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1.  Top 10 health care ethics challenges facing the public: views of Toronto bioethicists 
BMC Medical Ethics  2005;6:5.
Background
There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds.
Discussion
The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill.
Summary
Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge.
doi:10.1186/1472-6939-6-5
PMCID: PMC1180442  PMID: 15978136
2.  Is there a need for a formulary of clinically interchangeable medicines to guide generic substitution in Saudi Arabia? 
The escalating healthcare expenditure is a major challenge to sustainability of the healthcare systems. To confront the escalating health expenditure in general and medicines expenditure in particular, many countries promoted the use of generic medicines. To promote generic medicines, many countries have adopted a generic substitution (GS) policy and generic prescribing. To effectively implement the GS policy, it is evident in the literature that it is essential to have an evidence-based guide on therapeutic equivalence and formulary of interchangeable medicines to guide responsible GS. In Saudi Arabia, GS is permissive and pharmacists are given the right to perform GS. While the prescriber's approval is not a requirement, patient consent is required when performing GS. Although there are some general drug references, such as the Saudi National Formulary (SNF) and list of registered medicines in the Saudi market, but there is currently no information available to healthcare professionals that documents the therapeutic and bioequivalence between medicines. Thus, it is essential to have a formulary of interchangeable medicines to guide appropriate GS or at least to include such vital information regarding therapeutic equivalence and brand interchangeability as part of the SNF. That, in turn, will not only make healthcare professionals more confident when providing GS, but will also enable the avoidance of situations where GS is inappropriate.
doi:10.1016/j.jyp.2013.06.006
PMCID: PMC3758099  PMID: 24023460
Generic substitution; Generic medicines; Formulary
3.  Code of ethics for the national pharmaceutical system: Codifying and compilation 
Pharmacists as one of health-care providers face ethical issues in terms of pharmaceutical care, relationship with patients and cooperation with the health-care team. Other than pharmacy, there are pharmaceutical companies in various fields of manufacturing, importing or distributing that have their own ethical issues. Therefore, pharmacy practice is vulnerable to ethical challenges and needs special code of conducts. On feeling the need, based on a shared project between experts of the ethics from relevant research centers, all the needs were fully recognized and then specified code of conduct for each was written. The code of conduct was subject to comments of all experts involved in the pharmaceutical sector and thus criticized in several meetings. The prepared code of conduct is comprised of professional code of ethics for pharmacists, ethics guideline for pharmaceutical manufacturers, ethics guideline for pharmaceutical importers, ethics guideline for pharmaceutical distributors, and ethics guideline for policy makers. The document was compiled based on the principles of bioethics and professionalism. The compiling the code of ethics for the national pharmaceutical system is the first step in implementing ethics in pharmacy practice and further attempts into teaching the professionalism and the ethical code as the necessary and complementary effort are highly recommended.
PMCID: PMC3810583  PMID: 24174954
Pharmaceuticals; pharmacy ethics; pharmacy professionalism
4.  Knowledge, Attitudes, and Practices of Primary Care Physicians About Irritable Bowel Syndrome in Northern Saudi Arabia 
Background/Aim:
Primary health care (PHC) physicians manage most patients with irritable bowel syndrome (IBS). In Saudi Arabia, there are limited data on their knowledge, attitudes, and practices about this disorder. This study aimed to assess knowledge, attitudes, and practices of primary care physicians about IBS.
Patients and Methods:
A cross-sectional survey of 70 practitioners aged 36 ± 10.25 years was carried out in primary care centers in AlJouf Province of Saudi Arabia. The physicians were asked to fill a valid questionnaire containing their sociodemographic data, and well-modified questions regarding their knowledge, attitudes, and practices about IBS. Data was processed and analyzed using SPSS (version 15) program, and the level of significance was set at P<0.05.
Results:
A response rate of 92.9% yielded 65 questionnaires for analysis. Majority of physicians surveyed (83.1%) considered IBS as a common health problem in Saudi Arabia, and (55.4%) believed it is underestimated. There was a significant association between physicians’ qualifications and using diagnostic tools to facilitate IBS diagnosis (14.3% vs 35.5%; P<0.05), while utilization of “Rome or Manning criteria” was more frequent by physicians with master's degree (35.5%) compared to residents (14.3%). Also, 35.4% of physicians (15 males and 8 females) were not sure how to diagnose IBS.
Conclusions:
This study suggested that PHC physicians had a suitable attitude toward IBS, but they lacked knowledge, and their practices toward this condition were inappropriate.
doi:10.4103/1319-3767.96450
PMCID: PMC3371419  PMID: 22626796
Attitudes; irritable bowel syndrome; knowledge; practices; primary care
5.  OBESITY AND ASSOCIATED RISK OF CORONARY ARTERY DISEASE AMONG PATIENTS OF PRIMARY HEALTH CARE CENTERS IN ABHA, SAUDI ARABIA 
Objective:
To estimate the magnitude of obesity and its relation to the 10 year probability of developing coronary artery disease (CAD) in patients attending primary health care centers (PHCCs) in Abha, southern Saudi Arabia.
Subjects and Methods:
Saudi patients aged between 30-70 years who had attended three PHCCs in Abha city over a 6-month period (January to June 1998) and agreed to participate in the study were enrolled. All such patients had their weights and heights measured, body mass index (BMI) was calculated and they were screened for risk factors of CAD and requested to provide a fasting venous sample for lipoprotein analysis. The probability of developing coronary artery disease (PCAD) over the next ten years was calculated for each patient by means of the computer model based on Framingham heart study.2
Results:
A total of 858 subjects were studied: 46% males and 54% females. The percentage of obesity was 49% and overweight 35%; Females were dominantly obese while overweight was more prevalent in males. Of the study subjects 11.5% were hypertensive with significantly higher BMI than normotensives (P=<0.001); diabetes mellitus was represented in 29.6% with no significant difference in their BMI from nondiabetics. Smokers were 4.2% and they had a significantly lower BMI than non-smokers. Individuals with high-risk threshold of TC/HDL-c ratio (≥ 5.6% for women and ≥ 6.4% for men) represented 70.48% and had significantly higher BMI than those with low risk threshold. There was no direct relationship between BMI and PCAD10 (r2=0.007, p<0.12).
Conclusion:
(1) Obesity is an epidemic health problem with an expected upward trend in Saudi Arabia similar to that of LISA and Western Europe. (2) The risk factors for CAD were highly prevalent among the PHCC patients and had a strong significant association with obesity; thus weight control should be an integral part of the prevention of CAD at PHCCs level. (3) Although obesity was found to have a significant individual association with CAD risk factors, obesity per se had no significant direct relationship with the probability of CAD at 10 years. This confirms the conclusion reached by NCEP 11 that obesity caused CAD through the associated risk factors.
PMCID: PMC3444966  PMID: 23008610
Obesity; risk factors of CAD; probability of CAD
6.  Primary care physicians’ knowledge and perceived barriers in the management of overweight and obesity 
Objectives:
To determine the level of knowledge of primary health care physicians and the barriers perceived in the management of overweight and obesity in the Eastern Province of Saudi Arabia.
Setting:
Primary health care centers in Dammam and Al-Khobar cities, Saudi Arabia.
Design:
A cross-sectional study.
Materials and Methods:
One hundred and forty-nine physicians were surveyed. Data were collected with a specially made anonymous, self-administrated, structured questionnaire with a Cronbach alpha reliability of 0.85, and content validity by five experts was used to measure the knowledge and barriers from several different aspects of care provided by primary health care centers to the overweight and obese.
Results:
One hundred and thirty (87%) physicians responded. More than two-thirds of the respondents considered themselves as key players in the management of obesity. However, only one-third believed that they were well prepared to treat obesity. Eighty-three per cent of the respondents had a negative attitude toward the concept of overweight and obesity. It was noted that 76.9% of physicians advised patients to control their weight with sport and exercise together with low calorie diet. Sixty percent of the respondents used body mass index to diagnose obesity. Seventy-two percent of respondents did not use weight reduction medications to treat obesity. Lack of training, poor administrative support, and time constraints were identified as barriers in managing overweight and obesity.
Conclusion:
Respondents were aware of the magnitude of overweight and obesity as a major public health problem in Saudi Arabia, and they were also aware of the correct definition of overweight and obesity, as well as its effect in increasing mortality. Better training is required to improve some areas of awareness and management of the conditions.
doi:10.4103/2230-8229.121972
PMCID: PMC3957166  PMID: 24672270
Barriers; knowledge; obesity; overweight; primary health care physicians; Saudi Arabia
7.  Quality of work life among primary health care nurses in the Jazan region, Saudi Arabia: a cross-sectional study 
Background
Quality of work life (QWL) is defined as the extent to which an employee is satisfied with personal and working needs through participating in the workplace while achieving the goals of the organization. QWL has been found to influence the commitment and productivity of employees in health care organizations, as well as in other industries. However, reliable information on the QWL of primary health care (PHC) nurses is limited. The purpose of this study was to assess the QWL among PHC nurses in the Jazan region, Saudi Arabia.
Methods
A descriptive research design, namely a cross-sectional survey, was used in this study. Data were collected using Brooks’ survey of quality of nursing work life and demographic questions. A convenience sample was recruited from 134 PHC centres in Jazan, Saudi Arabia. The Jazan region is located in the southern part of Saudi Arabia. A response rate of 91% (n = 532/585) was achieved (effective response rate = 87%, n = 508). Data analysis consisted of descriptive statistics, t-test and one way-analysis of variance. Total scores and subscores for QWL items and item summary statistics were computed and reported using SPSS version 17 for Windows.
Results
Findings suggested that the respondents were dissatisfied with their work life. The major influencing factors were unsuitable working hours, lack of facilities for nurses, inability to balance work with family needs, inadequacy of vacations time for nurses and their families, poor staffing, management and supervision practices, lack of professional development opportunities, and an inappropriate working environment in terms of the level of security, patient care supplies and equipment, and recreation facilities (break-area). Other essential factors include the community’s view of nursing and an inadequate salary. More positively, the majority of nurses were satisfied with their co-workers, satisfied to be nurses and had a sense of belonging in their workplaces. Significant differences were found according to gender, age, marital status, dependent children, dependent adults, nationality, nursing tenure, organizational tenure, positional tenure, and payment per month. No significant differences were found according to education level of PHC nurses and location of PHC.
Conclusions
These findings can be used by PHC managers and policy makers for developing and appropriately implementing successful plans to improve the QWL. This will help to enhance the home and work environments, improve individual and organization performance and increase the commitment of nurses.
doi:10.1186/1478-4491-10-30
PMCID: PMC3543175  PMID: 22971150
Nurse; Nursing workforce; Primary health care; Quality of work life (QWL); Saudi Arabia
8.  Education and the improvement of clinical ethics services 
BMC Medical Education  2013;13:41.
The proliferation of clinical ethics in health care institutions around the world has raised the question about the qualifications of those who serve on ethics committees and ethics consultation services. This paper discusses some of weaknesses associated with the most common educational responses to this concern and proposes a complementary approach. Since the majority of those involved in clinical ethics are practicing health professionals, the question of qualification is especially challenging as the role of ethics committees and, increasingly, ethics consultation services are becoming increasingly important to the functioning of health care institutions. Since the challenging nature of health care finances often leads institutions to rely on voluntary participation of committed health professional with only token administrative or clerical support to provide the needed ethics services, significant challenges are created for attaining competence and functional effectiveness. The article suggests that a complementary approach should be adopted for sustaining and building capacity in clinical ethics. Ethics committees and consultation services should systematically adopt quality improvement techniques to effect designed changes in clinical ethics performance and to build ethical capacity within targeted clinical units and services. Demonstrating improvements in functioning can go a long way to build confidence and capacity for clinical ethics and can help in justifying the need for support. To do so, however, requires that ethics committees and consultation services first shift attention to those areas that demonstrate weak or questionable ethical performance, including the established practices of the ethics committee and consultation service, and second seek collaboration with the involved health care providers to pursue demonstrable change. Such an approach has a much better chance of improving the capacity for clinical ethics in health care institutions than relying on educational approaches alone.
doi:10.1186/1472-6920-13-41
PMCID: PMC3608248  PMID: 23517735
Clinical ethics; Ethics consultation; Ethics committees; Education; Quality improvement
9.  How physician executives and clinicians perceive ethical issues in Saudi Arabian hospitals. 
Journal of Medical Ethics  1999;25(1):51-56.
OBJECTIVES: To compare the perceptions of physician executives and clinicians regarding ethical issues in Saudi Arabian hospitals and the attributes that might lead to the existence of these ethical issues. DESIGN: Self-completion questionnaire administered from February to July 1997. SETTING: Different health regions in the Kingdom of Saudi Arabia. PARTICIPANTS: Random sample of 457 physicians (317 clinicians and 140 physician executives) from several hospitals in various regions across the kingdom. RESULTS: There were statistically significant differences in the perceptions of physician executives and clinicians regarding the existence of various ethical issues in their hospitals. The vast majority of physician executives did not perceive that seven of the eight issues addressed by the study were ethical concerns in their hospitals. However, the majority of the clinicians perceived that six of the same eight issues were ethical considerations in their hospitals. Statistically significant differences in the perceptions of physician executives and clinicians were observed in only three out of eight attributes that might possibly lead to the existence of ethical issues. The most significant attribute that was perceived to result in ethical issues was that of hospitals having a multinational staff. CONCLUSION: The study calls for the formulation of a code of ethics that will address specifically the physicians who work in the kingdom of Saudi Arabia. As a more immediate initiative, it is recommended that seminars and workshops be conducted to provide physicians with an opportunity to discuss the ethical dilemmas they face in their medical practice.
PMCID: PMC479169  PMID: 10070640
10.  APPOINTMENT SYSTEM IN PRIMARY CARE: OPINION OF CONSUMERS AND PROVIDERS 
Background:
The appointment system in primary care is widely used in developed countries, but there seems to be a problem with its use in Saudi Arabia.
Objectives:
(1) To explore opinions and satisfaction of consumers and providers of care in Primary Health Care regarding walk-in and the introduction of the appointment system. (2) To examine factors which may affect commitment to an appointment system in PHC.
Subject and method:
Two hundred sixty (260) consumers above the age of 15 years as well as seventy (70) members of staff were randomly selected from 10 Primary Health Care Clinics in the National Guard Housing Area, Riyadh and asked to complete a structured questionnaire designed to meet the study's objectives.
Results:
The majority of consumers and providers of care were in favour of introducing appointments despite their satisfaction with the existing walk-in sysem. Respondents saw many advantages in the appointment system in PHC such as time saving, reduction of crowds in the clinics and guarantee of a time slot. The main perceived disadvantage was the limitation of accessibility to patients especially with acute conditions. The main organizational advantages and disadvantages perceived by providers were related to follow-ups of chronic patients, no shows and late arrivals. The majority of the patients preferred appointments in the afternoon and the possibility of obtaining an appointment over the telephone.
Conclusion:
In this study, both consumers and providers supportted the idea of introducing the appointment mixed system in primary care, but further study is required
PMCID: PMC3410158  PMID: 23012154
Appointment System; Primary Health Care; Consumers/Providers′ Opinion; and Consultation.
11.  Communication with the seriously ill: physicians' attitudes in Saudi Arabia. 
Journal of Medical Ethics  1996;22(5):282-285.
OBJECTIVES: To study some ethical problems created by accession of a previously nomadic and traditional society to modern invasive medicine, by assessment of physicians' attitudes towards sharing information and decision-making with patients in the setting of a serious illness. DESIGN: Self-completion questionnaire administered in 1993. SETTING: Riyadh, Jeddah, and Buraidah, three of the largest cities in Saudi Arabia. SURVEY SAMPLE: Senior and junior physicians from departments of internal medicine and critical care in six hospitals in the above cities. RESULTS: A total of 249 physicians participated in the study. Less than half (47%) indicated they provided information on diagnosis and prognosis of serious illnesses all the time. Physicians who were more senior and those who spoke Arabic fared better than other groups. The majority (75%) preferred to discuss information with close relatives rather than patients, even when the patients were mentally competent. Most of the physicians (72%) felt patients had the right to refuse a specific treatment modality, and 68% denied patients the right to demand such a treatment if considered futile. Further analysis showed that physicians' attitudes varied along a spectrum from passive (25%) to paternalistic (21%) with the largest group (47%) in a balanced position. CONCLUSIONS: In traditional societies where physicians are regarded as figures of authority and family ties are important, there is a considerable shift of access to information and decision-making from patients to their physicians and relatives in a manner that threatens patients' autonomy. Ethical principles, wider availability of invasive medical technology and a rise in public awareness dictate an attitude change.
PMCID: PMC1377060  PMID: 8910780
12.  HEALTH CARE SERVICES IN SAUDI ARABIA: PAST, PRESENT AND FUTURE 
Health services in Saudi Arabia have developed enormously over the last two decades, as evidenced by the availability of health facilities throughout all parts of the vast Kingdom. The Saudi Ministry of Health (MOH) provides over 60% of these services while the rest are shared among other government agencies and the private sector. A series of development plans in Saudi Arabia have established the infra-structure for the expansion of curative services all over the country. Rapid development in medical education and the training of future Saudi health manpower have also taken place. Future challenges facing the Saudi health system are to be addressed in order to achieve the ambitious goals set by the most recent health development plan. These include the optimum utilization of current health resources with competent health managerial skills, the search for alternative means of financing these services, the maintenance of a balance between curative and preventive services, the expansion of training Saudi health manpower to meet the increasing demand, and the implementation of a comprehensive primary health care program.
PMCID: PMC3439740  PMID: 23008647
Health system; health statistics; primary health care; Saudi Arabia
13.  The Saudi Initiative for Asthma 
Annals of Thoracic Medicine  2009;4(4):216-232.
The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.
doi:10.4103/1817-1737.56001
PMCID: PMC2801049  PMID: 19881170
Asthma; guidelines; Saudi Arabia
14.  Building consensus on key priorities for rural health care in South Africa using the Delphi technique 
Global Health Action  2013;6:10.3402/gha.v6i0.19522.
Background
South Africa is currently undergoing major health system restructuring in an attempt to improve health outcomes and reduce inequities in access. Such inequities exist between private and public health care and within the public health system itself. Experience shows that rural health care can be disadvantaged in policy formulation despite good intentions. The objective of this study was to identify the major challenges and priority interventions for rural health care provision in South Africa thereby contributing to pro-rural health policy dialogue.
Methods
The Delphi technique was used to develop consensus on a list of statements that was generated through interviews and literature review. A panel of rural health practitioners and other stakeholders was asked to indicate their level of agreement with these statements and to rank the top challenges in and interventions required for rural health care.
Results
Response rates ranged from 83% in the first round (n=44) to 64% in the final round (n=34). The top five priorities were aligned to three of the WHO health system building blocks: human resources for health (HRH), governance, and finance. Specifically, the panel identified a need to focus on recruitment and support of rural health professionals, the employment of managers with sufficient and appropriate skills, a rural-friendly national HRH plan, and equitable funding formulae.
Conclusion
Specific policies and strategies are required to address the greatest rural health care challenges and to ensure improved access to quality health care in rural South Africa. In addition, a change in organisational climate and a concerted effort to make a career in rural health appealing to health care workers and adequate funding for rural health care provision are essential.
doi:10.3402/gha.v6i0.19522
PMCID: PMC3556680  PMID: 23364081
rural health; priorities; challenges; Delphi technique; health systems; leadership; management
15.  Ethical Community-Engaged Research: A Literature Review 
American journal of public health  2013;103(12):e7-e14.
Health research has relied on ethical principles, such as those of the Belmont Report, to protect the rights and well-being of research participants.
Community-based participatory research (CBPR), however, must also consider the rights and wellbeing of communities. This requires additional ethical considerations that have been extensively discussed but not synthesized in the CBPR literature.
We conducted a comprehensive thematic literature review and summarized empirically grounded discussions of ethics in CBPR, with a focus on the value of the Belmont principles in CBPR, additional essential components of ethical CBPR, the ethical challenges CBPR practitioners face, and strategies to ensure that CBPR meets ethical standards. Our study provides a foundation for developing a working definition and a conceptual model of ethical CBPR.
doi:10.2105/AJPH.2013.301605
PMCID: PMC3828990  PMID: 24134352
16.  Negative ethical behaviors in Saudi hospitals: How prevalent are they perceived to be? – Statement agreement study 
Avicenna Journal of Medicine  2013;3(3):57-62.
BACKGROUND:
There is limited information about the prevalence of unethical behavior and how is perceived among health care providers. The aim of this study is to assess such behavior and how is perceived.
MATERIALS AND METHODS:
This is a cross-sectional study among three groups of professionals. Total participants were 370 and included medical staff, medical residents, and nurses in five medical specialties in four tertiary hospitals in Saudi Arabia (two Ministry of Health Hospitals and two military Hospitals). Participants were asked to rate their agreement with occurrence of 15 “negative” unethical behavior scenarios in their workplace. The scenarios covered areas of “respect for persons”, “interprofessional relationships”, and “empathy with patients”.
RESULTS:
Majority of respondents agreed that “unethical” behavior occurred in their workplace, including confidentiality being compromised (36.3%), informed consent not taken properly (60.2%), and bad news not well-delivered (62.2%). Other significant area agreement included doctors lacking empathy (47.8%), patient autonomy not fully respected (42.5%), discrimination (41.2%), and being pressurized to write inaccurate reports (31.2%). Respondents in medicine had the lowest rate of agreement and those in psychiatry had the highest (mean of 49.8% and 82.3%, respectively). Respondents with length of employment of less than 6 years had significantly higher agreement that unethical behavior occurs compared to those with length of employment of more than 6 years. Males were more likely than females to agree that unethical behavior occurs. The biggest difference was seen in the behavior of “informed consent not properly taken” with a gender margin of 18.7% (P = 0.001).
CONCLUSION:
There is high prevalence of behavior that is considered unethical as perceived by various health care workers at Saudi hospitals.
doi:10.4103/2231-0770.118458
PMCID: PMC3818780  PMID: 24251232
Bioethics; ethics in hospitals; Saudi Arabia
17.  Knowledge, attitude, and practice of primary health care physicians in the management of osteoarthritis in Al-Jouf province, Saudi Arabia 
Background:
Primary health care (PHC) physicians manage most patients with osteoarthritis (OA). In Saudi Arabia, very little is known about the management of OA by PHC physicians. This study aims to assess knowledge, attitude, and practice of PHC physicians in the management of OA.
Materials and Methods:
During October 2011, a cross-sectional survey was conducted on physicians who were practicing at the primary care centers in AlJouf province of Saudi Arabia. The physicians were asked to fill a valid questionnaire comprised of 35 closed ended questions, 6 items about their socio-demographic characters, and a very well modified 29 questions about their knowledge, attitude, and practice in the management of OA. Data was processed and analysed using SPSS (version 16) program, the level of significance was set as Chi-square test was applied for analysis of categorical data.
Results:
Response rate (77/90=85.6% yielded 77 questionnaires for analysis. The mean ± SD age of respondents was 38 (12.3) years. Majority of the physicians surveyed, 58 (75.3%) considered OA as a common health problem in Saudi Arabia. Only 28 (36.4%) physicians surveyed will achieve continuity of care for OA, whereas more than half (n=44; 57.1%) will refer OA immediately or later to the specialists. The proportion of continuity of care for OA among physicians with diplomas was more than that found among general practitioner (57.1% vs 34.1%; <.05). Only 30 (39%) of physicians appeared to know the radiographic changes associated with OA. 21 (27.3%) of physicians manage an average of 5-10 patients with OA per week. Almost 3/4 th of the physicians (n=57; 74%) prescribe NSAIDs, and only (n=14; 18.2%) prescribe acetaminophen for OA. Less than 1/5 th of the physicians surveyed (n=12; 15.6%) prescribe herbal medicine for OA. Almost all physicians subscribe to regular training programs about OA.
Conclusions:
Appropriate attitude with lack of knowledge was found, and practice of our physicians with regards to this disorder appeared inappropriate. More education focusing on the disorder is recommended.
doi:10.4103/0300-1652.107556
PMCID: PMC3640242  PMID: 23661881
Attitude; continuity of care; knowledge; nonsteroidal anti-inflammatory drugs; osteoarthritis; practice; primary care
18.  The Dermatology workforce in Saudi Arabia: Current trends, challenges and future directions 
Objectives:
To provide a snapshot of the dermatology work force in Saudi Arabia.
Methods:
We collected data on the supply and distribution of dermatologists in Saudi Arabia. We discussed the current status of dermatology manpower issues in Saudi Arabia.
Results:
We found that between 1987 and 2007, the availability of dermatologists to population in Saudi Arabia rose by 60 %, from 2.35 to 3.76 dermatologists per 100,000 Saudi Arabian individuals. However, the current workforce is already out of balance in several ways. We have an excess of non-Saudi citizen dermatologists and a barely adequate supply of Saudi dermatologists. The dermatologist population is unbalanced with regard to gender and uneven in terms of geographic distribution.
Conclusions:
The dermatology workforce does not match well with the nation’s health care goals. We should create a more successful and stable match between the talent supply and health care system requirements.
PMCID: PMC3068825  PMID: 21475556
Dermatology; Manpower; Saudi Arabia
19.  Utilisation of Health Services by the Primary Health Care Centres-Registered Elderly People in Burraidah City, Saudi Arabia 
Objective:
To assess the pattern of and factors associated with geriatrics′ utilisation of health services.
Design:
A cross-sectional, study involving a random sample of 266 elderly subjects registered in the primary health care centres in Burraidah city, Saudi Arabia.
Setting:
The primary health care centres in Qassim Region, Saudi Arabia.
Methods:
Data was collected from PHC centres-registered elderly subjects at their homes. Information including utilisation of primary health centres, hospital admissions and duration of hospital stay were recorded.
Results:
The response rate was 96.7%. Twenty percent of the sample had not used any health services facility during the previous year. Two-thirds of subjects made visits to the primary health care centres, majority of them having made 6 visits or less. Significant factors positively associated with those visits were female, advancing age, and having a family. Three-quarters of the sample did not have hospital admissions. Significant factors positively associated with admissions were diabetes mellitus, hypertension, paralysis, advanced age, and living with a family.
Conclusions:
Geriatric health services utilisation by the study sample is affected by family ties and the high prevalence of chronic diseases. Subjects living alone or crippled by immobility may not be able to utilise available health services properly. Community based geriatrics services can help this vulnerable group.
PMCID: PMC3437139  PMID: 23008543
Geriatrics; Health services utilisation; Saudi Arabia
20.  A proposed rural healthcare ethics agenda 
Journal of Medical Ethics  2007;33(3):136-139.
The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional–patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional–patient relationship and allocation of resources. To date, there exists a limited focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad‐ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence—informed, rural‐attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population.
doi:10.1136/jme.2006.015966
PMCID: PMC2598268  PMID: 17329381
21.  Tertiary care availability and adolescent pregnancy characteristics in Saudi Arabia 
Background
In this study, we aimed to assess the rate of adolescent delivery in a Saudi tertiary health care center and to investigate the association between maternal age and fetal, neonatal, and maternal complications where a professional tertiary medical care service is provided.
Methods
A cross-sectional study was performed between 2005 and 2010 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. All primigravid Saudi women ≥24 weeks gestation, carrying a singleton pregnancy, aged <35 years, and with no chronic medical problems were eligible. Women were divided into three groups based on their age, ie, group 1 (G1) <16 years, group 2 (G2) ≥16 up to 19 years, and group 3 (G3) ≥19 up to 35 years. Data were collected from maternal and neonatal medical records. We calculated the association between the different age groups and maternal characteristics, as well as events and complications during the antenatal period, labor, and delivery.
Results
The rates of adolescent delivery were 20.0 and 16.3 per 1,000 births in 2009 and 2010, respectively. Compared with G1 and G2 women, G3 women tended to have a higher body mass index, a longer first and second stage of labor, more blood loss at delivery, and a longer hospital stay. Compared with G1 and G2 women, respectively, G3 women had a 42% and a 67% increased risk of cesarean section, and had a 52% increased risk of instrumental delivery. G3 women were more likely to develop gestational diabetes or anemia, G2 women had a three-fold increased risk of premature delivery (odds ratio 2.81), and G3 neonates had a 50% increased overall risk of neonatal complications (odds ratio 0.51).
Conclusion
The adolescent birth rate appears to be low in central Saudi Arabia compared with other parts of the world. Excluding preterm delivery, adolescent delivery cared for in a tertiary health care center is not associated with a significantly increased medical risk to the mother, fetus, or neonate. The psychosocial effect of adolescent pregnancy and delivery needs to be assessed.
doi:10.2147/IJWH.S57743
PMCID: PMC3979779
adolescent pregnancy; maternal mortality; maternal morbidity; neonatal mortality; neonatal morbidity
22.  Home intravenous antibiotics in a tertiary care hospital in Saudi Arabia 
Annals of Saudi Medicine  2011;31(5):457-461.
BACKGROUND AND OBJECTIVE:
Home intravenous (IV) antibiotic programs are becoming increasingly popular worldwide because of their efficacy and safety. However, in Saudi Arabia these programs have not yet become an integrated part of the health care system. We present our experience with a home IV antibiotic program, as one of the major health care providers in Saudi Arabia.
DESIGN AND SETTING:
Retrospective chart review of patients enrolled in the King Abdulaziz Medical City Home Health Care IV Antibiotic Program from 1 May 2005 (the start of the program) until 30 December 2007.
METHODS:
In addition to demographic characteristics, we collected data on the site of infection, the clinical diagnosis, the isolated microorganisms, and the type of antibiotics given. Outcome measures evaluated included the relapse rate, failure rate, the safety of the program, and readmission rates.
RESULTS:
Of the 155 patients enrolled, 152 patients completed the program. Those who completed the program had a mean (SD) age of 52.8 (23.9) years. The mean (SD) duration of the IV antibiotic treatment was 20.6 (17) days. Three patients refused to complete the intended duration of therapy. Peripherally inserted central catheter (PICC) lines were utilized in 130 patients (86%). One-hundred and thirty-one patients completed the intended duration of therapy, although the therapy was changed from the initial plan for 21 (13.8%) patients. Readmission to the hospital during therapy was required for 13 patients (8.5%). Osteomyelitis was the most frequently encountered diagnosis (65 patients, 42.8%), followed by urinary tract infection (36 patients, 23.7%).
CONCLUSIONS:
The home health care-based IV antibiotic program was an effective and safe alternative for in-patient management of patients with non-life-threatening infections, and was associated with a very low complication rate. Home IV antibiotic programs should be used more frequently as part of the health care system in Saudi Arabia.
doi:10.4103/0256-4947.84621
PMCID: PMC3183678  PMID: 21911981
23.  Impact of a diabetic foot care education program on lower limb amputation rate 
Background
Diabetic foot complications are a leading cause of lower extremity amputation. With the increasing incidence of diabetes mellitus in the Arab world, specifically in the Kingdom of Saudi Arabia, the rate of amputation will rise significantly. A diabetic foot care program was implemented at King Abdulaziz Medical City in Riyadh, Saudi Arabia, in 2002. The program was directed at health care staff and patients to increase their awareness about diabetic foot care and prevention of complications. The purpose of this study was to perform a primary evaluation of the program’s impact on the rate of lower extremity amputation due to diabetic foot complications.
Method
This pilot study was the first analysis of the diabetic foot care program and examined two groups of participants for comparison, ie, a “before” group having had diabetic foot ulcers managed between 1983, when the hospital was first established, and 2002 when the program began and an “after group” having had foot ulcers managed between 2002 and 2004, in the program’s initial phase. A total of 41 charts were randomly chosen retrospectively. A data sheet containing age, gender, medical data, and the presentation, management, and outcome of diabetic foot cases was used for the analysis.
Results
The before group contained 20 patients (17 males) and the after group contained 21 patients (16 males). There was no difference between the two groups with regard to age and comorbidities. The rate of amputation was 70% in the before group and 61.9% in the after group. There was a decrease in the percentage of toe amputation in the after group and an increase in the percentage of below-knee amputation in the before group. However, these changes were not significant.
Conclusion
The program, although evaluated at an early stage, has increased the awareness of both patients and health care staff about the prevention and management of diabetic foot disease, and decreased the rate of lower extremity amputation. We believe that the statistical proof of its impact will be evident in the final evaluation.
doi:10.2147/VHRM.S13569
PMCID: PMC2964945  PMID: 21057577
diabetic foot; prevention; complications; lower limb amputation
24.  KNOWLEDGE, ATTITUDE AND PRACTICE (KAP) OF PRIMARY HEALTH CARE PHYSICIANS AND NURSES TOWARDS HYPERTENSION: A STUDY FROM DAMMAM, SAUDI ARABIA 
Objective:
To evaluate the quality of management of hypertensive patients attending Primary Health Care Center (PHC) in Dammam city and to determine factors that possibly affect it.
Design:
A cross sectional study and direct interview.
Setting:
Dammam city.
Subjects:
All doctors and nurses from a randomly selected sample of Primary Health Care Centers during April 1994.
Main measures:
Measuring the knowledge, attitude and practice of doctors and nurses about hypertension management.
Results:
Hypertension is regarded as an important health problem in Saudi Arabia in the opinion of majority of doctors (80′0) and nurses (69%). Almost half of the doctors and nurses believe that nurses are sufficiently qualified to measure blood pressure of patients. Most of the doctors (96.7%) and nurses (86%) depend merely on face-to-face education of patients Thirty percent of doctors and 34% of nurses think that the care for hypertensive patients in their Primary Health Care Centers is inadequate.
Conclusions and recommendations:
Offering on job training of both physicians and nurses on hypertension management. Producing a well planned protocol on the national level. Implementing a total quality management and medical audit system to PHC centers.
PMCID: PMC3437162  PMID: 23008556
Hypertension; Primary care and practice; Saudi Arabia
25.  Patients seen at the Dermatology ambulatory office in a tertiary care center in Qassim region, Saudi Arabia 
Background
In Saudi Arabia where there is lack of dermatologists in primary health care centers, patients with simple or minor skin conditions have to attend to hospitals to be treated. We analyzed the data of patients with cutaneous disorders attending the tertiary referral hospital in Qassim region of Saudi Arabia, with the aim to identify the most common conditions that patients complain of, in order to define the areas where the education of General Practitioners in Dermatology must focus.
Methodology
All patients seen at the Dermatology ambulatory office in the Emergency Department of Qassim University affiliated hospital from January 2011 to December 2011 were included in this retrospective analysis. The medical records of the patients (history, physical examination and laboratory investigations) were analyzed to ascertain the diagnosis and the management of cases. All patients were evaluated by qualified dermatologists.
Results
A total of 1147 patients attended the Dermatology ambulatory office. Most patients were young adults in the age group 21–30 years (34.4%). Allergic skin diseases (65.2%), mostly dermatitis (48.8%) and urticaria (10.5%) were the most common for attendance, followed by infectious diseases (25.8%) and inflammatory and autoimmune disorders (5.3%). The management of the vast majority of cases (94.1%) consisted of systemic treatment and 58.2% patients required topical treatment. A reevaluation plan as outpatients was planned in 9.0% patients while only 0.3% of patients required admission in the hospital.
Conclusion
Allergic and infectious skin diseases were the most common cutaneous diseases in patients attending this tertiary University hospital, while the management of most patients did not require specialized care. On the basis of the present data, the training of primary health care providers in Dermatology should emphasize these common conditions, with the aim of improving primary care and alleviating the burden on hospital care.
PMCID: PMC3883602  PMID: 24421741
Dermatology; ambulatory office; Saudi Arabia

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