Abdullah I. Alsharif, FFCM*, Yahia M. Al-Khaldi, ABFM†

*The Director General of Health Affairs, Riyadh Region and †Health Sciences Colleges for Boys, Abha, Saudi Arabia


هدف الدراسة: يهدف هذا البحث إلى تقييم رضا ومعرفة آراء ومقترحات  السائحين تجاه خدمات مراكز الرعاية الصحية الأولية المستخدمة من قبلهم خلال صيف 2000م.

طريقة الدراسة: أجريت هذه الدراسة في خمسة من مراكز الرعاية الصحية الأولية بمنطقة عــســير  خلال شهر يوليو من عام 2000م . تم توزيع استبيان صممه الباحثان من خلال هذه المراكز الخمسة وذلك لجميع السائحين الذين تزيد أعمارهم على خمسة عشر عاماً، يستطيعون القراءة والكتابة، ولديهم الرغبة في الرد  على هذا الاستبيان . اشتمل الاستبيان على مدى رضا السائحين عن الخدمات الصحية المختلفة التي تقدمها المراكز الصحية وعن اقتراحاتهم لتحسين خدمات هذه المراكز. تم إدخال بيانات الاستبيان  وتحليلها بواسطة حاسب آلي مزود ببرنامج إحصائي.

النتائج: بلغ العدد الإجمالي للسائحين المشاركين في هذه الدراسة و الذين انطبقت عليهم شروط الاختيار    413 سائحاً ، بلغ متوسط أعمار المشاركين في البحث 29.2 سنة، كما أن نسبة الذكور قد بلغت 81.4% كما أن 37.3% من المشاركين يحملون شهادات علمية عالية ،مثلت  نسبة السائحين القادمين من المنطقة الغربية ما نسبته 32.7%  .   أشار 87% بأن الوصول إلى مراكز الرعاية الصحية كان سهلاً، كما أشار 88.6%  بأن وقت الدوام بهذه المراكز كان مناسباً . ذكر أكثر من 75% من المشاركين في هذه الدراسة  بأنهم قدموا للمراكز لأسباب علاجية.

تفاوت معدل الرضا عن مختلف الخدمات الصحية من 4.63 نقطة لتوفر الدواء إلى  4.85 نقطة لتعامل الطبيب المعالج.

قدم 26% من المشاركين في هذه الدراسة 17 اقتراحاً لتحسين الخدمات الصحية بالمراكز التي استخدموها.

الخلاصة: وجد في هذه الدراسة أن معظم السائحين المشمولين بهذه الدراسة كانوا راضين عن مختلف الخدمات الصحية المقدمة لهم من قبل المراكز الصحية المشمولة بالدراسة ، مع ذلك فقد قدم أكثر من ربع السائحين اقتراحات وملاحظات قيمة يمكن أن تؤخذ في الحسبان لتقديم خدمات صحية ذات جودة عالية خلال الأعوام القادمة.

الكلمات المرجعية: الرضا، السائحين، مراكز الرعاية الصحية الأولية، منطقة عسير.


Objective: The objective of this study was to assess the satisfaction of tourists who utilized health care services of five selected primary health care centers in Abha, Aseer region of Saudi Arabia in the summer of the year 2000.

Methods: This study was conducted during July of 2000 in five primary health care centers (PHCCs) in Aseer region, Saudi Arabia. Self-administered questionnaire designed by the   investigators was distributed   to all tourists   who   fulfilled the


Correspondence to:

Dr. Abdullah I. Alsharif, The Director General of Health Affairs, Riyadh Region, P.O. Box 56371, Riyadh 11554, Saudi Arabia

following criteria: aged above 15 years, can read and write and has intent on participating voluntarily. The questionnaire concerned satisfaction with different health care services delivered by the PHCCs and suggestions for the improvement of the services. Data was entered and analyzed using SPSS.

Results: A total of 413 tourists fulfilled the selected criteria .The mean age of the participants was 29.2 years; 81.4% were males, 37.3% were highly educated and 32.7% came from western province. PHCCs services were accessible to 87% and the working hours at PHCCs were suitable for 88.6% of the tourists. More than three-quarters of the visitors came for cure. Satisfaction with the different health services on a 5-point scale ranged from 4.63 points for availability of medications to 4.85 points for cooperation of treating doctors. Seventeen suggestions and comments were reported by 26% of the participants. Most of these suggestions and comments were about providing an adequate number of female doctors and medications.

Conclusion: This study revealed that most of the tourists who utilized the selected PHCCs in Aseer region were satisfied with most of the different PHCCs services. However, many tourists gave valid suggestions and comments which should be considered for the improvement of the quality of care in these PHCCs in the future.

Key Words: Satisfaction, tourists, PHCCs, Aseer Region.




During the last decade, Aseer Region has become one of the most popular resorts in Saudi Arabia to which thousands of tourists come every summer to enjoy its pleasant weather and participate in various re-creational activities.1 In 1998, it was reported that 7.4% of the total number of summer visitors utilized the primary health care services resulting in an increase in the demand on the primary health care services by 33%, as well as an additional 50,808 US Dollars on the cost of the dispensed drugs.2,3

        Customers' satisfaction is considered to be an important tool and indicator for measuring and evaluating the quality of health services in general and in the primary health care (PHC)  in particular.4 One decade after the first report on the utilization of the PHC services was presented, the opinions and suggestions of the summer visitors on these services are worth noting.5 The aims of this study are to assess the satisfaction of tourists who utilized PHC services in Aseer Region in the summer of 2000, and use the results obtained to improve the services.


This cross-sectional study was conducted in five primary health care centers in Abha, the capital city of Aseer Region, Southwest Saudi Arabia. The first two PHCCs are located within the city while the other three PHCCs are in the resort areas. Tourists were defined as persons who came from outside Aseer Region to spend part or the whole of the summer season. Those who fulfilled the following criteria were included in the study population: above 15 years old, able to read and write, attended any one of the above mentioned PHCs during July of the year 2000, willing to respond to this questionnaire voluntarily. The questionnaire designed by the investigators was based on valid satisfaction questionnaires which were previously used in local and international studies.6-11

        It consisted of six parts; the socio-demographic data, including age, sex, nationality, residence and occupation; the second part was on the accessibility of different PHC services (car park, availability of chairs in the waiting rooms and health education materials); the next was on the reasons for visiting PHC centers and utilizing clinics; part four concerned the satisfaction with the politeness and sensitivity of all the PHCC staff, the availability of drugs and waiting time. These questions were scored on a 5-point Likert scale as follows: 5 = very satisfied, 4 = satisfied, 3 = neutral, 2 = not-satisfied, 1 = not satisfied at all. The mean score of satisfaction of each service was calculated by adding together the degrees of satisfaction and dividing by the total number of respondents of each item. The fifth part was directed to evaluate specific processes during consultation. Four sub-questions eliciting Yes-No responses were included; (Did the physician respond to your enquiries and conduct the relevant physical examination, did nurses measure vital signs, did pharmacists explain how to use medications). The last question was an open-ended one about the client's suggestions to improve PHC services or any other comments he/she may have. The medical record receptionists explained the purposes of the study and asked the tourists who fulfilled the selection criteria to complete the questionnaire at the end of the visit to PHCC for collection and return to The Directorate General of Health Affairs every week.

        Data were entered into and analyzed by means of the statistical package for social sciences (SPSS) software. Appropriate significant tests were used accordingly and the p-value was considered significant if less than 0.05.


The total number of tourists who fulfilled the selection criteria of this study during the study period was 413. Table 1 shows the characteristics of the tourists who participated in this study. The mean age was 29.2 ± 13.9 years. Eighty one point four percent were males and Saudis, 37.3% were highly educated, 60.3% were married, 21.1% were students, 13.8% were teachers, 32.7% and 22% came from the Western and Central regions respectively. Primary health care centers (PHCCs) were accessible to 87%, 78% reported that parking area was

Table 1: Characteristics of summer visitor to Aseer Region, July 2000 (N=413)


No. (%)



336 (81.4)


60 (14.5)


17 (4.1)



336 (81.4)


42 (10.2)


   35 (8.5)

Educational status:

High education

154 (37.3)


95 (23)


   59 (14.3)


105 (25.4)

Marital status:


249 (60.3)


120 (29.1)


44 (10.8)



94 (22.8)


87 (21.1)


57 (13.8)


43 (10.4)


   18 (4.4)


9 (2.2)


4 (1.0)


16 (3.9)


  85 (20.6)

Residency place:

Western region

135 (32.7)

Central region

  91 (22.0)

Southern region

74 (18.0)

Eastern region

26 (6.3)

Gulf states

38 (9.0)


  49 (12.0)


Table 2: Satisfaction of summer visitors about different health care services at PHCCs, Aseer Region, July 2000


Mean score (+ SD)

Degree of satisfaction*











No response

No. (%)

Cooperation of


4.8 + 0.45

288 (15.5)

64 (15.5)

6    (1.5)



55    (13.3)

Cooperation of


4.85 + 0.44

330 (80.0)

41 (10.0)

4     (1.0)

2   (0.5)


36      (8.7)

Cooperation of


4.8 + 0.45

319 (77.2)

61 (14.8)

8    (2.0)



25      (6.0)

Cooperation of


4.8 + 0.43

264 (64.0)

54 (13.0)

4    (1.0)



91    (22.0)

Availability of drugs

4.6 + 0.86)

243 (59.0)

46 (11.0)

20  (5.0)

11 (3.0)


93    (22.5)

Reasonable waiting


4.63 + 0.65

225 (54.5)

66 (16.0)

20  (5.0)

3   (1.0)


99    (24.0)

*Degree of satisfaction on 5 points scale: 5=very satisfied, 4=satisfied, 3=neutral, 2=not satisfied, 1=not satisfied at all.    

†Mean and median of waiting time (8.2 & 5 minutes respectively).


adequate, 90% said that chairs were available in the sitting area, 71% indicated that health education materials were present, 88.6% of the tourists indicated that the duty hours at PHCCs were suitable. 

        Statistical analysis revealed that more patients who were single did not find parking space as compared to married visitors (X2=9.4, P= 0.02) and Non-Saudis compared to Saudis  (X2 =7.6, P=0.02) pointed that the working hours of PHCCs were inappropriate.

        With regards to the main reasons for visiting PHCCs, 76.5% of the tourists came for consultation and treatment, 6.5% for follow up, 3.6% to get a referral, 1% came to get a refill of their prescription, but 12% did not indicate the reason for their visits.

        Satisfaction of the tourists with various aspects of health services at PHCCs is shown in Table 2. Seventy percent were very satisfied with the reception, 80% with the consultation process, 77.2% with the nursing care, 64% with the pharmacist and 59% were very satisfied with the availability of drugs. Generally, the mean overall satisfaction was 4.8 points.

        On the fulfillment of tourists' expectations towards consultation and treatment, 88% and 86% respectively mentioned that physicians had answered their enquiries and carried out physical examination, 81% reported that the nurses had taken their vital signs and 78.5% had been given instructions on their medications by the pharmacists.     

        The mean and the median duration of the waiting time were 8.2 ± 8 and 5 minutes respectively. Fifty-four point five percent were satisfied with the waiting time. Males had a longer wait than females. However, it was not statistically significant (8 ± 8.3 vs 7.9±6.5 min, p0.05).

        Table 3 shows the 17 different suggestions and comments made by 28% of the tourists for improvement of the delivery of health services in the PHCCs. The vast majority of these suggestions and comments were about having continuous working hours  at  PHCCs (22.4%), the  provision  of

Table 3: Suggestions of tourists to improve PHC services in Aseer Region, July 2000


No. (%)


24-hour duty

26 (22.4)

Providing female doctors

19 (16.4)

Putting guidance signboards

18 (15.5)

Extension of PHCC

16 (13.8)

Increase of staff numbers

14 (12.0)

Providing adequate drugs

11 (9.5)

Improving doctors

8 (6.9)

Providing dental clinics

8 (6.9)

Bigger parking area

5 (4.3)

Providing X-rays

5 (4.3)

Providing pediatricians

4 (3.5)

Separate entrances for both sexes

3 (2.6)

Putting female area on the first floor

2 (1.7)

Providing Lab services

2 (1.7)

Providing drinking water

1 (0.9)

Putting welcoming notice

1 (0.8)

*Some tourists gave more than one suggestion or comment.

female doctors in the PHC (16.4%), provision of signboards (15.5%), extension of the PHC (14%) and increasing the number of physicians at PHCC (12%). 


Satisfaction with PHC services in Saudi Arabia has been investigated by many researchers in the last ten years. The total number of tourists who participated in this study was higher than similar studies carried out in Saudi Arabia.6,7,10,12

        Most of the respondents were Saudis, middle-aged and males from the central and western regions. These characteristics are similar to those reported by studies dealing with tourists in the Aseer Region in the last ten years.1,2,5 Accessibility of supportive services  (parking, seats, and health education materials) ranged from 71% for health education to 90% for availability of adequate seats in the waiting area. As health education is an essential element of PHC, it is very necessary to provide PHCCs with adequate posters, pamphlets to disseminate valid medical information particularly to tourists and travellers to help them to manage their common health problems themselves and take preventive measures. Furthermore, the provision of adequate chairs for seating, large waiting areas and parking are highly recommended.

        The current working hours which are from 7:30 AM to 1:00 PM, and 4:30 PM to 10:00 PM is considered short and inadequate particularly during summer months when the workload increases by 33%.2 As a result, it is suggested that the afternoon session be extended to 1:00 AM to make PHCCs more accessible and reduce the strain on the hospital services which should be used for real medical emergencies.

        More than 75% of study population came for a cure. This is similar to the figures reported by Mahfouz in 1993 and Al-Sharif in 1998.2,5 To minimize consultation for simple self-manageable conditions, it is important that tourists take preventive measures including the avoidance of unhygienic food. Satisfaction with different PHC services was found to be good. The mean satisfaction with receptionist was 4.8 points. This score was higher than that reported from Jeddah (1.65- 2.68 points) 7 and Al-Khobar (4.3).12 Of all the items assessed satisfaction with consultation scored the highest (80%). This high satisfaction score was the result of good histories being taken, and relevant physical examinations being done on 88% and 86% of the respondents respectively. After satisfaction adjustment, our findings were found to be higher than what was reported from three PHCCs in the city of Riyadh (3.57-3.71 points) and one general practice setting in the United Arab Emirates (4.38 points).6,8 The difference could be due to the rapid improvement in the quality of health services at PHCCs after the implementation of quality assurance in 1993.4 Satisfaction with nursing care scored 4.8 points on the average. Seventy-seven point two percent were satisfied with nursing care, and 81% reported that nurses measured their vital signs. On a four-point scale, Mansour and Al-Osimy found that satisfaction with nursing care ranged from 3.41-3.73 points.6

        Although, the provision of essential drugs is an element of PHC, satisfaction with pharmacist care and the availability of drugs scored 4.8 and 4.6 points respectively. Among the study population 3% were not satisfied with the availability of drugs. Providing PHCCs with adequate drugs to meet the extra number of patients seen as recommended by previous studies is restated here.2,3 It should be emphasized that the major role of pharmacists and their assistants is to instruct patients on the use of medications and their expected and common side effects. The median and mean of the waiting time were 5 and 8.2 minutes respectively. With this, 54.5% and 16% were very satisfied and satisfied respectively and the mean of satisfaction was 4.63 points. Studies from the city of Riyadh revealed that satisfaction with waiting time ranged from 1.37-1.73 on a four-point scale.6 Al-Faris found that waiting for a long time was the third commonest problem faced by patients attending PHCCs in Riyadh (47.7%).13 General satisfaction with different health services falls within the range reported from United States of America (75%-95%).14

        More than a quarter (28%) of the participants gave 17 suggestions and comments on how to improve various services in PHCCs (Table 3). These suggestions will be studied, evaluated and those that are feasible will be implemented out in order to improve the quality of health services and raise tourists' satisfaction. Since the facilities of the Ministry of Health are the only ones available for the summer visitors at Al-Soda, Al-Faraa and Al-Habala, action should be taken immediately to improve the PHCC services in these locations.


This study showed that tourists in Aseer Region were satisfied with the different services of PHCCs. However, there is still room for the improvement of some services such as the provision of an adequate number of female doctors, parking facilities, health education materials and adequate drugs. Suggestions given by the tourists should be implemented to improve the quality of health services and satisfy the users of those services.


1.     Al-Kahtani MM, Ibrahim AA. Size of tourism flow and characteristics of summer visitors to Aseer Region in 1997: Analytic study, Abha, Kingdom of Saudi Arabia. Chamber of Commerce and Industry, 1997.pp37-57(Arabic Version).

2.     Al-Sharif AI, Al-Khaldi YM, Al-Shahrani AM. Utilization of primary health care during summer. Saudi Med Journal 2000;21(4):376-8.

3.     Al-Sharif AI, Al-Khaldi YM. Cost of the drugs dispensed from primary health care centers for summer visitors to Aseer Region. Journal of Family & Community Medicine; 2001;8(1):41-4.

4.     The Scientific Committee of Quality Assurance in Primary Health Care. Quality Assurance in Primary Health Care Manual. Al-Helal Press.1st edition, Riyadh,1993.

5.     Mahfuoz AAR, Hamid A. Epidemiologic study of primary health care services utilization of summer visitors to Abha, Saudi Arabia. Journal of Community Health 1993; 18(2):121-5.

6.     Mansour AA, Al-Osimy MH. A study of satisfaction among primary health care patients in Saudi Arabia. Journal of Community Health 1993;  18(3):163-73.

7.     Al-Doghaither A. Consumers, satisfaction in primary health services in the city of Jeddah , Saudi Arabia. Saudi Med Journal 2000; 21(5): 447-54.

8.     Harrison A. Patients, evaluation of their consultations with primary health clinic doctors in United Arab Emirates. Family Practice 1996;13(1):59-66.

9.     Kinnersley P, Stott N, Petters T , Harvey I, Hackett P.A comparison of methods for measuring patient satisfaction with consultation in primary care. Family Practice 1996;13(1):41-51.

10.   Al-Omar BA. Patients, expectation, satisfaction and future behavior in hospitals in Riyadh city. Saudi Med Journal 2000;21(7):655-65.

11.   Jenkins M, Thomas A. The assessment of general practitioners registrars , consultation by a patient satisfaction questionnaire. Medical Teacher 1996; 18(4):347-50.

12.   Makhdoom YM, El-Zubier AG, Hanif M. Satisfaction with health care among primary health care centers attendees, in Al-Khobar, Saudi Arabia. Saudi Med Journal 1997; 18(3):227-30.

13.   Al-Faris EA, Khoja TA, Falouda M , Saed AAW. Patients, satisfaction with accessibility and services offered in Riyadh health centers. Saudi Med Journal 1996;17(1):11-7.

14.   Kurata–Nagwa A, Phillips D, Hoffman S, Werblum M. Patient and provider satisfaction with medical care. Journal of Family Practice 1992;35:176-9.




Kawther T. El-Shafie, MD Family and Community Medicine Department, College of Medicine, Sultan Qaboos University, Al-Khoud, Sultanate of Oman 


هدف الدراسة: إن الغرض من البحث هو معرفة الأعراض المعروفة والأقل معرفة لمرض ضعف نشا ط الغده الدرقيه.

طريقه الدراسة ونتائجها: أجريت الدراسة لأربعين ألف مريض أتوا للعلاج بمركز جامعة السلطان قابوس الصحى بمسقط خلال الثلاث سنوات الماضية. وتبين إن ثلاثة وستين مريضاً منهم يعانون من  نقص في نشاط الغدة الدرقيه, وذلك بنوعيه السريرى أو دون السريرى. وأجرى بحث يتعلق بأعراض وعلامات المرض.

الاستنتاجات: إن الأعراض وعلامات مرض نقص نشاط الغدة المتعارف عليها فى المراجع الطبية المعتبرة ليست موجودة بالصورة المعروفة. بل وجدت أيضاً حالات نادرة , ليست منشورة فى المراجع الطبية والخاصة بهذا المرض , مثل عدم المقدرة على نطق الكلام صحيحا وصعوبة البلع .

الكلمات المرحعية: الأعراض,ضعف نشاط الغده الدرقية.


Objective: This study was to review the common and unusual symptoms of hypothyroidism.

Method: A retrospective study was done of forty thousand patients attending Sultan Qaboos University Health Center (SQU), within a period of three years. Sixty-three patients proved to have either clinical or subclinical hypothyroidism and were screened for the different symptoms & signs of hypothyroidism.

Results: The well-known symptoms and signs of hypothyroidism reported in the medical textbooks were uncommon in this study. Symptoms such as dysarthria and dysphagia not usually mentioned in the medical textbooks were reported.

Conclusion: Early diagnosis by screening both middle-aged as well as older patients is advantageous.

Key Words: Hypothyroidism, Symptoms.




Primary hypothyroidism is a common medical problem occurring in approximately 1 to 3% of the total population, with an annual incidence rate of 1 to 2 in 1000, in females; and 2 in 10000 in males.1 The clinical presentation of hypothyroidism in young patients is well detailed in classical medical textbooks.2 Overt hypothyroidism is associated with typical symptoms and signs such as the slowing of motor activity, constipation, cold intolerance, menorrhagia, stiff muscles, sleep apnea, dry skin, weight gain, snoring, and a hoarse voice.2 Less



Correspondence to:

Dr. Kawther T. El-Shafie, Family and Community Medicine Department, College of Medicine, Sultan Qaboos University, P.O. Box 35, Al-Khoud 123, Sultanate of Oman


common symptoms involve the heart, muscle, joints, and blood.3  Rai highlighted the fact that the well-known signs and symptoms of hypothyroidism in older patients reported in textbooks are uncommon.4 The objective of this study was to find out the similarity of the symptomatology of hypothyroidism in all age groups to the typical ones reported in the medical textbooks.


In this study, 63 out of 40,000 adult patients who attended SQU clinic within a period of three years, were diagnosed both by the general practitioners and the residents, to have clinical or subclinical hypothyroidism (free T4 is normal and Thyroid Stimulating hormone is high). This indicated a frequency of 16 per 10000 (0.16%) and accounted for 53% of the 118 patients with different types of thyroid diseases seen at the clinic. All the patients had recent primary hypothyroidism of different etiologies. A retrospective study was done from the patients' notes by using a check list including age, sex, region of the community, nationality, past medical history, family history of thyroid disease and any medications being taken. It also included a detailed list on the typical symptoms and signs of hypothyroidism as illustrated in Table 1 as well as unusual symptoms such as dysphagia and dysarthria. It also included the vital signs of pulse rate, blood pressure, the body mass index (BMI), and signs of hypothyroidism such as hypothyroid face, enlarged thyroid gland, dry skin, delayed ankle jerk relaxation time, recession of frontal hair and eyebrows, myopathy, cerebellar signs, and effusions. The diagnosis was chemically confirmed by high serum thyroid stimulating hormone (TSH) levels (10 miu/L), and low serum free thyroxin level (FT4), (< 9 PmoL/L). The normal value of TSH is between 0.3 and 5.0 miu/L and that of FT4 between 9.3 and 23 PmoL/L).


Sixty-three out of 118 patients with different types of thyroid diseases were found to have hypothyroidism. Thirty had hypothyroidism with low free T4 and high TSH, while 33 had subclinical hypothyroidism that is with normal free T4 and high TSH. Eight patients out of the 30 patients who were hypothyroid, were already diagnosed and came for follow up. Of the hypothyroid patients, 66% were females, 66% were middle aged between 40-60 years old, with a mean of 50 years. Ten percent were below 20 years, 3% were more than 60 years old. Half of the patients were Omanis. All had normal past medical histories with no family history of thyroid disease.

        The presenting symptoms of these patients are shown in Table 1. Fatigue, the commonest symptom accounted for 25%, followed by constipation which accounted for 20%. Rare symptoms such as dysarthria and dysphagia associated with hoarse voice, sleep apnea, all of which were localized in the oropharyngeal region were observed in one patient. The patient had no goiter to explain these symptoms. Clinical and radiological investigations were done to exclude other possible neurological causes. Another rare presenting symptom was the swelling of the lower limbs, which was observed in another patient. Twenty-four patients (10 hypothyroid plus 14 subclinical hypothyroid) were asymptomatic, accounting for 38% of patients with hypothyroidism. Seven patients had only one symptom, and that was either constipation or fatigue. Three patients had two symptoms. Three had three symptoms, and one had four symptoms. Four patients had only one sign of hypothyroidism, either dry skin or the presence of a goiter. Only one patient had two signs. The remaining

Table 1: Distribution of hypothyroid symptoms and signs among study population in Oman


No. of patients


No symptoms of hypothyroidism






Weight gain


Carpal tunnel syndrome








Sleep apnea





Dry skin




Odema of the lower limbs


No signs of hypothyroidism


patients, i.e. 25 out of 30 patients with hypothyroidism, had no signs. The 38 patients with subclinical hypothyroidism were asymptomatic and had no signs. Some classical signs of hypothyroidism such as hoarseness of voice, hair loss, bradycardia, and confusion were uncommon. All patients showed normal blood count and erythrocyte sedimentation rate (ESR), with normal biochemical findings.


The aim of this study was to determine the clinical features of hypothyroidism in different age groups by comparing the frequencies of the clinical signs and symptoms. The frequency rate of this disease was 16:10000 patients. The results of this study showed that the problem is not uncommon in Oman. Most of these patients were middle-aged, the mean being 50 years. The majority were females. Thyroid disorders are more common in women than in men. This gender difference can be accounted for, in part, by the fact that thyroid disorders are by nature autoimmune which is more frequently in women than in men.11 Almost half of these patients were asymptomatic for hypothyroidism. The majority of symptoms were vague and not specific to a particular disease. The major presenting symptom was fatigue, not a specific symptom for hypothyroidism which was the only symptom in 30% of the patients. The well-known signs were also not common. It seems that the symptomatology of hypothyroidism for this middle-aged group (40-60 years) of patients was not much different from that of the elderly group (above 60 years). A lot of studies have proved that thyroid dysfunction in the elderly often goes undiagnosed,4-7 because symptoms attributed to thyroid disease, such as lassitude, depression, and change in appetite may also be the result of old age. The result of this    study was different from the result of Stanely.6 He stated that, in the middle-aged and young patients, the diagnosis of hypothyroidism can be done by clinical presentation and their symptoms can readily be identified when they develop.6 In this study, the well-known symptoms and signs of hypothyroidism, reported in the medical text books,1 and observed by Stanely,6 were uncommon among the group of middle-aged patients. The majority of these patients had clinical features that could be attributed to other conditions. Besides the lack of the usual well-known signs in the majority of the patients who were asymptomatic, hypothyroidism was obscured by the presence of concurrent unrelated illness.

        One patient presented with the unusual symptom of dysarthria,8 and dysphagia9 as well as sleep apnea and snoring,10 all of which were symptoms localized in the otolaryngeal region and not mentioned in the medical textbooks.


Symptoms and signs of hypothyroidism reported in medical textbooks cannot be relied on for diagnosing hypothyroidism in both middle-aged as well as the elderly. Earlier diagnosis through screening has an advantage over diagnosis by clinical presentation.


1.     Eduardo G, Davd SC. Primary hypothyroidism. Current Therapy in Endocrinology and Metabolism 1997;6:94-9.

2.     Wilson JD, Braunwald E. Harrison’s Principles of Internal Medicine (ed14). New York, NY. Mc Graw-Him. 1998; 2021-3.

3.     Klein, Levey GS. Unusual manifestation of hypothyroidism. Arch Intern Med 1984;144:  123-8.

4.     Rai GS, Gluck T. Clinical presentation of hypothyroidism in older persons. American Geriatric Society 1995;43(5):592-3.

5.     Doucer J, Teivalle CH, Chassagne PH, et al. Does age play a role in clinical Presentation of hypothyroidism. J Am Geriatric Soc 1994;42: 984-6.

6.     Russin SJ. Thyroid screening. Postgraduate Medicine 1995;98(2):54-68.

7.     Thomas CPT, Francis MC. Common thyroid disorders in the elderly. Postgraduate Medicine 1992;92(3):225-30.

8.     Stollberger C, Finsterer F. Dysarthria as the leading symptom of  Hypothyroidism. American Journal of Otolaryngology 2001;22:70-2.

9.     Reiss M. Dysphagia as a symptom of myxedema. Schweig Rundsch Med Prax 1998;87(18):627-9.

10.   Rosenow F, Mc Carthy V, Carusa  CA. Sleep apnea in endocrine diseases. J Sleep Press 1998;7:3-11.

11.   Ahmed SA, Penhale WJ, Talal N. Sex hormones, immune responses, and Auotoimmune diseases. Am J Pathol 1985;121:531-51.

12.   Wilson JD, Braunwald E. Harrison’s Principles of Internal Medicine (ed 15).  New York, NY; McGraw-Him 2001; 2066-7.




Emad A. Koshak, FRCPC, Haytham A. Zakai, PhD

Faculty of Medicine and Allied Sciences, King Abdulaziz University Hospital, Jeddah, Saudi Arabia


المقدمة: يمثل تحليل البراز دوراً مهماً بين اختبارات قبل التوظيف لفحص الطفيليات المعوية في العمّال الجدّد. هدف الدراسة : استكشاف طيف الطفيليات المعوية في عينات غائط العمّال قبل التوظيف وعائلاتهم خلال سنة واحدة في مستشفى جامعة الملك عبد العزيز. طريقة الدراسة: تم اختيار المرشّحين بشكل متسلسل من تحليل البراز الواحدة الروتينية لعمّال قبل التوظيف. وتم فحص البراز باستعمال أسلوب أثير الفورمالين في مختبر الطفيليات في مستشفى جامعة الملك عبد العزيز. نتائج الدرسة: تمت دراسة مائتين واثنين وتسعين عينة براز مختلفة من العمّال قبل التوظيف وعائلاتهم. أعمارهم تراوحت من 3 إلى 72 سنة (متوسط 32) تشمل إناث 58.6 % منهم. اكتشفت الطفيليات المعوية في 161 عاملا (55 %). كان انتشار الطفيليات المعوية في العمّال السعوديين منخفضا جدا عن غير السعوديين، 15.8 % مقابل 57.9 % (0.001p <). في جميع الحالات الإيجابية، وجدت طفيليات معوية مسبّبة المرض في 40 % منهم واشهرها كانت الدودة السوتية (39.1%)، دودة أنكلستوما (34.2 %)، و الأميبة الحالّة للأنسجة (16.1%). كما وجدت طفيليات غير مسبّبة المرض في 19.5 % منهم، أشهرها كانت أرومة بلاستوسيستيس هومينيس (34.8%)، الوئيدة القزمة (29.8%)، و أميبة القولون (15.5%). وجد نوع طفيلي واحد في 75 حالة (46.6 %) و وجدت طفيليات متعددة مختلفة في 86 حالة (53.4 %). كان هناك إرتباط عال هامّ بين كشف الطفيليات المسبّبة للمرض وغير المسبّبة للمرض (0.001p<). الخلاصة: عدوى البراز بالطفيليات المعوية المسبّبة للمرض وغير المسبّبة للمرض هو اكتشاف شائع في أكثر من نصف العمّال قبل التوظيف وعائلاتهم. والارتباط بين الطفيليات غير مسبّبة  للمرض ومسبّبة المرض تعكس احتمالية عوامل متبادلة وأن أخطارهم المحتملة لا يمكن تجاهلها. إن فحص البراز الفعّال واستراتيجيات علاج الطفيليات المعوية في العمّال الجدّد يجب أن تفرض بشكل مستمر.

الكلمات المرجعية: اختبارات قبل التوظيف، تحليل براز، الطفيليات المعوية.


Introduction:Stool analysis plays an important role in pre-employment tests for the screening of intestinal parasites in new workers.

Objective: to explore the spectrum of intestinal parasites in stool samples of workers and their families during the pre-employment tests over a one-year period at King Abdulaziz University Hospital (KAUH).

Methods:Subjects were selected sequentially from routine single stool analysis forms  labeled for  pre-employment  tests. Stool  specimens  were  examined using the


Correspondence to:

Dr. Emad A. Koshak, Department of Internal Medicine, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia

formalin ether technique at the parasitology laboratory at KAUH.

Results:Two hundred and ninety two different stool samples of the workers and their families were studied. Their ages ranged from 3 to 72 year old (mean 32 ± 8.5 SD) and females formed 58.6% of the number. Intestinal parasites were detected in 161 workers (55%). The prevalence of intestinal parasites in Saudi workers was significantly lower than non-Saudi nationals, 15.8% versus 57.9% (p<0.001). Of all the positive cases, pathogenic intestinal parasites were found in 40 % of them and the commonest were Trichuris trichuria (39.1%), Hookworm (34.2%), Entamoeba histolytica (16.1%). Non-pathogenic parasites were found in 19.5% and the commonest were Blastocystis hominis (34.8%), Endolimax nana (29.8%), Entamoeba coli (15.5%). One type of parasite was found in 75 (46.6%) and multiple different parasites were found in 86 (53.4%). There was a high significant correlation between the detection of pathogenic and non-pathogenic parasites (p<0.001).

Conclusion:Infestation of stools with pathogenic and non-pathogenic intestinal parasites is a common finding in more than half of the new workers and their families. The correlation between non-pathogenic and pathogenic parasites reflects mutual risk factors, and their potential hazards cannot be overlooked. Effective stool screening and eradication strategies for intestinal parasites in new workers should be rigorously enforced.

Key Words: Pathogenic intestinal parasites, nonpathogenic parasites, pre-employment, stool analysis.




Intestinal parasitic and protozoan infections are amongst the most common infections worldwide. WHO estimates that more than two thirds of the world's population in tropical countries are infected with one or more species of parasites.1-3 Based on other reports, it is estimated that some 3.5 billion people are affected, and that 450 million are ill as a result of these infections.4,5 Each year, some 65000 deaths are directly attributable to hookworm infections, and another 60000 to Ascaris lumbricoides. Entoameoba histolytica which causes amoebiasis is estimated to cause severe illness in 48 million people, killing 70,000 each year.

        Hence, there is a growing trend towards the use of laboratory tests to screen asymptomatic individuals.6 Conducting such tests for newly appointed workers (pre-employment) is not only a means of improving their productivity or regulating hiring practices, but also a way of reducing the transmission of dangerous communicable diseases. These tests have become a standard procedure for assessing the suitability for jobs before issuing local official work permits. Of these tests, stool analysis is an effective screening tool for imported parasitic infections in 'pre-employments' and immigrants.7,8 Diverse spectrums of parasites are commonly encountered in a large proportion of stool samples of workers that have just been hired. This could be attributed to the diversity of their geographic origins, their varied socioeconomic backgrounds and living standards.

        At the general clinics of King Abdulaziz University Hospital (KAUH), a single sample stool analysis for ova and parasites is requested routinely with every 'pre-employment' medical checkup. This is a mandatory screening test in all Saudi hospitals before a work permit is issued. In KAUH, the annual cost of stool analyses for new workers is more than 400,000 Saudi Riyals. This work is a trial to explore the spectrum of intestinal parasites found in single stool samples of 'pre-employment' workers and their families over a one-year period at KAUH.


Subjects and stool samples

This study was performed in the Clinical Parasitology Laboratory at KAUH, Jeddah, Saudi Arabia. Subjects from the general clinics were selected by going through stool analysis forms labeled for pre-employment examination of new workers and their families. Stool samples in sterile plastic containers sent sequentially for analysis were included in the study. Files of these cases were collected from the Medical Records Department and reviewed for demographic data and other clinical information. The study period was from January 98 until January 99. A single sample stool analysis for ova and parasites was performed routinely in all cases as the government rules for the issue of work permit demands.

Stool analysis method

A single normally passed stool specimen was collected. A stool analysis was performed using formalin ether technique as described by Cheesbrough.9 In a conical test tube, 20 grams of stool was mixed in 10 ml of normal saline and strained through a double layer of gauze. The mixture was washed three times with normal saline at a centrifugation speed of 500 g for 5 minutes. The supernatant was removed after the last wash and the deposit mixed in 10 ml of 10% formal-saline and allowed to stand for 10 minutes. Three ml of ether was added and the mixture was shaken vigorously for one minute. The tube was then centrifuged at 300 g for 10 minutes and the top 3 layers were removed. One drop of iodine was added to the deposit, mixed, and examined under light microscopy for parasitic ova and cysts.

Statistical analysis

Data was entered into a personal computer. Frequency tables and statistical analyses for significant difference were performed by Chi-square test using a SPSS statistical program (Version 10.1).


Two hundred and ninety two different stool samples from asymptomatic preemployment workers and their families were studied. Their ages ranged from 3 to 72 years old (mean age of 32 ± 8.5 SD). Females were 171, which made up 58.6% of all cases, as shown in Table 1. Indonesian nationals numbering 92 workers (31.5%) predominated, followed by Filipino nationals 46 (15.8%) as shown in Table 1. Only 19 were Saudis, that is, 6.5% of all cases. The prevalence of intestinal parasites in workers with Saudi nationality was significantly lower than non-Saudi nationals, 15.8% versus 57.9% (X2=12.7, p<0.001).

      Positive infestation with intestinal parasites was found in the stools of 161 workers, which accounts for more than half of the studied group (55.1%). Of these positive stool results, pathogenic parasites where detectable in 72.7% of them. The commonest pathogenic intestinal parasites were Trichuris trichuria (39.1%), followed by Hookworm (34.2 %), Entamoeba histolytica (16.1%), Ascaris lumbricodes (6.8%), and others (10.4%) as shown in Table 2. Non-pathogenic parasites were detected in 35.4% of all positive stool samples.  The   commonest   of   these  were


Table 1: General characteristics of the pre-employment workers


All Cases

Positive Stool for Parasites




Percent of Positive Cases

Percent within Group















































































*X2=12.7, p<0.05

Table 2: Distribution of the different pathogenic intestinal parasites in the positive cases



Percent of positive cases

Percent of all cases

Pathogenic parasites




Trichuris trichuria








Entamoeba histolytica




Ascaris lumbricoides




Strongloides stercoralis




Giardia lamblia




Hymenolepes nana








Chlnorchis sinensis




Table 3: Distribution of the different non- pathogenic intestinal parasites in the positive cases



Percent of positive cases

Percent of all cases

Non-pathogenic parasites




Blastocystis honinis




Endolimax nana




Entamoeba coli




Iodamaeba butschilli








Trichomonas hominis*




*X point -6

Table 4: Distribution of multiple parasitic infestations

Parasites type


Percent of all cases

Percent of positive cases





Negative stool




Positive stool




Single parasite




Multiple types

























Blastocystis hominis(34.8%), Endolimax nana (29.8%), Entamoeba coli (15.5%), Iodamaeba butschilli (8.7%), and others (2.5%) as shown in Table 3. There was a very strong correlation between the presence of pathogenic and non-pathogenic parasites in the stool samples (X2=20.9, P<0.001). The spectrum of different types of parasites varied from a single parasite in 75 cases (25.7%) to multiple types of parasites in 86 cases (29.5%), as shown in Table 4.


This work was conducted to explore the variety of intestinal parasites found in the stool analysis of 'pre-employment' workers seen at KAUH. Female predominance (58.7% of studied cases) was expected because of the large numbers who were employed as housemaids of the university staff, and health care workers.

        In this study, intestinal parasites were detected in more than half (55%)of the stool samples of all examined workers. Pathogenic parasites were noticeable in around 40% of the studied workers. The commonest pathogenic intestinal parasites found were Trichuris trichuria (39.1%), followed by Hookworm (34.2 %), Entamoeba histolytica (16.1%), and Ascaris lumbricodes (6.8%). These findings largely agrees with other previous studies in a nearby geographical area.10-12 The results were anticipated since most of the examined workers were from tropical and subtropical countries where such infestations are common.4,13 Multiple infestation with several different parasites (e.g., hookworms, roundworms and amoebae) are common, and their harmful effects are often aggravated by co-existent malnutrition or micronutrient deficiencies.4,5 Although the studied sample size was small, the low prevalence of intestinal parasites in Saudi workers is probably a reflection of the better socioeconomic backgrounds, living standards, and hygiene compared to the other studied cases. Confirmation of these findings needs to be explored thoroughly.

        The other finding in this study is that non-pathogenic parasites were detectable in 19.5% of all stool samples. The commonest non-pathogenic parasites were Blastocystis hominis (34.8%), followed by Endolimax nana (29.8%) and Entamoeba coli (15.5%). Although infections with these parasites usually present no symptoms, the presence of non-pathogenic parasites in a stool sample is a reflection of a low state of hygiene.13 Non-pathogenic parasites are prevalent but are usually harmless except in immunocompromised hosts.13 This study demonstrated a high significant correlation between the detection of pathogenic and non-pathogenic parasites. It has been recommended that certain workers such as food handlers and housemaids should be treated even for the non-pathogenic parasites since these parasites may overshadow the pathogenic parasites.14,15 Moreover, some studies have shown that the presence of non-pathogenic parasites may depress food intake in some individuals.16

        The number of parasitic infestations isincreasing, with cases occurring in all WHO regions.4 Recent reports estimated that by the year 2025 more than half of the population in developing countries will be urbanized and, as a consequence, a large number of people will live in shanty towns where E. histolytica, Giardia lamblia¸ A. lumbricoides and Trichuris trichiura will find favorable grounds for transmission.

        In our experience at KAUH, only one single specimen is usually presented for the stool analysis of pre-employment subjects, who are frequently not followed up after receiving their laboratory results. The validity of using a single stool sample for the screening for parasites is very much in doubt.17 Although most of these workers are apparently healthy, a persistent carrier state of parasites should be excluded. In order to prevent the spread of pathogenic parasites, subjects should receive appropriate anti-parasitic therapy based on the results of their stool analysis. In addition, these workers should be given health education to improve their social habits and food safety.

        A repeat of stool analysis is recommended in certain cases to ensure the absence of pathogenic parasites. Some authors have recommended that stool analysis should be repeated on three samples collected on three consecutive days to ensure the highest possible accuracy in detecting parasites and that there should be a follow-up of infected subjects after they have received the appropriate treatment.18,19 Protocol for stool screening and the use of sensitive techniques may be strictly implemented for workers employed in such jobs as housemaids and food handlers. The cost-effectiveness of the routine screening of three stool samples before work permits are issued needs to be explored.

        In conclusion, pathogenic intestinal parasites were common in the pre-employment stool screening of workers and detected in 40% of asymptomatic new workers at KAUH. This could be attributed to their geographic origins and their different socioeconomic backgrounds and living standards. Although infestation with non-pathogenic parasites usually shows no symptoms, their presence in a stool sample is a reflection of low level of hygiene. Non-pathogenic parasites correlate highly with pathogenic parasites and their hazards need to be explored. Effective strategies for screening, eradication and prevention of intestinal parasites in new workers should be formulated and carried out.


1.     WHO (1987). Prevention and Control of Intestinal Parasitic Infections. Report of a WHO Expert Committee. WHO Technical Report Series No. 749.

2.     Report of a WHO scientific group. Technical report series 805 WHO Geneva, 1990.

3.     Bundy DAP, Chan MS, Medley GF, Jamison D, Savioli L. Intestinal nematodes. In: Murray CJL, Lopez AD eds. The Global Epidemiology of Infectious Diseases. Cambridge, Harvard University Press. 1996.

4.     Intestinal Parasites: Disease status Burdens and trends recent epidemiological data Control activities Control strategies Progress Ongoing collaborations Research projects Specific information The Disease Relevant WHO documents. Modified: December 21, 2000, url: http://www.who.int/ctd/intpara

5.     Chan MS. The global burden of Intestinal Nematode Infections- Fifty years on. Parasitology Today 1997;13:438-43.

6.     Eddy DM. How to think about screening. In: Eddy DM. Common Screening Tests. Philadelphia: American College of Physicians; 1991:1-21.

7.     Gyorkos TW, Frappier-Davigon LF, Maclean JD, Viens P. Effect of screening and treatment on imported intestinal parasite infections: result from a randomized, controlled trial. Am J Epidemiol 1989;129:753-61.

8.     Persson A, Rombo L. Intestinal parasites in refugees and asylum seekers entering the Stockholm area. 1987-88: evaluation of routine stool screening. Scand J Infect Dis 1994;26:199-207.

9.     Cheesbrough M. Medical laboratory Manual for Tropical Countries. 2nd ed. vol. 1, (1991) pp:605-606. ELBS with Tropical Health Technology/ Butterworth Heinemann.

10.   Osama I, Bener A, Shalabi A. Prevalence of intestinal parasites among expatriate workers in Al-Ain, UAE. Annals of Saudi Medicine 1993;13(2):126-9.

11.   Al-Madani AA, Mahfouz AA. Prevalence of intestinal parasitic infections among Asian female housekeepers in Abha District, Saudi Arabia. Southeast Asian J Trop Med Public Health 1995;26(1):135-7.

12.   Shurie HH, Srivatsan BP. Prevalence of intestinal parasites in newly appointed employment at JebelAli Free Zone, Dubai, UAE. J Bah Med Soc 1996;8(1):20-4.

13.   Farthing, Cevallos, Kelly. Intestinal protozoa. In: Cook G. Mansons Tropical Diseases. London: WB Saunders; 1996. p. 1255-98.

14.   Moody AH. Laboratory diagnosis. In: Cook G. Manson's Tropical Diseases. London: WB Saunders; 1996. p. 1737-49.

15.   Amin AM. Blastocystis hominis among apparently healthy food handlers in Jeddah, Saudi Arabia. J Egypt Soc Parasitol 1997;27(3):817-23

16.   Arneberg P, Folstad I, Karter AJ. Gastrointestinal nematodes depress food intake in naturally infected reindeer. Parasitology 1997;112 (2):213-9

17.   Kawatu D, Lees RE, Maclachlan RA. Screening for intestinal parasites. Is a single specimen valid? Can Fam Physician 1993;39:1748-50.

18.   Faro CJ, Reidelberger RD, Palmer JM. Suppression of food intake is linked to enteric inflammation in nematode-infected rats. Am J Physiol Regul Integr Comp Physiol. 2000;278(1):118-24.

19.   Report of the WHO informal consultation on monitoring of drug efficacy in the control of schistosomiasis and intestinal nematodes. Geneva, 8 - 10 July 1998 (WHO/CDS/CPC/SIP/99.1).






...What do patient's expect



Khalid A. Bin Abdulrahman, MD , ABFM , Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia


هدف الدراسة:التعرف على توقعات المرضى قبل دخولهم على أطباء الرعاية الصحية الأولية وتحديد العوامل المؤثرة في ذلك.

طريقة الدراسة: تم اختيار عينة عشوائية من المرضى المراجعين لخمسة مراكز رعاية صحية أولية في مدينة الرياض بلغت (944) مريض كما تم توزيع إستبانة على هؤلاء المرضى قبل دخولهم على أطباء الرعاية الصحية الأولية.

نتائج الدراسة: تبين أن 74.6% من المرضى يفضلون الأطباء السعوديين كما أن الغالبية (92.2%) يفضلون إجراء فحوصات كثيرة لمشاكلهم الصحية. وأوضحت الدراسة أن ثلثي المرضى (78%) يشعرون بالارتياح التام عندما يتعرض الطبيب للجوانب الشخصية المتعلقة بمشاكلهم الصحية عند الحاجة إلى ذلك . ومن جهة أخرى تبين أن نصف عينة الدراسة يعتقدون أن الدور الرئيس الذي يقوم به طبيب الرعاية الصحية الأولية هو تحويل المرضى من مراكز الرعاية الأولية إلى الأطباء الأخصائيين في المستشفيات العامة. بينما يعتقد حوالي 55% من المرضى أن طبيب الرعاية الصحية الأولية لا يستطيع التعامل مع الجوانب النفسية والاجتماعية المرتبطة بالأمراض العضوية . كما أوضحت الدراسة أن السبب الشائع لزيارة الطبيب هو الفحص العام.

الخلاصة والتوصيات:على أطباء الرعاية الأولية التعرف على توقعات المرضى حتى يتمكنوا من مراعاة رغباتهم أو لمساعدتهم في توضيح المناسب منها وتصحيح المفاهيم الخاطئة عن الرعاية الأولية وكذلك عليهم التنبه على أجندة المرضى الخفية ومراعاتها لما لها من أثر إيجابي في رضى المرضى. وأخيراً ينبغي أن يتدرب جميع أطباء الرعاية الأولية على المفاهيم الأساسية للرعاية الصحية الأولية لكي يقوموا بدورهم بشكل فاعل.

الكلمات المرجعية:توقعات المرضى، مهارات التواصل، الرعاية الصحية الأولية، المملكة العربية السعودية.


Objective: To explore patient’s expectations before consulting their general practitioners (GPs) and determine the factors that influence them.

Methods: A cross sectional survey was carried out in five primary care centers representing different areas of Riyadh city, Saudi Arabia using a self-administered questionnaire distributed to patients before consulting general practitioners. A sample of 944 Saudi patients was randomly selected.

Results:  74.6% preferred Saudi doctors, and 92.6% would like to have more laboratory tests for the diagnosis of their illnesses.  More than two third of the patients (78.0%) felt entirely comfortable when talking with GPs about the personal aspects of their problems. About half thought that the role of GP was mainly to refer patients  to  specialists,  while  55.2%  believed  that  the  GP cannot  deal  with  the


Correspondence to:

Dr. Khalid Bin Abdulrahman, Department of Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, KSA

psychosocial aspect of organic diseases. The commonest reason for consulting GPs was for a  general check up.

Conclusion:The GP has to explore patients’ expectations so that they can either be met or their impracticality explained. GPs should search for patient's motives and reconcile this with their own practice. GP should be trained to play the standard role of Primary Care Physician.

Key Words: Patients’ expectation, communication skills, general practice, Saudi Arabia.



Good communication between doctors and their patients is an essential part of a medical care, and the expression of patient needs is an essential dimension of the communication process.1,2-6 Findings from patient-centered research can help us to improve our understanding of problems in health care. Understanding patients’ expectations and evaluations in everyday life promises to elucidate doctors’ problems with non-compliance.7 Good doctor-patient relationship occurs when the doctor has a clear understanding of a patient needs.1,8        Consumer satisfaction is generally considered the extent to which consumers feel that their needs and expectations are being met by the services provided.9 Meeting or failing to supply the care patients hoped for is an important predictor of patient satisfaction.10

        There is little or no information on the patient’s expectations at a primary care level in Saudi Arabia and most countries in the Middle East. The current study was undertaken to explore the patient’s expectations before consulting their general practitioners (GPs) and to examine the factors that influence these expectations.



Since the implementation of primary health care services in 1980 in Saudi Arabia, 1766 primary health care centers (PHCC) belonging to Ministry of Health have been established. The total number of GPs are 3260, only 240 (7.4%) of whom are Saudis. In the Riyadh region, there are about 673 GPs, only 26 (3.8%) of whom were Saudis.11 The majority of the practicing GPs in Saudi Arabia are non-Saudis who have no formal training nor qualification in family medicine.12


A cross-sectional study was conducted at five primary health care centers (PHCC) representing different geographical areas of Riyadh City (the capital of Saudi Arabia) during the month of January 1997.


A systematic random sampling was used to select every third Saudi patient aged 15 and above. The target number was 20-25 male patients and the same number of female patients daily, for five consecutive days at all five selected primary care centers.

Data collection

A self-administered anonymous question-naire was given to the selected patients before consulting their GPs. The questionnaire included thirteen questions exploring patient needs and expectations. The patient’s views on the kind of GP they are looking for, the role of GP, whether they expect drug prescription and the reasons for consultation were included in the questionnaire. The patient was considered illiterate if he/she could not read and write, while, patients who had had primary, intermediate or high school education were considered to be at pre-university level of education. Patients who had university or post university formal education were considered to have high level of education. Five-point Likert type scale was used to measure the degree of respondents in most of the questions. However, in some, close-ended (yes or no) type was also used.

        The questionnaire was subjected to a pilot study at King Khalid University Academic primary care clinics. The questionnaire was modified according to the responses received.

Data analysis

The data were analyzed using SPSS/PC statistical package (13). Chi-square statistical test was used to compare between categorical variables. P-value < 0.05 was considered significant.


Nine hundred and forty four patients (944) were enrolled in the study. Most of the patients in the study sample were below 60 years of age. More than half (53.3%) of them were male. About half of the patients were at pre-university education level and 9.1% illiterate. The majority (74.6%) of the patients of whom were males than females (42.8% and 31.8% respectively) preferred to be seen by Saudi doctors (p<0.0001) (Table 1).

        The majority of patients (78.0%) would be entirely comfortable when talking with GPs about the personal aspects of their problems if necessary. About one third (34.5%) of the patients were happy if the GPs prescribed a lot of drugs for them.

        Most (94.9%) patients liked to have some explanation of their illnesses           and the results of any test done from their GPs. 92.6% of patients would like to have more tests done to confirm the diagnosis of their illnesses (Table 1).

Table 1: Patient's perceptions regarding what sort of GPs they are looking for in Saudi Arabia, 1997



No. (%)


No. (%)


No. (%)

Do you prefer Saudi or non-Saudi doctor?


403 (42.8)

300 (31.8)

703 (74.6)


98 (10.4)

141 (15.0)

239 (25.4)


501 (53.2)

441 (46.8)

942 (100)

I feel comfortable when GP prescribe too many drugs?

Agree and strongly agree

173 (18.5)

150 (16.0)

323 (34.5)

Disagree and strongly disagree

327 (34.9)

287 (30.6)

614 (65.5)


500 (53.4)

437 (46.6)

937 (100)

I want the GP to explain the nature of my illness and to show me the results of tests that have been done

Agree and strongly agree

483 (51.4)

408 (43.5)

891 (94.9)

Disagree and strongly disagree

18 (1.9)

30 (3.2)

48 (5.1)


501 (53.4)

438 (46.6)

939 (100)

I want more tests to be done for reassurance

Agree and strongly agree

465 (49.6)

411 (43.2)

876 (93.4)

Disagree and strongly disagree

35 (3.7)

27 (2.9)

62 (6.6)


500 (53.3)

438 (46.7)

938 (100)

Table 2: The role of GP from patient's perspective



Agree and

strongly agree

No. (%)

Disagree and

strongly disagree

No. (%)

The role of GP mainly to refer patients to different specialists:


43 (4.7)

41 (4.5)


240 (26.1)

213 (23.1)

High education

154 (16.7)

230 (25.0)


437 (47.4)

484 (52.6)

I do not think that the GP can deal with the psychosocial aspects of organic diseases:


55 (5.9)

29 (3.1)


259 (27.9)

201 (21.6)

High education

199 (21.4)

186 (20.0)


513 (55.2)

416 (44.8)

I am sure that the GP can reach to the right diagnosis of my case and I believe that his management is the right one:


62 (6.7)

21 (2.3)


316 (34.1)

144 (15.5)

High education

259 (27.9)

126 (13.6)


637 (68.6)

291 (31.4)

Table 3: Common reasons for consultation in relation to gender among patients attending PHC centers in Riyadh, Saudi Arabia

Reasons for




Yes (%)

No (%)

Yes (%)

No (%)

Yes (%)

No (%)

General check-up

234 (24.9)

266 (28.3)

265 (28.2)

175 (18.6)*

499 (53.1)

411 (46.9)

To get referral letter

164 (17.5)

333 (35.5)

186 (19.6)*

254 (27.1)*

350 (37.0)

587 (62.6)

To get sick leave

143 (15.2)

354 (37.7)

147 (15.7)

294 (31.3)†

290 (30.9)

648 (69.1)

*Statistically significant difference p<0.0001   †Statistically not significant p=0.1316

Table 4: Patient's expectations regarding drug prescription in relation to gender and education level




Yes (%)



Higher  education

Yes (%)

Yes (%)

Yes (%)


29 (3.1)

158 (17.0)

130 (14.0)

317 (34.1)


28 (3.0)

153 (16.5)

94 (10.1)

275 (29.6)


57 (6.1)

311 (33.5)

224 (24.1)

592 (63.7)

        About half (47.4%) of the study sample, 26.1% of whom had pre-university education thought that the role of GP was mainly to refer patients to different specialists (Table 2).

        More than half (55.2%) of patients, 33.8% of whom were illiterate or had pre-university education did not think that the GPs could deal with the psychosocial aspects of organic diseases (Table 2).

        About 70% of the study sample, 40.8% of whom were illiterate or had pre-university education was sure that the GP could reach the right diagnosis of their problems and that his or her management was the right one (Table 2).

        The commonest reason for consulting GPs was to have a general checkup. The next reason was to get a referral letter, and next was to get sick leave (53.1%, 37.0 and 30.9% respectively) (Table 3).

        About two thirds (63.7%) of the patients expected to receive drug prescriptions on consulting their GPs. There was no significant difference between male and female (p = 0.2324) (Table 4).


The finding that most patients were below 60 years of age, the economically productive segment of the society, is consistent with the demographic picture of Saudi Arabia as a young population.

        The majority of patients preferred Saudi doctors. This could mean that doctor-patient communication is much easier when both patient and doctor come from the same culture. In contrast, expatriate doctors may have communication problems since 31.3% of non-Saudi doctors did not speak Arabic.12

        About one third of the patients were satisfied with GPs who prescribed a lot of drugs. This is higher than was found in the Eastern Province.14 This could be explained by the belief of some patients that taking a number of medications would shorten the period of recovery.

        Most patients  expected GPs to spend some time explaining the nature of their illnesses and the results of tests done. This is consistent with the findings of other studies.1 A finding that was expected was that about half of the study sample thought that the GPs main role was to refer patients to different specialists. This finding is much higher than the actual referral rate (3.2-4.2%).15 Furthermore, this figure is also higher than the real expectations, where 37% of the patients consulted the GPs to get referral letters.

        This could be interpreted as the finding that 31.4% of the study sample was not sure that the GP could reach the right diagnosis and management. In addition, some patients thought that some medical problems (e.g. surgical, eye or ear) were within the peerview of GPs. Saudi patients would sometimes insist on referral to hospital because they felt that care was much better there. This idea is not necessarily true and should be strongly discouraged in patients.16 About half of the patients did not realize that GPs could deal with the psychosocial aspects of organic diseases. This could reflect the patient’s previous experience of the medical care by the GPs. The commonest reason for consulting GPs was for a general check-up.  This finding is lower than in other studies.1

        The second commonest reason for consulting GPs was to get a referral letter. This is higher than what was found in Western populations.1,3 This finding highlights the role of GPs from the patients' perspective; which indicates that our public still underestimates the role of GP. Public awareness of the actual role of GPs should be raised on the individual and community level. General practitioners should have adequate training, in doctor-patient communication and interviewing skills, in order to improve the GPs role in patient care.

        About two-thirds of the patients expected drug prescriptions on consulting their GPs. This finding is consistent with the findings of other studies in Western populations,17-19 but relatively lower than findings in Eastern populations.20 In a similar population in Riyadh, Kalantan's finding of drug expectation was higher (88%).21 This may be due to factors relating to doctors and patient beliefs. Doctors may contribute to this by their prescribing habits, prescribing too readily because of over- estimation of patients' expectation for drugs.20,22,24 Also the fact that in Saudi PHCC drugs are free to all residents and most expatriates may contribute to this high prescribing rate.23-25

        It is interesting to note that the majority of patients would be entirely comfortable when talking with GPs about the personal aspects of their problems when necessary. This finding should emphasize the importance of a holistic approach in general practice consultation; to include physical, psychological, and social dimensions of the patient’s problem.

        General practitioners should be skilled in discerning their patient’s expectations, so that, they can either be met or its appropriateness explained.26,27 Since one third of patients in this study consulted their GPs to get sick leave, doctors should try to discern their patient’s agenda and reconcile this with their own.28 Unmet expectations adversely affect patients and physicians alike. The lack of fulfillment  of patients’ requests plays a significant role in patients’ beliefs that their physicians did not meet their expectations for care.29 GPs should be trained well enough to play the standard role of Primary Care Physicians. Undergraduate medical education should be adopted to make it compatible with patients and community needs.


The author is grateful to Professor Jamal S. Jarallah, of the Department of Family and Community Medicine, King Saud University, for reviewing the manuscript of this study. My thanks also go to my undergraduate students (Al-Rajhi YH, Al-Okla KS, Al-Shayban AI, Al-Omran A, Al-Koblan S) for their great efforts in data collection. Many thanks for Mr. Mohammed Ejaz for secretarial assistance.


1.     Williams S, Weinman J, Dale J, Newman S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectation affect patient   satisfaction. Fam Pract 1995; 12 (2): 193-201.

2.     Salmon P, Sharma N, Valori R, Bellenger N. Patients’ intentions in primary care: relationship to physical and psychological symptoms and their perception by general        practitioners. Soc Sci Med 1994; 38: 585-592.

3.     Webb S, Lioyd M. Prescribing and referral in general practice: a study of patients’ expectations and doctors’ action. Br J Gen Pract 1994; 44: 165-9.

4.     Joos SK, Hickman DH, Borders LM. Patients’ desires and satisfaction in general medicine clinics. Public health Rep 1994; 108: 751-9.

5.     Van de Kar A, Van der Girinten R, Meertens R, Knottnerns A, Kok G. Worry: a particular determinant of consultation illuminated. Fam Pract 1992; 9: 67-75.

6.     Arborelins E, Bremberg S. What can doctors do to achieve  a successful consultation? Video - taped interviews analyzed by the consultation map method. Fam Pract 1992; 9: 61-6.

7.     Verbeek-Heida PM. How patients look at drug therapy: consequences for therapy negotiations in medical consultation. Fam Pract 1993; 10 (3):326-9.

8.     Strasser R. The doctor-patient relationship in general practice. Med J Aust 1992;156:334-8.

9.     Al-Doghaither AH, Saeed AA. Consumers’ satisfaction with primary health services in the city of Jeddah, Saudi Arabia. Saudi Med J 2000; 21 (5): 447-54.

10.   Mckinley RK, Stevenson K, Adams S, Manku-Scott TK. Meeting patient expectations of care: the major determinant of satisfaction with out-of hours primary medical care. Fam Pract 2002;19(4):333-8

11.   Ministry of Health ( Saudi Arabia). Annual Health Report. Riyadh: Dar Al-Helal Press; 2000.

12.   Kalantan KA, Mohammed HA, Al-Taweel AA. Factors influencing job satisfaction among primary care physicians in Riyadh, Saudi Arabia. Annals of Saudi Medicine 1999; 1(4):126.

13.   Statistical package for social science. Windows - Version  6.0; Microsoft 1993.

14.   Chan CSY. What do patients expect from consultations for upper respiratory tract infections? Fam Pract 1996; 13(3): 229-35.

15.   Al-Mazrou YY, Al-Shammari SA, Siddique M, Jarallah JS. A preliminary report on the effect of referral system in four areas of the Kingdom of Saudi Arabia. Annals of Saudi Medicine 1991; 11 (6): 663-8.

16.   Saeed AA, Mohammed BA, Magzoub ME, Al-Doghaither AH. Satisfaction and correlates of patients’ satisfaction with physicians’ services in primary health care centers. Saudi Med J 2001; 22(3): 262-7

17.   Britten N. Patient demand for prescriptions: a view from  the other side. Family Practice 1994;11(1):62-6.

18.   Cartwright A, Anderson R. General Practice revisited a second study of patient and their doctors.  London; Tavistock Publication; 1981.

19.   Fitton F, Acheson HWK. The doctor/patient relationship. London: HMSO; 1979.

20.   Lam CLK, Catarivas MG, Lander IJ. A pill for every ill? Fam Pract 1995;12 (2):171-5.

21.   Kalantan KA. Expectations of Saudi Patients for medications following consultations in                 Primary health care in Riyadh. Journal of Family & Community Medicine 2002; 9(3):27-33.

22.   Stimson GV. General practitioners’ estimates of patient expectations, and other aspects of their work. Swonsea: Medical Sociology Research Centre; 1975.

23.   Khoja TA, Al-Shammari SA, Farag MK, Al-Mazrou Y. Quality of prescribing at primary care centres in Saudi Arabia. J Pharm Technol 1996; 12: 284-8.

24.   Virji A, Britten N. A study of the relationship between patients’ attitudes and doctors’ prescribing. Fam Pract  1991;8: 314-9.

25.   Felimban FM. The prescribing practice of primary health care physicians in Riyadh city. Saudi Med J 1993; 14 (4): 353-8.

26.   McBride CA, Shugars DA, DiMatteo MR, et al.  The physician’s role: Views of the public and the profession on seven aspects of patient care. Arch Fam Med 1994;               3(11): 948-53.

27.   Pendleton D, Scnofield T, Tate P, Havelock P. The consultation: An approach to learning and teaching. Oxford: Oxford University Press; 1984.

28.   Tate P. The doctor’s communication hand book. Oxford and New York; Radcliffe Medical Press; 1994.

29.   Bell RA, Kravitz RI, Thom D, Krupat E, Azari R. Unmet expectations for care and the patent-physician relationship. Gen Intern Med 2002; 17(11): 817-24.


...Health education


Parveen Rasheed, MD, Latifa S. Al-Sowielem,FFCM

Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia


هدف الدراسة: إيجاد مستوى إدراك بالنسبة للحمل ومصدر المعلومات بين النساء الولودات اللاتي يزرن المستوصفات الصحية في الخبر .

طريقة الدراسة: علمت دراسة مقطعية في ثلاثة مراكز للرعاية الصحية الأولية في الخبر خلال فترة اسبوعين في أبريل 2001م وقد تمت مقابلة 581 امرأة ولودة من المؤهلات للدراسة بمساعدة الاستبيان.

نتائج الدراسة: تم ابلاغ نسبة كبيرة من النساء عن بعض المسائل الصحية للحمل مثل : استهلاك المواد الغذائية الضرورية كمنتجات الحليب ( 7و74%) ، الغذاء العني بالبرونين  (4و71%) والفواكهة (2و68%)، عدد ساعات الراحة اليومية الضرورية ( 9و81%) ، والحاجة للتمرينات (6و83%) ، وأهمية وتوقييت الزيارات في قترة الحمل وخطورة التدخين في الحمل (3و99%) ، والمباعدة الملائمة بين الأطفال (7و97%) . ومع ذلك كثير من النساء لديهن نقص في المعرفة عن أهمية إستهلاك المواد الغذائية المحتوية على الألياف ( 1و55%) لتجنب الإمساك والتغيرات المطلوبة في الغذاء خلال الفترة المبكرة من الحمل لتجنب الغثيان والتقيئ ، والأمراض التي يتأثر بها الجنين بسبب تدخين الأم ، العدوي بالحصبة الألمانية ونقدم السن بالأم. ولم يكنَّ يعلمن بأهمية الإجراءات اثناء الحمل ، مثل فحص الدم والعناية بالثدي أثناء الحمل والتلقيح لمنع مرض التيتانوس والحصبة الألمانية .

وكان مستوى التعليم العالي مرتبطاً بعلاقة متبادلة هامة مع المعرفة الأفضل لبعض المسائل الصحية. وقد مثل الأطباء والممرضات مصدراً ضعيفاً للمعرفة الصحية (6و35%).

التوصيات: هناك حاجة ماسة لتطوير برامج التثقيف الصحي المرتبطة بالحمل من خلال المراكز الصحية الأولية ووسائل الإعلام المختلفة لتحسين مستوى المعرفة لدى النساء عامة والحوامل خاصة وذلك للإقلاق من المشاكل الصحية المرتبطة بالحمل.

الكلمات المرجعية: التثقيف الصحي، الحمل، المعلومات الصحية.


Objective: To find out the level of health awareness related to pregnancy and the sources of information among parous women visiting the Primary Health Centers in Al- Khobar.

Methods: This is a cross-sectional study conducted at three Primary Health Centers in Al-Khobar during a two-week period in April 2001. Five hundred and eighty one parous women who were eligible for the study were interviewed with the help of a questionnaire.


Correspondence to:

Dr. Parveen Rasheed, Department of Family & Community Medicine, College of Medicine, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia

Results: A large proportion of the women were well informed about certain health issues of pregnancy such as dietary intake of essential foods like dairy products (74.7%), Protein-rich foods (71.4%) and fruits (68.2%), the hours of daily rest necessary (81.9%), the need for exercise (83.6%), the importance and timing of antenatal visits, the risk of smoking in pregnancy (99.3%) and proper spacing of babies (97.7%). However, many women had no knowledge of the importance of taking high-fiber foods (55.1%) to avoid constipation, the required dietary changes in early pregnancy to prevent nausea and vomiting, and the ill-effects of maternal smoking on the fetus, Rubella infection and advancing maternal age on the fetus. They were also not aware of the importance of the various antenatal procedures such as blood examination, breast-care during pregnancy and immunizations to prevent Tetanus and Rubella infection. A higher literacy level of the women was significantly correlated with better knowledge on certain health parameters. Physicians and nurses constituted poor sources of health information (35.6%).

Conclusion: There is a need to restructure the Health Education programmes relating to pregnancy delivered through PHCs and the mass media for better knowledge among women of childbearing age can decrease pregnancy-related problems and improve perinatal outcome.

Key Words:  Health education, Pregnancy, health knowledge.



Health Education, one of the essential elements in the delivery of Primary Health Care as dictated by the Alma Ata conference (1978) is expected to be conducted from the Primary Health Centers (PHCs) of the Kingdom in an effective manner. The national "Plan of Action" for activities of the PHCs, which is revised annually emphasizes that health information on antenatal care and related matters must be properly disseminated so that women can improve their knowledge, attitude and skills for a healthy pregnancy and delivery. Health Education on this subject is also promoted through the mass media, including the national TV and a wide range of informative literature distributed. In other countries too,1,2,4 efforts are made by the health-care providers to ensure that there is adequate health awareness among pregnant women. However, several studies have shown that many women either lack knowledge1-4 or show a lack of concern for certain health risks in pregnancy,1,2 This indicates that there is the need for a more effective drive to educate women and help them to acquire appropriate knowledge and develop attitudes towards a healthy pregnancy. Though the primary health care programme and health education strategies have been implemented for more than two decades now in Saudi Arabia, little is known about the information women need on pregnancy and the extent to which they have benefited from the knowledge they have acquired through these channels of communication. The current study was, therefore, conducted on parous women who used the PHC facilities in Al-Khobar to find out their level of awareness of health matters relating to pregnancy and their sources of information.


A cross-sectional study was conducted on women who visited three randomly selected PHCs in Al-Khobar during a two-week period in April 2001 from 8.30 am to 12 noon. Because of unavoidable logistic limitations, it was not possible to carry out the study in the afternoon sessions. Consequently, the data may not be as diverse as one may have wished. All married women who were of child-bearing age (15-45 years) and had been through at least one pregnancy were selected for the study. It was assumed that parous women should have had adequate exposure to health information on pregnancy. Any deficiencies in their knowledge would perhaps be a reflection of the inadequacies of the education provided through the PHC and the mass media.

        Five hundred and eighty-one women were eligible for the study. They were asked questions on issues relating to health in pregnancy by means of a specially designed questionnaire. The information was elicited by trained interviewers. Information was sought on (a) their demographic profile and parity status, (b) the recommended dietary pattern in pregnancy, that is, foods that would promote the health of mother and baby, and those that should be avoided in the first trimester of gestation to avoid nausea and vomiting and those that help to avoid constipation; (c) the number of hours of rest advisable during the day and at night; (d) the necessity and type of exercise encouraged in pregnancy; (e) the safe maternal age for a healthy fetal outcome and (f) the harmful effects of cigarettes/shisha smoking or the diseases like Rubella in pregnancy. The women were asked about their awareness of the importance of antenatal check-ups, the suggested frequency and timing of antenatal visits, the significance of routine laboratory tests, the immunizations recommended and the breast-care practices in pregnancy for successful breastfeeding. The women’s opinion was also sought on the ideal spacing of pregnancies. Finally, they were also asked the source(s) of their health information.

        Data were analyzed using the SPSS package programme. Distributions and bivariate analyses of data were done. The chi-square test of significance was used where appropriate. A p-value of less than 0.05 was considered significant.


Out of the 581 parous women recruited for the study, 435 (75%) were Saudis within the age range of 15-45 years (Mean 31.4; SD 6.84). Most were in the 21-30 years (42%) and 31-40 years (41.2%) age groups. The women were grouped into three categories according to their literacy status as follows; 125 (21.5%) were either illiterate or had no schooling, 217 (37.3%) had reached primary or intermediate level and 239 (41.1%) had completed high school or had college education.

Food in pregnancy

A survey on the food items necessary for maternal health and fetal growth showed that while a large proportion of women (71.4%) mentioned meat/fish/eggs, 74.7% dairy products and 68.2% fruits, fewer women (44.9%) named such essential foods as vegetables, 52.5% green leafy vegetables and 16.3% complex carbohydrates. Though more women who were Para 3 (77.1%) obtained a high knowledge score of 3-6 on this topic compared to those who were Para 1 (68%), the results were insignificant (p=0.1). Information on food patterns that are generally considered able to control or reduce nausea and vomiting of early pregnancy was sought. Nearly one–third of the women (31.3%) reported that they were not aware of them, others advocated small frequent meals (12.2%), a decreased intake of certain food items including oil-rich foods (38.5%), tea/coffee (17.5%) and spicy foods (17.1%). A large group of women (44.8%) believed that avoidance of sugar/sugary foodstuffs including chocolate, meat/fish/eggs, carbohydrate-rich foods like rice/pasta, milk, soft drinks and sour or very salty food items would help to prevent nausea and vomiting in pregnancy. Parity did not influence the knowledge score for the recommended changes in food intake during early pregnancy. Responses to the question on the dietary requirements for the prevention of constipation showed that a large number of women (54.7%) were not aware of the importance of high fiber foods such as vegetables and fruits and whole grain products (82.1%) nor the requirement of an increased fluid intake (46.5%).

Rest in pregnancy

The women were asked about the amount of daily rest necessary in pregnancy. A majority of the respondents (81.9%) rightly thought that 7-8 hours of night rest was adequate. An afternoon rest period of 2-3 hours was suggested by 57.1% women while 16% of the women believed that one hour or less was enough.

Exercise in pregnancy

Ninety-five women (16.4%) were not in favor of any exercise during pregnancy and 53 (9.1%) had no knowledge of its importance. A large proportion of those who advocated exercise considered walking (64.4%) as the best form of physical activity. Few women (13.6%) suggested swimming/aerobics/jogging or “special antenatal exercises”.

Breast care in pregnancy

Out of 581 women, 288 (49.5%) were not aware of the importance of regular cleaning of the nipples, 553 (95.2%) did not know about the application of skin softeners and 470 (80.9%) about manual expression of fluid from the breast during the last trimester of pregnancy. Only 5 (0.86%) women suggested that it was important to wear a good supportive undergarment.

Rubella in pregnancy

A large proportion of women (57%) reported that they lacked information about the adverse effects of Rubella infection in pregnancy. Fetal congenital anomalies (31.5%) and abortion (12.6%) were the two most common conditions cited by those who were aware of the effects of Rubella. Table 1 shows that the literacy level of the women significantly influenced their awareness of the consequences of maternal Rubella (p<0.01).

Smoking and pregnancy

A vast majority of the women (99.3%) responded affirmatively to the possible harmful influence of smoking during pregnancy. While fetal congenital malformation (24.3%), decreased fetal growth (11.4%) and abortion/premature delivery (5.3%) were mentioned, half of the women (50.6%) mentioned the general effects of smoking on health such as, cancer or a discomfort of the respiratory tract by the occurrence of “suffocation, dyspnoea, hypoxia and asthma.” Literacy level did not have a significant effect on the women's knowledge of the possible risks of congenital malformation, decreased fetal growth or abortion/premature delivery as a consequence of maternal smoking (p0.05).   

Safe maternal age for pregnancy

Out of 581 women, 15 (2.6%) did not respond to the question on the safe maternal age (upper limit) for a healthy outcome of pregnancy. Thirty-eight percent of the women felt that both the mother and the fetus were safe if the pregnancy occurred up to the age of 39 years, while 44.5% women believed it would be safe up to 45 years. A few women (9.8%) saw no risk to pregnancy even after the age of 45 years.

Table 1: Distribution of women by literacy level and knowledge of the adverse consequences of rubella infection in pregnancy (n=581)

Knowledge status

Literacy Level


Illiterate or Non-schooled (n=125)

No. (%)

Primary or

Intermediate (n=217)

No. (%)

High school or College (n=239)

No. (%)

No knowledge

88 (70.4)

131 (60.4)

113 (47.3)



37 (29.6)

86 (39.6)

126 (52.7)



          12 (9.6)

26 (12.0)

35 (14.6)


25 (20.0)

60 (27.6)

98 (41.0)

CM=Congenital malformation    *statistically significant

Table 2: Distribution of mothers by literacy level and knowledge of the safe upper limit of maternal age for a healthy pregnancy outcome (n=581)

Literacy Level



<30 years

No. (%)

30-39 years

No. (%)

40-45 years

No. (%)

46 years

No. (%)

Illiterate or Non-schooled (n=125

  7 (5.8)

29 (24.2)

63 (52.5)

  21 (16.8)

Primary of Intermediate (n=217)

16 (7.5)

88 (41.3)

91 (42.7)

18 (8.3)

High Schoolof College(n=239)

21 (9.0)

98 (42.1)

98 (42.1)

16 (6.7)

No response =15, A vs B p<0.01

Table 3: Distribution of women by literacy level and knowledge about reasons for blood examination in pregnancy (n=581)

Knowledge status

Literacy Level


Illiterate or Non-schooled (n=125)

No. (%)

Primary or

Intermediate (n=217)

No. (%)

High school or College (n=239)

No. (%)

No knowledge

24 (19.2)

32 (14.7)

           18 (7.5)



101 (80.8)

185 (85.3)

221 (92.5)



65 (52.0)

110 (50.7)

164 (68.6)


Blood group

9 (7.2)

15 (6.9)

  44 (18.4)


*Statistically significant

Table 2 shows that knowledge of the adverse effects of advancing maternal age on pregnancy (40 years) increased significantly with rising literacy level (p<0.01).

Spacing between pregnancies

The mothers were questioned on the ideal spacing between pregnancies. A large proportion of them (59.5%) preferred two-year intervals between births while some of them (38.2%) stated three years or more. Very few women (2.3%) did not believe in spacing of pregnancies.

Antenatal care

a. Importance of antenatal care: The vast majority (97.2%) of women had understood the importance of antenatal care. Nearly two-thirds of them (63.2%) believed that it was necessary for the monitoring of fetal growth. Other responses included “to have a safe pregnancy and delivery” (40.4%) and “to detect maternal and fetal complications” (36.3%).

b. Antenatal visits: Out of 581 women, 534 (91.9%) were aware that the first visit for antenatal care should be in the first trimester of pregnancy. A large proportion of the women (78.2%) believed that more than 8 antenatal visits were required during the entire period of pregnancy.

c. Importance of blood examination:Seventy-four women (12.7%) were not aware of the reasons for blood examination in pregnancy with significant differences observed among the different literacy levels of the women as expected (p<0.01) (Table 3). Among those who were knowledgeable, the most common reasons mentioned for blood examination were to diagnose Anemia (58.3%) and Diabetes (51.6%). Few women mentioned Blood Groups (11.7%) and diseases such as Hepatitis B (4.3%) and Syphilis (1%) as reasons for the Blood test. Literacy played a significant role in the responses given by the women for the detection of anemia (p<0.01) and blood groups (p<0.01) (Table 3). 

Table 4: Distribution of women by parity and knowledge of immunization by tetanus toxoid in pregnancy



No. (%)

No knowledge*

No. (%)



28 (37.3)

47 (62.7)



231 (45.7)

275 (54.3)






*p = 0.17 (not statistically significant)

d) Immunization in pregnancy:More than half of the women (53.7%) were not aware of the immunizations recommended during or prior to pregnancy. Of those who knew, 44.6% rightly mentioned protection against tetanus as one of the reasons for immunization. Parity level did not exert a significant influence on their knowledge of the tetanus vaccine (p=0.17). None of them mentioned protection from rubella by immunization before pregnancy (Table 4).

Sources of health information

The most common sources reported by the women for health information in pregnancy included doctors/nurses (35.6%), relatives/ friends (36.1%), books/magazines (35.3%), their mothers (25.1%) and TV/Video programmes (20.7%).


The data indicate that many women were well informed about certain aspects of pregnancy such as the necessary dietary requirements, the need of adequate daily rest and exercise, timing of the antenatal visits, the importance of not smoking during pregnancy and the proper spacing of babies. However, the large gaps in other areas of knowledge is a cause of concern, considering that all the women in the study population had had at least one previous pregnancy, were PHC users and should have been exposed to or had the curiosity to explore health matters relating to pregnancy.

        Many women were ill-informed about the importance of eating vegetables and other high fiber foods to prevent constipation, a condition commonly observed in pregnancy; nor was there much mention of green leafy vegetables which are a good source of Folic acid. Moreover, a large proportion of the women were not aware that avoiding certain types of foods and following acceptable dietary regimes minimized nausea and vomiting of early pregnancy. Eiser and Eiser1 reported in their study on young primiparas in the UK that many women were also not aware of the dietary changes required in pregnancy.

       Though a large proportion of the women (74.5%) in the present study were in favor of exercise in pregnancy, most of them (64.4%) suggested walking only. There was no specific mention of breathing and relaxation exercises which are recommended during this period. Swimming which is an acceptable physical activity in pregnancy was also not commonly reported, as it is not a popular exercise, in general, for women in this part of the world.

        With the numerous campaigns in this region against smoking, the vast majority of women were generally aware that smoking was harmful to health. However, more than half of them did not know its specific ill-effects on the mother and the fetus. In the UK, though young primiparas were aware of the harmful effects of smoking in pregnancy, there was a general lack of concern for the risks of smoking and its effects on their own pregnancy.1 Similar observations were made among female health professionals in the USA.2 In their study on low-income pregnant women in Louisiana (USA) Arnold et al3 reported that knowledge about the health effects of smoking in pregnancy varied significantly according to levels of literacy. This is contrary to our findings, possibly because of the lack of literature for the public or health education on maternal smoking in this region.

        More than half of the study population were unaware of the consequences of Rubella infection during pregnancy. This is in line with the findings of a study in Australia4 where, the importance of immunity to Rubella and the effects of Rubella infection in pregnancy could not be identified by 41% of the pregnant women at their first antenatal visit despite having had pre-pregnancy counseling sessions. While one-third of the women in our study cited congenital malformation, a health risk to the fetus as a consequence of maternal Rubella, young primiparas in the UK specifically indicated damage to limb development suggesting to the authors that there was general confusion in this group between the effects of Rubella and the drug Thalidomide.1 Our findings support the need to create an awareness among women on primary prevention strategies for birth defects in general and Rubella infection in particular.

        Advancing maternal age beyond the age of 35 years can adversely affect the outcome of pregnancy with an increased risk of having a child with Down’s syndrome among other things. More than half of the women in the present study (54.3%) were not aware of this. Though, in general, as the literacy level of the women rose, there was a significant positive improvement in knowledge (p<0.01), a substantial proportion of the high school/college educated women (51%) remained unaware of the safe age for pregnancy, indicating a lack of discussion of this subject at the health center or in the mass media.

        It was encouraging to note that a vast majority of women (97.4%) had understood the importance of antenatal visits and cited appropriate reasons for their check-up. They believed in antenatal care early in pregnancy and regular follow-ups as recommended. Their response, however, should not be taken as a reflection of women in the general community since those in the study group were urban women attending the PHCs. A Maternal and Child Health Community Survey (1991) conducted in different regions of Saudi Arabia showed that though utilization of antenatal care services was high (86%), almost one-third of the non-attenders (30%) believed that they did not need it.5 A notable point observed in the present study was that though the subjects were PHC users, many of them lacked information on the importance of antenatal procedures such as blood examination, immunization with Tetanus Toxoid and breast care during pregnancy. A decreasing literacy level was found to be a significant factor in the lack of awareness of these health practices (p<0.01). Moreover, physicians and nurses constituted poor sources of health information (35.6%) for these mothers. Research data from another region of Saudi Arabia has also shown that pregnant women did not perceive the medical staff as a significant channel of health information.6 One wonders if this is indicative of the PHC health workers' inability to fulfill their function of educating the patients on health matters. It may also be that the language barrier between the largely non-Arab staff and the local population inhibits effective communication.

        The results of this investigation underlines the need to intensively reactivate the health education programmes through the local PHCs as well as the mass media. It seems that the current programmes are inadequate and need to be revamped. In health centers where the medical staff is largely non-Arabic speaking, it is vital that health-educators/medical staff be drawn from the local region or that staff who are fluent in Arabic be assigned for this purpose. Educational interventional research studies7,8 conducted during the antenatal period have been highly effective in improving the knowledge and health habits of pregnant women. Creating awareness among the local women of childbearing age about the prevention of health problems in pregnancy, healthy practices during the gestational period, and the importance of the various procedures in antenatal care, will increase their satisfaction, improve perinatal outcome and ultimately reduce the burden of pregnancy-related preventable problems on the health services.


1.     Eiser C, Eiser JC. Health Education needs of primigravidae. Child Care Health and Development 1985; 11:53-60

2.     Roth LK, Taylor HS. Risks of smoking to reproductive health: assessment of women’s knowledge. Am J Obstet Gynecol 2001;184:934-9

3.     Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level and knowledge of tobacco effects among low-income pregnant women. Prev Med  2001;32:313-20

4.     Marsack CR, Alsop CL, Kurinczuk JJ, Bower C. Pre-pregnancy counselling for the primary prevention of birth defects: rubella vaccination and folate intake. Med J Aust  1999;170:143-4

5.     Baldo MH, Al-Mazrou YY, Farag MK, Aziz KM, Khan MU. Antenatal care, attitudes and practices. J Trop Pediatr  1995;41:21-9

6.     Hashim TJ. Pregnancy experience, knowledge of pregnancy, childbirth and infant care and sources of information among obstetric patients at King Khalid Hospital, Riyadh. J R Soc Health 1994; 114:240-4

7.    Verma M, Chhatwal J, Varughese PV. Antenatal period: an educational opportunity. Indian Pediatr 1995;32:171-7

8.     Guillen RM, Sanchez RJL, Toscano MT, Garrido FMI. Maternity education in primary care. Efficacy, utility and satisfaction of pregnant women. Aten Primaria 1999;24:66-70