
2009.http://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/BP.pdf (accessed 11 Dec2014).
12 Saudi Arabia’s 2014 Budget Emphasizes Long-Term Development. U.S.-Saudi Arabian
Business Council. 2013.http://www.us-
sabc.org/custom/news/details.cfm?id=1541#.VLROoivF98M
Page 16 of 20
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13 Vanderschuren M, McKune D. Emergency care facility access in rural areas within the
golden hour?: Western Cape case study. International Journal of Health Geographics
2015;14:5. doi:10.1186/1476-072X-14-5
14 Gonçalves J, Ferreira JA, Condessa B. Making regional facility location decisions: the
example of Hospital do Oeste Norte, Portugal. Geospatial health 2014;9:1.
doi:10.4081/gh.2014.1
15 Murad AA. Using geographical information systems for defining the accessibility to health
care facilities in Jeddah City, Saudi Arabia. Geospat Health 2014;8:295.
doi:10.4081/gh.2014.295
16 Al-Doghaither AH. Inpatient satisfaction with physician services at King Khalid University
Hospital, Riyadh, Saudi Arabia. East Mediterr Health J 2004;10:358–64.
17 Ali M el-S null, Mahmoud ME. A study of patient satisfaction with primary health care
services in Saudi Arabia. J Community Health 1993;18:49–54.
18 Qatari GA, Haran D. Determinants of users’ satisfaction with primary health care settings
and services in Saudi Arabia. International Journal for Quality in Health Care 1999;11:523–
31. doi:10.1093/intqhc/11.6.523
19 Awareness Campaigns. Kingdom of Saudi Arabia - Ministry of Health Portal.
http://www.moh.gov.sa/en/HealthAwareness/Campaigns/Pages/default.aspx (accessed 12
Jan2015).
20 Agrawal A, Mayo-Smith MF. Agrawal, A., & Mayo-Smith, M. F. (2004). Adherence to
computerized clinical reminders in a large healthcare delivery network. Medinfo
2004;11:111–4.
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STROBE Statement—checklist of items that should be included in reports of observational studies
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
p. 3
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found p.3
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported
p. 4
Objectives 3 State specific objectives, including any prespecified hypotheses p. 4
Methods
Study design 4 Present key elements of study design early in the paper p. 4
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection p. 4
Participants 6 (a) Cohort study—Give the eligibility criteria, and the sources and methods of
selection of participants. Describe methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of
case ascertainment and control selection. Give the rationale for the choice of cases
and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants p. 4
(b) Cohort study—For matched studies, give matching criteria and number of
exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of
controls per case
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there
is more than one group
Bias 9 Describe any efforts to address potential sources of bias
Study size 10 Explain how the study size was arrived at
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why p. 5
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding
p. 6
(b) Describe any methods used to examine subgroups and interactions
(c) Explain how missing data were addressed p. 6
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was
addressed
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy
(e) Describe any sensitivity analyses
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed p. 7
(b) Give reasons for non-participation at each stage
(c) Consider use of a flow diagram
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders p. 7 – 11
(b) Indicate number of participants with missing data for each variable of interest
(c) Cohort study—Summarise follow-up time (eg, average and total amount)
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time
Case-control study—Report numbers in each exposure category, or summary measures of
exposure
Cross-sectional study—Report numbers of outcome events or summary measures p. 7 – 11
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included p. 7 – 11
(b) Report category boundaries when continuous variables were categorized
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses
Discussion
Key results 18 Summarise key results with reference to study objectives p. 12
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias p. 12
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence p. 12 – 14
Generalisability 21 Discuss the generalisability (external validity) of the study results p. 14
Other information
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable,
for the original study on which the present article is based p. 14
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and
unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and
published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely
available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is
available at www.strobe-statement.org.
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Access and barriers to health care in the Kingdom of Saudi Arabia, 2013: Findings from a National Multistage Survey
Journal: BMJ Open
Manuscript ID: bmjopen-2015-007801.R1
Article Type: Research
Date Submitted by the Author: 01-Apr-2015
Complete List of Authors: El Bcheraoui, Charbel; Institute for Health Metrics and Evaluation, Tuffaha, Marwa; Institute for Health Metrics and Evaluation, Daoud, Farah; Institute for Health Metrics and Evaluation, Kravitz, Hannah; Institute for Health Metrics and Evaluation, AlMazroa, Mohammad; Ministry of Health of the Kingdom of Saudi Arabia, Al Saeedi, Mohammad; Ministry of Health of the Kingdom of Saudi Arabia, Memish, Ziad; Ministry of Health of the Kingdom of Saudi Arabia, Basulaiman, Mohammed; Ministry of Health of the Kingdom of Saudi
Arabia, Al Rabeeah, Abdullah; Ministry of Health of the Kingdom of Saudi Arabia, mokdad, ali; Institute for Health Metrics and Evaluation, University of Washington
<b>Primary Subject Heading</b>:
Global health
Secondary Subject Heading: Health services research, Epidemiology
Keywords: General diabetes < DIABETES & ENDOCRINOLOGY, Hypertension < CARDIOLOGY, Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PRIMARY CARE, PREVENTIVE MEDICINE
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Access and barriers to health care in the Kingdom of Saudi Arabia, 2013: Findings from a
National Multistage Survey
Charbel El Bcheraoui, [email protected], Institute for Health Metrics and Evaluation, University
of Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Marwa Tuffaha, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Farah Daoud, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Hannah Kravitz, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
Mohammad A. AlMazroa, [email protected], Ministry of Health of the Kingdom of
Saudi Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Mohammad Al Saeedi, [email protected], Ministry of Health of the Kingdom of Saudi
Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Ziad A. Memish, [email protected], Ministry of Health of the Kingdom of Saudi Arabia,
Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Mohammed Basulaiman , [email protected], Ministry of Health of the Kingdom of
Saudi Arabia, Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
Abdullah A. Al Rabeeah, [email protected], Ministry of Health of the Kingdom of Saudi Arabia,
Assadah, Al Murabba Riyadh 12613, Saudi Arabia.
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Ali H. Mokdad, [email protected], Institute for Health Metrics and Evaluation, University of
Washington, 2301 Fifth Ave., Suite 600, Seattle, WA 98121, USA.
†Corresponding Author:
Ali H. Mokdad, PhD
Director, Middle Eastern Initiatives
Professor, Global Health
Institute for Health Metrics and Evaluation
University of Washington
2301 5th Avenue, Suite 600
Seattle, WA 98121
Tel: +1-206-897-2849
Fax: +1-206-897-2899
Keywords: health care, health system, access, barriers, Saudi Arabia
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ABSTRACT
Objectives: We analyzed data from a large household survey to identify barriers to health care in
the Kingdom of Saudi Arabia.
Methods: The Saudi Health Interview Survey (SHIS) is a national multistage survey of
individuals aged 15 years or older. The survey combined a household questionnaire and a
laboratory blood analysis. We used a backward elimination multivariate logistic regression
model to measure association between 1) diagnosis, 2) treatment, and 3) control of hypertension
or diabetes and socio-demographic factors, history of diagnosis with chronic conditions, and type
of, and distance traveled to, the clinic last visited.
Results: Between April and June 2013, a total of 10,735 participants completed SHIS and were
invited to the local health clinics. Hypertensive individuals, women, older individuals, and those
previously diagnosed with diabetes and hypercholesterolemia were more likely to have been
diagnosed with hypertension than their counterparts. Among participants diagnosed with
hypertension, the likelihood of being treated increased with age and education. The likelihood of
having uncontrolled blood pressure despite treatment increased with education and a history of
diagnosis with hypercholesterolemia.
Type of clinic visited and distance traveled to last clinic visit were not associated with diagnosis
or treatment of hypertension or control of blood pressure.
Similar factors were associated with the likelihood of diagnosis and treatment among diabetic
individuals. Having uncontrolled HbA1c levels, despite treatment, was less common among
those who visited governmental clinics other than those of the Ministry of Health, compared to
those who visited Ministry clinics.
Conclusions: Our findings highlight the importance of individual characteristics in health care-
seeking practices rather than system-based potential barriers. Saudis seem to mostly seek health
care when sick. Hence, the Saudi Ministry of Health needs to implement a comprehensive plan
including health education and investigations to understand the barriers and bottlenecks to health
care-seeking behavior.
STRENGTHS AND LIMITATIONS OF THIS STUDY
• First nationally representative study on access and barriers to healthcare in the Kingdom
of Saudi Arabia.
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• Highlights the importance of individual, over environmental and systematic,
characteristics in healthcare seeking behavior among Saudis.
• Calls for in-depth investigations on beliefs and attitudes affecting health care seeking
behavior among Saudis.
• Cross-sectional design that limits assessment of causality.
• Lowered response rate for laboratory testing.
INTRODUCTION
In the Kingdom of Saudi Arabia (KSA), health care is offered for free to Saudi citizens[1]
through more than 2,000 primary health care centers and 420 hospitals.[2] We have previously
reported that Saudis do not make use of periodic health examinations despite their availability for
free.[3] In a more specific example, we have also reported that only a low percentage of women
who should be screened for breast cancer are.[4]
The Saudi Ministry of Health is investing considerable effort and money to prevent disease and
promote health, with a special focus on non-communicable diseases. However, and despite these
efforts, funds, and the free health care system in KSA, more than 1.9 million (15.2%) and 1.7
million (13.4%) Saudis aged 15 years or older are hypertensive and diabetic, respectively.[5,6]
Furthermore, 57.8% and 43.6% of those affected have not been diagnosed with hypertension and
diabetes, respectively, while among those diagnosed, 31.1% and 9.0% are not treated. Among
those treated, 55.0% and 29.1% do not have their condition under control.
Distance to health care settings and types of health care settings have been reported to impact
patients’ health care-seeking behavior.[7–10]
To identify barriers to health care in KSA, we analyzed data from a large household survey on
the relation of distance traveled to health care clinics and type of clinics last visited and
compared these data with diagnosis, treatment, and control of hypertension and diabetes.
METHODS
The Saudi Health Interview Survey (SHIS) is a national multistage survey of individuals aged 15
years or older. Households of Saudi citizens were randomly selected from a national sampling
frame maintained and updated by the Census Bureau. The Ministry of Health divides KSA into
13 health regions, each with its own health department. We divided each region into subregions
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and blocks used by the KSA Department of Statistics. All regions were included, and a
probability proportional to size was used to randomly select subregions and blocks. Households
were randomly selected from each block. We used a computer assisted personal interviewing
methodology for data collection. A roster of all household members was collected, and an adult
aged 15 or older was selected to be surveyed through a simple random sampling algorithm
programmed to the computers used for data collection. If the randomly selected adult was not
present, our surveyors made an appointment to return, and a total of three visits were made
before the household was considered as a nonresponse. Blood pressure of the randomly selected
adult was measured at the household by a trained professional.
The survey included questions on socio-demographic characteristics, health care utilization, and
self-reported chronic conditions. These conditions included diabetes, hypercholesterolemia, and
hypertension.
To measure diagnosed hypertension, diabetes, and hypercholesterolemia status, respondents were
asked three separate questions: “Have you ever been told by a doctor, nurse, or other health
professional that you had 1) diabetes mellitus, otherwise known as diabetes, sugar diabetes, high
blood glucose, or high blood sugar; 2) hypercholesterolemia, otherwise known as high or
abnormal blood cholesterol; 3) hypertension, otherwise known as high blood pressure?” Women
diagnosed with diabetes or hypertension during pregnancy were not counted as having these
conditions.
A total of three blood measurements were taken with the participant resting and at five-minute
intervals. We followed National Health and Nutrition Examination Survey (NHANES)
guidelines for determining blood pressure level.[11] Respondents were considered to have
hypertension if they met any of the following criteria: 1) measured diastolic or systolic blood
pressure exceeding 89 or 139 mmHg, respectively, or 2) measured diastolic or systolic blood
pressure not exceeding the appropriate threshold, but the respondent reported taking medications
for hypertension. Hence, respondents who were on drugs for hypertension were considered
hypertensive even if their measured diastolic or systolic blood pressure did not exceed 89 or 139
mmHg, respectively.
Respondents who completed the questionnaire were invited to local primary health care clinics to
provide a blood sample for laboratory analysis. All blood samples were analyzed in a central lab
at the King Fahd Medical City in Riyadh. COBAS INTEGRA400 plus was used to measure
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blood levels of HbA1C, or glycated hemoglobin. We followed NHANES guidelines for
determining diabetes status.[11] Respondents were considered to be diabetic if they met any of
the following criteria: 1) measured HbA1c equaling or exceeding 6.5% (48.5 mmol/mol) or 2)
measured HbA1c not equaling or exceeding 6.5% (48.5 mmol/mol), but the respondent reported
taking medications for diabetes. Hence, the subgroup diabetic includes those with measured
HbA1c equal or above 6.5% or taking medication for diabetes.
To assess use of health care services, participants were asked, “What was the type of the clinic
that you last visited for medical attention for any reason?” and “How far away was the facility
you attended from your home?”
Statistical analysis
We used a backward elimination multivariate logistic regression model to measure association
between 1) diagnosis, 2) treatment, and 3) control of hypertension or diabetes and sex, age,
marital status, education, history of diagnosis with diabetes, hypercholesterolemia, hypertension,
and type of, and distance traveled to, the clinic last visited. The logistic regression eliminated
missing data. Data were weighted to account for the probability of selection and age and sex
post-stratification based on census data for age and sex distribution of the Saudi population.
Weighting methodology
Two sets of sampling weights were generated and incorporated into the dataset for analysis.
First, we created an individual sampling weight for all respondents to account for 1) the
probability of selection of an eligible respondent within a household, 2) the probability of
selection of the household within a stratum, and 3) the post-stratification differences in age and
sex distribution between the sample and the Saudi population.
For individuals who completed the lab-based blood analysis, we computed an additional
sampling weight used in analyzing data from clinic visits to account for 1) the individual
sampling weight described above, 2) the probability of visiting a clinic, 3) socio-demographic,
behavioral, and health differences between respondents who visited the clinic and those who did
not, and 4) the post-stratification differences in age and sex distribution between the respondents
who visited the clinic and the Saudi population. We used SAS 9.3 for the analyses and to account
for the complex sampling design.
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RESULTS
Between April and June 2013, a total of 10,735 participants completed the SHIS — a response rate of 89.4% — and were invited to
the local health clinics. The remaining 1,265 completed part of the household enumeration, or all of it, but the selected adult did not
complete the survey.
An estimated total of 1,957,191 (15.2%) Saudis aged 15 years or older had hypertension (measured or reported taking blood pressure
medication). Of these, 1,119,027 were undiagnosed. Women (adjusted odds ratio [AOR] = 1.87; 95% confidence interval [95% CI]:
1.23 – 2.85), older individuals (AOR = 1.05; 95% CI: 1.03 – 1.07), and those previously diagnosed with diabetes (AOR = 2.38; 95%
CI: 1.60 – 3.53) and hypercholesterolemia (AOR = 2.76; 95% CI: 1.72 – 4.44), were more likely to have been diagnosed with
hypertension than men, younger individuals, and those without such a history of diagnosis (Table 1).
Table 1: Distribution and logistic regression for diagnosis, treatment, and control of hypertension by different factors, hypertensive Saudis aged
15 years or older, Kingdom of Saudi Arabia, 2013
Diagnosis among those hypertensive Treatment among those diagnosed Control among those treated
Socio-demographic
characteristics, health
care access, and
diagnoses of chronic
conditions
N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI)
Sex
Males 492 (54.49; 2.21) REF 417 (53.34; 2.37) REF 165 (49.66; 3.62) REF
Females 459 (45.51; 2.21) 1.87 (1.23 – 2.85) 416 (46.66; 2.37) 1.82 (0.81 – 4.09) 195 (50.34; 3.62) 1.61 (0.85 – 3.08)
Age (years)* 1.05 (1.03 – 1.07) 1.08 (1.05 – 1.12) 1.01 (0.99 – 1.03)
15 – 24 4 (0.65; 0.33) 3 (0.59; 0.34) 1 (0.50; 0.50)
25 – 34 41 (5.06; 0.95) 23 (3.13; 0.84) 13 (4.53; 1.70)
35 – 44 105 (12.10; 1.42) 78 (10.08; 1.35) 40 (11.07; 2.08)
45 – 54 215 (27.42; 2.06) 191 (27.76; 2.21) 79 (28.86; 3.46)
55 – 64 243 (27.92; 2.06) 227 (29.83; 2.25) 106 (30.83; 3.33)
65+ 343 (26.86; 1.82) 311 (28.61; 2.01) 121 (24.21; 2.90)
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Marital status
Currently married 696 (78.40; 1.77) REF 607 (77.83; 1.93) REF 257 (74.25; 3.17) REF
Never married 33 (5.15; 1.16) 0.95 (0.38 – 2.39) 22 (4.41; 1.20) 2.37 (0.58 – 9.75) 11 (5.69; 2.05) 1.73 (0.40 – 7.53)
Separated, divorced, or
widowed 220 (16.45; 1.47) 0.67 (0.39 – 1.17) 202 (17.76; 1.64) 0.66 (0.24 – 1.80) 91 (20.06; 2.74) 1.88 (0.88 – 4.05)
Education
Primary school or less 593 (57.79; 2.18) REF 533 (59.20; 2.32) REF 217 (52.12; 3.62) REF
Elementary or high
school completed 225 (27.48; 2.03) 1.00 (0.63 – 1.58) 195 (27.10; 2.16) 2.86 (1.16 – 7.08) 86 (29.26; 3.48) 2.25 (1.12 – 4.50)
College degree or
higher education 131 (14.73; 1.46) 1.81 (1.06 – 3.09) 104 (13.70; 1.53) 2.78 (1.14 – 6.79) 57 (18.62; 2.77) 4.63 (2.14 – 10.02)
Type of clinic last
visited
Ministry of Health 618 (72.44; 2.23) 548 (71.97; 2.40) 229 (70.65; 3.77)
Other governmental
clinic 70 (8.89; 1.29)
61 (8.66; 1.37)
31 (9.69; 2.11)
Private clinic 112 (18.67; 2.03) 101 (19.37; 2.20) 41 (19.67; 3.52)
Distance travelled to
clinic (km)**
1.01 (0.99 – 1.03)
0 – 2 218 (36.87; 2.66) 189 (36.90; 2.85) 79 (39.24; 4.50)
3 – 5 159 (25.65; 2.46) 138 (24.43; 2.56) 56 (24.82; 4.04)
6 – 10 116 (19.79; 2.22) 107 (20.04; 2.33) 42 (18.68; 3.40)
11 – 35 84 (14.49; 1.97) 78 (15.45; 2.21) 27 (12.14; 2.82)
36 – 100 21 (3.20; 0.86) 19 (3.18; 0.91) 10 (5.12; 1.90)
Diagnosis history of
diabetes
No 484 (51.91; 2.23) REF 406 (48.91; 2.39) REF 168 (47.77; 3.62)
Yes 462 (48.09; 2.23) 2.38 (1.60 – 3.53) 423 (51.09; 2.39) 2.21 (1.05 – 4.62) 188 (52.23; 3.62)
Diagnosis history of
hypercholesterolemia
No 557 (63.01; 2.22) REF 473 (61.06; 2.39) REF 192 (56.85; 3.70) REF
Yes 322 (36.99; 2.22) 2.76 (1.72 – 4.44) 300 (38.94; 2.39) 1.78 (0.82 – 3.84) 143 (43.15; 3.70) 1.89 (1.12 – 3.18)
*AOR for age should be considered as for an increase of 10 years.**AOR for distance should be considered as for an increase of one kilometer.AOR: adjusted
odds ratio; CI: confidence interval; REF: reference.
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Among participants diagnosed with hypertension, 78.9% reported taking medication for their condition. The likelihood of being
treated increased with age (AOR = 1.08; 95% CI: 1.05 – 1.12) and among those who completed elementary or high school (AOR =
2.86; 95% CI: 1.16 – 7.08) or college (AOR = 2.78; 95% CI: 1.14 – 6.79) (Table 1).
About 45% of participants on medication for hypertension had their blood pressure controlled. Hence, about 390,338 adults had
uncontrolled blood pressure. The likelihood of having uncontrolled blood pressure despite treatment increased among those who
completed elementary or high school (AOR = 2.25; 95% CI: 1.12 – 4.50) and college (AOR = 4.63; 95% CI: 2.14 – 10.02) and those
previously diagnosed with hypercholesterolemia (AOR = 1.89; 95% CI: 1.12 – 3.18)
Type of clinic visited, and distance travelled to last clinic visit were not associated with diagnosis or treatment of hypertension or
control of blood pressure.
A total of 5,590 individuals went to the local clinics and provided blood samples for analyses — a response rate of 52.1%. A total of
1,745,532 (13.4%) Saudis aged 15 years or older had diabetes. Among those that our survey identified as diabetic from blood exams,
43.6% were undiagnosed. Older individuals (AOR = 1.05; 95% CI: 1.03 – 1.08) and those previously diagnosed with hypertension
(AOR = 2.39; 95% CI: 1.09 – 5.25) and hypercholesterolemia (AOR = 5.64; 95% CI: 2.37 – 13.44) were more likely to be diagnosed
than younger individuals and those without such a history of diagnosis (Table 1).
Among participants diagnosed with diabetes, 91.0% reported taking medication for their condition. The likelihood of being treated
increased among those with a college degree (AOR = 5.79; 95% CI: 1.57 – 21.32) (Table 2).
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Table 2: Distribution and logistic regression for diagnosis, treatment, and control of diabetes by different factors, diabetic Saudis aged 15 years
or older, Kingdom of Saudi Arabia, 2013
Diagnosis among those with diabetes Treatment among those diagnosed Control among those treated
Socio-demographic
characteristics, health
care access, and
diagnoses of chronic
conditions
N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI) N (Weighted%; SE) AOR (95% CI)
Sex
Males 392 (61.88; 2.52) 378 (61.40; 2.57) 167 (57.88; 3.92) REF
Females 309 (38.12; 2.52) 302 (38.60; 2.57) 149 (42.12; 3.92) 1.50 (0.76 – 2.97)
Age (years)* 1.05 (1.03 – 1.08) 1.03 (1.00 – 1.07) 1.02 (1.00 – 1.05)
15 – 24 11 (3.01; 1.01) 10 (2.91; 1.01) 7 (2.14; 1.01)
25 – 34 28 (5.59; 1.29) 27 (5.50; 1.30) 32 (14.31; 2.95)
35 – 44 76 (12.43; 1.73) 73 (12.39; 1.77) 82 (29.46; 3.79)
45 – 54 175 (29.90; 2.62) 168 (29.69; 2.66) 76 (28.83; 3.80)
55 – 64 182 (27.80; 2.37) 179 (28.28; 2.43) 114 (22.71; 3.06)
65+ 229 (21.28; 1.95) 223 (21.23; 1.98) 316 (100.00; 0.00)
Marital status
Currently married 535 (82.08; 1.88) 521 (82.31; 1.90) 65 (12.60; 2.08) REF
Never married 27 (5.80; 1.41) 26 (5.76; 1.43) 316 (100.00; 0.00) 0.35 (0.06 – 2.13)
Separated, divorced, or
widowed 138 (12.12; 1.38)
132 (11.94; 1.40)
521 (0.00; 0.00) 0.67 (0.27 – 1.66)
Education
Primary school or less 461 (58.87; 2.62) 445 (58.46; 2.66) REF 32 (13.07; 2.71)
Elementary or high
school completed 172 (29.59; 2.45)
167 (29.75; 2.48) 1.01 (0.34 – 3.00) 316 (100.00; 0.00)
College degree or
higher education 68 (11.53; 1.65)
68 (11.79; 1.69) 5.79 (1.57 – 21.32) 445 (0.00; 0.00)
Type of clinic last
visited
Ministry of Health 469 (79.94; 2.25) REF 454 (79.71; 2.30) REF 225 (86.23; 2.89) REF
Other governmental 48 (8.35; 1.57) 0.44 (0.14 – 1.34) 46 (8.47; 1.61) 4.35 (0.41 – 46.45) 16 (3.96; 1.13) 0.28 (0.10 – 0.79)
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clinic
Private clinic 59 (11.70; 1.77) 0.65 (0.28 – 1.52) 58 (11.82; 1.81) 1.00 (0.17 – 5.75) 21 (9.81; 2.72) 0.54 (0.21 – 1.43)
Distance travelled to
clinic (km)*
0.98 (0.96 – 1.00) 0.97 (0.93 – 1.02) 1.01 (0.98 – 1.04)
0 – 2 167 (46.04; 3.54) 162 (46.24; 3.59) 72 (46.16; 5.36)
3 – 5 113 (19.46; 2.51) 110 (18.92; 2.51) 57 (17.54; 3.09)
6 – 10 83 (20.11; 2.67) 82 (20.23; 2.71) 36 (19.37; 4.23)
11 – 35 52 (11.39; 2.33) 51 (11.55; 2.37) 29 (16.19; 4.24)
36 – 100 6 (3.00; 1.88) 6 (3.05; 1.91) 2 (0.74; 0.56)
Diagnosis history of
hypertension
No 432 (63.73; 2.56) REF 419 (63.96; 2.60) 193 (61.26; 3.95)
Yes 267 (36.27; 2.56) 2.39 (1.09 – 5.25) 259 (36.04; 2.60) 122 (38.74; 3.95)
Diagnosis history of
hypercholesterolemia
No 449 (72.36; 2.39) REF 437 (73.16; 2.42) REF 203 (72.15; 3.56)
Yes 205 (27.64; 2.39) 5.64 (2.37 – 13.44) 196 (26.84; 2.42) 0.54 (0.20 – 1.52) 97 (27.85; 3.56)
*AOR for age should be considered as for an increase of ten years. **AOR for distance should be considered as for an increase of one kilometer. AOR: adjusted
odds ratio; CI: confidence interval; REF: reference.
About 70.9% of participants on medication for diabetes had their diabetes controlled. Hence, about 397,541 adults had uncontrolled
diabetes. The likelihood of having uncontrolled levels of HbA1c despite treatment decreased among those who visited governmental
clinics other than those of the Ministry of Health (AOR = 0.28; 95% CI: 0.10 – 0.79), compared to those who visited the Ministry
clinics (Table 2).
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DISCUSSION
This is the first national study that examines barriers to health care utilization in KSA. Our
findings highlight the importance of individual characteristics in health care-seeking practices,
rather than system-based potential barriers. Our results show that neither distance to nor type of
health care clinic were barriers to diagnosis, treatment, or control of two leading chronic disease
in KSA. Our findings are of great importance as the Ministry continues to invest in building
infrastructure throughout the Kingdom. The 2014 Ministry of Health budget calls for building 34
new hospitals.[12] Therefore, it is crucial to assess the Saudis’ reasons for not seeking care and
address this aspect in order to improve health and reduce burden.
Access to health care is an important determinant of health. Several studies have shown that the
availability of facilities within accessible distance improve health. Therefore, in some countries,
including South Africa, KSA, and Portugal, distance to key populations is considered when
planning on building new health facilities.[13–15] Saeed at al. (2001) had found that the longer
the distance travelled to primary health care centers in Riyadh, the lower was the patients’
satisfaction with 39% of patients considering the primary health care center was far or very
far.[16] However, in our study, distance was not an issue, and we didn’t observe any association
between type of health care facilities used, or distance to health care facilities, and health
outcomes or use of health services in KSA.
The study of Saeed et al. was not the only one to focus on patients’ satisfaction in KSA. Other
small, nonrepresentative studies have examined patient satisfaction with health care facilities and
services in KSA and were focused on the Saudi Ministry of Health primary health care centers.
Most studies showed a high rate of dissatisfaction among users. Of facilities’ characteristics,
distance travelled, facilities’ working hours, absence of specialty clinics, waiting time, waiting
area structure, and confidentiality measures were the negative factors most impacting patients’
satisfaction. Of staff characteristics, surgeons’ services, language barriers with physicians, and
communication about health status were the factors most correlated with dissatisfaction. As for
patients’ characteristics, women and the least educated seem to be more satisfied than men and
more educated patients.[17–19] Other relevant areas of health care services in KSA have been
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studied as well as they pertain to health care utilization and patient satisfaction. For instance,
Alahmadi (2010) has researched patient safety culture in Saudi health care facilities.
Interestingly, the author found that interest of management and patient safety procedures are only
triggered after an adverse event has occurred. More so, the author notes the under-reporting of
errors, even when actual harm occurs due to a widespread culture of blaming individual workers
for errors.[20]
Our study has some limitations. First, our data are from a cross-sectional study, and therefore we
cannot assess causality. However, our study is based on a large sample and used a standardized
methodology for all its measures. Second, only 52% of respondents completed the visit to a
health clinic and had their blood drawn for analysis. However, our weighting methodology
accounted for this bias by applying a post-stratification adjustment using socio-demographic
characteristics, health behaviors, previously diagnosed non-communicable diseases, and
anthropometric measurements of respondents from the household survey. Third, our study is a
household survey and reflects only on individual factors that can affect access to, and utilization
of health care. Also, we did not collect data on satisfaction with health care services. More so,
our study cannot assess system-based factors that affect the health care seeking behavior of the
Saudi population. Such factors can be better understood through health care facility surveys, and
exit interviews with patients leaving health care facilities.
Despite the density of health facilities and the free health care system in KSA,[2,21] Saudis do
not seem to seek prevention or care until after developing disease symptoms or reaching an
advanced stage of illness. However, the Saudi Ministry of Health invests considerable funds in
prevention and health promotion campaigns.[22] It is crucial for the Ministry to understand why
Saudis abstain from using preventive services, including periodic health examinations and
screenings for preventable diseases. Given the lack of information on this in KSA, formative
research through qualitative research methods is needed, as no assumptions exist regarding the
reasons behind seeking health care, or the lack of care-seeking, among Saudis. However, the
focus on individual factors is not enough. System-based factors should also be inquired to
understand relevant aspects of the system, including the quality of care. Findings from such
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studies can help modify and improve the system in order to incentivize the Saudi population to
benefit more from their free health care system.
Our findings showed a higher likelihood for women to be diagnosed with chronic conditions,
such as hypertension. However, no difference exists among those diagnosed when it comes to
treatment or control of the condition. Indeed, getting diagnosed requires that one actively seeks
health care. In parallel, the health system should play an equivalent role in seeking out
undiagnosed patients through organized screening programs and protocols, such as national mass
screening campaigns targeting specific diseases. More so, getting treated and having one’s
condition controlled once diagnosed relies more on the health care provider’s interaction with the
patient and their follow-up. Women are doing a better job seeking care, but both sexes have a
long way to go to improve health and reduce burden.[5] Diagnosis is the first step toward
controlling a condition. Patients have to be monitored and followed to ensure proper dosage of
medication and to reinforce behavioral changes. Hence, regular checkups have to be scheduled
and the patient must be reminded to come to the clinic.
Our results show the importance of health education and programs to reach the population at
home and in the workplace. Clearly, Saudis are not taking advantage of the free medical services
and medications. The Saudi Ministry of Health could easily implement programs to generate
reminders for visits to clinics, which could help control diseases and reduce burden. Such
systems are available in many countries, where patients are notified about their next scheduled
visits.[23] In KSA, such systems are more likely to be successful, as patients get their
medications refilled for free from health clinics.
In parallel to understanding individual behavior, the Saudi Ministry of Health needs to assess
specific characteristics in their health care facilities. For instance, a targeted survey can measure
the bottlenecks, including stocks, equipment, and staff, that health care facilities and their users
face. A parallel geographically linked survey, coupled with patient exit interview surveys, could
determine the impact of access and bottlenecks on the health of Saudis.
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The Arab culture promotes health and encourages prevention over treatment; an old Arab
proverb says, “Prevention is better than treatment.” However, our findings do not point in this
direction. Saudis seem to mostly seek health care when sick. Free and available health care
services in close proximity are not enough to get Saudis to utilize the care offered. The Saudi
Ministry of Health needs to do more than building additional health care facilities. It needs to
implement a comprehensive plan that includes health education and plans to understand the
barriers and bottlenecks to health care-seeking behavior and access.
Funding
This study was financially supported by a grant from the Ministry of Health of the Kingdom of
Saudi Arabia.
Acknowledgments
We would like to thank Kate Muller at the Institute for Health Metrics and Evaluation for editing
the manuscript.
Competing Interest
The authors declare no conflict of interest
Contributorship Statement
Authors contributed to this study in different ways: AHM and CEB conceived and designed the
study. MB, ZAM, MAS, MAA performed the study. AHM and CEB analyzed the data. CEB,
AHM, FD, MT, HK, MB, ZAM, MAS, MAA and AAR wrote the manuscript. AAR supervised
the study. All co-authors are responsible for the content of this article and have read and
approved the final manuscript.
Data Sharing Statement
The data collected for this study is not publicly available. Any request to access the data needs to
be addressed to the Saudi Ministry of Health.
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REFERENCES
1 Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: an overview. East
Mediterr Health J 2011;17:784–93.
2 Saudi Arabian Monetary Agency. Fourty ninth annual report: Latest economic
developments.
http://www.sama.gov.sa/sites/samaen/ReportsStatistics/ReportsStatisticsLib/5600_R_Annual
_En_49_Apx.pdf
3 El Bcheraoui C, Tuffaha M, Daoud F, et al. Low uptake of periodic health examinations in
the Kingdom of Saudi Arabia, 2013. Journal of Family Medicine and Primary Care;
Accepted March 2015. In press.
4 El Bcheraoui C, Basulaiman M, Wilson S, et al. Breast cancer screening in saudi arabia: free
but almost no takers. PLoS ONE 2015;10:e0119051. doi:10.1371/journal.pone.0119051
5 El Bcheraoui C, Memish ZA, Tuffaha M, et al. Hypertension and its associated risk factors
in the Kingdom of Saudi Arabia, 2013: a national survey. Int J Hypertens 2014;2014.
doi:10.1155/2014/564679
6 El Bcheraoui C, Basulaiman M, Tuffaha M, et al. Status of the diabetes epidemic in the
Kingdom of Saudi Arabia, 2013. Int J Public Health 2014;59:1011–21. doi:10.1007/s00038-
014-0612-4
7 Buzza C, Ono SS, Turvey C, et al. Distance is relative: unpacking a principal barrier in rural
healthcare. J Gen Intern Med 2011; 26 Suppl 2:648–54. doi:10.1007/s11606-011-1762-1
8 Ward B, Humphreys J, McGrail M, et al. Which dimensions of access are most important
when rural residents decide to visit a general practitioner for non-emergency care? Aust
Health Rev Published Online First: 22 December 2014. doi:10.1071/AH14030
9 Yamauchi Y, Fujiwara T, Okuyama M. Factors Influencing Time Lag Between Initial
Parental Concern and First Visit to Child Psychiatric Services Among ADHD Children in
Japan. Community Ment Health J Published Online First: 23 December 2014.
doi:10.1007/s10597-014-9803-y
10 Schoeps A, Gabrysch S, Niamba L, et al. The Effect of Distance to Health-Care Facilities on
Childhood Mortality in Rural Burkina Faso. Am J Epidemiol 2011;173:492–8.
doi:10.1093/aje/kwq386
11 Centers for Disease Control and Prevention. National Health and Nutrition Examination
Survey: Health Tech/Blood Pressure Procedures Manual. cdc.gov.
2009.http://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/BP.pdf (accessed 11 Dec2014).
12 U.S.-Saudi Arabian Business Council. Saudi Arabia’s 2014 Budget Emphasizes Long-Term
Development. U.S.-Saudi Arabian Business Council. 2013.http://www.us-
sabc.org/custom/news/details.cfm?id=1541#.VLROoivF98M
Page 17 of 21
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
group.bmj.com on August 23, 2015 - Published by http://bmjopen.bmj.com/Downloaded from
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18
13 Vanderschuren M, McKune D. Emergency care facility access in rural areas within the
golden hour?: Western Cape case study. International Journal of Health Geographics
2015;14:5. doi:10.1186/1476-072X-14-5
14 Gonçalves J, Ferreira JA, Condessa B. Making regional facility location decisions: the
example of Hospital do Oeste Norte, Portugal. Geospat Health 2014;9:1.
doi:10.4081/gh.2014.1
15 Murad AA. Using geographical information systems for defining the accessibility to health
care facilities in Jeddah City, Saudi Arabia. Geospat Health 2014;8:295.
doi:10.4081/gh.2014.295
16 Saeed AA, Mohammed BA, Magzoub ME, et al. Satisfaction and correlates of patients;
satisfaction with physicians; services in primary health care centers. Saudi Medical Journal
2001;22:262–7. doi:10.15537/3281
17 Al-Doghaither AH. Inpatient satisfaction with physician services at King Khalid University
Hospital, Riyadh, Saudi Arabia. East Mediterr Health J 2004;10:358–64.
18 El Shabrawy MA, Mahmoud ME. A study of patient satisfaction with primary health care
services in Saudi Arabia. J Community Health 1993;18:49–54.
19 Qatari GA, Haran D. Determinants of users’ satisfaction with primary health care settings
and services in Saudi Arabia. International Journal for Quality in Health Care 1999;11:523–
31. doi:10.1093/intqhc/11.6.523
20 Alahmadi HA. Assessment of patient safety culture in Saudi Arabian hospitals. Qual Saf
Health Care 2010;19:1–5. doi:10.1136/qshc.2009.033258
21 Clark M, Almalki M. Health care system in Saudi Arabia: an overview. Eastern
Mediterranean Health Journal 2011;Vol.17.
22 Saudi Ministry of Health. Awareness Campaigns. Kingdom of Saudi Arabia - Ministry of
Health Portal. http://www.moh.gov.sa/en/HealthAwareness/Campaigns/Pages/default.aspx
(accessed 12 Jan2015).
23 Agrawal A, Mayo-Smith MF. Adherence to computerized clinical reminders in a large
healthcare delivery network. In: Medinfo 2004. Amsterdam: : IOS Press 2004. 111–4.
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1
STROBE Statement—checklist of items that should be included in reports of observational studies
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
p. 3
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found p.3
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported
p. 4
Objectives 3 State specific objectives, including any prespecified hypotheses p. 4
Methods
Study design 4 Present key elements of study design early in the paper p. 4
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection p. 4
Participants 6 (a) Cohort study—Give the eligibility criteria, and the sources and methods of
selection of participants. Describe methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of
case ascertainment and control selection. Give the rationale for the choice of cases
and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants p. 4
(b) Cohort study—For matched studies, give matching criteria and number of
exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of
controls per case
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there
is more than one group
Bias 9 Describe any efforts to address potential sources of bias
Study size 10 Explain how the study size was arrived at
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why p. 5
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding
p. 6
(b) Describe any methods used to examine subgroups and interactions
(c) Explain how missing data were addressed p. 6
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was
addressed
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy
(e) Describe any sensitivity analyses
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed p. 7
(b) Give reasons for non-participation at each stage
(c) Consider use of a flow diagram
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders p. 7 – 11
(b) Indicate number of participants with missing data for each variable of interest
(c) Cohort study—Summarise follow-up time (eg, average and total amount)
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time
Case-control study—Report numbers in each exposure category, or summary measures of
exposure
Cross-sectional study—Report numbers of outcome events or summary measures p. 7 – 11
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included p. 7 – 11
(b) Report category boundaries when continuous variables were categorized
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses
Discussion
Key results 18 Summarise key results with reference to study objectives p. 12
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias p. 12
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence p. 12 – 14
Generalisability 21 Discuss the generalisability (external validity) of the study results p. 14
Other information
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable,
for the original study on which the present article is based p. 14
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and
unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and
published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely
available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is
available at www.strobe-statement.org.
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national multistage survey Kingdom of Saudi Arabia, 2013: findings from a Access and barriers to healthcare in the
Basulaiman, Abdullah A Al Rabeeah and Ali H Mokdad MohammedMohammad A AlMazroa, Mohammad Al Saeedi, Ziad A Memish,
Charbel El Bcheraoui, Marwa Tuffaha, Farah Daoud, Hannah Kravitz,
doi: 10.1136/bmjopen-2015-007801 2015 5: BMJ Open
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