FACTITIOUS DISORDER


FACTITIOUS DISORDER IN SAUDI ARABIA: A REPORT OF TWO CASES

Tariq A. Al-Habeeb, KSUF (Psych), College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

                    

تتصف الإضرابات المصطنعة بوجود أعراض عضوية أو نفسية يتظاهر بها الفرد قصدا أو يختلقها دون وجود بواعث جلية سوى رغبته في انتحال الدور المرضي. ولم تدرس هذه الاضطرابات في مرضى سعوديين إلا نادرا. وفي هذه المقالة نعرض حالتين مرضيتين لرجل وامرأة سعوديين مصابين بهذا الاضطراب، وأظهر كل منهما ملامح متلازمة منشوسن. وقد نشد كل منهما –مثلهم مثل كثير من المرضى النفسيين –العلاج عند المعالجين الشعبيين قبل مراجعتهم للمستشفي. وعلى الرغم من اختلاف العوامل الاجتماعية والحضارية فإنه من الواضح أن الوعي والقبول لدى الأطباء بإمكانية حدوث الاضطرابات المصطنعة هو مطلب مهم لتشخيصها.

Factitious disorders are characterized by physical or psychological manifestations that are intentionally produced or feigned with no apparent external incentives in order to assume the sick role. These disorders are rarely reported or may be under-reported in Saudi patients. We describe here two male and female Saudi cases of such disorders. Both presented  predominantly  with  features of Munchausen’s syndrome. Like most psychiatric patients both had sought help from traditional healers prior to their reporting to the hospitals. Inspite of the socio-cultural factors, it is clear that doctors’ awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis.

Key Words:Factitious disorders, cultural factors.

INTRODUCTION

Socio-cultural factors are important in the epidemiology and psychopathology of various psychiatric disorders1,2 including factitious ones. They have an influence on the pathways to seeking medical help.3 In addition, illness behavior has cultural overtones in Arab patients.4

                        Factitious disorders are characterized by physical, and psychological signs or symptoms that are intentionally produced with no external incentives to feign illness.5 These disorders have been reported from various cultures.6,7

                        A distinction should  be  made  between factitious disorders and malingering. In the latter, the patient produces symptoms with an obvious goal. In factitious disorders, the motivation to be a patient is vague and obscure.

                        Munchausen’s syndrome, in its classic description, is  an  uncommon  subtype of factitious disorder which has received great attention.7,8 This syndrome is the earliest description of a  factitious  disorder with predominantly physical signs and symptoms. Although factitious disorders are common among males, recent reviews indicated a


Correspondence to:

Dr. Tariq A. Al-Habeeb, Assistant Professor and Consultant, Head, Division of Psychiatry, College of Medicine, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia


preponderance of female patients.9 The probable judgement that a particular symptom is produced intentionally is made both by direct evidence and with the exclusion of other causes of the symptoms. Almost in all reported cases of factitious disorders with physical symptoms, no obvious major mental disorder has been found. However, many such patients have been described as  having  underlying  masochistic, borderline or dependent personality traits.9 Although the prognosis is usually poor, patients who have adequate psychosocial support with less severe personality pathology can do better. In this article, two patients who suffered from such disorders are described.

CASE 1

A 45-year-old, illiterate, Saudi housewife was referred from a medical ward for psychiatric consultation. During her stay in the medical ward, she was investigated for skin lesions distributed mainly on the abdomen and both thighs, but not on her back or other areas of the body inaccessible to the hand. The dermatologist suspected factitious dermatosis (dermatitis artefacta).

                        Her case history revealed that two years prior to her current psychiatric consultation, she was hospitalized for vague abdominal pain, but all investigations were normal. After discharge from the hospital, she consulted a traditional healer who treated her by cauterization. During the following two years, she presented with recurrent skin lesions on the abdomen, arms and both thighs. Some of the lesions were new, others were exacerbations of old lesions. The lesions were incapacitating and prevented her from performing her usual household choices. Her family background showed that she had four growing children. Her illness had created marital discord but there was no family history of mental illness. Furthermore, she had no past history of serious physical or mental illness. Her premorbid personality revealed underlying dependent personality traits. The examination of the mental state did not show any major disorder.

                        During her stay in the psychiatric ward for observation, the  lesions  were  dressed properly. Evidence of intentional production of skin lesions on healed sites and on new areas was reported. When confronted with evidence of  their factitious nature, she  denied  doing herself any harm. Surprisingly, she did not demand discharge.

                        The judgement that the skin lesions were produced intentionally was made by direct evidence from the staff in the ward and by excluding other causes of these lesions. She was discharged from the psychiatric ward after three months and given a follow-up appointment in the psychiatric clinic but she never showed up.

CASE 2

A 39-year-old, single, illiterate and unemployed Saudi male presented with dramatic severe abdominal pain. He was vague and inconsistent when questioned in detail about the nature of the pain. When  all  of the investigations proved negative, he started to complain of chest pain. Intentional production of physical symptoms was suspected and he was referred for psychiatric assessment.

                        His past history showed that he had been admitted to different general hospitals in Saudi Arabia, some of which were far from his hometown. The information received from some of these hospitals showed that repeated medical and surgical consultations, including extensive investigations, did not reveal any physical disorder. In addition, psychiatric assessment showed no evidence of mental disorders either.

                        During his stay in the psychiatric unit, he presented with acute renal pain, hematuria and evidence of self-induced blood tinged stool. On confronting the patient about the factitious nature of his complaints after organic causes  had  been ruled out, he became angry and discharged himself. Two months later, he presented to the hospital in a deaf-mute state but left the hospital when again confronted. Similarly, he did not benefit from traditional healers whom he had visited many times, on the advice of his relatives. He continued to appear in the hospital with different symptoms. Once he simulated the symptoms of acute asthma. We managed him by confronting his symptoms but remaining supportive.

DISCUSSION

One of the essential clinical features of the above two cases is the intentional production of physical symptoms. The first case is that of factitious dermatosis, the second is  of  chronic  physical symptoms associated with multiple hospitalizations. The first case  of  dermatitis  artefacta was preceded  by  cauterization  from a traditional healer which might have acted as a predisposing factor. The second case is similar in presentation to other classic cases of Munchausen’s syndrome10 described in several cultures.

                        It is  important for clinicians to remember that with factitious disorder there could be some real physical illnesses that need appropriate management.11

                        The behavior of these two patients has cultural dimensions. To travel, females in the Saudi culture need “mahram” (a person whom they cannot legally marry) who might  not always  be available.12 This requirement restricts their travel creates an important feature of what was known as wandering  type of  Munchausen’s syndrome.13 In  females,  the  type of    Munchausen’s syndrome that is characterized by less severe psychopathology, a higher functioning  level and  less frequent  factitious behavior is classified as non-prototypical.14 This classification seems to be justified as revealed in case 1, though it has recently been criticized8 because the criteria for classification are not applicable in a good number of factitious disorder cases.

                        New modern hospitals are common in Saudi Arabia. For submissive female and male patients, falling sick is a means of receiving attention, avoiding responsibility and preserving their integrity. This might be incorporated  into  the psychopathology of factitious disorders in Saudi culture.

                        In spite of socio-cultural factors, it is clear that doctors’ awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis. Once factitious disorder is diagnosed, it  is  important to confront  the  patient  but  remain  supportive. Confrontation should be carefully planned. In Saudi culture, it would be inappropriate to inform the relatives that the patient is feigning the  symptoms, since this may precipitate psychotic breakdown of the patient.

                        Interestingly,  both  patients  consulted traditional healers during their factitious behavior. Although consulting traditional healers could be explained partially by the religious background of the Saudi culture, it is interesting that in spite of the modern treatment available in Saudi Arabia, patients including those with factitious disorder, still consult traditional  healers with their somatic and psychological symptoms.

REFERENCES

1.   Kleiman A, Good B. Culture and depression. Berkly: University Press; 1985.

2.   Chakraborty A. Cultural perscpectives in Indian psychiatry (Editorial). Indian J Psychiatry 1992;34:1-2.

3.   Roglers LH, Cortes  DE. Help seeking pathways: A unifying concept in mental health care. Am J Psyciatry 1993; 150:554-61.

4.   El-Islam F. Cultural aspects of illness behaviour. Arab J Psychiatry 1995; 6:13-18.

5.   American Psychiatric Association (1994): Diagnostic and Statistical Manual of Mental Disorders (4th ed) Washington DC: Author.

6.   Bhatia RS. Pseudosickness. J Assoc Physcians India1990;38:514.

7.   Folk DG. Munchausen’s syndrome and other factitous disorders. Neurologics Clinic 1995; 13(2):267-81.

8.   Sutherland AJ, Rodin RM. Factitous disorders in General Hospital settings: clinical features and a review of literature. Psychosomatics 1990;31:392-9.

9.   Rebecaa MJ. Factitious disorders. In: Kaplan HI, Sadock BJ, editors. Comprehensive Textbook of Psychiatry, 5th ed. Baltimore: Williams & Wilkins; 1995. 1271-9.

10.Asther R. Munchausen’s syndrome. Lancet 1951;1:339-41.

11.Jeffrey D. Munchausen’s syndrome and substance abuse. J Subst Abuse Treat 1994;11(3): 247-51.

12.Qureshi NA, Hegazy IS. Munchausen’s syndrome and trihexyphenidyl dependence. Indian J Psychiatry 1993;35:187-8.

13.Carney MWP, Brown JP. Clincial features and motives among 42 artifactual illness patients. Br J Med Psychol 1983;56:57-66.

14.Nadelson T. False patients/real patients: A spectrum of disease presentation. Psychotherapy and Psychosomatic 1985;44: 175-84.



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FACTORS INFLUENCING


FACTORS INFLUENCING PATIENTS’ UTILIZATION OF PRIMARY HEALTH CARE PROVIDERS IN SAUDI ARABIA

Badran A. Al-Omar, PhD, Khalid S. Bin Saeed, PhD

Master’s Program in Hospital & Health Administration, College of Administrative Sciences, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة: تحديد العوامل التي تؤثر على استخدام المرضى لمقدمي الرعاية الصحية الأولية في المملكة العربية السعودية.

طريقة الدراسة:تم جمع البيانات من خلال استبانة مصممة لتحقيق هدف البحث، حيث تم توزيعها عشوائيا على عينة شملت 408 من المرضى في خمسة مراكز للرعاية الصحية الأولية بوزارة الصحة، وخمسة من مراكز الرعاية الأولية بالقطاع الخاص. وقد تم جمع هذه البيانات خلال الفترة من 15 فبراير إلى 15 مارس 1998م. تم استخدام تحليل التمايز الإحصائي المتدرج للمجموعتين بالنسبة للعوامل المؤثرة على استخدام المرضى لتلك المراكز.

نتائج الدراسة:دلت نتائج الدراسة أن سبعة عوامل من ثلاثة وثلاثين عاملا لديهم التأثير المعنوي في عملية التمييز بين المرضى الذين يعالجون في المراكز الصحية الحكومية والمراكز الصحية التابعة للقطاع الخاص. هذه العوامل هي: (1) مصدر الدفع، (2) توافر مصادر أخرى للدخل، (3) المسافة بين مكان إقامة المريض والمركز، (4) التعليم، (5) المفاضلة في جنس الطبيب، (6) المفاضلة في اختيار الطبيب السعودي، (7) الجودة المدركة للهيئة الطبية.

التوصيات:توصي الدراسة بالتركيز على ناحية التوزيع الأمثل لمقدمي الخدمة الصحية من ناحية جنس الطبيب، بحيث يكون هناك نوع من توافر الجنسين في كل مركز. كما توصي الدراسة بالاهتمام بجودة الخدمات الصحية المقدمة من قبل المراكز الصحية الأولية في المجموعتين. وتوصي الدراسة أيضا باستمرار البحث العلمي في مجال الاستخدام الأمثل للخدمات الطبية في مراكز الرعاية الأولية.

الكلمات المرجعية:استخدام المرضي، مقدمو الرعاية الصحية الأولية، تحليل التمايز المتعدد، جودة الخدمة.   

Objective:To determine the factors that significantly discriminate between Ministry of Health (MOH) and private primary health care patients in Riyadh City, Saudi Arabia.

Methodology: Through a self-administered questionnaire, data were collected from 408 randomly selected patients in five MOH primary health care centers and five private dispensaries. Data collection was conducted from February 15 to March 15, 1998. Two-group stepwise discriminant analysis was utilized in analyzing the data.

Results: Seven of the 33 factors were found to be statistically significant in discriminating between MOH and private patients. These factors were: (1) source of payment, (2) availability of other sources of income, (3) distance between residence and

Correspondence to:

Dr. Badran A. Al-Omar, PhD, Assistant Professor and Coordinator, Master’s          Program in Hospital & Health Administration, College of Administrative Sciences, King Saud University, P.O. Box 61435, Riyadh 11565, Saudi Arabia

Primary Health Care (PHC) provider, (4) education, (5) preference for similar-gender doctors, (6) preference for Saudi doctors, and (7) perceived quality of medical staff.

Conclusion: The study notes that PHC providers cannot control the sociodemographic characteristics of  patients. Therefore,  policy  makers  should focus  on  ensuring that PHC facilities have enough male and female doctors. Furthermore, the quality of the medical staff of these facilities should be upgraded to improve the overall quality of the services they provide. The conduct of further studies related to the utilization of health care providers is also recommended.

Key Words:Patients’ utilization, primary health care providers, stepwise discriminant analysis, quality of services.


 

INTRODUCTION

                                Primary health care (PHC) can be considered the first contact between the patient and the health care system. It includes all the basic health care services provided to every member of the society. Thus, PHC is essential for attaining an acceptable level of health for the general public. It is also an integral and critical component of the entire health care system of any country. Therefore, PHC services should be accessible and available to the entire population, regardless of their economic or social class and geographical location.1

                                In the Kingdom, the Ministry of Health (MOH) has the primary responsibility of meeting  the  health  care needs of the general population. The MOH also emphasizes the importance of PHC services by implementing a referral system, the only means  of  gaining  access to secondary and tertiary care. By 1997, the MOH was operating a total of 1,737 PHC centers throughout the Kingdom.2

                                The government continues to shoulder the bulk of the responsibility for meeting the health care needs of the public. However, the government also emphasizes the importance of the private sector in the overall development including health care of the Kingdom. In fact, the concept of privatization was highlighted in the Sixth Development Plan.3 The private sector responded so well to this government initiative of privatization, that by 1997, there were 611 private dispensaries operating in various parts of the Kingdom.2

                                Increasing the number of facilities may be a  good start  for   any PHC initiative. However, the success  of  any PHC program in accomplishing its objectives and goals is largely dependent on good management. To get high  quality of  PHC services,  the management must continually strive to meet the patients’ needs at minimum costs.4 Furthermore, the quality of services provided by PHC facilities should not only be maintained, but also continually improved.5

This study was conducted with the main objective of determining the factors that influence patients’ utilization of PHC providers in Riyadhcity. In view of the dearth of published materials in this area, the information generated by this study will be useful for policy makers in their attempt to improve the services available to patients. Specifically, this study aimed to determine the factors that best discriminate between MOH and private PHC patients.

METHODOLOGY

Al-Dayel6 and Al-Omar7 tested the reliability and validity  of  an  initial version of the questionnaire utilized in this study and later revised to suit PHC settings. To test the reliability and validity of the revised questionnaire, 10 PHC patients (five MOH patients and five private patients) were asked to answer the questionnaire. Their comments and suggestions were incorporated in the final version of the questionnaire, which measured with coefficient alpha had a reliability of 0.85.

                                The questionnaire included 11 socio-demographic and 22 attitudinal factors. The responses were ranked on a four-point scale: 1=not important at all; 2=not important; 3=important; 4=very important. A total of 450 questionnaires were distributed to a stratified sample drawn from five MOH-PHC centers and five private PHC centers or dispensaries. It should be noted here that no inclusion or exclusion criteria were used in the selection of respondents. Of the total number of questionnaires distributed, 408 were found valid and included in the analysis (194 from MOH-PHC centers and 214 from private dispensaries). Thus, the response rate of the data collected from February 15 to March 15, 1998was 81.6%.

                                The SPSSPC+ statistical package was utilized in the data analysis, a two-group discriminant analysis to answer the study question, a Chi-square test to determine the significance of the function, and the Wilks’ Lambda test to determine the significance of each independent variable (note that the new versions of SPSS replace missing values with mean in the DA). Furthermore, descriptive statistics (frequencies, percentages, means and standard deviation) were also used in the data analysis.

RESULTS AND ANALYSIS

Table 1 presents the socio-demographic and attitudinal factors included in the study. This table shows that, on the average, the MOH primary care patients were older, had more family   members, lower educational level and lower monthly income than private patients. The MOH had a higher percentage of Saudis and patients who were in employment. Furthermore, the MOH had a lower percentage  of males, married  patients, and patients with a source of income other than their employment. Moreover, a much higher proportion of MOH patients had a source of payment other than themselves and also had a relatively better health status than private patients.

                                The results of the test for equality of group means are shown in Table 2. It can be seen from this table that among the 34 factors considered in this study, only eight factors yielded statistically significant group means between MOH and private patients. These factors were: (1) source of payment, (2) preference for Saudi doctors, (3) nationality, (4) education, (5) distance between residence and PHC provider, (6) availability of same gender doctors, (7) accessibility of PHC provider, and (8) availability of other sources of income.

                                Table 3 shows that the results of the two- group stepwise discriminant analysis reveal seven factors that significantly discriminate between MOH and private patients: (1) source of payment, (2) availability of other sources of income, (3) distance between residence and PHC provider, (4) education, (5) preference for same gender doctors, (6) preference for Saudi doctors, and (7) perceived quality of medical staff. The results mean that only these seven factors independently and significantly discriminate between MOH and private patients.

                                The discriminant function was also found to be statistically significant (chi-square= 65.857; p < 0.0001). A high canonical correlation (about 0.80) for the discriminant function and a high percentage (greater than 85%) of grouped cases correctly classified are also


 

Table 1: Frequency distribution, means and standard deviation (SD) for the Socio-demographic factors included in the study

VARIABLE

MOH PATIENTS

PRIVATE PATIENTS

n

%

Mean

SD

n

%

Mean

SD

Age (years)

3.11

11.02

30.82

8.67

25 years old or less

51

37.78

50

32.26

26 – 35 years old

51

37.78

64

41.29

More than 35 years old

33

24.44

41

26.45

Number of family members

6.59

2.98

5.64

3.04

Five or less

67

42.68

108

61.36

More than five

90

57.32

68

38.64

Education

2.93

0.94

3.25

0.91

Little

12

6.19

5

2.38

Intermediate

53

27.32

41

19.52

Secondary

68

35.05

70

33.33

Undergraduate

58

29.90

84

40.00

Postgraduate

3

1.55

10

4.76

Gender

0.53

0.50

0.62

0.49

Male

101

53.16

131

61.50

Female

89

46.84

82

38.50

Monthly salary

3952.4

2256.4

4312.7

2571.8

Less than SR 2,500

46

33.09

35

28.93

SR 2,501 – SR 4,999

56

40.29

53

43.80

SR 5,000 or more

37

26.62

33

27.27

Nationality

0.80

0.40

0.64

0.48

Saudi

153

79.69

78

36.45

Non-Saudi

39

20.31

136

63.55

Marital status

0.65

0.48

0.72

0.45

Married

125

64.77

155

72.43

Unmarried

68

35.23

59

27.57

Occupation

0.63

0.48

0.61

0.49

Employed

120

62.83

129

61.43

Unemployed

71

37.17

81

38.57

Has other source of income

0.10

0.31

0.22

0.41

Yes

17

10.37

35

21.60

No

147

89.63

127

78.40

Source of payment

0.09

0.29

0.81

0.39

Self

18

9.42

171

81.43

Others

173

90.58

39

18.57

Perceived health status

1.52

0.64

1.59

0.61

Good

105

54.69

98

46.23

Fair

76

39.58

105

49.53

Poor

9

4.69

7

3.30

Very poor

2

1.04

2

0.94

Table 2: Test for equality of group means

FACTOR (Measurement code)

WILKS’ LAMDA

F-VALUE

P-VALUE

Source of payment (1=Self; 0=Others)

0.6809

31.40

0.0000*

Preference for Saudi doctors†

0.8537

11.49

0.0012*

Nationality (1=Saudi, 0=Non-Saudi)

0.9053

7.01

0.0101*

Education (1=Little, 5=Postgraduate)

0.9237

5.54

0.0215*

Distance between residence and PHC provider†

0.9254

5.40

0.0232*

Availability of similar-gender doctors†

0.9259

5.36

0.0237*

Accessibility of PHC provider†

0.8381

4.42

0.0393*

Availability of other sources of income (1=Yes, 0=No)

0.9430

4.05

0.0482*

External design of the center of dispensary†

0.9466

3.78

0.0561

Availability of doctor who speaks similar language†

0.9537

2.99

0.0886

Number of family members (continuous)

0.9589

2.87

0.0948

Availability of medicine†

0.9694

2.11

0.1506

Availability of diagnostic facilities†

0.9762

1.63

0.2056

Availability of advanced medical equipment†

0.9789

1.44

0.2337

Cost of treatment†

0.9798

1.38

0.2440

Availability of 24-hour services†

0.9829

1.16

0.2850

Perceived health status (1=Good, 4=Very poor)

0.9832

1.14

0.2888

Monthly salary (continuous)

0.9834

1.12

0.2918

Easy admission procedures†

0.9865

0.92

0.3408

Physical setting of the center or dispensary†

0.9897

0.69

0.4083

Perceived quality of administrative staff†

0.9899

0.68

0.4115

Marital status (1=Married, 0=Unmarried)

0.9912

0.60

0.4418

Perceived quality of medical staff†

0.9914

0.58

0.4487

Existence of relationship with a staff of the center or dispensary†

0.9951

0.33

0.5667

Availability of specialized doctors†

0.9968

0.22

0.6447

Perceived quality of nursing staff†

0.9984

0.11

0.7405

Cleanliness of the center or dispensary†

0.9985

0.10

0.7555

Availability of entertainment facilities†

0.9991

0.06

0.8018

Waiting time†

0.9993

0.05

0.8307

Age (continuous)

0.9997

0.02

0.8846

Occupation (1=employed, 0=unemployed)

0.9998

0.01

0.8889

Convenience of appointments†

0.9999

0.00

0.9724

Friendliness of the staff†

1.0000

0.00

1.0000

*Statistically significant at p<0.05

†1=Not important at all; 4=Very important  

Table 3: The discriminant analysis results after seven steps

FACTOR

WILKS’ LAMBDA

SIGNIFI-CANCE

STANDARD COEFFICIENTS

Financial factors

Source of payment

0.6810

0.0000

0.5855

Availability of other sources of income

0.4727

0.0000

0.5606

Accessibility of provider

Distance between residence and PHC provider

0.5863

0.0000

0.3542

Socio-demographic factors

Education

0.5200

0.0000

-0.5183

Provider characteristics

Preference for similar-gender doctors

0.4244

0.0000

0.4045

Preference for Saudi doctors

0.3871

0.0000

0.3014

Quality of staff

Perceived quality of medical staff

0.3633

0.0000

-0.4103

Group classification Results

Predicted Groups

Actual Group

Group

N

MOH

Private

MOH-PHC provider

0

194

166 (85.6%)

28 (14.4%)

Private PHC provider

1

214

  31 (14.5%)

183 (85.5%)

Percentage of grouped cases correctly classified = 85.54%

Canonical correlation = 0.7979, Chi-square = 64.294, p-value = 0.0000

Discriminant function’s group centroids: MOH-PHC patients (Group 0) = -1.3625

Private PHC patients (Group 1) = 1.2490


 

presented in Table 3. The group centroid of –1.3625 for the MOH-PHC patients (group 0) and 1.2490 for the private PHC patients (group 1) can be explained as the number of standard deviations each group is from the average of both groups (the standardized average for both groups is zero).8 The centroids show a significant degree of discrimination between MOH and private PHC patients. The canonical correlation of 0.7979 means that 63.66% of the variance in the utilization of PHC provider can be explained by the model.

                                In the discriminant analysis, each significant factor was entered into the model according to its contributing power to the differentiation between the two groups.9 The estimates for this model reveal that the source of payment was the strongest predictor of the utilization of PHC provider. Thus, a patient who would pay for his or her treatment could be expected to choose a private PHC provider.

                                The distance between residence and PHC provider was the next strongest discriminating factor. In a study conducted in the Cameroons, distance was also found to strongly influence  the  utilization of health  care provider.10 The results of this study mean that a patient who reckoned this factor as important was more likely to choose a public PHC provider. This supports the findings of Al-Omar7 and Egunjobi.11

                                The third discriminating factor was education, implying that the more educated patients were more likely to go to private PHC providers. This may indicate some dissatisfaction among educated patients with the PHC services provided by MOH facilities. These results agree with the findings of Al-Dayel6 but contradict that of Bin Saeed12 who found  no  significant  influence of education on the choice of health care facilities.

                                The significance of the preference for same gender doctors confirm the findings of Al-Zahrani13 that patients were more likely to go to private health care providers if they preferred to be treated by doctors of the same gender. The preference for Saudi doctors indicates that patients were more likely to go to MOH facilities if they preferred to be treated by Saudi doctors.

                                The perceived quality of medical staff was  another  statistically significant  discriminating factor between MOH and private patients. An earlier study found that patients considered the quality of medical staff as the most important factor in choosing a health care facility.14 The results of this study support the findings of Bin Saeed12 that those patients who thought of the quality of care as important were more likely to seek treatment in private health care facilities.

CONCLUSION

This study  primarily  focused  on determining the independent factors that significantly discriminate between MOH and privte PHC patients. The results of this study suggests that PHC settings must give serious  consideration  to   the  significant  factors  obtained  by this study in order to meet the expectations of their patients. It should be noted that the socio-demographic characteristics of the patients are  beyond  the  control  of PHC providers. Therefore, PHC policy makers should  focus  on  those factors within their control, such as providing enough number  of  both  male   and  female  doctors, especially Saudi doctors. The results of this study indicate the heavy reliance of private facilities on non-Saudi doctors.

                                Primary health care facilities should also focus on improving the quality of its medical staff since the results of this study indicate that patients consider this factor as vital in their  utilization  of  PHC  providers. The quality of PHC medical staff in MOH facilities could be improved through the provision of continuing education and training activities. It is our view that it would be economical to improve the quality of service in PHC facilities with the provision of advanced medical equipment.

                                At this point, it is important to note that due to certain limitations of this study there should be caution in generalizing its findings. Since the sample of the study was taken from one geographical area it cannot be viewed as representative of  the  entire  population. Furthermore, the total number of respondents was relatively small compared to the total primary health care patient population. Nonetheless, these findings provide an important starting point for future research.

                                Finally, the findings of this study suggest that further studies focusing on a different geographical area or greater number of respondents should be done on the utilization of health care facilities and providers. Other statistical techniques may also be utilized. The data generated by these studies can fill in the serious paucity of information in this area. The information thus obtained will be invaluable to policy makers, especially in dealing with the greater demand for high quality care at the lowest possible cost.

ACKNOWLEDGMENT

The authors are grateful to Mr. Menahi Al-Kahtani for his assistance in collecting the data.

REFERENCES

1.     Kleczkowski B, Elling R, Smith D. Health system support for Primary Health Care. Geneva: World Health Organization, 1984.

2.     Ministry of Health. Annual Health Report 1997. Riyadh: Ministry of Health; 1997.

3.     Ministry of Planning. Sixth Development Plan: 1995-2000. Riyadh:Ministry of Planning;1995.

4.     Ovrerveit J. Health Service Quality: An Introduction to  Quality Methods for Health Services. London: Blackwell; 1992.

5.     Amsden DM, ButlerHE, Amsden RT. SPC simplified for services: Practical tools for continuous quality improvement. Quality Resources; New York: 1991.

6.     Al-Dayel S. Patient choice of hospitals in Saudi Arabia[Master’s thesis]. Riyadh; King Saud University: 1997.

7.     Al-Omar BA. Determinants of consumers’ healthcare provider choice. Saudi Medical Journal 1999 (in press).

8.     Hair JF, AndersonRE, Tathma RL. Multivariate data analysis with readings. New York: Macmillan; 1987.

9.     Munro BH. Statistical methods for health care research. 3rd ed. Philadelphia; Lippincott: 1997.

10.   Tembon AC. The Northwest provinceof Cameroon. International J of Health Planning and Management 1996; 11:53-67.

11.   Egunjobi L. Factors influencing choice of hospital: A case study of the northern part of Oyo State, Nigeria. Social Science and Medicine 1985; 17:585-9.

12.   Bin Saeed KS. Factors affecting patients’ choice of hospitals. Annals of Saudi Medicine 1998;18:420-4.

13.   Al-Zahrani G. Why do patients choose private hospitals in Jeddah city [Master’s Thesis]? Riyadh; King Saud University: 1996.

14.   Jensen J. Choosing a hospital. American Demographics Journal 1987; 9:44-47.


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MEDICAL CAREER


CHOOSING A MEDICAL CAREER: WHAT INFLUENCES SECONDARY SCHOOL FEMALE GRADUATES?

Badria K. Al-Dabal, FFCM (KFU), Department of Family & Community Medicine, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة: تقييم اتجاهات وأسباب اختيار طالبات الثانوية العامة الالتحاق بكلية الطب والعلوم الطبية.

طريقة الدراسة:شملت الدراسة طالبات الثانوية العامة اللآتى تقدمن للالتحاق بكلية الطب والعلوم الطبية بجامعة الملك فيصل بالدمام عام 1996م، وعددهن 191 طالبة. وتم إجراء دراسة مقطعية مستعرضة. وقد استخدم استبيان معد لتلك الدراسة تم تعبئته من قبل الطالبات.

نتائج الدراسة:بلغ عمر الطالبات المشاركات في الدراسة 18.3 ±0.94 سنة، وقد وصلت النسبة العامة لمعدل الطالبات الملتحقات بقسم الطب البشري وتقنية المختبرات والتمريض 94.02%، 91.26%، 86.78% على التوالي. وكانت الرغبة الشخصية هي السبب الرئيسي للالتحاق بكلية الطب لدى 85.7% من الطالبات، وبينما أبدت 109 طالبة (75.1%) بعض المعلومات عن مهنة الطب، لم يتيسر ذلك لدى 42.9% منهن. وقد توقعت 161 طالبة (84.3%) منهن مواجهة بعض الصعوبات في الدراسة.

الاستنتاجات:لقد بينت الدراسة أن الرغبة الشخصية هي السبب الرئيسي في التحاق الطالبات بالكلية، كما أن هناك نسبة ليست بالقليلة من الطالبات ممن ليس لديهن أية معلومات عن التخصص، وأن 80% من الملتحقات يتوقعن وجود بعض الصعوبات في كلية الطب. كذلك بينت الدراسة أن الغالبية العظمى من الطالبات الملتحقات بقسم تقنية المختبرات لم يكن لديهن الرغبة في الالتحاق بقسم التمريض. وهناك حاجة لتعزيز الخطة المتبعة حاليا في الكلية لتوعية طالبات الثانوية العامة بالتخصصات الموجودة في كلية الطب والعلوم الطبية.

الكلمات المرجعية:اتجاهات ، طالبات، مهنة.

Objective:To assess attitudes and reasons of secondary school female students for choosing medicine as a career.

Design:A cross-sectional study with a sample of 191 female students, who responded to an administered questionnaire.

Results: The mean age of the students was 18.3 ± 0.94. The mean general average test scores for female students who applied to medicine, MLT and Nursing was 94.02%, 91.26% and 86.78% respectively. Personal interest was the main reason in 85.7% of the applicants. Only 109 students (57.1%) of the study group have any knowledge about the profession of Medicine. One hundred sixty one of the students (84.3%) expected difficulties in their studies.

Conclusion: The study showed that personal interest was the main reason behind the students’ choice. A sizable proportion had no knowledge of the specialty they opted for, while more than 80% of the applicants anticipated some difficulties upon entering the Medical College. The majority of MLT applicants were not interested in

Correspondence to:

Dr. Badria K. Al-Dabal, P.O. Box 1102, Dammam 31431, Saudi Arabia

nursing as a specialty. The current strategy for educating secondary school female students about Medical College programmes should be strengthened.

Key Words:Attitudes, female students, career.


INTRODUCTION

The Kingdomof Saudi Arabiais a fast developing country, that has achieved great advances in all aspects of life. Education is one of the fields where marked progress and expansion are evident. More girls are now enrolled in educational institutions than before and universities are now offering Secondary School female graduates programmes suitable for the Saudi society.1 Medicine and Medical Sciences are amongst the choices which attract Secondary School females particularly those who had high scores at the end of their Secondary School education.

The annual intake of the four Medical Colleges in Saudi Arabia one of which is the College of Medicine in King Faisal University is approximately 600 students.2 The admission policies in the four colleges are similar. A certain minimum percentage of the overall (general) average score and the special  (scientific)  average  of the secondary school leaving certificate exam, constitute the first requirement for registration for the College Admission Test and interview. All applicants to the Collegeof Medicineand Medical Sciences (CMMS) at King Faisal University (KFU) who satisfy these criteria are required to take the admission test. This test includes a written examination in Physics, Mathematics, Biology, Chemistry, English and Islamic Culture. In addition, there is the personal interview for each applicant. The admission test and interview scores are used as a second step screening for selecting candidates.3


In this study, an attempt is made to identify the attitudes and reasons underlying Secondary School female students’ decision to enter Medical College. It is known that some of them join the Medical Schoolwithout any prior awareness of or interest in the programme of study. The later group of students  usually  either  withdraw or are dismissed from the college before completing the programme. This obviously leads to waste of  the  students and faculty’s time, and a misuse of limited resources, which could have been more beneficial to more interested and highly motivated students. It is hoped that the findings will assist in the selection of students who will pursue the medical curriculum to a successful completion and graduate as doctors needed in the Kingdomof Saudi Arabia.


MATERIAL AND METHODS

This cross-sectional study included all female students who applied to join the CMMS in Dammam, in 1996. The college offers three programs leading to a Bachelor’s Degree in Medicine and Surgery, in Medical Laboratory Technology (MLT), and in Nursing.

The applicants were interviewed and each of them completed a questionnaire designed to obtain the demographic and personal data as well as other variables. The latter included: the general and special subject averages, reasons for choosing one of the three programmes, expectation of possible difficulties in the course of studies, and ideas about the chosen programme. Data were analyzed on a personal computer using SPSSpackage. The statistical tests were X2-test and ANOVA.

RESULTS

The total number of students interviewed was 191. Of these, 132 (69.1%) had applied for medicine, 45 (23.6%) for medical laboratory technology  (MLT) and the rest for  nursing. The mean age was 18.3 ± 0.94. 26% of the students’ fathers, and 39.8% of their mothers, respectively, were either illiterate or just able to read and write. On the other hand, 41% of students’ fathers and 21.5% of their mothers,  respectively,  had  secondary and university education. Of the fathers 8.4%  had  gone  on to higher  education. Almost  the  same  pattern  was observed with regard to primary and intermediate education. Fifty percent of the fathers of the applicants for medicine and nursing and 62.2% of the fathers of the  applicants  for  MLT, were professionals, the overall overage being 52.9%. Unskilled labourers constituted 40.3% of all the fathers: 43.9%, 42.9%, 28.9% for Medicine, Nursing and MLT respectively. The majority of the mothers were housewives (91.1%): 90.9% of the mothers of the applicants for medicine, 95.6% of MLT and 78.5% of  nursing  but  these differences were not statistically significant (X2 = 3.82, P 0.05).


                       


The mean general average score for female students who had applied to do medicine was the highest 94.02%, followed by 91.26% for MLT and 86.78% for nursing (F=33.061), P < 0.01). The corresponding mean special averages, were 92.22, 89.50 and 82.24% (F=36.376, P < 0.01).

Eighty (41.9%) of the students had relatives working in the medical field (43.2% in medicine, 48.9% in MLT and 7.1% in nursing). A statistical significant difference was observed as regards the presence of relatives in the medical field and specialty chosen (P < 0.01). Approximately 29% of the relatives were either sisters or brothers: Of those, 21.1% and 45.5% were applicants for Medicine and MLT respectively. The rest of the relatives were either uncles, aunts or sisters-in-law.

Table 1 depicts the reasons for choosing the specialty. Personal interest was the main reason in 85.7% of the applicants (86.4%, 86.7% and 78.6%) being for medicine, MLT and nursing respectively. The next reason with an overall rating of 69.6% was that it was a humane profession. Specialty-wise the percentages for this attribute were 78.0, 44.4 and 71.4 in the three specialties, respectively (X2=7.93, P<0.01). While more than 60.0% of the applicants for medicine and nursing claimed that their choice was influenced by national need, only 44.4% of the MLT applicants were of this opinion (X2 = 6.56, P<0.05).

The study showed that 109 students (57.1%) had some ideas about the specialty while 82 students (42.9%) had no ideas at all. When asked about the sources of information regarding the specialty, friends and relatives ranked first for MLT and medicine applicants (60.9% and 38.0%, respectively). However, for nursing applicants, their own reading ranked first (57.1%). The proportion of applicants  whose  choice  of specialty was motivated by university visits was only 6.4% (Table 2). Table 3 shows the anticipated difficulties as stated by the applicants. One hundred sixty one students (84.3%) expected to have problems. The majority were nursing applicants (92.9%), followed by medicine (86.4%). Long hours of study was the most frequent single difficulty anticipated by medicine and MLT students, while mixing with males was the most important problem for nursing students. This latter difficulty was second in rank for medical and MLT students. None of the nursing applicants had considered disruption of their family lif


e by their work, 12% of medicine and MLT applicants acknowledged would. About 10% of all applicants thought that using English  as  the  medium of instruction was one  of the  difficulties they envisaged.  Unexpectedly,  only  6.3%  of  the



Table 1:Reasons for choosing the specialty

Reasons for choosing the

Specialty

specialty

Medicine

No (%)

MLT

No (%)

Nursing

No (%)

Total

No (%)

Personal interest

114 (86.4)

39 (86.7)

11 (78.6)

164 (85.7)

Humane profession

103 (78.0)

20 (44.4)

10 (71.4)

133 (69.6)*

Family pressure

  22 (16.7)

5 (11.1)

0

27 (14.1)

Prestigious & respectful career

13 (9.8)

2 (4.4)

-

   15 (7.9)

The only specialty present in the area

3 (2.3)

9 (20.0)

1 (7.1)

13 (6.8)

Nation needs

  87 (65.9)

20 (44.4)

9 (64.3)

116 (60.7)†

*X2=7.93, p < 0.01, †X2=6.56, p < 0.05

Table 2:Sources of knowledge about the specialty

Specialty

Source of knowledge

Medicine

No (%)

MLT

No (%)

Nursing

No (%)

Total

No (%)

Friends and relatives

30 (38.0)

14 (60.9)

2 (28.6)

46 (42.2)

Reading

24 (30.4)

7 (30.4)

4 (57.1)

35 (32.1)

University visits

5 (6.3)

1 (4.3)

1 (14.3)

  7 (6.42)

Others

20 (25.3)

1 (4.3)

-

21 (19.3)

Total

79 (100)

23 (100)

7 (100)

100 (100)

Table 3:Difficulties anticipated by the female students

Specialty
Expected difficulties

Medicine

No (%)

MLT

No (%)

Nursing

No (%)

Total

No (%)

Hard work

9 (6.8)

2 (4.4)

1 (7.1)

  12 (6.3)

Using English language in teaching

14 (10.6)

5 (11.1)

1 (7.1)

20 (10.5)

Mixing with males

22 (16.7)

6 (13.3)

5 (35.7)

33 (17.3)

Spending long time in studying

26 (19.7)

8 (17.8)

1 (7.1)

35 (18.3)

Interference with family life

17 (12.9)

6 (13.3)

-

23 (12.0)

More than one reason

26 (19.7)

7 (15.6)

5 (35.7)

38 (20.0)

No difficulty

18 (13.6)

11 (24.4)

1 (7.1)

30 (15.7)

Total

132 (100)

45 (100)

14 (100)

191 (100)


applicants believed that the specialties require hard work.

On asking MLT applicants the reasons for not choosing nursing as a specialty, 73.3% said that they were not interested in the specialty, 8.9% stated that the specialty was looked down on by the society, and 11.2% gave more than one reason.


DISCUSSION

Enrollment in the Collegeof Medicineand Medical Sciences is considered one of the most suitable fields for Saudi girls. Students who are interested in enrolling in Colleges are required to have high scores in the Secondary School certificate examination as a prerequisite for admission. It is expected that the involvement of relatives in the medical field can influence an applicant’s choice. The study confirmed this, since more than one third of the applicants had a relative in the medical field.

In the study, 85.7% of the applicants indicated that their choice of specialty was mainly influenced by personal interest. This obviously is a very important motivating factor for the candidate to complete the programme of study, despite any difficulties. Furthermore, such an interest would also help the graduate to pursue her career with dedication.

The study also showed that about one fifth of the students wanted to enter the medical college  because of family pressure


, interest and because it was a respectable profession. This was more so for applicants for medicine. None of the students applying for nursing stated this as a reason. This result supports the motion that enrollment in a medical faculty is fast becoming prestigious for female students and their families. This social attitude may result in forcing some students to enter medical college who have neither the aptitude nor the inclination necessary for the successful completion of the programme.1 More than two thirds of the students chose a career in Medicine, MLT and nursing because they considered them humane professions, and this was more so for those who chose the medical specialty. This can be explained by students’ awareness of the nature of this profession.

It is very important for a student to know something about the specialty she wishes to pursue as a future career in order to determine its suitability for her knowing the possible difficulties that the student might face in a particular specialty will help her to weigh her capabilities vizaviz the demands of that specialty. In this study it was found that more than one third of the students had chosen a specialty without any prior knowledge of it. This may explain why some students transfer to other, possibly less


demanding, programmes of study, sometimes to a completely different area, such as architecture or computer science.1 The main sources of knowledge for those who know something of their chosen specialty were friends and relatives. This study also showed that university visits played a minimal role (6.9%) in elucidating the requirements of a programme of study for a certain  specialty to the students. Yearly visits for female students in secondary schools to learn about the specialty offered at King Faisal Universityare arranged. Perhaps the objectives of the visits and the way they are conducted should be revised to make them more meaningful to prospective students.


                        Prospective applicants  to the  medical  college need to have a certain attitude and be highly motivated. A previous study indicated that most of the students found the programme more demanding than they had anticipated.1 More than two thirds of the students in this study expected that there would be difficulties in the course of their study in the medical college. About one fifth of the students thought that one of the main difficulties would be the long hours of study. Integration of males and females at the work place also presented a problem since Saudi female students and their families prefer on religious and cultural grounds to study and work  in  a segregated environment. This finding is supported by another study which considered that segregation of sexes in the work environment is a major incentive that would attract more Saudi nationals into nursing.4 Kassimi5 considered that segregation of sexes was unique to Saudi Arabia, and that it could  be more effectively achieved by establishing medical schools for females only.

                        Twenty-three (12%) of the students envisaged that entering medical college would interfere with family life in the future. In her study of the reasons for Saudi female medical students dropping out of King Abdulaziz University, Islam1 found that marriage was the main reason for withdrawal in later years. It accounted for 16% of all female students drop-out in the fourth year.1 In her study of the effect of medical practice in social and psychological status of female Saudi physicians, Mgrbal6 found that about half of the female physicians in Dammam area found it hard to strike a balance between their medical career and their family responsibilities. Several others also found that female physicians suffered from a conflict between their career demands and social obligations.7-11

                        Using English language in teaching was considered by 10% of the students as one of the anticipated difficulties. This result supports other findings that the use of English as a medium of instruction in medical education, is one of the problems that medical students faced.12-13 Albar12 found that over 70% of both medical students and residents at King Faisal Universitywould prefer Arabic as the language of their medical education.

                        Students applying for MLT were asked why they did  not choose  nursing as a career. About three-fourths of them indicated that they were not interested in nursing, while nearly 9% of them argued that the specialty was frowned on by the society. This indicated that nursing as a career was perceived as relatively low in status in comparison to other occupational choices. In  her study of  the attitudes  towards  nursing, Jackson4 found that reluctance to choose nursing as a career in Saudi Arabiais based on the perception of low image, along with current traditional social values of the society.

                        In conclusion, this study shows that personal interest was the main reason for the choice of medicine for a future career. A sizeable proportion had no knowledge of the specialty they had opted for, while more than 80% of the applicants anticipated some difficulties upon entering the medical college. University visits played a minimal role in educating students about career alternatives available at the Collegeof Medicineand Medical Sciences. The majority of MLT applicants were not interested in the nursing specialty.

                        It is recommended that the current strategy for enlightening the secondary school female students about  the  medical college programmes should be strengthened. Every student should have enough knowledge about the college, methods of teaching and their chosen future profession, before applying to the college. The public should be educated on the importance of the different specialties and their role in the development of this country. Parents should refrain from pressurizing their daughters in their career selection. The current negative image of the nursing profession could be reversed with the help of the media in public education.


REFERENCES

1.Islam S. Enrollment and drop-out of Saudi female medical students at King Abdulaziz University. In: Proceedings of the fourth Saudi Medical Conference. King Faisal University, 1980:390-401.

2.Medical schools and medical students (editorial). Annals of Saudi Medicine 1989; 9(1):1-2.

3.El-Mouzan MI, Lutfi AM, Absood GH. Secondary school and college admission test scores as predictors of performance of medical students in premedical subjects. Saudi Medical Journal 1991; 12(6):477-80.

4.Jackson CL, Gary R. Nursing: Attitudes, perceptions and strategies for progress in Saudi Arabia. Annals of Saudi Med 1991;1194:452-8.

5.Kassimi MA. Problems of undergraduate medical education in Saudi Arabia. Med Educ 1983; 17:233-4.

6.Mgrbal KM. The effect of medical practice on social and psychological status of Saudi female physicians at Dammam area


(dissertation). King Faisal University, 1993.


7.Swerdlow AJ, Mcneilly RH, Rue ER. Women doctors in training: problems and progress. BMJ 1980; 281:754-8.

8.Myers MF. The female physician and her marriage: An overview. Am J Psychiatry 1984;1416(11): 1386-91.

9.Microys G. Women as doctors, wives and mothers. Can Fam Physician 1986; 32:339-342.

10.Schaller JG. The advancement of women in Academic Medicine – Commentary. JAMA 1990;264:1854-5.

11.Robbins L, Ronnins E, Katz SE, Geliebter B, Stern M. Achievement motivation in medical students. J Med Edu 1983;58:850-8.

12.Albar AA, Sssuhaimi AA. Attitude of medical students and postgraduate residents at King Faisal Universitytowards teaching medicine in Arabic. Saudi Medical Journal 1996; 17(2):230-4.

13.  Danaraj TJ. Problems of medical education in developing countries. In: Proceedings of the fourth Medical Conference, King Faisal University, 1980:388-391.


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