Access and utilisation of primary health care services comparing urban and rural areas of Riyadh Providence, Kingdom of Saudi Arabia

There was higher female participation compared to males, which could be reflective of more general patterns of health care utilisation [27, 28]. However, research that has explored health service use in Islamic societies has shown that often females have lower rates of healthcare utilisation [29]. This is often because they remain dependent on men to make decisions about healthcare, with women not normally allowed out to visit a health facility or health care provider alone [30]. The higher participation of females in non-Islamic societies may also be related to the presence of a female administering the questionnaire during recruitment; an essential consideration when conducting research with women in the Saudi Traditional Islamic segregated context [31, 32].

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

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

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

Whilst it may have been hypothesized that rural patients would want extra opening hours compared to their urban counterparts, this finding was not supported. For example, urban respondents were shown to want increased opening hours particularly in the evenings, with rural respondents significantly more likely to state that they did not want extra opening hours. This may be related to the economic growth and the increased levels of employment found in the more urbanised provinces of KSA [46]. Further, this finding may be related to the international legislative commitments that have centred on women’s welfare and increasing their societal and economic role [47, 48]. For example, recent evidence has shown that the number of women in employment in Saudi Arabia quadrupled, from 48,000 in 2009 to over 200,000 in 2012 [48]. Differences are found in urban and rural communities, with rural mothers less likely to be employed and more likely to engage in household chores and parental activities [49, 50]. Inconvenient clinic times for PHCC remains a core barrier to accessing health services [51‐54], more flexible opening times for urban respondents should serve to improve health outcomes and increase levels of patient satisfaction.

Distance from the patients’ residence was viewed as a barrier to accessing PHCCs for participants residing in rural areas but not from those residing in urban areas. There is an extensive evidence base that continues to suggest that distance from health facilities, often referred to as the ‘distance decay’ effect, has a detrimental impact on health care utilisation [55‐57]. It is widely reported that the KSA population is reluctant to travel long distances to PHCCs because of the hot climate found in the summer months [56, 58]. Households within KSA have high rates of car ownership, so the availability of transportation to the PHCC was not considered an important factor that may intersect with distance from residence as a barrier to accessing the PHCC [59].

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

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

This study found that there was good overall communication between the doctor and patient respondents. The majority of patient respondents said that their doctor listened carefully, had enough time to discuss their medical problem and, if they had questions to ask the doctor, they got the answers and were treated with respect and dignity. These are some of the ideal features patients report as being important to creating positive relationships between the doctor (and other health care professionals) and patient [65‐67]. However, there were significant differences found between patient respondents in urban and rural areas in relation to understanding the treatment or action that was explained, with fewer rural patient participants feeling that doctors explained reasons for any treatments. This may be related to levels of expectations as previously reported.

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

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

Patient satisfaction has been used as an indication/measure of quality of care. Overall, patient participants were positive about their PHCCs and the majority said they went to the PHCC because the PHCC dealt with them in a satisfactory way. This research highlighted that patients had high levels of satisfaction with this finding consistently for both urban and rural patients. This finding supports existing evidence, which has reported high levels of patient satisfaction with PHCC’s in the KSA [71, 73, 74].

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

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