Causal Explanation for Patient Engagement with Primary Care Services in Saudi Arabia: a realist review

Problem

Saudi Arabia (SA) has a rapidly developing universal health care system and is maturing from its very hospital focussed origins. However, health service usage suggests estimates of up to 65% of the cases seen in secondary emergency hospitals classified as non-urgent that could appropriately be managed in primary health care (PHC). Primary healthcare development in Saudi has lagged behind secondary care, and evidence suggests that citizens are ambivalent or dissatisfied with these services.Previous research has focused on the quality and patient satisfaction of primary care services in Saudi Arabia. Yet, uncertainty still exists about causal explanations of patient engagement with primary care services and potential ways to improve thisThe aim of this review is to understand causal explanations of patient engagement with the Saudi PHC.

Approach

A realist approach was chosen as patient engagement with PHC is complex. We undertook systematic searches and identified data relevant to the Saudi primary healthcare delivery and patient engagement. A range of types of data such as qualitative, quantitative, mixed-method research and grey literature (incorporating related media items) were included as was stakeholder involvement. A realist review methodology has been used for the data synthesis where we developed an initial programme theory, searched for evidence as outlined, undertook study selection and data extraction. Through data synthesis the programme theory was refined.

Findings

We identified 33 articles. The data sources were most frequently cross-sectional surveys and gave us information on different domains in the primary care setting. A pathway of patient engagement was generated with 6 steps. Many CMOs (Context-Mechanism-Outcome Configuration) were identified to produce the programme theory. Important contexts such as; patient's perception, patient's needs, healthcare type, friends/ families’ influences, and patient's socio-cultural factors were identified. The causal mechanisms included trust in, disbelief with or misconceptions of primary care, patients’ perceptions of GPs’ knowledge, GP/patient communication, PHC accessibility & opening hours, specialised care in PHC setting, and strict gatekeeping policies.

Consequences

Patient engagement with primary care services is an important topic in SA, particularly in the context of Saudi’s 2030 vision for healthcare. Patient engagement with PHC is a complex process, and little is known about patient drivers and how better engagement might be achieved. No previous realist reviews have been undertaken on this or any related topic in the primary care setting in SA. This review has extended our understanding of patient engagement with primary care services in SA. We will develop outputs to inform future interventions aiming to improve patient engagement with primary care services in SA. We believe our findings provide important insights for healthcare providers and policymakers not only in SA but in other settings developing primary healthcare systems.