Quality of primary care from the patient perspective in Saudi Arabia

230 Pages·2016·3.42 MB·English

by  Khalid Awad Alahmary

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Electronic Theses and Dissertations
5-2014
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Khalid Awad Alahmary
University of Louisville
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Alahmary, Khalid Awad, "Quality of primary care from the patient perspective in Saudi Arabia : a multi-level
study." (2014). Electronic Theses and Dissertations. Paper 22.
https://doi.org/10.18297/etd/22
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QUALITY OF PRIMARY CARE FROM THE PATIENT
PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY

By

Khalid Awad Alahmary
B.S., King Saud University, 2000
B.S.N., George Mason University, 2003
M.S.N., University of Pittsburgh, 2008

A Dissertation
Submitted to the Faculty of the
School of Public Health and Information Sciences of the
University of Louisville in Partial Fulfillment of the
Requirements for the Degree of

Doctor of Philosophy

Department of Health Management and Systems Sciences
University of Louisville
Louisville, Kentucky

May, 2014
Copyright © 2014 by Khalid Awad Alahmary
All Rights Reserved

QUALITY OF PRIMARY CARE FROM THE PATIENT
PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY

By

Khalid Awad Alahmary
B.S., King Saud University, 2000
B.S.N., George Mason University, 2003
M.S.N., University of Pittsburgh, 2008

A Dissertation Approved on

March 31, 2014

by the following Dissertation Committee:

_________________________________
Dissertation Director
Robert Steiner, M.D., M.P.H., Ph.D.

__________________________________
Robert Esterhay, M.D.

__________________________________
Raymond Austin, Ph.D.

__________________________________
Karunarathna Kulasekera, Ph.D.
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DEDICATION

This dissertation is dedicated to my loving parents, Awad and Salihah Alahmary
who have surrounded me with their eternal love, support, and sincere prayers; to my
loving wife Eman Alahmary who has encouraged me to pursue my dreams and has
been supportive and patient throughout my doctoral studies; and to my wonderful
daughters, Maiar and Ala who have given my life new meaning.

I thank you all from the bottom of my heart. I love you all.

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ACKNOWLEDGMENTS

First of all, I thank Allah, He is the Mighty and the Majestic, who has blessed me
with his willing and grace to pursue my dreams and to earn the PhD degree.
I would like to express my sincere gratitude and deepest appreciation to my
Committee Chair and mentor, Professor Robert W. Steiner for his continued support,
mentorship, and leadership. His encouragement, methodological advice, and
interpersonal skills are largely responsible of the quality of my experience and the
completion of my journey to obtain the PhD degree. Without his support, guidance,
and consistent advice this work could not have been completed. Dr. Steiner has
inspired me to become a life-long learner, a good scientist, and a change agent to lead
a social change toward health and social justice.
I would also like express my deepest thanks and appreciation to Dr. Robert
Esterhay for providing me with his support and pearls of wisdom, especially during
my most difficult times. Dr. Esterhay is a true motivational leader who taught me to
be persistent and goal-oriented person, which enabled me to achieve my academic
goal to obtain the PhD degree. I would also like to express my deepest thanks and
appreciation to Dr. Raymond Austin for his time and expertise in teaching me to think
more broadly about my dissertation work in the context of policy development and
evaluation, which has helped me to improve the quality of my dissertation. My
sincere gratitude and thanks also go to Dr. Karunarathna Kulasekera for teaching me
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and guiding me to select and apply the appropriate statistical methods, which made
my dissertation meaningful and worthwhile.
I would like to thank all of my friends who have kept me in their thoughts and
encouraged me during my eight years of graduate studies in the U.S. since I began
pursuing my master degree in May of 2006. Special thanks go to my friend Dr. Adel
Bashatah for his support and encouragement and for his constant international phone
calls to cheer me up and to ask about my progress.
I would also like to thank all the staff at the Ministry of Health and the
Ministry of National Guard who facilitated the approval and access to data for my
research study. Special thanks go Dr. Ali Al-Farhan, Deputy Executive Director of
Primary Healthcare at NGHA for his warm reception and immediate assistance in
giving me access to the NGHA Primary Care System. I also thank the team of data
collectors who helped me to collect primary survey data from 612 patients in 16
primary care centers in Riyadh.
I would like to acknowledge King Saud bin Abdulaziz University for Health
Sciences for supporting my PhD scholarship. Special thanks go to His Excellency Dr.
Bandar Al Knawy, President of KSAU-HS and his Executive Assistance Mr. Fareed
Bahnas for approving the final extension of my scholarship, which enabled me to
complete my PhD studies.
I would also like to acknowledge and thank Dr. Ahmad Al Amry, Dean of the
College of Public Health and Health Informatics who has put his trust in me to
become a member of the new and growing college.

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ABSTRACT
QUALITY OF PRIMARY CARE FROM THE PATIENT
PERSPECTIVE IN SAUDI ARABIA: A MULTI-LEVEL STUDY

Khalid A. Alahmary

May 10, 2014

Objectives: To assess primary care performance for measures of patients’ experience in
Community-based Primary Care (CPC) and Employer-based Primary Care (EPC)
systems in Saudi Arabia, to examine variations in performance across the two systems,
and to explore factors at both the individual-level and the organizational-level that
explain variations in primary care performance.
Design and Methods: This is an observational and cross-sectional study, using
comparative design and survey research methods. The newly revised and re-translated
Arabic version of the Primary Care Assessment Survey (PCAS) was used to measure
patients’ experience of primary care. PCAS operationalizes the IOM definition of
primary care, which identified core domains of primary care as accessibility of care,
continuity of care, comprehensiveness of care, coordination of care, interpersonal
treatment, communication, and community orientation. A two-stage cluster, matched
sampling was employed to select 16 primary care centers (eight CPC and eight EPC
centers) in Riyadh, the capital and largest city (population > 5.5 million) in Saudi Arabia.
A systematic random sampling was employed to collect primary survey data from 612
adult patients visiting the selected primary care centers.
Results: After adjusting for differences in the patient-mix and taking into account the
multi-level structure of data by means of multi-level modeling, EPC performed
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statistically significantly better than CPC in interpersonal care (Mean = 68.3, 95% CI
EPC
[± 6.3] vs. Mean = 59.5, 95% CI [± 5.9], p = 0.024, Effect Size (d) = 0.36) and
CPC
communication (Mean = 69.8, 95% CI [± 4.9] vs. Mean = 64.4, 95% CI [± 5.5], p
EPC CPC
= 0.035, d =0.22), in addition to the total quality score (Total PCAS = 60.4, 95% CI
EPC
[± 2.9 ] vs. Total PCAS = 56.1, 95% [± 3.3], p = 0.009, d =0.31). CPC performed
CPC
statistically significantly better than EPC in community orientation (Mean = 47.8,
CPC
95% [± 5.7] vs. Mean = 35.5, 95% [± 6.2], p = 0.003, d =0.50) and accessibility of
EPC
care (Mean = 67.4, 95% [± 5.7] vs. Mean = 63.5, 95% [± 4.5], p = 0.025, d=0.23).
CPC EPC
There were no significant differences between CPC and EPC in coordination of care (p=
0.098), comprehensiveness of care (p = 0.208), and visit-based continuity of care (p =
0.354). Patient-level (compositional) variables explained a significant proportion (R2 =
0.14) of the observed level-one (within-centers) variations in measures of patients’
experience. Those variables include gender, self-perceived health status, and patient-
reported co-morbidity. Female patients, reporting poor health, and reporting chronic
conditions are each statistically significantly associated with lower ratings of patients’
experience of care. Organizational-level (contextual) variables explained a significant
proportion (R2 = 0.78) of the observed level-two (between-centers) variations in measures
of patients’ experience. Those organizational variables include practice type and
proportions of family physicians in a center. EPC centers and those centers with higher
proportions of family physicians are each statistically significantly associated with better
patients’ experience. Finally, aspects of care that were statistically significantly
associated with better patients’ experience include knowing the name of the physician
and being with the same physician for longer durations.
Conclusion: Enhancing continuity and quality of patient-physician relationships may
improve the overall patients’ experience of care. Healthcare systems in Saudi Arabia
might embrace the Bio-Psycho-Social model to foster a culture of health and caring.
Effective, community-oriented primary care systems have the potential to re-orient health
systems’ from a sole focus on sickness and disease, to include additional approaches for
prevention and wellness at the societal level. Positive indicators of health, at both the
individual and community levels, are needed to better align existing healthcare systems
with this goal, mission and vision to improve population health.
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