ARABIZATION IN MEDICAL


ARE WE READY FOR ARABIZATION IN MEDICAL EDUCATION?

Hassan M. Ismail, MD, FRCP, King Fahd Hospitalof the University, Al-Khobar,        Saudi Arabia

هدف الدراسة: الحصول على وجهات نظر أعضاء هيئة التدريس بكلية الطب بجامعة الملك فيصل بالدمام عن موضوع تعريب التعليم الطبى.

طريقة الدراسة: أجريت دراسة مقطعية بكلية الطب بجامعة الملك فيصل بالدمام بين يناير ويونيو 2001م باستخدام إستبيان مكون من 41 سؤالاً و ذلك لمعرفة آراء أعضاء هيئة التدريس بأقسام العلوم الأساسية والسريرية حول ما يتعلق بالبحث العلمى بالكلية و كان من ضمن هذه الأسئلة سؤالان فى موضوع التعريب و النشر والترجمة باللغة العربية.

نتائج الدراسة:كانت نسبة المشاركة فى الإستبيان 67% (74 من مجموع 110 عضو هيئة تدريس ) و هم يشملون 22 أستاذاً و 27 أستاذاً مشاركاً و 23 أستاذاً مساعداً و محاضرين ينتمون إلى 24 قسماً ( 6 أقسام علوم أساسية و 18 قسماً سريرياً). و كانت نسبة نتيجة للتعريب  34 (46 %) موافقون و 40 (54%) غير موافقين.

الخلاصة: يعتبر أعضاء هيئة التدريس العمود الفقرى فى تطبيق التعريب فى التعليم الطبى. و توضح النتيجة من هذا المسح المبدئى بكلية الطب بجامعة الملك فيصل أنه ما زالت هنالك مسافة كبيرة لبلوغ هذه الغاية فى تعليم الطب بالعربية.

الكلمات المرجعية:مرحلة البكالوريوس، التعليم الطبى، التعريب، المملكة العربية السعودية.

Objective:To obtain the views of faculty members of the Collegeof Medicine, King Faisal Universityon Arabization of medical education.

Methods:A cross-sectional study was conducted in the Collegeof Medicine, King Faisal University, Dammam, between January and June 2001 using a standardized 41-item questionnaire to obtain the views of faculty members in both basic science and clinical departments on issues relating mainly to scientific research. The responses were recorded on a 5-point scale: strongly agree, agree, undecided, disagree and strongly disagree. A couple of questions were used to probe the issue of publications in Arabic and translations into Arabic.

Results:The response rate of faculty was 67% (74 of a total of 110 faculty members). The participating faculty members included 22 professors, 27 associate professors, 23 assistant professors and 2 lecturers belonging to 24 departments (6 basic sciences, 18 clinical). Thirty- four members (45.9%) were in favor of Arabization and 40 (54%) were against.

Conclusions:Faculty members form the backbone for the implementation of Arabization in medical education. The opinions obtained in this preliminary survey of the faculty of the Collegeof Medicineat King Faisal Universityindicate that we are still far from achieving this goal in our medical education.

Key Words:  Undergraduate, medical education, Arabization, Saudi Arabia.

Correspondence to:

Dr. Hassan M. Ismail, P.O. Box 40152, Al-Khobar 31952, Saudi Arabia

INTRODUCTION

Arabization has been an objective for educators in Arab medical schools for some time.1 Several reasons have been given in support of this including an improvement in the speed of reading a medical text in Arabic by about 43% and an increase in comprehension by 15%.2 The Arab Medical Union established in 1961 had as its first objective the arabization of medical education and received the backing of the WHO and the Council of Arab Health Ministers to publish the Unified Arab Medical Dictionary as a stepping stone for the achievement of this goal.3 However, out of over 90 colleges of medicine in the Arab world, only 5 teach in Arabic.2 Surveys of medical students in Saudi Arabia have clearly shown the students’ support for arabization.1,4 The present report is a small offshoot of a study carried out at King Faisal University, Dammam, Saudi Arabia primarily to examine the views of faculty members in the College of Medicine on scientific research activities and other relevant issues in the college.5 The aim is to focus on an important issue that was not the primary objective of the main study but requiring essential further research in the process of developing a well planned program for Arabization.

METHODS

A cross-sectional study was conducted in the Collegeof Medicineat King Faisal University, Dammam, Eastern provinceof Saudi Arabiabetween January and June 2001 using a questionnaire.  Faculty members in both the basic and clinical departments were surveyed.  The questionnaire consisted of 41 items mainly addressing issues on scientific research in the Collegeof Medicine. These items included issues pertaining to the presence or absence of strategic goals and objectives for research, quality of research, process of application, facilities for research, obstacles to scientific research, as well as the means to enhance scientific research. The responses were obtained on a 5 grade scale: strongly agree, agree, disagree, strongly disagree and undecided. A couple of questions addressed research publications in Arabic and medical books translated into Arabic. The data were entered as a standard data base file and analyzed using a personal computer.

RESULTS

The target population consisted of 110 faculty members in 4 categories (professors, associate professors, assistant professors and lecturers) in 24 departments (6 Basic Sciences, 18 Clinical Sciences).  There were 74 responders (67%):  22 professors, 27 associate professors, 23 assistant professors and 2 lecturers. Most of these 41 (55%) were in the clinical sciences, 9 (12%) were involved in the Basic Sciences and 24(32%) had combined Basic and Clinical Sciences involvement.  Thirty-four members (46%) were in favor of  arabization and 40(54%) were against. One item on the questionnaire was on the nationality of the faculty, whether they were Arabic or non-Arabic speaking. Data obtained from the college records indicated that 56% of the faculty members in the college of medicine were non-Saudis, but the majority of these were Arabic speaking.

DISCUSSION

Both educators and learners generally consider the use of the mother tongue at all levels of education a cornerstone for the success of the educational process. For medical students who had had all their pre-university education in Arabic, reading medicine in Arabic is naturally the first choice.1,3,4 The obvious improvement in reading speed and comprehension supports Arabization.2 Arabization has also been the main objective of the Arab Medical Union for over 40 years.3 However, for a smooth and effective changeover from English to Arabic, there should be faculty members who are very fluent in both languages to cover all the subjects in the curriculum of both sciences, basic and clinical. A quick review of the indexed biomedical research refereed journals showed a dearth of journals published in Arabic. Besides, with the present rate of the growth of knowledge, newly published textbooks are virtually out of date by the time they go to press. This situation calls for the creation of specialized infra structure and foundation for Arabization. At present, it is of paramount importance that students master the English language in order to keep up with the majority of worldwide medical literature published in English.1,2 Thus, the implementation of Arabization in medical education is a fundamental change which requires sustained effort and support of every Arab country, through the allocation of resources for the engagement of capable faculty members, and the acquisition of all the required up-to-date textbooks and educational material for basic and clinical sciences necessary for implementation before a political decision is made. The establishment of an association of all the medical colleges in all Arab countries will be a useful nucleus to unify, supplement and complement efforts for the production of unified educational resources in terms of faculty development, and the production of textbooks as well as various basic and clinical teaching materials. Moreover, the encouragement of research on arabization and the provision of special scholarships for talented faculty to engage in Arabization will be a means of promoting a focused approach on Arabization. Arabization is a logical and reasonable ambition, the success of which depends on faculty members. However, the present status indicates that the majority of our faculty members are not ready for it.

REFERENCES

1.     Al-Jarallah JS, Al-Ansari LA.  Views of medical students on medical education in Arabic (Arabic). Journal of Family & Community Medicine 1995;2(2):63-72.

2.     Al-Sibai ZA, Othman M. Defense for medical education in Arabic. Journal of Family & Community Medicine 1994;1(1):1-9.

3.     Health Bulletin. What is the Arab medical Union? 2002 www.medistatweb.com/health/Hassan_alkhreiss. shtml.

4.     Al-Suhaimi SA, Albar AA. The position of medical students on arabization of high education. Majallat Risalat Alkhaleej 1412H;42:41.

5.     Al-Gindan Y, Al-Sulaiman A, Al-Muhanna F, Abumadini M. Views Research and research activities in a university in Eastern Saudi Arabia. Saudi Med J 2002; 23(11):1324-6.


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PSYCHIATRIC REFERRALS


A COMPARISON OF PSYCHIATRIC REFERRALS WITHIN THE TEACHING HOSPITAL WITH THOSE FROM PRIMARY CARE AND GENERAL HOSPITALS IN SAUDI ARABIA

Tariq A. Al-Habeeb, KSUFpsych, College of Medicine, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة: يهدف هذا البحث إلى دراسة التحاويل إلى العيادة النفسية في مستشفى الملك خالد الجامعي بالرياض من حيث عمر وجنس المريض ومصادر التحاويل والتشخيص. طريقة الدراسة: تم اختيار 427 تحويلاً للاستشارات النفسية داخل مستشفى الملك خالد الجامعي بالرياض بطريقة عشوائية على مدى عام وتم مقارنتها مع تحاويل المستشفيات العامة ومراكز الرعاية الصحية الأولية إلى مستشفى الصحة النفسية بالقصيم. نتائج الدراسة: وجد اختلاف ذو دلالة إحصائية بين أعمار المرضى في الفئات الثلاث ، كما أن نسبة الذكور كانت الأبرز في عينة المستشفى الجامعي. وقد كانت العيادات النفسية والباطنية أكثر من سواها من العيادات في المستشفيات العامة في التحويل إلى مستشفى الصحة النفسية، بينما كانت عيادات الأطفال هي الأكثر تحويلاً في عينة المستشفى الجامعي. ولقد كان مرض الفصام أقل في عينة المستشفى الجامعي في حين كان مرضى الذهانات الحادة أكثر شيئاً ما في عينة المستشفيات العامة لكن اضطرابات المزاج والقلق كانت أقل بكثير. كما كانت اضطرابات القلق الاكتئابي والاضطرابات النفسجسمية وكذلك الصرع أقل بشكل كبير في عينة المستشفى الجامعي في حين كانت اضطرابات الشخصية أكثر في تلك العينة. وأما الاضطرابات النفسية عند الأطفال فقد كانت أكثر في المرضى المحولين من مراكز الرعاية الصحية الأولية. الخلاصة: إن مصادر تحويل المرضى وكذلك طرق تشخيص الأمراض النفسية في المملكة العربية السعودية تختلف حسب مصدر التحويل وهذا يتماشى مع التقارير الدولية عن التحاويل النفسية. بالإضافة إلى الحاجة إلى البحث في الجوانب الأخرى في منهجية تحويل المرضى فإن الأبحاث المستقبلية يجب أن تشمل متابعة المرضى المحولين للاستشارات النفسية.

الكلمات المرجعية: التحاويل النفسية ، الرعاية الأولية ، المستشفيات العامة ، المستشفيات الجامعية ، طرق التشخيص ، الاستشارات النفسية ، المرضى المحولين ، خدمات الصحة النفسية.

Objective:This study aims at examining the pattern of psychiatric referrals with particular reference to (1) age and gender (2) source of referrals and (3) diagnosis of referred patients within a teaching hospital.

Method:Four hundred and twenty seven referrals (n=427) for psychiatric consultation within KKUH were selected prospectively by systematic randomization over a period of one year, and were compared with a general hospital (n=138) and primary health care (n=402) psychiatric referrals to a mental health facility.

Results:The age of referred patients across the three settings differedsignificantly and  the  male   patients  were  slightly  over-represented  in  theteaching  hospital

Correspondence to:

Dr. Tariq A. Al-Habeeb, Head, Division of Psychiatry, College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472, Saudi Arabia

referrals. Pediatric clinics in the teaching hospital constituted significant sources of psychiatric referrals as compared to the general hospitals. Schizophrenic disorders and acute psychoses were significantly less among teaching hospital referred patients, whereas anxiety and mood disorders were much more common among teaching hospital and primary care patients. The number of personality disorders diagnosed  in teaching hospital settings was significant.

Conclusions:In Saudi Arabia,sources of psychiatric referrals and diagnostic patterns of mental disorders differ across the three levels, and this is comparable to international research on psychiatric referrals. Besides exploring other aspects of referral process, researchers at the three settings should carry out follow-up studies to assess the impact of psychiatric consultations on the global outcome of referred consultees.

Key Words: Psychiatric referrals, primary care, general hospitals, teaching hospital,  diagnostic pattern, psychiatric consultations, referred consultees, mental health facility.

INTRODUCTION

Primarily, the referral system or consultation-liaison consisted mainly of three interrelated and integrated components. They are the referring physician/consultant, patient and the consultant the patient is referred to. The dynamic process of referring a patient is triggered by various related reasons including thedeficientskills of the referring physician/consultant, diagnostic and therapeutic conundrums of the patient, and the greater expertise of the consultant to whom the patient is referred.1 The success of referral system requires, inter alia, close collaboration,meaningful discussion and communication among health providers and consumers, clearly specified objectives by the referring physician and a comprehensive interview of the patient coupled with a feedback by the consultant.2 However, as in primary health care (PHC), there is evidence that both the general and teaching hospital population with or without medical diseases suffer from a number of psychiatric disorders, somatic symptoms, sub-threshold conditions, and comorbid disorders and,therefore, require psychiatric-consultation liaison services.3-5 Further, the reported prevalence of psychiatric morbidity and comorbidity in the general hospital (GH) population is certainly higher (up to 84%), than the PHC patients (20-50%).6-8 Moreover, the referral rate within the GH and teaching hospital (TH) settings varies between 0.7% to 23%8-10 attributable to different referral sources,11 sociodemographic and clinical characteristics of the patients, and the skills of the referring clinicians.4-7,12-14

                                To the author’s knowledge, only one descriptive study with a small sample (n=97)15 has explored the pattern of psychiatric consultations in a university TH in the Arab Gulfcountries. Therefore, the present study aims to examine the sociodemographic parameters-age and gender,  sources of psychiatric referrals, and the diagnostic patterns of psychiatric disorders among referred patients within a TH as compared with psychiatric referrals from GHs and primary health care centers(PHCCs) to the Buraidah Mental Health Hospital (BMHH). The main reason for addressing only those three issues was that the information related to these items on the referral forms was readily obtainable and fairly reliable.

                                Based on previous clinical experience and extensive review of relevant literature, the author hypothesizes, (i) there would be age- and gender-divergent differences among TH, GHs and PHC referred patients, (ii) the sources of referrals in a TH would be more diverse than the GHs and PHCC; (iii) the diagnostic pattern in the TH would be more varied and complex than the GHs and PHCC. The findings of this study may lead to an improvement in the psychiatric consultation-liaison services in THs, and the development of similar services in GHs and PHC not onlyin the Kingdom of Saudi Arabia (KSA) but also in other Gulf countries.

MATERIAL AND METHODS

Teaching Hospital, GH, AND PHC Samples

King Khalid University Hospital, a 834-bed tertiary care hospital with almost all specialty departments, offers outpatient and inpatient health services to clients referred from all over the KSA. The TH sample, restricted to psychiatric consultations sought within this hospital, comprised patient referral forms (n=427), which were selected randomly, every third to the psychiatry clinic, by a trained nurse over a period of one year from June 1999 to June 2000. Conventionally, the referral form of each referred patient for psychiatric consultation together with feedback report is appended to the patient's file. The noted data in the selected referral forms were photocopied. Notably, TH consultant psychiatrists and BMHH psychiatric specialists use mainly the DSM-IV16 for diagnostic purpose, though they had a broad knowledge of the ICD-10.17 The final diagnoses made by the consultant psychiatrists in the TH and psychiatric specialists in the BMHH were considered in this research. These diagnoses were made in accordance to the DSM-IV criteria at both settings. Despite the use of similar diagnostic criteria at the two settings, the reliability and validity of these diagnoses needing different investigations is questionable, an obvious limitation of the methodology of this study.

                                The randomly selected psychiatric referral letters of patients (n=540) referred from GHs (n=138) and PHCCs (n=402) of Al-Qassim area to BMHH, the details of which are described elsewhere,1 would be used for comparison with the TH sample. The BMHH was selected because it is located in a semi-urban area with many different health facilities, representing different sections of the population in the KSA and a good source of referral.

PATIENT REFERRAL FORM, KKUH

Only one type of patient referral form was used in KKUH. This contained several items, in three categories, (i) “patient referred from” including: name of referring physician, status, clinic/ward, (ii) “patient referred to” and this included: name of consulted physician, status, clinic/ward, and finally (iii) “details about the patient” including patient’s name, file number, age, sex, marital status, occupation, whether the referralwas urgent or elective, the presenting complaint, history of present illness, past history, current drugs taken, allergy if any, physical examination, provisional diagnosis, reason of referral, signature of referring physician, date, and the investigations undertaken. There are about 24 items on the referral form and the referring physicians are expected to complete all items with the relevant information.

                                Like the TH referral form, PHCCs referral forms had similar items, but with a few differences (1) the item 'name of referred consultant' was present  only in TH and GH referral forms (2) the items 'patient's education, marital status, and allergy' were present only in TH referrals and (3) items 'patient’s address and official and doctors’ stamp' were not on TH referral form. Notably,  GHs, private hospitals, and clinics, referring mental patients to BMHH, also usedreferral letters with various items. 

STATISTICAL ANALYSIS

The data on the TH referral letters were entered into the computer. Besides frequency analysis, both Chi-square and t-tests were also used as appropriate. The Statistical Package for Social Sciences (SPSS) 10.0 program for windows was used. The p-value of 0.05 or less was considered significant.

RESULTS

The mean age of patients referred from GHs (31.53 ±18.14) and PHCCs (30.32 ±18.69) was significantly higher than the mean age of TH patients (25.99 ±16.03) (p<0.05). The gender distribution in TH (males 58.3%, females 41.7 %), GH (males 53.6%, females 46.4%) and PHCCs (males 49.3%, females 50.7%) referred patients was analyzed yielding a statistically significant trend(p<0.036).

                                Though the sources of PHCCs patients (n=402) referred to the BMHH were numerous, they were categorized mainly as: (i) Ministry of Health (MOH)-PHCCs (n=349, 86.8%), (ii) others (n=53, 13.2%). Overall, physicians working at the MOH-PHCCs mostly referred mental patients to psychiatric institutions for consultation. The sources of GH patients (n=138) referred to BMMH were: (i) general non-teaching hospitals (73.9%), (ii) specialist hospitals (2.9%), (iii) psychiatric hospitals outside the Al-Qaseem region (13%), and finally iv) psychiatric clinics  in general and specialist hospitals (10.2%). The comparison of the main referring specialties of TH and GH is shown in Table 1. Further, among the studied total referrals to BMHH, the number of PHC referrals were 402 (74.3%) while in the TH sample, 178 (41.7%) were referred from TH-based Primary Care Clinics (TH-PCCs). The revealed diagnostic pattern of mental disorders in TH, GHs and PHCCs referred patients is shown in Table-2.

Table 1: Distribution by specialties among GH and TH referrals

Referring Specialties

GH

TH

p-value

No. (%)

No. (%)

Medicine

77 (55.8)

46 (10.8)

0.0001

Emergency services

17 (12.3)

23 (5.4)

         0.042

Neurology

3 (22)

28 (6.6)

         0.1

Dermatology

2 (1.5)

5 (1.2)

         0.7

Gastroenterology

2 (1.5)

7 (1.6)

         0.7

Psychiatry

31 (22.5)

2 (0.5)

0.0001

Surgery

3 (2.2)

19 (3.6)

         0.68

Pediatric

3 (2.2)

58 (13.6)

0.0001

Primary care clinics

-

178 (41.7)

-

Obstetrics and Gynecology

-

13 (3.2)

-

Self-referred

-

24 (5.7)

-

Source of referral not noted

-

24 (5.7)

-

Total

138

427

-

Table 2: Psychiatric diagnoses in TH, GH and PHC referrals

Diagnosis

TH

GH

PHC

p-value

Diagnosis (%)

Diagnosis (%)

Diagnosis (%)

Dementia

20 (4.7)

13 (9.4)

20 (5.0)

   0.098

Schizophrenic disorder

22 (5.1)

25 (18.1)

62 (15.4)

0.0001

Acute psychosis

6 (1.4)

7 (5.1)

8 (2.0)

   0.036

Mood disorders

152 (35.6)

34 (24.6)

118 (29.4)

   0.029

Anxiety disorder

117 (27.4)

19 (13.8)

70 (17.4)

0.0001

Anxiety depression

-

7 (5.1)

26 (6.5)

0.0001

Somatoform disorders

7 (1.6)

14 (10.2)

22 (5.2)

0.0001

Seizure disorder

-

6 (4.3)

18 (4.5)

0.0001

Childhood disorders

58 (13.6)

1 (0.7)

30 (7.5)

0.0001

Personality disorders

      21 (4.9)

-

-

0.0001

Psychosomatic disorders

-

-

13 (13.2)

-

No psychological disorders

5 (1.2)

-

-

-

Diagnoses missing

-

4 (2.9)

  1 (0.25)

-

Miscellaneous

19 (4.4)

8 (5.9)

     14 (3.5)

  0.48

Total

427

138

402

-

DISCUSSION

This study examined the sociodemographic parameters, sources of referrals and diagnostic pattern of psychiatric disorders by assessing the referral letters of patients sent for psychiatric consultation. Unlike TH and PHCCs referral formats, referral forms differed a great deal among GHs, private GHs and clinics. This finding may explain some of the differences including inadequate information found across national and international studies of psychiatric referrals.1 Hence, there is a needto formulate a uniform psychiatricreferral form for use in all THs, GHs, PHCCs and nongovernmental health delivery systems in the KSA. This step in health developmentwould help referring clinicians to be consistent in their documenting data on the referred patients. This would consequently assist researchers in making fair deductions on the information in psychiatric referrals and possibly, improve the overall quality of the referral process. This may also bring clinical advantages including correct diagnosis and appropriate treatment.18,19

                                According to this study, the age of TH referred patients was comparatively low,a finding which is in agreement with other studies.3 In addition, most of the patients referred for psychiatric consultation from the three sources were adults, which supports the general view that psychiatric disorders preferentially afflict the young adult population worldwide. Also in agreement with other studies was the finding that fewer,20,21 male patients were referred from PHCCs while there were fewer females in the TH. This is not in consonance with other research findings.4,7,10,15 The findings of this study suggest that in this culture, males have free mobility as well as easy access to health care at the tertiary level while females need male chaperones, who are not always available when a visit to the health facility is required.  It is therefore much easier for women to go to PHCCs and GHs close to their residences. Moreover, in the PHC settings, records reveal that more women than men present with mental illnesses.22 Although most types of psychiatric disorders, except drug abuse and antisocial personality disorders, afflict females more than males,4,23,24 the latter tend to manifest severe psychiatric disorders that necessitate referrals to secondary-tertiary care for extensive evaluation, correct diagnosis and suitable treatment. Other socioclinical parameters  of referred patients,7,15 not considered in this study, may shed additional light on thereferral process at the three health delivery systems. For instance, physical comorbidity, one of the important predictors of severity of mental disorders and also a known reason for referral,25 was reported in 17% to 38% of referred patients who didrequire additional intervention by medical specialists.5

                                As expected, the sources of referrals of psychiatric patients to BMHH were inherently numerous as compared to TH, possibly the result of the study design. Notably, TH-PCCs referrals for psychiatric consultations were half those of  PHC referrals to BMHH. The reason for this may bethat with the exposure to and management of numerous psychiatric cases the TH-PCC doctors have become more skilled at diagnosing and managing patients without referring them to psychiatric consultants. However, further studies are needed to confirm these tentativefindings. According to this study, a significant portion of GH patients were referred mainly from three departments while in the TH  referrals came from many more departments and this is in line with the results of earlier studies.11,15This finding could be explained by the fact that unlike in Riyadh, there is only one psychiatric hospital in Al-Qaseem region that provides inpatient services and to which most patients with serious mental disorders and  psychiatric emergencies are referred.26 Unlike others,15 pediatric clinics in the TH referred more patients for psychiatric consultation than the GHs. This could be explained by the accessibility to and availability of child psychiatrists within the TH and also by the pediatric consultants' ability to detect some child psychiatric disorders.  Interestingly, as in TH but unlike GHs, a significant percentage of children (7.5%) were referred from PHCCs toBMHH. This meant that as has been suggested it was necessary to provide appropriate training to PHC physicianson child mental health.27  According to this study,the pattern of  obstetric and gynecology referrals, 3.2% versus none from GHs and PHCCs, can be attributed to the common belief in Al-Qaseem region that some psychiatric disorders in pregnancy were part of the physiological changes in pregnancy known as “wahm”.28 There should be collaboration between obstetric staff and the consultation-liaison psychiatrist at the three health levelsto provide better care for pregnant women with mental problems. According to this study, the reasons underlying self-referrals (5.7%) and missingsources of referrals (5.7%), both of which influence psychiatric services,29 should be explored.

                                The pattern of psychiatric disorders among patients referred for psychiatric consultation is reported to vary widely worldwide.4,13,15,30 Unlike organic psychotic disorders,10,15 acute psychosis and schizophrenia, anxiety-depression and somatoform disorders were the least found among TH patients, a finding consistent with other reports.4,15,31 Generally, GH patients with somatic focus are less likely to be referred for psychiatric consultation despite associatedsignificant psychiatric morbidity.9 The higher proportion of schizophrenic disorders (15.4%) among patients referred from PHCCs to BMHHis disturbing, because only 5% of the patients attending PHCCs are reported to have psychotic disorders. The implication of this is that PHC physicians should have adequatepsychiatric skills to be able to prescribe psychotropic drugs,32 to deal with patients presenting with psychotic disorders and refer them promptly to a psychiatric specialist center. On the other hand, mood, anxiety, and personality disorders were recognized significantly among TH referred patients, which is similar to some15 but dissimilar to reports from other studies.30 In one study, theauthors concluded that although depression was unrecognized in medical patients, it might also be inappropriately suspected andcause the delay of neuromedicalevaluation.33

                                The diagnosis of mixed anxiety-depression,18 tentatively referred to as cothymia,34 only considered by psychiatric specialists among patients referred from GHs and PHCCs to BMHH, may indicate an increased risk for more severe mood and anxiety disorders.35 In contrast, the consultant psychiatrists in THs may be highly skilled in differentiating mixed anxiety-depression disorders into anxiety and mood disorders or this ability to differentiate reflects their expertise. Similarly, the superior skill of the consultant was reflected in diagnosing the most difficult patients with different personality disorders. However, one study reported that psychiatrists are not perfect in terms of high cure rate or making a definite diagnosis initially.36 Notably, the diagnosis of seizure disorders formed part of the GH and PHCC referrals instead of neurology clinics where such patients in THs are usually referred. This was because until recently neurology clinics were not available in the GHs of Al-Qassim region. A group of child psychiatric disorders and psychosomatic disorders, commonly diagnosed among patients referred from PHCCs, could be the result of the inability of the PHC physicians to manage child psychiatric and psychosomatic disorders. However, parental acceptance that a child needs psychiatric help determines the referral of the child for psychiatric consultation.37 Unlike other studies,5,15 this study didnot examine the associated medical diseases. It has been suggested that psychiatric consultants at the three health levels should also have adequate medical skills and the appropriate medical training to manage mental patients with comorbid medical diseases.5,6

CONCLUSIONS AND RECOMMENDATIONS

The findings of this study are consistent with research mostly undertaken in Western countries.Though there are some differences in referral formats, sources of referral and diagnostic pattern of mental disorders. In the light of these results, the following recommendations are suggested, (1) health planners should structure and validate a referral letter that could be used uniformly at all three health levels in the KSA, (2) Psychiatrists should have adequate skills in liaison psychiatry to evaluate difficult, referred  patients suffering froma variety of psychopathologies, (3) in addition to establishing psychiatric consultation-liaison services at  three health settings, there is a definite need to first develop psychiatry in PHC in the KSA, and finally (4) at three settings, researchers should carry out follow-up studies to assessing the impact of psychiatric consultations on the outcome of referred patients.

REFERENCES

1.     Qureshi N A, Al-Habeeb TA, Al-Ghamdy YS, et al. An analysis of psychiatric referrals, Saudi Arabia. The Arab J Psychiatry 2001;12: 53-65.

2.     Leonard I, Babbs C, Creed F. Psychiatric referrals within the hospital-the communication  process. J R Soc Med 1990; 83:241-4.

3.     Creed F, Guthrie E, Black D, Tranmer M. Psychiatric referrals within the general Hospitals: Comparison with referrals to General practitioners. Br J Psychiatry 1993;162: 204-11.

4.     Neehall J, Beharry N. The pattern of in-patient psychiatric referrals in a general hospital. West Indian Med 1993;42:155-7.

5.     Qureshi N A, Al-Habeeb TA, Al-Ghamdy YS, et al.  Psychiatric co-morbidity in primary care and hospital referrals, Saudi Arabia. Eastern MediterraneanH J 2001;7: 492-501.

6.     Alaja R, Tienari P, Seppa K, et al. Patterns of comorbidity  in relation to functioning (GAF) among general hospital psychiatric referrals. European Consultation-Liaison Workgroup. Acta Psychiatr Scand 1999;99:135-40.

7.     Fava GA, Pavan L. Consultation psychiatry in an Italian general hospital: a report on 500 referrals. Gen Hosp Psychiatry 1980; 2:35-40.

8.     Martucci M, Balestrieri M, Bisoffi G, et al. Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological Survey. Psychol Med 1999;29:823-32.

9.     Clarke DM, Minas IH, McKenzie DP. Illness behaviour as a determinant of referral to a psychiatric consultation/liaison service. Aust N Z J Psychiatry 1991;25:330-7.

10.   Adeyemi JD. In-patient psychiatric referrals in a teaching hospital: a case controlled report. J Psychosom Res 1996;41: 427-33.

11.   Freyne A, Buckley P, Larkin C, Walsh N. Consultation liaison psychiatry within the general hospital: referral pattern and management. Ir Med J 1992;85:112-4.

12.   Ozkan S, Yucel B, Turgay M, Gurel Y. The development of psychiatric medicine at Istanbul Faculty of Medicine and evaluation of 889 psychiatric referrals. Gen Hosp Psychiatry 1995;17:216-23.

13.   TayWK, Oh TG. Psychiatric referrals in the general hospital. SingaporeMed J  1993; 34: 557-9.

14.   Al-Ansari EA, El-Hilu S, El-Hihi MA, Hassan KI. Patterns of psychiatric consultations in Kuwait General Hospital. Gen Hosp Psychiatry 1990;12: 257-63.

15.   Mahgoub OM. Psychiatric consultations in a university teaching hospital. Saudi Med J 1998;19:599-603.

16.   American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, IV version, Washington DC, APA 1994.

17.   World Health Organization. International Classification of Disease, 10th revised version (ICD-10). Geneva, WHO, 1992.

18.   Qureshi N A, Schmidt HG, van der Molen HT, Al-Habeeb TA, Al-Magzoub MEMA, Ghadvi H. Quality of psychiatric referrals in Saudi Arabia: structural equation modeling approach  [in press]

19.   Al-Amri AH, Qureshi N A, Abdelgadir MH, Al-Beyari TH, El-Haraka EA, Abdelnasser A. A descriptive study of referral letters in three primary health care centers, Al-Qassim region, Saudi Arabia. Int J Health Educ 1997;35:87-90.

20.   Strathdee G, King MB, Araya R, Lewis S.A standardized assessment of patients referred to primary care and hospital psychiatric clinics. Psychol Med 1990;20:219-24.

21.   Dhavale HS, Barve RG. Psychiatric referral pattern in general hospital. J Postgrad Med 1990;34:199-202.

22.   Herran A, Vazquez-Barquero JL, Artal J, Garcia J, Iglesias C, Montejo J, Diez- Manrique JF. The recognition of mental illness in primary health care and it determining factors. Actas Esp Psiquiatr 1999;27:87-95.

23.   Kisely SR, Goldberg DP. Physical and psychiatric comorbidity in general practice. Br J  Psychiatry 1996;169:236-42.

24.   Florenzano R, Labra JF, Riquelme F, Fullerton C, Marchandon A, Rocco C. Psychiatric patients from general hospitals: pathways followed before consultation. Rev Med Chil 1992;120:651-6.

25.   Qureshi N A, Al-Habeeb TA, Al-Ghamdy YS, Magzoub MEMA, Schmidt HG. Psychiatric referrals: psychiatric symptomatology in primary care and general hospitals, Al-Qassim region, Saudi Arabia. Saudi Medical J 2001; 22:619-24.

        26.Qureshi NA, Al-Amri AH, Abdelgadir MH, Al-Beyari TH. A study of utilization pattern of psychiatric emergency services (PES) in Al-Qassim Region, Saudi Arabia. Saudi Med J 1997;18:137-43.

27.   Garralda E. Child and adolescent psychiatry in general practice. Aust N Z J Psychiatry 2001;35:308-14.

28.   Tsai SJ, Lee YC, Yang CH, Sim CB. Psychiatric consultations in obstetric inpatients. J  Obstet Gynaecol Res 1996; 22:603-7.

29.   Chaturvedi SK, Balaraju KB, Upadhyaya M, Rao S. Psychiatric referrals in a neuropsychiatric centre.  Int J Soc Psychiatry 1989;35:197-203.

30.   CarrVJ, Lewin TJ, Walton JM, Faehrmann C, Reid AL. Consultation-liaison psychiatry  in general practice. Aust N Z J Psychiatry 1997;31:85-94.

31.   Altamura AC, Carta MG, Tacchini G, Musazzi A, Pioli MR. Prevalence of somatoform disorders in a psychiatric population: an Italian nationwide survey. Italian Collaborative Group on Somatoform Disorders. Eur Arch Psychiatry Clin Neurosci 1998;248:267-71.

32.   Qureshi N A, Al-Habeeb TA, Al-Ghamdy YS, Magzoub MEMA, Schmidt HG. Psychotropic drug prescriptions in primary care and general hospitals, in Saudi Arabia. Saudi Pharmaceutical J 2001;9: 193-200.

33.   Boland RJ, Diaz S, Lamdan RM, Ramachandani D, McCartney JR. Overdiagnosis of depression in the general hospital. Gen Hosp Psychiatry 1996; 18:28-35.

34.   Tyrer P. The case for cothymia: mixed anxiety and depression as a single diagnosis (editorial). Brit J Psychiatry 2001;179:191-3.

35.   Katon W, Roy-Byrne PP. Mixed anxiety and depression. J Abnorm Psychol 1991;100:337-45.

36.   Parker G, Wright M, Robertson S, Sengoz A. To whom do you refer? A referrer satisfaction study. Aust N Z J Psychiatry 1996;30:337-42.

37.   Hong CP, Lim LC. Child psychiatric consultations in a general hospital. Singapore  Med 1999;40:584-6.


-0001-11-30

WORK-RELATED ASSAULTS


WORK-RELATED ASSAULTS ON NURSING STAFF IN RIYADH, SAUDI ARABIA

Ashry G. Mohamed, DrPH, Collegeof Medicine, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة: تحديد مستوى العنف الموجه للممرضات داخل المستشفيات فى الرياض

طرقة الدراسة: باستخدام اسلوب الدراسة المقطعية تم توزيع 500 استمارة  عشوائيا بين الممرضات في مستشفيات القطاعين الحكومى و الخاص بالرياض. بالاضافة الى المعلومات الشخصية فقد احتوى الاستبيان على اسئلة عن مدى تعرض الممرضات للعنف وخصائص المعتدي وأسباب العنف من وجهة نظر الممرضات وكذلك المستشفى والقسم الذى تعرضن فيه للعنف.

نتائج الدراسة: تم ملء 434 استبيانا 341 ممرضة و 93 ممرض بمتوسط أعمار36,1   ±6,97 سنة. أفاد 235 تعرضهم للعنف , 93,2 % منهم تعرضوا للعنف بالكلام, 32,8% هددوا كلاميا بالإيذاء البدنى , 28,1% تعرضوا لمحاولة الإيذاء البدنى,17,4% للتحرش الجنسى بينما كان 16,1% ضحايا الايذاء البدنى. العاملات في قسمى الطب النفسى و الطوارئ أكثر عرضة للعنف (84,3% و62,1% بالتتابع). ذكرت الممرضات ان النقص فى اعداد رجال الأمن (82%) و كذلك قلة عدد الممرضات(63%) وعائق اللغة (36,3%) وكذلك تحرك رواد المستشفى داخلها بدون قيود (21,5%) هى أهم أسباب العنف داخلالمستشفيات.

التوصيات: زيادة عدد رجال الأمن وهيئة التمريض داخل المستشفيات وخلق وعى عام فى المجتمع عن تلك المشكلة تمهيدا لتغيير سلوك الأفراد فى معاملة الممرضات و الممرضين.

الكلمات المرجعية: العنف فى بيئة العمل, الخطر المهنى, مخاطر التمريض

Objective: To determine the extent of work-related violence against nurses in hospitals in Riyadh.

Materials and methods:Through a cross sectional approach, a self administered questionnaire was offered to 500 active-duty nurses selected randomly. In addition to the demographic characteristics, the questionnaire inquired about exposure to workplace violence, hospital  and department of employment  at the time of exposure, characteristics of the assailant and nurses’ perception of the causes of violence.  Results: Out of 434 respondents, 93 (21.4%) were males, and 341 (78.6%) females. The mean age was 36.1 ±7.97 years. Workplace violence  was experienced by 235 (54.3%) nurses. Of these 93.2% were exposed to harsh insulting language, 32.8% to verbal threat, 28.1% to attempts of physical assault, 17.4% to sexual harassment and 16.2% to actual physical assault.   Nurses working in psychiatry and emergency units had  the highest rate of exposure to violence (84.3% & 62.1% respectively) Nurses perceived shortage in security personnel (82%), shortage in nursing staff (63%), language barrier (36.3%) and unrestricted movement of patients in hospitals (21.5%) as causes of their exposure to violence. 

Correspondence to:

Dr. Ashry G. Mohamed, Family & Community Medicine Department (34), College of Medicine & KKUH, King Saud University, Riyadh 11461, Saudi Arabia

Recommendations:  improve security in hospitals by increasing the number of security officers on duty and increase the community’s awareness of the problem.

KeyWords:Workplace violence , occupational risk, nursinghazards. 

INTRODUCTION

Assaults on health professionals in the workplace is a public health and legal problem.1 Violence against nurses is a silent epidemic.1,3 Until relatively recently, little attention had been paid to this problem. Today, concerns are rising about the escalating levels of violence against nurses.4

Nurses are the primary care givers in hospitals and are more likely to encounter violence because of the amount of time spent in direct patient care.5  Most nurses are not trained to manage explosive situations.5,6 They are likely to under report exposure to violence because of their fear that employers may deem assaults the result of their negligence or poor job performance.1 In addition, some nurses consider violence as part of their job.7,8

Violence against nurses impairs job performance after the incident.9  It also reduces job stisfaction and may compel nurses to leave their job.10

Though, an international phenomenon, there are few cross-cultural studies on violence in health care.7 In Saudi Arabia, nurses as well as attendants of hospitals are recruited from different geographical and cultural areas.  The aim of the present work is to determine the extent of violence against nurses working in hospitals in Riyadh city, in order to direct future management strategies.

MATERIAL AND METHODS

The study was conducted with a cross sectional design. On the assumption that one quarter of nurses were exposed to violence at work (20-30%) a sample size of 288 nurses was required  at 95% level of significance. Expecting a moderate participation rate, 500 nurses were asked to participate in the study. A list of all hospitals in Riyadh was obtained from different sources. Using a proportional allocation method, five hospitals were chosen as follows: one university hospital, one MOH hospital, one private hospital, the mental health hospital  and one military hospital.

Within the health care facilities, the nurses were selected randomly and confidentially offered a structured questionnaire. In addition to the personal characteristics, the questionnaire inquired about exposure to violence in the hospital, the type of violence, departments of employment  at the time of exposure, their perception of causes of violence in the hospitals and characteristics of the assailant.

Each questionnaire was revised for completeness and consistency in the same hospital.  SPSS version 9 was used for data tabulation and analysis.  Occurrence of violence was expressed as percentage.Chi square test  was used to examine the association between various demographic and workplace factors and violence against nurses at 95% level of significance.

RESULTS

Out of 500 nurses invited to participate in the study, 434 (86.8%) completed the questionnaire; 93 males (21.4%) and 341 females (78.6%). Their mean age was 36.1 ± 7.97 years.  Two hundred thirty five nurses (54.3%) reported a history of violence against them. Of these, 219 (93.2%) were exposed to harsh insulting language, 77(32.8%) to verbal threat, 66(28.1%) to attempts of physical assault, 41(17.4%) to sexual harassment and 36(16.2%) were victims of physical assaults (Figure 1).

Table 1:Characteristic of the assailants on nurses, Riyadh 2002

Characteristic

No. (%)

Status:

Patients

143 (60.8)

Patients' companion

116 (49.4)

Physician

58 (24.7)

Other nurse

62 (26.4)

Others

  10 (4.3)

Gender:

Male

215 (91.5)

Female

  91 (38.7)

Age:

Child

  12 (5.1)

Adolescent

33 (14.4)

Adult

76 (32.3)

Middle age

88 (37.4)

Elderly

27 (11.5)

Language:

Arabic

165 (70.2)

English

21 (8.9)

Other

54 (22.9)

Drug user

48 (20.4)

Table 1 shows that the assailants were patients (60.9%), patients’ companions (49.4%), physicians (24.7%) and nurse colleagues (26.4%).  More than 90% of the nurses exposed to violence were attacked by males and 37.4% by middle-aged assailants. Arabic was the mother tongue of 70.2% of the assailants. Only 20.4% of them were drug users.

Table 2:Demographic characteristics of nurses and exposure to violence, Riyadh 2002

Characteristic

Exposed to violence

No. (%)

Not exposed to violence

No. (%)

p-value

Age in years:

<30

59 (25.1)

47 (23.7)

<0.001

30-

89 (37.9)

74 (37.4)

40-

65 (27.7)

77 (38.9)

50-60

22 (9.4)

1 (0.5)

Gender:

Male

  75 (31.9)

18 (9.1)

*

Female

160 (68.1)

181 (90.9)

Nationality:

Saudi

17 (7.2)

2 (1.0)

*

Other Arabs

38 (16.2)

19 (9.6)

Indians

23 (9.8)

63 (31.8)

Canadians

18 (7.7)

1 (0.5)

Filipinos

131 (55.7)

110 (55.3)

Others

  8 (3.4)

  3 (1.5)

*p-value approached zero

                Table 2 shows that 37.9% of the nurses abused were in their fourth decade. Those in the fifth decade constituted (27.7%) of those exposed to violence and 38.9% of those not exposed to violence. There was a  significant statistical association between age and exposure to violence (p<0.001). Females constituted the majority of those exposed (68.1%) and those nurses not exposed (90.9%). More than half of the nurses exposed and  those not exposed were Filipinos (55.7% and 55.3% respectively).  The association between both gender and nationality with exposure to violence was  statistically significant (p<0.001).

    Table 3 shows that the nurses who worked in mental health hospital constituted 23% of  nurses exposed to violence and that only 4% of them were not exposed. One fifth of the nurses exposed to violence worked in psychiatry departments (20.9%).  Hospital, department and duration of working hours are significantly associated with the exposure to violence (p<0.001).

Table 3:Work-related factors and violence against nurses, Riyadh 2002

Factor

Exposed to violence

No. (%)

Not exposed to violence

No. (%)

p-value

Hospital:

General

116 (49.4)

112 (56.6)

<0.001

Mental

  54 (23.0)

  8 (4.0)

Private

  65 (27.7)

79 (39.4)

Department:

Emergency

26 (11.0)

32 (16.3)

<0.001

Medicine

75 (31.9)

  18 (9.0)

Psychiatry

49 (20.9)

21 (10.8)

Surgery

  16 (6.7)

37 (18.7)

Ob/Gyn

40 (17.2)

75 (38.0)

Pediatric

29 (12.3)

  14 (7.2)

Hours of work:

<8

126 (53.6)

86 (43.4)

<0.001

9-12

90 (38.3)

111 (56.1)

12

19 (8.1)

2 (1.0)

                Nurses perceived that the shortage of security personnel (82%), shortage of nursing staff (63%), inability to understand the language (36.3%) and unrestricted movement of patients in hospitals (21.5%) were the main causes of violence against them. 

DISCUSSION

For many years, health care workers have faced a significant amount of the risk of job-related violence. Assaults represent a serious  safety and health hazard for this service industry and violence against its employees is on the increase.1  The present work revealed that 54.3% of the nurses in Riyadhhad been exposed to violence. Similar findings were reported by Whitehorn and Nowlan who reviewed the issue of nurse abuse in Canada and found that half of all registered nurses have been physically assaulted in the workplace.11  A higher rate was reported by Erickson et al where 82% of the studied nurses in mid-south USA reported exposure to patient assaults in the course of their duties.12 This rate can not be generalized as a convenient sample from emergency departments was used.

   A survey conducted in emergency departments, ICU and general floor nurses in Floridarevealed that 88% and 74% of nurses were victims of verbal and physical assaults respectively in one year.13 The present work with a somewhat higher rate of verbal assaults (93.2%), but a much lower rate of physical assaults (16.2%) may be due to cultural and environmental variation. Graydon et al reported the same pattern of dominance of verbal abuse in Canada.14

                Many studies revealed that nurses in the  emergency and psychiatric departments were at a significantly greater risk of assaults.3,15 The present work in which 62.1% and 84.3% of  the nurses working in emergency and psychiatry departments were victims of violence respectively, is in agreement with this. A multiregional study in a psychiatric setting in the USA found that 76% of nurses had been physically assaulted at least once.16 However, studies revealed that mental health nurses seem to be better able to  control  aggressive situations than general nurses who tended to rely more heavily upon the help of others.4,17

                The present work found that there was more violence in mental hospitals (87.1%) than the general hospitals (50.9%) and in the private hospitals (45.1%). In the same vein, Grenade and Mac Donald in UKreported that assault rate was much higher in mental hospitals than in the general hospitals.17

                The current study showed that the most common violent assailants were middle aged. Derazon et al reported the same finding, where middle-aged men of low socioeconomic level consituted the majority of violent patients.18 The lack of communication may be the reason for the high percentage of Arabic speaking assailants (70.2%), for coming from a different linguistic background, the nurses may not be able to communicate effectively.

                On the demographic characteristics of nurses, the present study reveals that male nurses were more exposed to violence than females. This  is consistent with the oriental culture which considers assault of males on females a shameful behaviour. It also reveals that age was associated with exposure to violence, but this may be explained as a cummulative effect.

                Nurses in the present work perceived that the shortage of nursing staff and security personnel were the main causes of violence against them. In agreement with this finding Lee et al found that high patient / personnel ratio in hospitals is associated with increased risk of violence.3 Occupational Safety and Health Administration (OSHA) reported that low staffing levels was a major cause of violence.1 Other studies revealed that recreational drug usage and alcohol was a third cause of violence.18 The present work found that one fifth of the assailants were drug users.

                From this study, it is clear that violence against nurses is a serious public health problem and an improvement in the security provided in hospitals may help to alleviate.  It is also recommended that the community awareness of this problem be improved and some means found to change the attitude of patients and the community towards nurses.

REFERENCES

1.     OSHA. Guidelines for preventing workplace violence for health care and social service workers. US Dpartment of Labor. 1998.

2.     Harilow S. Ending the silence on violence. Australian Nursing Journal 2000;V(10):26-30.

3.     Lee SS, Gerberich SG, Waller LA, Anderson A, Mc Govern P. Work-related assault injuries amonhg nurses. Epidemiology 1999;10:685-91.

4.     Duxbury J. An exploratory account of registered nurses’ experience of patient aggression in both mental and general nursing settings. J Psychiatry Ment Health Nurs 1999;6(2):107-14.

5.     Hurlebaus AE, Link S. The effects of an aggressive behaviour management program on nurses’ level of  knowledge, confidence and safety.  Nurs  Staff Dev 1977;13(5):260-5.

6.     Hurlebaus A. Aggressive behavior management for nurses: an international issue? Healthc Prot Manage 1994;10(2):97-106.

7.     Nolan P, Saores J, Dallender J, Thomsen S, Aretz B.  A comparative study of expences of violence of English and Swedish mental health nurse.  Int J Nurs Stud 2001;38(4):419-26.

8.     Derazon H, Nissimian S, Yosefy C, Peled R, Hay E. Violence in the emergency department.  Harefuah 1999;137(3-4):95-101.(english abstract)

9.     Fernandes CM, Bouthillette F, Raboud JM, et al.   Violence in the emergency department: a survey of health care workers. CMAJ 1999;16:1245-8.

10.   Findorff-Dennis MJ, Mc Goven PM, Bull M, Hung J.  Work related assaults.  The impact on victims.  AAOHNJ 1999; 47(10):456-65.

11.   Whitehorn D, Nowlan M.  Towards an aggression free health care environment. Can Nurse 1997;93(3):24-6.

12.   Erickson L, Williams-evans SA.  Attitutes of emergency nurses regarding patient assaults. J Emerg Nurs 2000;26(3):210-5.

13.   May DD, Grubbs LM.  The extent, nature, and precipitating factors of nurse assault among three groups of  registered nurses in regional medical centre. J Emerg Nurs 2002;28(1):11-17.

14.   Graydon J, Kasta W, Khan P.  Verbal and physical abuse of nurses.  Can J Nurs Adm 1994;7(4):70-89.

15.   Levin PF, Hewitt JB, Misner ST.  Insights of nurses about assault in hospital-based emergency departments.  Image of Nurs Sch 1998;30(3):249-54.

16.   Poster EC, Ryan J.  A multiregional study of nurses, beliefs and attitutes about work safety and patient assault. Hosp Community Psychiatry 1994;45(11):1104-8.

17.   Grenade G, Macdonalds E.  Risk of physical assaults among student nurses. Occup Med 1995;45(5):256-8.

18.   Jenkins MG, Rocke LG, Nicholl BP, Hughes DM.  Violence and verbal abuse against staff in accident and emergency departmentss: a survey of consults in the UKand Republicof Ireland.  A Accid Emerg Med 1998;15(4):262-5.


-0001-11-30

PERCEPTION OF BODY WEIGHT


PERCEPTION OF BODY WEIGHT AMONG SAUDI SCHOOL CHILDREN

Baha Abalkhail, MD, DrPH, Sherine Shawky, MD, DrPH, Tawfik Ghabrah, MD, DrPH

Department of Community Medicine and Primary Health Care, College of Medicine and Allied Health Sciences, King Abdulaziz University, Jeddah, Saudi Arabia

هدف الدراسة :  تهدف هذه الدراسة إلى استكشاف التصور الشخصي لوزن الجسم بين طلاب مدارس مدينة جدة وكذلك التعرف على العوامل الأساسية المؤثرة في هذا التصور الشخصي وعلى الأهداف والممارسات الخاصة لمعالجة السمنة لديهم.

طريقة الدرسة: استقصت المعلومات من عينة أخذت من 42 مدرسة للطلبة و42 مدرسة للطالبات بمدينة جدة في إبريل عام 2000م بطريقة المقابلة الشخصية . والمعلومات شملت العوامل الاجتماعية والديموغرافية واختيار الأغذية والتصور الشخصي عن وزن الجسم والاهداف والممارسات المعالجة والمسيطرة على السمنة بالاضافة الى القياسات الفعلية للوزن والطول . وسأل الطلاب عن تصورهم الشخصي لوزن جسمهم على النحو التالي {الاختيارات تضمنت : نحافة ،  قليل الوزن ، وزن مناسب ، زيادة قليلة في الوزن ، زيادة كبيرة في الوزن (السمنة). حسبت نسبة و معدل الانتشار وفترة الثقة على قياس 95%  وعملت نماذج في الانحدار الثنائي المتعدد لقياس نسبة الأفضلية ( OR ) في محاولة إنقاص وزن وممارسة طرق متعددة لمعالجة السمنة .

نتائج الدراسة :وجد أن التوزيع الخاص بالتصور الذاتي لحجم الجسم مشابه تقريباً للتصنيف الخاص بمعامل السمنة ( BMI) لنفس العمر والجنس ماعدا الطلاب المصابين بسمنة حيث وجد أن 21.3% منهم يتصورون بأنفسهم زيادة قليلة في الوزن و 5.5% يتصورون بأنفسهم  زيادة كبيرة في الوزن ( سمنة ) مع انه بقياس معامل السمنة الفعلي لديهم وجد أن في 13,4 % منهم على زيادة  قليلة في الوزن وفي  13.5% منهم زيادة كبيرة في الوزن ( السمنة ) . حوالي نصف الطلاب ذكروا أانهم يتناولون ثلاثة عناصر غذائية على الأقل من الفواكه وعصير الفواكه يومياً وثلثهم ذكروا انهم يتناولون أربعة عناصر غذائية على الأقل من الخضراوات يومياً . ثلث عينة الدراسة مارسوا محاولات لتخفيف الوزن وهو ما يتوافق مع نسبة الزيادة في الوزن والسمنة للعينة . حوالي 28% من الطلاب مارسوا التقليل من الغذاء والدهون والسعرات الحرارية و31% منهم مارسوا الرياضة و 17.6% منهم انخرطوا في رياضة عنيفة لتخفيف وزنهم . اما الامتناع عن الطعام لمدة 24ساعة فكانت ممارسة من 10% منهم .الإناث كانوا أقل عرضة للزيادة في الوزن والسمنة عن الذكور ولكن تصورهم الشخصي في صورة زيادة كبيرة في وزنهم ( السمنة ) ومحاولاتهم لتخفيف الوزن كانت بنسبة اكبر فيهم عن الذكور . وجد في الدراسة أيضا أن العوامل المصاحبة لممارسات تخفيف الوزن بطريقة التقليل من الغذاء والدهون والسعرات الحرارية هي الزيادة في العمر ومستوى عال من الحالة الاجتماعية والسمنة الفعلية والذين لديهم تصور شخصي على أن لديهم زيادة كبيرة في الوزن.

Correspondence to:

Dr. Bahaa Abalkhail, Department of Community Medicine and Primary Health Care, Faculty of Medicine and Allied Health Sciences, King Abdulaziz University, P.O. Box 9029, Jeddah 21413, Saudi Arabia

أما الامتناع عن تناول الطعام لمدة 24 ساعة كانت ممارسة أكثر في الاناث والكبار في العمر والذين لديهم سمنة فعلية . ممارسة الرياضة كانت أكثر بين كبار السن و الذين لديهم أمهات على مستوى متوسط وعالي في التعليم والذين لديهم سمنة فعلية أو متصورة .أما ممارسة الرياضة العنيفة فكانت أكثر من قبل الذكور وصغار السن و الذين يتناولون ثلاثة عناصر غذائية على الأقل من الفواكة وعصير الفواكة وأربعة عناصر غذائية على الأقل من الخضروات يومياً والذين يتصورون أنفسهم على زيادة كبيرة في الوزن .

الخلاصة: وجدت في الدراسة أن زيادة الوزن والسمنة الفعلية كانت منتشرة بين طلاب المدارس وليس كل الذين لديهم سمنة فعلية لديهم تصور صحيح عن حجم وزنهم .يتضح من نتائج الدراسة ضرورة عمل برامج تثقيفية تداخليه في مرحلة الطفولة ومرحلة عمر المدارس لتعزيز الاختيار الصحي للغذاء ورفع الوعي و المعرفة الذاتية عن وزن الجسم المثالي وعن السمنة الإكلينيكية وتشجيع الممارسات الصحية لتخفيف الوزن مثل الرياضة وتثبيط الطرق الغير لائقة صحياً في ممارسات تخفيف الوزن .

الكلماتالمرجعية: المراهقين، الأطفال، التصور الشخصي للسمنة، زيادة الوزن، ممارسة الرياضة، غذاء ، الممارسات لتخفيف الوزن.

Objectives: The objectives of this study were to explore the perception of body weight among students in schools in Jeddah City and identify the main determinants of self-perceived obesity, weight management goals and practices.

Material and Methods: Data were collected from a sample of Saudi school children of 42 boys’ and 42 girls’ schools in Jeddah city during the month of April 2000. Personal interviews were conducted to collect data on socio-demographic factors, food choices, perception of body weight, weight management goals and weight management practices, as well as the actual measurement of weight and height. Students were asked about their perception of their body weight [responses included: very underweight (thin), slightly underweight, about right weight, slightly overweight and grossly overweight (obese)]. Proportion, prevalence and 95% confidence intervals were calculated. Multiple logistic regression models were fitted to calculate the adjusted odds ratio (OR) for an attempt  to lose weight and weight management practices.

Results: The distribution of self-perception of body size was nearly similar to the measured body mass index ( BMI) classification except for the overweight students, where 21.3% perceived themselves, as slightly overweight and 5.5% as very overweight although 13.4% were actually overweight and 13.5% were obese by BMI standards. Approximately half the students took at least 3 pieces of fruit or fruit juice servings, and a third ate at least 4 vegetable servings per day. A third of the students managed to lose weight. This coincides with the proportion of those actually overweight and obese. Around 28.0% of the students ate less food, fat or calories, 31.0% took exercise and 17.6% were engaged in vigorous exercise to lose weight or prevent weight gain. Staying for at least 24 hours without food which is a potentially harmful means of weight control was practiced by 10.0% of students. Females were less likely than males to be overweight and obese but more likely to perceive themselves as grossly overweight and more likely to try to lose weight. Factors associated with efforts to lose weight by eating less fat or fewer calories were older age, high social class, being actually obese and perceiving oneself as being obese. Staying for at least 24 hours without eating was mainly practiced by females, older age groups, and the actually obese. Exercise was done mainly by the older age groups, those with educated and highly educated mothers, obese and perceiving oneself as being obese. Vigorous exercise was mainly performed by males, younger age groups, taking < 3 pieces of fruit or fruit juice servings per day, eating < 4 vegetable servings per day, and those perceiving themselves as obese.

Conclusion: Overweight and obesity are prevalent among our youth and not all obese have a correct image of their body size. Highly recommended are intervention programs of education on nutrition starting in childhood through school age to promote and ensure healthy food choices, improve student’s awareness of ideal body size and clinical obesity, encourage physical exercise but discourage potentially harmful weight control measures.

Key Words: Overweight, perceived obesity, diet, physical activity, weight management, children, adolescents.

INTRODUCTION

Obesity is associated with increased risk of morbidity and mortality1 related to a variety of diseases such as coronary heart diseases,2-4 hypertension,5,6 non-insulin dependent diabetes7-9 and some cancers.10 It appears to be traceable from childhood into adulthood. Overweight during late adolescence is most strongly associated with increased risk of overweight and obesity in adulthhod.11

                Adolescence is a time of high nutritional requirements; nonetheless dieting by teenage girls in an effort to control body weight is well-documented.12 In fact, obesity phobia is so pervasive among female adolescents that it has been described as 'a normative discontent'.13 This desire for thinness by girls as young as 9 years,14 has its origins in the 'narrow hipped, thin ankle' idea of female beauty depicted by society.15  By the age of nine, girls and boys already differ in their body shape and aspirations. Initiatives to reduce obesity should acknowledge these early strongly held views by the different genders or risk the promotion of unwarranted pursuit of thinness by girls.14

                The consequences of restrained eating during the teenage years have raised many concerns. A lower intake of all micronutrients has been reported among dieting British girls aged 16-17 years compared with girls who were not dieting.16 Furthermore, in a 12-month follow-up study of 176 London schoolgirls aged 15 years, Patton et al17 reported that the relative risk of ‘dieters’ developing an eating disorder was eight times that of 'non-dieters'. The effects of dieting on cognitive functioning have also been noted.18

                Recommendations for the long-term treatment and prevention of obesity in adults include multi-component interventions that combine a healthy diet and exercise with behavior modifications designed to facilitate the maintenance of these lifestyle changes throughout life. The United States' objectives for healthy dietary behavior and physical activity include increased consumption of fruits and vegetables, reduced consumption of dietary fat, performance of at least 30 minutes of moderate physical activity most days of the week, participation in vigorous physical activity that promotes the development of cardio-respiratory fitness for 20 or more minutes at least 3 days per week, and regular performance of physical activities that enhance and maintain muscular strength and flexibility.19,20 Therefore, declining physical activity, particularly incidental activity, is believed to be an important contributor to the burgeoning prevalence of obesity in Western nations.21 Increasing physical activity is therefore, viewed as an important component of attempts to control weight.21,22 Physical activity has been shown to complement dietary restriction or changes in diet composition undertaken for weight reduction.23 Importantly, physical activity aids the preservation of lean body tissue usually lost during dietary restriction, while the additional elevation of energy expenditure further enhances negative energy  balance.22 Although weight loss attributable to increased physical activity may be small, it has been repeatedly shown to play an important role in the maintenance of weight loss. In addition, there is evidence to suggest that physical activity is important in preventing weight gain over time.24

                Reduction of the disease burden of obesity in a population depends on identifying the risk factors that influence body weight. Obesity is an end result of many factors. The most important are the life-style factors and cultural perception of the ideal body weight. Food choice and physical activity assisted by behavior modification designed to facilitate these life style practices are believed to be the principal contributors to the prevalence of obesity.25-27 The cultural norms delineate the predominant perception of ideal body weight. Western culture has a prevailing perception that low body weight is attractive.28 In the past, overweight and obesity were perceived in Arab countries as signs of good health, wealth and authority. However, with advancing education, development of health care services and improvement of health awareness, this view has changed and people have become more concerned about being overweight. Considerably high proportions of Saudi youth that is, approximately 27.5% boys and 28.0% girls, were observed to be overweight and obese. No studies exploring the perception of body weight in Saudi Arabian adolescents have been done, to our knowledge, and the few available studies concentrate on adult women only.29 The objectives of this study were to explore the perception of body weight among school students in Jeddah city, and to identify the main determinants of perceived obesity. There is also a description of the demographic distribution of selected weight management goals and practices among Saudi students and the types of food choices associated with these weight management goals and practices.

MATERIAL AND METHODS

Study population

Jeddah city, with a population of 2.1 million, is one of the largest cities in the Kingdom of Saudi Arabia. The last available Saudi population census, in the year 1993 indicates that it has  a total of 692 government schools and 327 private schools, around half of which are for boys and half for girls.

Sample Selection

The sample of 42 boys’ schools and 42 girls’ schools was selected by stratified sampling technique with proportional allocation to type of school (government or private) and educational level during the month of April 2000.  A large sample size was considered (2860 students) with an equal sample distribution in both sexes to ensure that the fourth year medical students were given enough exposure on how to conduct a field survey (interviewers). However, the prevalence of obesity by self-perception was unknown in our study population. One class from each educational level starting from the fourth grade upward was randomly chosen in the selected schools. All students in the selected class present during the study period were considered. Only students of Saudi nationality were considered for this study. A participation rate of around 99.0% was attained. Approval for the conduct of the field survey was obtained from the Ministry of Education and The General Presidency for Girl’s Education in the Jeddah region. These letters of approval were given to each school principal to ensure cooperation.

Data Collection

Data were collected during April 2000 by 220 male and female fourth year medical students trained in interviewing skills, and directly supervised by the medical staff. The month prior to the data collection was spent on questionnaire development and a pilot study, and the correction of the questionnaire.  Data were collected by personal interviews using a structured questionnaire, which included information on socio-demographic factors, food choices, perception of body weight, weight management goals and weight management practices, as well as, direct measurements of weight and height.

                Although both variables were collected in the study, mother’s rather than the father's educational level was used since mother's education was better for ranking (more variability) between children in the different social classes. They were classified into low (no school, primary and attended intermediate school), middle (completed intermediate and secondary schools) and high (attended or completed college and higher). Type of school was taken as a proxy measure for the social class status, since it is well known in Saudi society that private schools are mainly attended by the higher social class and governmental schools by the lower social class, and since only Saudis were selected for the study, it was assumed that this would be valid to a large extent.

                Consumption of fruits and vegetables was measured using five separate questions on the form. It elicited information on the number of times the students had eaten fruit or drunk fruit juice, eaten green salad, carrots and other vegetables (excluding potatoes) during the last 7 days. Responses included: 0 times, 1-3 times per week, 4-6 times per week, one time per day, 2 times per day, 3 times per day and 4 or more times per day. Then both variables were classified into two levels according to their   frequency distributions to minimize any misclassification. Students also were asked about their perception of their body weight [responses included: very underweight (thin), slightly underweight, about right weight, slightly overweight and grossly overweight (obese)]. The very underweight and slightly underweight categories were combined and seen as comparable to measured body mass index variable. This scale of five categories response options is mutually exclusive and inclusive of all possible responses on weight perception.

                Weight was measured without shoes using Seca (model 777) personal scale to the nearest 0.1 kg and height was taken without shoes using the standard measuring tape to nearest 0.1 cm. Body mass index ( BMI) was calculated as the measured weight in kg/(measured height in m)2. The measured body mass indexes were classified into 5 categories according to age and gender thus: thin (< 5th percentile), underweight (³ 5th percentile - < 15th), normal weight (³15th - < 85th percentile), over weight (³ 85th percentile to < 95th percentile) and obese (³ 95th percentile). Reference BMI percentiles were derived from the first National Health and Nutrition Examination Survey (NHANES).30 This classification is in accordance with the recommendation of the expert committee on clinical guidelines for overweight in adolescence31 and World Health Organization (WHO) expert committee in overweight.32 Thin and underweight categories were combined in the analysis.

                Weight management goals were assessed by asking students to report on what they were doing about their weight. Responses included: lose weight, gain weight, stay the same weight, not trying to do anything about weight. Their Weight management practices were assessed using the four separate questions mentioned above. The first three questions were: During the last 30 days, did you do any [exercise, eat less food, fewer calories or low fat food,  stay without eating for 24 hours or more] to lose weight or try not to gain weight? (Responses included: no, yes). The fourth question was, excluding sports at schools, how often do you exercise vigorously enough to work up sweat? Responses included: never or rarely, 1-3 times per month, once per week, 2-4 times per week, 5-6 times per week, and daily.

Data entry and analysis

Data entry and analysis were done using SPSS for windows version 9.0. Proportions, prevalence, and 95% confidence intervals (95%CI) were calculated. Multiple logistic regression models were fitted to calculate the adjusted Odds Ratio (OR) for being grossly overweight (obese) by self-perception, separatelyl for male and female

tudents to determine the predictors of perceived obesity. In subsequent analyses, separate logistic regression models were used to determine the demographics and food choice behavior associated with specific weight management goals and practices. Differences between proportions and prevalence estimates were considered statistically significant if (95% CI) did not overlap, and adjusted odds ratios were considered statistically significant if (95% CI) did not include 1.0.

RESULTS

A total of 2,860 students of Saudi nationality were included in the study (Table 1). There were 49.1% males and 50.9% females. Their ages ranged from 9-21

Table 1: Socio-demographic characteristics of Saudi school students in Jeddah, Saudi Arabia2000

Total Population       (n= 2,860)

Male

(n= 1,403)

Female

(n= 1,457)

%

(95%CI)

%

(95%CI)

%

(95%CI)

Age (years):

9-12

37.0

(35.2-38.8)

32.6

(30.1-35.1)

41.2

(38.7-43.7)

13-15

32.7

(31.0-34.4)

32.1

(29.7-34.5)

33.2

(30.8-35.6)

16-21

30.3

(28.6-32.0)

35.3

(32.8-37.8)

25.5

(23.3-27.7)

Type of school:

Government

88.9

(87.7-90.1)

92.9

(91.6-94.2)

85.0

(83.2-86.8)

Private

11.1

(9.9-12.3)

7.1

(5.8-8.4)

15.0

(13.2-16.8)

Mother education:

Low

55.7

(53.9-57.5)

56.0

(53.4-58.6)

55.4

(52.8-58.0)

Middle

29.6

(27.9-31.3)

31.4

(29.0-33.8)

27.9

(25.6-30.2)

High

14.7

(13.4-16.0)

12.7

(11.0-14.4)

16.7

(14.8-18.6)

CI= confidence interval

Table 2: Perceived body weight, measured body weight ( BMI), food choice and weight management goals and practices among Saudi school students by gender in Jeddah Saudi Arabia, 2000

Total Population (n= 2,860)

Male

(n= 1,403)

Female

(n= 1,457)

%

(95%CI)

%

(95%CI)

%

(95%CI)

Bodyweight, self-perception *

Underweight

24.9

(23.3-26.5)

27.0

(24.7-29.3)

23.0

(20.8-25.2)

About right weight

48.2

(46.4-50.0)

48.5

(45.9-51.1)

48.0

(45.4-50.6)

Slightly overweight

21.3

(19.8-22.8)

20.3

(18.2-22.4)

22.4

(20.3-24.5)

Grossly overweight(obese)

5.5

(4.7-6.3)

4.3

(3.2-5.4)

6.7

(5.4-8.0)

Bodyweight, BMI(percentiles)†

Underweight (<15th)

21.2

(19.7-22.7)

25.7

(23.4-28.0)

16.8

(14.9-18.7)

Normal weight(?15th-<85th)

51.9

(50.1-53.7)

46.1

(43.5-48.7)

57.7

(55.2-60.2)

Overweight (?85th-<95th)

13.4

(12.2-14.6)

14.3

(12.5-16.1)

12.5

(10.8-14.2)

Obese (?95th )

13.5

(12.2-14.8)

14.0

(12.2-15.8)

13.0

(11.3-14.7)

Food choices

Fruits ³3 times/day‡

56.7

(54.9-58.5)

56.4

(53.8-59.0)

56.0

(53.5-58.5)

Vegetables ³4 times/day§

28.9

(27.2-30.6)

31.4

(29.0-33.8)

26.1

(23.7-28.3)

Weight management goals**

Lose weight

30.0

(28.3-31.7)

24.9

(22.6-27.2)

34.6

(32.2-37.0)

Keep same weight

8.2

(7.2-9.2)

9.1

(7.6-10.6)

7.4

(6.1-8.7)

Gain weight

10.9

(9.8-12.0)

12.3

(10.6-14.0)

9.6

(8.1-11.1)

Do nothing about weight

50.9

(49.1-52.7)

53.7

(51.1-56.3)

48.4

(45.8-51.0)

Weight management practices††

Eat less food, fat or calories

No

71.9

(70.3-73.5)

77.7

(75.5-79.9)

66.4

(64.0-68.8)

Yes

28.1

(26.5-39.7)

22.3

(20.1-24.5)

33.6

31.2-36.0)

Stay without eating for 24 hours

No

90.0

(88.9-91.1)

91.0

(89.5-92.5)

89.0

(87.4-90.6)

Yes

10.0

(8.9-11.1)

9.0

(7.5-10.5)

11.0

(9.4-12.6)

Exercise

No

69.0

(67.3-70.7)

67.2

(64.7-69.7)

70.7

(68.4-73.0)

Yes

31.0

(29.3-32.7)

32.8

(30.3-35.3)

29.3

(27.0-31.6)

Exercise vigorously‡‡

No

82.4

(81.0-83.8)

69.9

(67.5-72.3)

93.9

(92.7-95.1)

Yes

17.6

(16.2-19.0)

30.1

(27.7-32.5)

6.1

(5.8.-6.3)

CI= confidence interval, BMI= body mass index

*Response to question “Assess your nutritional status”

†based on measured weight and height, body mass index ( BMI= weight [kg]/ height [m]2) was used to define categories in percentiles, reference BMIpercentiles were derived from the first National Health and Examination Survey using the guidelines proposed by the expert committee on clinical overweight for adolescence and WHO

‡took ³3 servings of fruits and fruit juice/day during the last 7 days

§³4 servings of green salad, carrots and other vegetables excluding potatoes/day 

**Response to question “ which of the following have you been trying to do about your weight during the last 30 days?”

††To lose weight or keep from gaining weight, during the last 30 days

‡‡Answer to question, "how often do you exercise vigorously enough to work up sweat?"

Table 3: Prevalence of measured obesity with demographic factors, food choice, weight management goals and practices among school students by gender in Jeddah, Saudi Arabia2000

Measured Obesity ?95th percentile)

Male

Female

%

(95%CI)

%

(95% CI)

Age (years):

9-12

12.9

(11.1-14.7)

11.5

(9.9-13.1)

13-15

14.2

(12.4-16.0)

15.7

(13.8-17.6)

16-21

14.9

(13.0-16.8)

12.1

(10.4-13.8)

Type of  school:

Government

13.3

(11.5-15.1)

12.8

(11.1-14.5)

Private

24.0

(21.8-26.2)

14.6

(12.8-16.4)

Mothers' education:

Low

11.3

(9.6-13.0)

11.9

(10.2-13.6)

Middle

15.3

(13.4-17.2)

15.3

(13.5-17.1)

High

17.7

(15.7-19.7)

12.6

(10.9-14.3)

Food Choices:

Fruits *

< 3 times/day

15.6

(13.7-17.5)

14.7

(12.9-16.5)

³3 times/day

12.7

(11.0-14.4)

11.9

(10.2-13.6)

Vegetables †

< 4 times/day

13.3

(11.5-15.1)

13.3

(11.6-15.0)

³4 times/day

15.1

(13.2-17.0)

12.6

(10.9-14.3)

Weight management goals ‡

Lose weight

33.7

(31.2-36.2)

26.0

(23.7-28.3)

Keep same weight

5.8

(4.6-7.0)

3.7

(2.7-4.7)

Gain weight

1.2

(0.6-1.8)

2.9

(2.0-3.8)

Do nothing about weight

9.5

(8.0-11.0)

7.4

(6.1-8.7)

Weight management practices §

Eat less food, fat or calories

No

10.8

(9.2-12.4)

8.1

(6.7-9.5)

Yes

25.4

(23.1-27.7)

22.9

(20.7-25.1)

Stay without eating for 24 hours

No

13.1

(11.3-14.9)

11.2

(9.6-12.8)

Yes

24.2

(22.0-26.4)

28.1

(25.8-30.4)

Exercise

No

9.7

(8.2-11.2)

9.9

(8.4-11.4)

Yes

23.1

(20.9-25.3)

20.7

(18.6-22.8)

Exercise vigorously **

None

14.8

(12.9-16.7)

13.4

(11.7-15.1)

³one time/week

12.9

(11.1-14.7)

16.5

(14.6-18.4)

CI= confidence interval, BMI= body mass index

*took ³3 servings of fruits and fruit juice/day during the last 7 days

†³4 servings of green salad, carrots and other vegetables/day during the last 7 days excluding potatoes

‡Response to question, “ which of the following have you been trying to do about your weight during the last 30 days?”

§To lose weight or keep from gaining weight, during the last 30 days

**Answer to question, "how often do you exercise vigorously enough to work up sweat?"

Table 4: Prevalence of perceived grossly overweight (obese) with demographic, food choice, weight management goals and practices among school students by gender in Jeddah, Saudi Arabia 2000

Self-perceived obesity

Male

Female

%

(95%CI)

%

(95% CI)

Age (years):

9-12

1.5

(0.9-2.1)

4.0

(3.0-5.0)

13-15

5.8

(4.6-7.0)

7.2

(5.9-8.5)

16-21

5.5

(4.3-6.7)

10.2

(8.6-11.8)

Type of  school:

Government

4.0

(3.0-5.0)

5.7

(4.5-6.9)

Private

8.1

(6.7-9.5)

12.4

(10.7-14.1)

Mothers' education:

Low

3.9

(2.9-4.9)

5.0

(3.9-6.1)

Middle

4.4

(3.3-5.5)

9.1

(7.6-10.6)

High

4.4

(3.3-5.5)

10.4

(8.8-12.0)

Food Choices

Fruits *

< 3 times/day

4.5

(3.4-5.6)

8.4

(7.0-9.8)

³3 times/day

4.3

(3.2-5.4)

5.5

(4.3-6.7)

Vegetables †

<  times/day

3.9

(2.9-4.9)

7.4

(6.1-8.7)

³4 times/day

5.3

(4.1-6.5)

4.5

(3.4-5.6)

Weight management goals ‡

Lose weight

14.1

(12.3-15.9)

15.5

(13.6-17.4)

Keep same weight

0.8

(0.3-1.3)

0.9

(0.4-1.4)

Gain weight

1.2

(0.6-1.8)

1.4

(0.8-2.0)

Do nothing about weight

1.6

(0.9-2.3)

2.4

(1.6-3.2)

Weight management practices §

Eat less food, fat or calories

No

2.5

(1.7-3.3)

3.0

(2.1-3.9)

Yes

10.6

(9.0-12.2)

14.0

(12.2-15.8)

Stay without eating for 24 hours

No

3.9

(2.4-4.9)

5.7

(4.5-6.9)

Yes

8.1

(6.7-9.5)

13.8

(12.0-15.6)

Exercise

No

2.2

(1.4-3.0)

4.3

(3.3-5.3)

Yes

8.8

(7.3-10.3)

12.3

(10.6-14.0)

Exercise vigorously **

None

4.1

(3.1-5.1)

7.9

(6.5-9.3)

³one time/week

5.2

(4.0-6.4)

10.8

(9.2-12.4)

CI= confidence interval, BMI= body mass index

*took ³3 servings of fruits and fruit juice/day during the last 7 days

†³4 servings of green salad, carrots and other vegetables excluding potatoes/day during the last 7 days

‡Response to question “ which of the following are you trying to do about your weight?”

§To lose weight or keep from gaining weight, during the last 30 days

**Answer to question, "how often do you exercise vigorously enough to work up sweat?"

years (mean=13.9, SD=2.8). The majority (88.9%) attended government schools and 14.7% of students’ mothers reached high level of education. Compared to females, males were older in age, more in government schools and their mothers were at the lower educational level.

                As shown in Table 2, the overall students’ perception of their body weight was nearly similar to their measured body mass index classification except in the group of overweight students, where 21.3% of the students perceived themselves as slightly overweight and only 5.5% as grossly overweight (obese), although 13.4% of students were actually classified by measured BMI as overweight and 13.5% as obese. Similar misclassifications of the overweight and obese were detected for both genders. Also, 56.7% took ³ 3 fruit or fruit juice servings per day and similar proportions were detected for males and females. Only a third ate ³ 4 vegetable servings per day, with males eating more vegetables than females. Around half of the students had no plans to do anything about their weight. The weight management goals differed by gender as males either tended to keep   their   weight   or  gain  weight  while females were keener to lose weight. Approximately, a third of the students reported that they ate less food, fat or fewer calories and 10.0% stayed without eating for at least 24 hours. Females were more likely to decrease their food, fat and calorie intake and stay for at least a day without eating than males. Among all students 31.0% did physical exercise and only 17.6% participated in vigorous physical activity. Female students were less likely than males to participate in physical exercise, especially vigorous exercise.

                The bivariate analysis in (Table 3) contains the percent (prevalence) of measured obesity in each of the categories of a specific variable. It showed that the actually obese male students were those attending private schools, born to mothers of middle and high educational level, had the weight management goal to lose weight, had practiced weight management in the form of staying without eating for at least 24 hours, ate less food, fat or calories and exercised. Actually obese females were those in the 13-15 years old age group, who had weight management goals to lose weight, had practiced weight management in the form of staying without eating for at least 24 hours, ate less food fat or calories and had exercise.

                Self-perception of being grossly overweight (obese) is shown in Table 4. Older males aged 13-15 and 16-21 years compared to 9-12 years, and attending private schools,  were those who perceived themselves as obese. Older females attending private schools, born to middle and highly educated mothers and taking less than three fruits or fruit juice servings and less than four vegetable servings daily were those who perceived themselves as obese. Both males and females who perceived themselves as obese intended to lose weight, ate less food, fat or calories, stayed for at least 24 hours without eating and had exercise.

                Multiple logistic regression models were fitted to examine the effect of various risk factors on trying to lose weight and weight management practices. As shown in Table 5, factors associated with trying to lose weight were being female, older in age, attending private school, born to highly educated mother, actually obese and perceiving oneself as obese. While for weight management practices, those who ate less food, fat or calories were the females, older, born to highly educated mothers, the actually obese and those who perceived themselves as obese. Still those who stayed

for at least 24 hours without eating were the females, belonged to the older age groups, the actually obese and those who perceived themselves as obese. Physical activity in the form of exercise was associated with the older groups, those born to middle and highly educated mothers, the actually obese and those who perceived themselves as obese. Lastly, participation in vigorous exercise was mainly among males, the younger age groups, those who ate at least 3 fruit servings and at least 4 vegetable servings per day and those who perceived themselves as obese.

DISCUSSION

The distribution of self perception of body size was similar to the classification of the measured body mass index except for those who perceived themselves as overweight. Although 13.4% of students were classified by measured body mass index into overweight and 13.5% as obese, 21.3% of students perceived themselves as slightly overweight and 5.5% as grossly overweight. This misclassification was reported by both genders. The meaning of "obesity" differs from the medical definition for many people, particularly pre-adolescence and adolescence age. Clinical and public health weight reduction programs, which do not take this into account, are unlikely to be successful, for the simple reason that those students who were actually obese may perceive themselves as slightly overweight or normal weight, and so do nothing to lose weight. Females were less likely than males to be overweight and obese but more likely to perceive themselves as grossly overweight (obese) and more likely to attempt to lose weight. Increasing age was the only risk factor that influences males to perceive themselves as obese. Among females, the risk factors associated with perceiving themselves as obese were increasing age, being in private schools and high maternal level of education. Age and gender differences in the perception of body weight have been previously described.33,34

                Fruit and vegetable intake are very important measures to ensure healthy low calorie diet.25,26 Over half of the students reported that they took at least 3 fruits or fruit juice servings daily and third of them ate at least 4 vegetable servings daily. This large percentage of daily intake of fruits could be due to the high consumption of canned fruit juices rather than fresh fruits or fresh juices in this age group. French fries could be responsible for the high daily reported intake of vegetables. Students could have assumed that french fries could stand for ordinary potatoes which were specifically mentioned in the vegetables intake question, as a vegetable serving.  This false level in the number of fruit and vegetable servings taken per day could explain the non-association found between the attempt to lose weight and weight management practices, (especially those  concerning food intake) and daily intake of either vegetables or fruits. Similar findings were detected in previous studies.34 Before considering the implications of this finding, a methodological limitation in measuring dietary behaviors must be acknowledged. A multiple 24-hour dietary recalls or semi-quantitative food frequency questionnaires with extensive dietary food items would give a better estimation of fruits and vegetable intake. The goal of a third of students was to lose weight. This number agrees with the proportion of the actually overweight and obese. The figure was less than the figure of American undergraduate college students attempting to lose weight. Nearly half (46%) of the total number investigated were trying to lose weight although they were not as overweight and obese as the Saudi students.34 Around, 28.0% ate less food, fat or calories. Only 31.0% did exercise and 17.6% were engaged in vigorous exercise to lose weight or avoid gaining weight, which is low compared to American students, 50% of whom did normal exercise and 64% of whom were engaged in vigorous exercise.35  In our study, the lack of exercise was found to be even worse in females than in males. In a study done on Saudi women from an urban health center in the Eastern province in Saudi Arabia similar findings were obtained. In that study 75% of these women were either not exercising at all or doing so in frequently, a feature expected in the middle and lower social class group of women in this region.29 Females were more likely than males to try to lose weight. Besides, females were more likely than males to reduce their food, fat or calories intake but less likely to participate in vigorous exercise in an effort to lose weight or keep from gaining weight. These results confirm previous research findings showing that weight loss attempts were prevalent; that especially older age groups actively made the effort to lose weight or avoid gaining weight; that males were the ones who usually excercised;36-38 and that diet restriction was usually by females.37 Older students, especially females, were more likely to adopt regular, rather than vigorous exercise to lose weight since compared to the male schools, female schools were less likely to include exercise or physical activity in general in its program. Cultural barriers and societal restriction added more to the discrepancy since females in general in Saudi society do not exercise in public. Even the small number of female health clubs allowed to function in the Kingdom have a membership of women of high social class only. Potentially harmful weight control by abstaining from food for at least 24 hours was the practice of 10.0% of the students. Females were again more likely to employ potentially harmful measures to reduce their weight than males.

                High social class, reflected by attendance at private schools and high maternal education, was another factor associated with perception of onself as obese especially among females. High social class was still associated with the desire to lose weight, eat less food, fat or calories and have exercise. These results emphasize the importance of education in general and maternal education in particular to combat overweight and obesity and the adoption of healthy weight management practices.

                Overweight and obesity start as early as childhood and influence adult body size. Thus actions to combat these two conditions should start early in childhood. Schools provide an ideal forum for reaching large numbers of youngsters. More than 3.9 million students are currently enrolled in the Kingdom's 20,000 schools. The educational setting in schools provide numerous opportunities to positively influence physical activity and nutrition, increase students' awareness of ideal body size and clinical obesity, strengthen weight management goals, and advocate healthy weight management practices, especially in adolescent females to prevent and treat overweight and obesity. There is a dearth of nutritional health education intervention programs in schools. These should be developed and implemented to encourage and ensure engagement in moderate physical activity (such as walking), especially among females and older adolescents. This can be an effective method of increasing caloric expenditure, promote fresh fruit and vegetable intake an important component of a nutritionally rich, low caloric diet; rather than canned fruit juices and french fries; discourage harmful weight control measures, and increase students' awareness of ideal body size and clinical obesity.

                In conclusion, many of our adolescents in schools are putting their health at risk through lifestyle choices that include insufficient physical activity and unhealthy food choices, resulting in a high prevalence of overweight and obesity. Not all obese adolescents have a correct image of their body size. Information from our cross-sectional survey provides the data base that can help in developing intervention programs which are recommended for use from childhood through school age to promote healthy food choices, encourage physical exercise and discourage potentially harmful weight control measures.

REFERENCES

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2.        Rimm EB, Stampfer M, Giovannucci E, Ascherio A, Spiegel-Man D, Colditz GA, Willet WC. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older USmen. Am J Epidemiol 1995;141:1117-27.

3.        Larsson B. Obesity, fat distribution and cardiovascular disease. Int J Obesity 1991; 15:53-7.

4.        Despres JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C. Regional distribution of body fat, plasma lipo- proteins, and cardiovascular disease. Arteriosclerosis 1990;10:497-511.

5.        Stamler R, Stamler 1, Ricdlinger WF, Algera G, Roberts RH. Weight and blood pressure: findings in hypertension screening of one million Americans. JAMA 1978;240:1607-10.

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7.        Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes. Diabetes Care 1994;17:961-9.

8.        Zimmet P, Dowse G, Finch C, Sergeantson S, King H. The epidemiology and natural history of NIDDM - lessons from the South Pacific. Diabetes Metab Rev 1990;6:91-124.

9.        Hartz AJ, Rupley DCJr, Kalkhoff RD, Rimm AA. Relationship of obesity to diabetes: influence of obesity and body fat distribution. Prev Med 1983; 12:351-7.

10.     Pi-sunyer FX. Medical hazards of obesity. Ann Intern Med 1993;119:655-60

11.     GuoSS, Roche AF. Chumlea WC,. GardnerJD, Siervogel RM.The predictive value of childhood body mass index values for overweight at age 35 y. Am J Clin Nutr 1994;59:810-9.

12.     Hill AJ, Oliver S, RogersPJ. Eating in the adult world: the rise of dieting in childhood and adolescence. Brit J Clin Psychol 1992;31:95-105.

13.     Wadden TA, Foster GD, Stunkard AJ, Linowitz JR. Dissatisfaction with weight and figure in obese girls: discontent but not depression. Int J Obes 1989;13:89-97.

14.     Hill AJ, Draper E, Stack J. A weight on children's minds: body shape dissatisfaction at 9 years old. Int J Obes 1994;18(6):383-9.

15.     Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. New Engl J Med 1993;329:1008-12.

16.     CrawleyHF, Shergill-Bonner R. The nutrient and food intakes of 16-17 year old female dieters in the UK. J Hum Nutr and Dietetics 1995; 8:25-34.

17.     Patton GC, Johnson-Sabine E, Wood K, Mann AH, Wakeling A. Abnormal eating attitudes in London schoolgirls-a prospective epidemiological study: outcome at twelve month follow-up. Psychol Med 1990;20:382-94.

18.     Rogers PJ, Edwards S, Green MW, Jas P. Nutritional influences on mood and cognitive perfornance: the nenstrual cycle, caffeine and dieting. Proc Nutr Soc 1992;51:343-51.

19.     US Dept of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta. GA: US Dept of Health and Human Services. Centers for Disease Control and Prevention. National Centerfor Chronic Disease Prevention and Health Promotion, 1996.

20.     Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7.

21.     World Health Organization. Obesity, preventing and managing the global epidemic: Report of the WHO consultation on obesity. World Health Organization: Geneva, 1997.

22.     Garrow JS, Summerbell CD. Meta-analysis: Effect of exercise, with or without dieting, on the body compostion of overweight subjects. Eur J Clin Nutr 1995;49:1-10.

23.     Pavlou KN, Krey S, Steffee WP. Exercise as an adjunct to weight loss and maintenance in moderately obese subjects. Am J Clin Nutr 1989;49:1115-23.

24.     Saris WHM. Fit, fat and fat free: The metabolic aspects of weight control. Int J Obes 1998;22:S15-S21.

25.     World Health Organization. Obesity, preventing and managing the global epidemic: Report of the WHO consultation on obesity. World Health Organization: Geneva, 1997.

26.     National Institutes of Health. National Heart, Lung, and Blood Institute' Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Washington, DC. US Dept of Health and Humaun Services, Public Health Service. ;-National heart, lung and blood institute, 1998.

27.     American Medical Association. Council on Scientific Affairs. Treatment of obesity in adults. JAMA 1988; 260:25-17-51.

28.     Nichter M, Nichter M. Hype and weight. Medical Anthropolol 1991;13: 249-84.

29.     Rasheed P. Perception of body weight and self-reported eating and exercise behaviour among obese and non-obese women in Saudi Arabia. Public Health 1998;112(6):409-14.

30.     MustA, Dallal GE, Dietz WH. Reference data for obesity: 85th percentiles of body mass index (wt/ht2) and triceps skin fold thickness. Am J clin Nutr 1991; 53: 839-46. Erratum: Am J clin Nutr 1991;54:773.

31.     Himes JH, Dietz WH. Guidelines of overweight and adolescent preventive services: Recommendation from an expert committee. Am J clin Nutr 1994;59:307-16.

32.     WHO (1995) Physical Status; The use and interpretation of Anthropometry. WHO Technical Report 854.

33.     Garner DM, Garfinkel PE, Schwartz D, Thompson M. Cultural expectations of thinness in women. Psychol Rep 1980;47:483-91.

34.     Lowry R, Galuska DA, Fulton JE, Wechsler H, Kann L, Collins JL. Physical activity, Food Choice, and Weight Management Goals and Practices Among U.S. College Students. Am J Prev Med 2000;18(1):18-27.

35.     Kann L, WarrenCW, Harris WA. et al. Youth risk behavior surveillance - United States, 1995. In: CDC surveillance summaries, September 1996. MMWR Morb Mortal Wkly Rep 1996;45:1-84.

36.     Timperio A, Cameron-Smith D, Buras C, Salmon J, Crawfird D. Physical activity beliefs and behaviours among adults attempting weight control. Int J obesity 2000;24:81-7.

37.     Crawford D, Owen N, Broom D, Worcester M, Oliver G. Weight-control practices of adults in a rural community. Aust NZ J Public Health 1998; 22:73-9.

38. Levy AS; Heaton AW. Weight control practices of US adults trying to lose weight. Ann Intern Med 1993;199:661-6.


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EXPECTATIONS OF SAUDI PATIENTS


EXPECTATIONS OF SAUDI PAT IENTS FOR MEDICATIONS FOLLOWING CONSULTATIONS IN PRIMARY HEALTH CARE IN RIYADH

Khalid A. Kalantan, MD, ABFM, MHSc, College of Medicine, King Saud University, Riyadh, Saudi Arabia

خلفية:إن معرفة توقعات المرضى عن صرف الأدوية بعد زيارة أطباء الرعاية الصحية الأولية ذو أهمية بالغة في إعداد برامج التوعوية التي تهدف الى الاستخدام الأمثل للأدوية الطبية.

طريقة الدراسة:لتحديد توقعات المرضى فيما يتعلق بصرف الأدوية بعد كل زيارة لأطباء الرعاية الصحية الأولية ، تم توزيع985  استبانة على عينة عشوائية من المرضى المراجعين لخمسة مراكز رعاية صحية أولية تمثل شمال و جنوب وشرق و غرب و وسط مدينة الرياض ، و ممن تزيد أعمارهم عن خمسة عشر سنة  وذلك  قبل دخولهم على أطباء الرعاية الصحية الأولية.

نتائج الدراسة:بينت الدراسة أن غالبية المرضى ( 87.8 %) دائماً يتوقعون أن تصرف لهم أدوية في نهاية كل استشارة طبية. وتبين أيضاً أن 88.9 % قد صُرف لهم أدوية في الزيارة السابقة ، وأن 66 % صُرف لهم 2- 3 أنواع من الأدوية في آخر زيارة ، ويعتقد معظم المرضى أن هذا العدد كثير جداً. كما تبين أن 70 % استخدموا الأدوية التي صُرفت لهم بشكل كامل حسب الوصفة الطبية. ووُجد أن أعلى نسبة استجابة واستخدام للأدوية المصروفة هم المرضى الذين مستواهم التعليمي بين المتوسط  والثانوي. كما لوحظ أن 22 % من المراجعين يعتقدون أنه يلزم وبصورة دائمة استعمال الأدوية لجميع الأمراض، وغالبية من يعتقد ذلك من الأميين أو من كان تعليمه دون المرحلة الجامعية.

الخلاصة و التوصيات:غالبية المرضى الذين يراجعون مراكز الرعاية الأولية بالرياض يتوقعون أن يصرف لهم أدوية عند كل زيارة. ينبغي اعداد برامج توعية عامة وخاصة للمرضى والأطباء على حد سواء لتفعيل الاستخدام الأمثل للأدوية.

الكلمات المرجعية:توقعات المرضى، وصف الأدوية ، الرعاية الصحية الأولية، المملكة العربية السعودية.   

Background: Knowing patients’ expectation for medication after each consultation is of the utmost importance in designing public education programs on the rational use of drugs.

Objective: To determine whether patients in Riyadh, Saudi Arabia, expect drugs after each primary care consultation.

Subjects and Methods: A sample of 985 Saudi patients aged 15 and above was randomly selected. A cross-sectional survey was carried out at five randomly selected primary care centers, using a self-administered questionnaire distributed to patients before being seen by primary care doctors.

Correspondence to:

Dr. Khalid A. Kalantan, Department of Family & Community Medicine (34), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia

Results:  Most patients (87.8%) always expect drug prescriptions. Eighty nine percent (88.9%) had been prescribed drugs in the previous consultation. Sixty six percent (66%) had received 2-3 drugs during their previous consultation. The majority thought it was too much. Seventy percent (70%) took all their prescribed drugs. Patients with intermediate and high school education had the highest compliance rate (32%). Twenty two percent (22%) thought it was always necessary to use a drug for an illness. The level of education of the majority of patients ranged  from illiterate to various levels of pre-university education.

Conclusion: Most Saudi patients expect drugs. General and specific health education should be given to both patients and doctors.

Key Words:           Patients’ expectation, Drug prescription, Primary health care, Saudi Arabia

.

INTRODUCTION

Irrational use of drugs is a known factor for increased morbidity stemming from the evolution of resistant strains as result of misuse of antibiotics. In addition, irregular use of drugs is a known factor for the poor control of chronic diseases such as hypertension and diabetes mellitus. This increases the risks of complications of cerebro-vascular accidents, amputations and blindness and chronic disabilities. The prescription of medicines is one of the most important factors in the rising costs of health services in both developing and developed countries.1-2

                The annual budget of the Ministry of Health (MOH) in Saudi Arabia is rising. In 1979, 2.61% of the national budget was given to the MOH. Seventeen years later it rose to 4.9%.3,4

                In 1993, the prescribing rate in Riyadh ranged between 10.2 and 11.8 prescriptions per patient per year.5 This is greater than that reported for the UK: 7.0, Australia: 7.7 and Sweden: 4.7.  Felimban FM5 found that 85% of consultations ended with a prescription.

                Patients strive for recognition of their views in their encounter with doctors.6,8 Bradley9 found that the commonest reason given by doctors for prescribing medicine is patients’ expectations. It was also found that when doctors did not live up to the patient’s expectations, there was dissatisfaction resulting in a negative effect on the outcome of the therapy.8,10-13 Some patients may thus receive prescriptions when they actually do not need them. This suggests that unwanted prescriptions might be responsible for drug wastage.11

                The concept of patients’ demands for prescriptions is familiar to many General Practitioners (GPs). Current research evidence shows that doctors cite patients’ demands as a factor in their prescribing habits.9,11,14,15  Stimson16 showed a linear relation between the doctors’ estimations of their patients’ expectation for drugs and their own prescribing rates.

                Though many studies have been conducted in the far East17 and in the West9,11,14,15,18,19 around patient’s expectations and their effect on doctor’s prescriptions,9,11,14,15 only a few have been done in Saudi Arabia.1,5,20

                The aim of the current study is to find out whether patients expect a medication with each primary care consultation.

SUBJECTS AND METHODS

There are 68 primary health care centers ( PHCC) in Riyadh city. The current cross-sectional survey was conducted at five, randomly selected, PHCC, representing different geographical areas (north, south, west, east & center) of Riyadh city during the month of January 1997. A systematic random sampling was used to select every third Saudi patient aged 15 and above. A self-administered anonymous questionnaire was given to the selected patients before they consulted their primary care doctors.

                The questionnaire included nine questions, divided into two parts. The first part represented patient's expectations for the present consultation, while the second part represented questions related to the previous consultation. Non-Saudis were excluded from the study. Only medical cases were included.

                A pilot study was conducted among (20) patients (10 males and 10 females) at King Khalid University Academic Primary Care Clinics. The questionnaire was modified according to the responses received.

                Among the illiterate, the questionnaire was completed through an interview, so patients’ responses may have been influenced by the interviewer. 

                The data were analyzed using SPSS/PC statistical package.21 Chi-square statistical test was used to compare the categorical variables. P-value <0.05 was considered as significant.

RESULTS

                One thousand and fourteen patients (1014) were enrolled in the study. All responded. However, 29 questionnaires were excluded because they were either dental cases or the information given was incomplete. Questionnaires included in the final analysis were 985 (97.1%). About half (52.1%) of the 985 patients were males. The demographic characteristics of the study sample are shown in Table 1.

                Most patients (88.0%), 46.0% of whom were males expected drug prescriptions (Table 2). The most frequent reasons given for not expecting drugs were reassurance and request for laboratory tests (36.9% and 15.5% respectively). Whereas the least

Table 1: The sociodemographic characteristics of patients attending PHC centers in Riyadh, Saudi Arabia

Variables

Sex

Total

No. (%)

p-value

Male

No. (%)

Female

No. %)

Age group:

15-40

362 (36.8)

409 (41.5)

771 (78.3)

<0.001

41-65

143 (14.5)

53 (5.4)

196 (19.9)

65

  8 (0.8)

10 (1.0)

18 (1.8)

Total

513 (52.1)

472 (47.9)

985 (100)

Education:

Illiterate

51 (5.8)

80 (8.1)

131 (13.3)

<0.001

Primary

80 (8.1)

82 (8.3)

162 (16.4)

Secondary school

197 (20.0)

190 (19.3)

387 (39.3)

Higher education

185 (18.8)

120 (12.2)

305 (31.0)

Total

513 (52.1)

472 (47.9)

985 (100)

Table 2: Patient’s expectations of drug prescription in relation to age and sex in RiyadhPHC centers, Saudi Arabia

Age group

Expectation of drug prescription

Total n=982

p-value

Male

Female

Yes

No

Yes

No

Yes

No

No. (%)

No. (%)

No. (%)

No. (%)

No. (%)

No. (%)

15-40

319 (32.5)

43 (4.4)

362 (36.8)

45 (4.6)

681 (69.3)

88 (9.1)

0.72

41-65

124 (12.6)

18 (1.8)

46 (4.5)

7 (0.7)

170 (17.3)

25 (2.5)

0.92

65

   8 (0.8)

-

  6 (0.6)

4 (0.4)

14 (1.4)

4 (0.4)

0.09

Total

451 (45.9)

61 (6.3)

414 (42.1)

56 (5.7)

865 (88.0)

117 (12.0)

0.99

Table 3:Patients’ expectations of drugs per prescription in relation to age at RiyadhPHC centers, Saudi Arabia

Age group

Expected number of drugs per script

Total

No. (%)

One

Two-Three

Three

No. (%)

No. (%)

No. (%)

15 - 40

138 (16.0)

509 (59.3)

29 (3.4)

276 (78.7)

41 – 65

32 (3.7)

121 (14.1)

16 (1.9)

169 (19.7)

65

  3 (0.3)

10 (1.2)

  1 (0.1)

14 (1.6)

Total

173 (20.1)

640 (74.5)

46 (5.4)

859 (100)*

Table 4:Medication behavior of PHC patients in relation to education level at Riyadh, Saudi Arabia

Medication behavior

Education Level

N=985

Total

No. (%)

Illiterate

Primary

Secondary

Higher Ed.

No. (%)

No. (%)

No. (%)

No. (%)

Always need drugs with illness

47 (4.7)

41 (4.2)

82 (8.3)

47 (4.8)

217 (22.0)

Always expected drug prescription

120 (12.1)

150 (15.2)

342 (34.7)

253 (25.8)

865 (87.8)

Complete all prescribed medication

93 (9.4)

110 (11.2)

263 (26.7)

223 (22.6)

689 (69.9)

frequent reason for not expecting drugs was that the participants were already on medication (2.4%).

                The majority (74.5%) of patients expected two to three drugs per prescription. A prescription of more than three drugs were expected by the lowest number of patients (5.4%)  (Table 3).

                Twenty two percent of the patients thought that it was always necessary to use a drug for any illness. Their educational level was below university level (Table 4).

                The percentage of patients who completed their prescribed drugs was (69.6%). In this category those with university or higher education was 22.6% as shown in Table 4.

                Two thirds (66%) of the patients were given two to three drugs per prescription during their previous consultation. The majority of them (70.2%) thought that the drugs prescribed were too many.

                Sixty percent of the patients were     aware of the side effects,  but  there  was no

Table 5:PHC patient's views toward previously prescribed drugs in relation to sex at Riyadh, Saudi Arabia

Drug's aspects

Sex

Total

p-value

Male

Female

No. (%)

No. (%)

No. (%)

No. of prescribed drugs/script:

No prescription

39 (4.0)

57 (5.9)

96 (9.9)

1

  98 (10.1)

85 (8.7)

183 (18.8)

2 – 3

336 (34.5)

306 (31.5)

642 (66.0)

3

30 (3.1)

21 (2.2)

51 (5.3)

Total

503 (51.7)

469 (48.3)

972 (100)

0.1

Appropriateness of that number:

Appropriate

40 (4.4)

23 (2.4)

     63 (6.8)

Little

58 (6.3)

40 (4.4)

98 (10.7)

Much

336 (36.5)

310 (33.7)

646 (70.2)

Do not know

51 (5.5)

63 (6.8)

114 (12.3)

Total

485 (52.7)

436 (47.3)

921 (100)

0.05

Awareness of side effects:

Aware

313 (32.0)

276 (28.2)

589 (60.3)

Not aware

195 (20.0)

193 (19.7)

388 (39.7)

Total

508 (52.0)

469 (48.0)

977 (100)

0.38

statistically significant difference between male and female patients (p 0.38) (Table 5).

                The main source of awareness was personal experience with drugs (23.7%), followed by the media or the reading of medical books (21.0%). However, only 13.5% of the information was given by doctors.

DISCUSSION

One part of the questionnaire concerned the previous consultation, giving rise to recall bias.

                The finding that most patients were below 65 years of age is consistent with demographic picture of Saudi Arabia as a young population.

                The majority of patients thought that it was not always necessary to take a drug for an illness. However, most Saudi patients  expected to be given a prescription when they went to consult their primary care doctors. This is higher than that found in Western11,16,22,23 and Eastern 17 populations.

                The high drug-prescription rate might be due to doctor’s habits and patients’ beliefs. Doctors may contribute to this by their prescribing habits, prescribing too readily because of over estimation of patients’ expectations for drugs.11,16,17,22,23 Generally, doctors prescribe to satisfy their patients since they believe that the patients might go to another doctor to seek the advice. Also, high prescribing rate may be because drugs are prescribed free of charge in Saudi PHCC.5,24 Hence, over-prescribing makes life easier for doctors as it reduces consultation time and increases the number of patients seen every day.5,11

                However, low education level of the patients was found to be associated with this high expectation percentage, as the majority of those who expected drugs ranged between illiterate to having pre-university level of education.

                This belief in medication decreased with the higher level of education i.e., the groups with higher education.

                Although the majority of patients had been given 2-3 drugs per prescription in the previous consultation, they thought they were too many. This may explain why about 2/3 of patients expected 2-3 drugs in the current consultation. Physicians usually prescribed 2-3 drugs because according to the quality assurance manual of MOH, they could write up to a maximum of three drugs per prescription. 25

                A high percentage of patients were not aware of the side effects of drugs, which indicates inadequate health education. This may be because of the faith patients had in doctors. “A doctor could not possibly harm me!”

                Among those who were aware of side effects, only 13.5% of them obtained their information from doctors. This reflects the lack of information from doctors.5

                Among those who did not expect drugs, the most frequent reason was reassurance.  This is consistent with the finding of other studies.11

                In conclusion, this study has shown that most patients always expect drug prescriptions. Most of the patients had been prescribed drugs in previous consultations. About a quarter of the patients thought it was always necessary to use a drug for any illness. The majority of these ranged from illiterate to those with various degrees of pre-university education. It is recommended that primary care physicians should play a major role in patients’ education, particularly on the optimal use of drug therapy in patient care, and the harmful effects of drugs. There should be better doctor-patient communication to improve the awareness of patients’ expectations. It is also recommended that physicians restrict their prescriptions to what the patient really needs. General and specific health education measures should be given to patients, assistant pharmacists and doctors.

ACKNOWLEDGMENT

I would like to thank the following students; Hatem A. Kalantan, Thamer A. Nouh, Khaldoon A. Al-Jerian, Aous A. Mansouri and Riyadh M. Al-Bgumi, for their great assistance.

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