Community Health Needs Assessment of Primary Healthcare in Saudi Arabia: A Cross-Sectional Study

The Kingdom of Saudi Arabia (KSA) has an advanced healthcare system.^[1] However, in the last decades, the KSA healthcare has faced many challenges in terms of growth of the Saudi population, increasing number of older people, changing patterns of disease, increased costs of health services, poor access to some healthcare facilities, a significant increase of chronic diseases, and inequality in distribution of healthcare services.^[2–4] Therefore, continuous assessment of community health needs is essential to predict, recognize, and act on these changes.^[5]

Community Health Needs Assessment (CHNA), also called community health assessment, is a systematic health assessment that collects and analyzes comprehensive data to identify key health needs and issues for a specific population group.^[6] The Public Health Accreditation Board defined it as “a systematic examination of the health status indicators for a given population that is used to identify key problems and assets in a community.”^[7] The CHNA is a core public health function, a process and the product of assessment; it is a collection, analyzing and using data to develop priorities and plan actions to improve public health.^[8] The findings of the CHNA are usually used as a base for community health improvement plans, and it shares all of its processes.^[6] The CHNA focuses on information relevant to groups to develop treatment plans accordingly,^[9] and does not address individual medical needs.

Moreover, CHNA should not be conflated with disease prevention assessment. Therefore, CHNA examines overall well-being, since health is not simply the absence of illness.^[9,10] Completing the CHNA should be considered an ongoing and modifiable process that can be repeated and updated regularly, intending to disclose the needs, gaps, and goals of the planned work toward community health.^[11]

Understanding the community’s needs, resources, health issues, strengths, and weaknesses is essential for community members and healthcare leaders.^[12] CHNA harnesses the best strategies and interventions to reduce healthcare utilization disparities and fill any healthcare gaps.^[11] Collecting and analyzing the data in the CHNA is essential to recognize the community’s health concerns, identify the associated factors that influence the community’s health, and explore the resources and challenges that affect those factors.^[5,13]

Improving the healthcare of individuals and communities is an essential part of the vision of the KSA, which emphasizes the importance of population health management in reducing diseases and increasing life expectancy.^[14,15] For example, through the 2030 vision, Saudi Arabia aims to raise public awareness about chronic diseases to control them and reduce their complications.^[14] Thus, conducting CHNA in all Saudi Arabia provinces and regions becomes a priority to overcome the current healthcare challenges and to keep pace with the KSA vision. Studies assessing community health in Saudi Arabia regions are limited.^[16] This study aims to understand the community’s health problems and range of healthy behaviors and determine the priority health problems in Hail, Northern Saudi Arabia. By conducting a CHNA, a snapshot of the health of the Hail–Northern Saudi Arabia community can be captured and reviewed by the different stakeholders to address the unmet needs uncovered. The survey data help facilitate community discussions to remove barriers that keep individuals and the entire community from thriving.

Ethical approval to conduct this study and a waiver of consent was obtained from the institutional review board.

Before publishing the research, we secured approval from the Hail Health Cluster. Additionally, we obtained the necessary institutional review board (IRB) approval from King Fahad Medical City, Riyadh, Saudi Arabia (IRB Log No. 22-316) to ensure compliance with ethical research standards. We conducted an observational descriptive cross-sectional study based on 20 primary healthcare centers (PHCCs) involving attending adults during the work days for 1 month (ending in March 2021). Data were collected by the physicians of the PHCCs, using a standard questionnaire (Supplemental Material). The data were compiled and managed by the Population Health Management (PHM) designated task force during the study period. The PHM task force was responsible for designing the study, collecting data, preparing data for analysis, and establishing a timeline for completion. This study served as a screening tool for a CHNA in Hail, Saudi Arabia, as part of a broader quality improvement initiative.

A total of 336 participants were approached to participate in this study. Of these, 303 agreed to participate (response rate: 90%). A total of 276 participants were included in the analysis after excluding 27 participants who did not meet the age inclusion criteria or had missing gender data. Of these, 107 (38.8%) were men and 169 (61.2%) were women.

The study was conducted in the central-northern areas of Hail, Saudi Arabia. Hail is the eighth-largest province of the 13 regions of the KSA (103,887 km²) and the ninth largest by population (731,147 in 2019; 2% of KSA population).^[17] Hail City is the largest city in the province. Other cities in the province include al-Ghazalah, Shinan, and Baq'aa. Since the selection criteria were random, we included 20 PHCCs of the 110 PHCCs in the region.^[18]

The study participants were approached by using a convenience sampling technique. We included adult (≥ 18 years) men and women who visited the PHCCs in the Hail region and who agreed to be part of this survey.

The physicians of the PHCCs collected data by using the CHNA standard questionnaire (Supplemental Material). The questionnaire consists of the following: demographic information (e.g., sex, marital status, educational level, age, employment status, body mass index, healthcare insurance, and household member), the health status of self (e.g., self-reporting of current health status, and last routine doctor’s visit), the health status of adults and children (routine healthcare access and accessing private sectors), health facilities access information (routine healthcare, routine access, and ability to see a doctor), receiving of healthcare procedures (receiving of preventive procedures), traveling for healthcare (traveling to seek healthcare and the reasons for traveling), source of medical information (place and person), safety measures and behaviors (e.g., wearing a seat belt, smoking habits, substance abuse, sleeping and eating habits), health problems (e.g., history of chronic diseases), childcare (special needs), and perceived community problems (the most serious community problems). Data were collected between Feb 20 and Mar 20, 2021.

All variables were reported across the study, using descriptive statistics to describe the characteristics of study participants and their answers. Categorical variables were summarized as numbers and percentages, and continuous variables were summarized as mean and standard deviation. We conducted an exploratory analysis to see the difference between male and female participants, using the chi-square test or Fisher exact test for categorical variables and the Mann-Whitney U test for continuous variables, as the normality test showed that the continuous variables were not normally distributed. We used pairwise deletion for missing data. Data analyses were conducted with IBM SPSS Statistics 27.0 (IBM, Chicago, IL, USA).

This study served as a screening tool for a CHNA in Hail, Northern Saudi Arabia, as part of a broader quality improvement initiative to enhance the quality of work and build on the findings in promoting the services. Before publishing the research, we secured approval from the Hail Health Cluster. Additionally, we obtained the necessary IRB approval to ensure compliance with ethical research standards.

The intent of publishing our findings is to address the lack of studies in this area and to provide valuable data that can aid the scientific community in developing strategies for community health improvement. We believe disseminating this information is of considerable interest and utility, given its potential to inform future health policy and practice. All procedures performed by study participants followed the institutional and national research committee’s ethical standards.

Overall, the mean age of participants was 40.4 ± 14.4 years. The data show that male participants were older (44.1 ± 16.0 y) than female participants (38.2 ± 12.9 y) (p = 0.002). The mean body mass index (BMI) was 28.9 ± 5.6, with a higher weight observed among women at 30.0 ± 6.0 than for men at 27.1 ± 4.2 (p < 0.0001).

Most participants were married (195 [72%]), followed by single status (61 [22.5%]). A total of 108 (40.6) had a degree after high school, whereas 90 (33.8%) did not finish high school. Most participants lived with six or more household members (136 [50.6%]) or three to five household members (107 [39.8%]). One or more seniors (≥ 65 years) lived within the household of 106 (40.5%) participants, and 270 (78.1%) participants had one or more children (≤ 18 years) living within the household. Most participants owned their houses (215 [83.7%]). Employment status showed that 125 (46.1%) participants were unemployed, and 181 (66.8%) participants did not have private insurance. The rate of unemployment was reported more by women (110 [66.3%]) than by men (15 [14.3%]) (p < 0.0001). More results regarding participants’ characteristics are shown in Table 1.

As shown in Supplemental Table S1 (available online), almost half of the participants reported a good current health status (126 [46.7%]), and only 45 (16.7%) participants reported fair health status, similar to a very good status (45 [16.7%]). Few participants reported poor health status (20 [7.4%]). There was no statistical difference between male and female participants regarding their health status. In the last 12 months, 197 (74.1%) participants had a routine doctor visit, 114 (43.3%) participants visited a dentist, and 81 (30.8%) participants reported being sick in the last month. Most women reported receiving prenatal care during pregnancy (108 [85%]), and 78 (62.4%) women performed breastfeeding. Around half of the participants used primary healthcare at a routine healthcare facility (138 [52.5%]) and 8 (10.6%) participants used the physicians’ offices. Our findings show that around half of the participants (135 [52.9%]) were always able to visit the doctors when needed. Of these, men were better able to see doctors when required (64 [64%]) than women (71 [45.8%]) (p-value = 0.02).

For children, 85 (34.6%) participants used physicians for routine healthcare, followed by a health department clinic (46 [18.7%]). Study participants reported no special needs among their children (19 [96.1%]). Only 6 (2.6%) reported autism, and 1 (0.4%) participant reported developmental delay; similarly, 1 (0.4%) participant reported the presence of a child in a wheelchair, or 1 (0.4%) for other.

Most participants did not travel outside the country for medical care (163 [60.4%]); the number of women who never traveled outside for medical care was 107 (65.2%), and the number of men was 56 (52.8%) (p-value = 0.013). Few participants always considered the private sector for medical care (33 [13%]), while 127 (50.2%) participants sometimes accessed the private sector. Difficulty in getting an appointment with a public doctor was the most typical reason for seeking the private medical sector (53 [24.8%]), followed by looking for better quality of services (47 [22%]).

Blood pressure checks (189 [74.1%]), blood sugar checks (189 [74.1%]), cholesterol screening (113 [4.3%]), dental examination (96 [37%]), vision screening (62 [24.3%]), and flu shot (51 [20.1%]) were the most common medical procedures within the last year, with no significant difference between male and female participants (Supplemental Table S1). Men never underwent prostate cancer screening. Women underwent few mammograms (21 [14%]) and Pap smears (8 [5.1%]). Among both genders, the colorectal examination was performed for 17 (6.7%) participants (Supplemental Table S1). Obesity (49 [18.2%]), dental health problems (23 [8.5%]), arthritis (12 [4.5%]), high blood pressure (12 [4.4%]), high cholesterol levels (11 [4.1%]), and diabetes (10 [3.7%]) were the most common health problems among the study participants as shown in Table 2.

Study participants sought medical information from more than one source (134 [51.3%]). However, healthcare providers were considered the primary source of health information (91 [34.9%]). Similarly, study participants trust physicians and nurses when seeking health information (106 [40.5%]). For more information about the health status and access to health, see Supplemental Table S1.

This study indicates that 144 (54.3%) participants always wear their seat belts when driving, and only 56 (22.1%) drive the posted speed limits. The number of participants who always eat at least five servings of fruits and vegetables daily was only 42 (15.6%), while 200 (89.6%) participants did so sometimes. Only 32 (2%) participants always ate fast food more than once weekly. However, (186 [69.7]) participants reported eating weekly fast food sometimes. Only 33 (12.5%) participants exercised regularly, and 142 (53.6%) sometimes exercised. Most respondents have never (or chose not applicable) smoked cigarettes (216 [79.7%]), chewed tobacco (258 [95.2%]), or used illegal drugs (226 [83.7%]). Washing hands with soap before eating or preparing food was familiar, with 196 (72.6%) participants reporting that they do so always and 55 (20.4%), sometimes. Fifty-eight (21.6%) participants said they always take vitamin pills or supplements daily, and 163 (60.8%), occasionally. Most participants got enough sleep each night: 121 (44.6%) always and 135 (51.1%) sometimes. Study participants reported that they felt happy about life always (124 [46.1%]) and 118 (43.9%), sometimes. Participants generally feel safe in the community, as 198 (78.3%) reported they always feel safe and 36 (14.2%), sometimes. More information about the safety and lifestyle practices is shown in Table 3.

Study participants perceived the following problems as among the most serious community problems: alcohol/drug use (112 [48.1%]), cancer (97 [20.3%]), stroke (96 [40.9%]), job availability (92 [40.2%]), high blood pressure (91 [37.9%]), HIV/AIDS (91 [33.9%]), smoking (90 [39.1%]), child abuse (88 [36.7%]), infectious diseases (87 [37.2%]), highway safety (86 [36%]), suicide (85 [36.6%]), heart diseases (83 [34.4%]), and asthma/respiratory disorders (81 [32.8%]) (Table 4).

In this study, we described the population’s social and health characteristics, health status, access to healthcare and health information, safety and lifestyle practices, and earnestly perceived community problems in Hail, Saudi Arabia, by using a standard CHAN questionnaire. In addition, we explored the differences between male and female participants.

The public health and primary healthcare systems in the KSA have improved in the last decade.^[2,19] The expansion in the development of medical cities, primary care settings, health technology, and operationalized self-services has improved the accessibility to medical care and medical information, which has resulted in better health outcomes.^[18,20] For example, the number of beds per 10,000 population increased from 17.2 in 2016 to 26 in 2020 in the Hail region.^[18] However, critical challenges such as chronic health problems still require calls to action to improve and reform primary healthcare.^[19] Our findings showed that the mean BMI of the participants was 28.9, reflecting an overweight. Most participants were overweight (41.5%) or obese (32.8%). Women reported higher BMI than male participants. Similarly, obesity was declared the most common health problem among the study participants. Obesity in our findings is higher than reported in a recent nationwide study (4709 participants).^[21] Althumiri et al^[21] reported a prevalence of obesity (BMI ≥ 30) in 2021 of 24.7% among the Saudi community and 20.1% in the Hail region. The differences in findings from our study could be related to the sample size and population, as our study targeted primary healthcare patients. However, both studies evidence obesity as a critical healthcare problem. Obesity is associated with several health problems, such as diabetes, hyperlipidemia, and hypertension, which emphasizes the need for urgent action.^[21,22]

Blood pressure and blood sugar checks were the most common medical procedures the participants underwent in the last year. Prehypertension, hypertension, prediabetes, and diabetes are common in Saudi Arabia, making these procedures familiar and routine.^[22–27] Conversely, cancer screening procedures were rarely performed. For example, no prostate cancer screening procedures were reported for men, and mammogram and Pap smears were not commonly performed for women. Colorectal cancer screening was not widely performed either. Breast, colorectal, and prostate cancers are the most common cancers in Saudi Arabia.^[28] Chaudhri et al^[29] reported an increase in trends in the most common cancers in Saudi Arabia. For example, colorectal adenocarcinomas increased from 69.9% of cases in 2011 to around 79.9% of cases for men and 79.3% for women in 2014.

Similarly, breast cancers increased to represent 30% of cancer cases in women.^[29] Another study revealed that the magnitude in the epidemiology of some cancer cases increased by 3-fold.^[28] This alarming rise in pace requires increasing awareness about the importance of performing cancer screening programs in the Hail region.

Our study reported the frequency of adherence to safety procedures and healthy lifestyle habits. For example, our findings showed that around half of the participants reported complete adherence to wearing seat belts and less frequent commitment to the posted speed limit while driving. Road traffic accidents (RTAs) are the fourth leading cause of death in Saudi Arabia.^[30] In 2020, RTA deaths exceeded 12,000, representing 9.19% of total deaths.^[30] Overspeed is the most common cause of RTAs in the KSA, and adherence to wearing a seat belt was reported to be low.^[31] These findings support the action plans of the 2030 vision in the KSA to reduce the number of RTAs.^[32] Initiating activities that target drivers’ behavior by increasing their awareness about the importance of adherence to traffic laws and by strengthened reinforcement of rules is vital to reducing RTAs.^[31]

Our findings showed high frequency for some healthy lifestyle behaviors such as lower rates of smoking, lower rates of eating fast food, and good adherence to washing hands before preparing and eating meals. However, our findings also find a low rate for practicing physical exercise, getting enough sleep, and eating fruits and vegetables. Obesity and overweight are known to be associated with the consumption of unhealthy food, low physical exercise, and unhealthy sleeping patterns.^[33–36]

Understanding the community’s needs, strengths, and weaknesses is vital for community members and healthcare leaders.^[12] CHNA collects and analyzes data to identify essential health needs and issues for a specific population group, and it should be used to set community health–improving plans.^[6] Healthcare leaders and stakeholders can use the findings of this study to develop healthcare strategies, regional public awareness programs, screening and prevention programs, and healthcare policies to control and prevent health problems and to improve the population’s health in the Hail region.^[37–40]

The CHNA is a systematic, data-driven approach to determining the health status, behaviors, and needs of these residents.^[41] CHNA has a central part to play, enabling practitioners, managers, and policy-makers to identify those needs,^[42] in addition to advancing policies and strategies to ensure effective population health systems that support optimal health.

The findings of this study should be interpreted in light of its strengths and weaknesses. This study is the first to report the community health needs of the Hail-region population, using a standard CHNA questionnaire. The main limitation of this study is its cross-sectional natureincluding eight PHCCs, which represents potential information and selection biases. In addition, the small sample size may limit the study findings’ generalizability to the Hail population’s primary care visitors. Further, there were many instances of missing data or unanswered questions by participants; however, we used the pairwise deletion technique to manage the missing data and reduce its negative effects.

This study is the first in the Hail region to assess and describe the primary healthcare participants’ community health problems and needs. Our findings reported positive health behaviors and good accessibility to healthcare services when needed. However, the study findings revealed healthcare challenges that required urgent action from Hail healthcare leaders. Obesity is found to be the most significant healthcare problem in this population. Healthcare leaders can use the findings of this study to control and prevent health problems and improve the population’s health in the Hail region by developing healthcare strategies, regional public awareness programs, screening and prevention programs, and by changing healthcare policies. Future research is needed, considering the limitations of this study.

Supplemental materials are available online with the article.

The data supporting this study’s findings are available from Hail Health Cluster. However, restrictions apply to the availability of these data, which were used under license for the current research and are not publicly available. Data can only be examined with an authorized Hail Health Cluster investigator. Request for access can be sent to the corresponding author.

The authors thank Hail Health Cluster and the Northern Business Unit at Health Holding Company, Saudi Arabia, and the Research Center at King Fahad Medical City, Riyadh, for the tremendous technical support.