Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Committee Chair

Steiner, Robert William Prasaad

Committee Co-Chair (if applicable)

Esterhay, Robert

Committee Member

Austin, Raymond

Committee Member

Kulasekera, Karunarathna

Author's Keywords

Primary medical care; Saudi Arabia


Patients--Care--Saudi Arabia; Medicine--Saudi Arabia


Objectives: To assess primary care performance for measures of patients’ experience in Community-based Primary Care (CPC) and Employer-based Primary Care (EPC) systems in Saudi Arabia, to examine variations in performance across the two systems, and to explore factors at both the individual-level and the organizational-level that explain variations in primary care performance. Design and Methods: This is an observational and cross-sectional study, using comparative design and survey research methods. The newly revised and re-translated Arabic version of the Primary Care Assessment Survey (PCAS) was used to measure patients’ experience of primary care. PCAS operationalizes the IOM definition of primary care, which identified core domains of primary care as accessibility of care, continuity of care, comprehensiveness of care, coordination of care, interpersonal treatment, communication, and community orientation. A two-stage cluster, matched sampling was employed to select 16 primary care centers (eight CPC and eight EPC centers) in Riyadh, the capital and largest city (population > 5.5 million) in Saudi Arabia. A systematic random sampling was employed to collect primary survey data from 612 adult patients visiting the selected primary care centers. Results: After adjusting for differences in the patient-mix and taking into account the multi-level structure of data by means of multi-level modeling, EPC performed statistically significantly better than CPC in interpersonal care (Mean EPC = 68.3, 95% CI [± 6.3] vs. Mean CPC = 59.5, 95% CI [± 5.9], p = 0.024, Effect Size (d) = 0.36) and communication (Mean EPC = 69.8, 95% CI [± 4.9] vs. Mean CPC = 64.4, 95% CI [± 5.5], p = 0.035, d =0.22), in addition to the total quality score (Total PCAS EPC = 60.4, 95% CI [± 2.9 ] vs. Total PCAS CPC = 56.1, 95% [± 3.3], p = 0.009, d =0.31). CPC performed statistically significantly better than EPC in community orientation (Mean CPC = 47.8, 95% [± 5.7] vs. Mean EPC = 35.5, 95% [± 6.2], p = 0.003, d =0.50) and accessibility of care (Mean CPC = 67.4, 95% [± 5.7] vs. Mean EPC = 63.5, 95% [± 4.5], p = 0.025, d=0.23). There were no significant differences between CPC and EPC in coordination of care (p= 0.098), comprehensiveness of care (p = 0.208), and visit-based continuity of care (p = 0.354). Patient-level (compositional) variables explained a significant proportion (R2 = 0.14) of the observed level-one (within-centers) variations in measures of patients’ experience. Those variables include gender, self-perceived health status, and patient-reported co-morbidity. Female patients, reporting poor health, and reporting chronic conditions are each statistically significantly associated with lower ratings of patients’ experience of care. Organizational-level (contextual) variables explained a significant proportion (R2 = 0.78) of the observed level-two (between-centers) variations in measures of patients’ experience. Those organizational variables include practice type and proportions of family physicians in a center. EPC centers and those centers with higher proportions of family physicians are each statistically significantly associated with better patients’ experience. Finally, aspects of care that were statistically significantly associated with better patients’ experience include knowing the name of the physician and being with the same physician for longer durations. Conclusion: Enhancing continuity and quality of patient-physician relationships may improve the overall patients’ experience of care. Healthcare systems in Saudi Arabia might embrace the Bio-Psycho-Social model to foster a culture of health and caring. Effective, community-oriented primary care systems have the potential to re-orient health systems’ from a sole focus on sickness and disease, to include additional approaches for prevention and wellness at the societal level. Positive indicators of health, at both the individual and community levels, are needed to better align existing healthcare systems with this goal, mission and vision to improve population health.