Over the past several decades, the Alma Ata declaration issued by the World Health Organization  has increasingly expressed the need for primary health care (PHC) to be accessible to all individuals and families living in communities worldwide. The conference listed the promotion of mental health treatments as one of the essential elements of PHC services which will reduce mental illness in a community and enhance patients’ coping strategies through proper prevention and treatment  . The goal of PHC is to provide fundamental healthcare needs and to offer global access to families and individuals in the community close to where they live and work. It is decentralized and requires the active participation of the community and family  . McDaniel, Hargrove, Belar, Schroeder, and Freeman  identified several goals that included the development and feasible implementation of treatments within PHC based on population care rather than the more intensive individual client-centered care typical of the specialized mental health setting. Ratzliff et al.  view behavioral integration into PHC as essential for enhancing access to care, producing better patient outcomes, reducing health care costs, and perhaps improving patient’s awareness of healthcare services.
Much evidence supports the need for integrating psychosocial and behavioral healthcare into PHC. For example, in developed countries, one-third of visits to PHC centers were related to psychosocial and behavioral problems  , and more than two-thirds of the PHC medical appointments were related to psychosocial concerns  . In industrialized North America and Western Europe, 25% of disability that leads to premature death was accounted for by mental disorders  . In a developing country such as Lebanon, an epidemiological survey showed that 17% of respondents met the criteria for at least one mental disorder within a 12-month period   . In the capital city of Riyadh in KSA, 30% to 40% of those seen in PHC clinics had mental disorders  . Another study in KSA showed that mental health problems are often thought to have religious or somatic causes, making them difficult for mental health practitioners to diagnose and treat  . Literature from adjacent African countries supports these findings    . Regretfully, it was clear that most of these mental health cases were treated either by PHC medical professionals or by religious/traditional healers    and that perhaps less than one-third of patients ever met with a psychologist or other mental health providers  .
Therefore, integrated psychosocial and behavioral health services into PHC settings is essential for providing treatment and diagnosis of patients with mental disorders, designing strategies to prevent mental disorders and ensuring the existence of qualified healthcare practitioners to provide proper psychosocial services and counseling  . This integration is expected to result in several advantages such as reduction of stigma  , family burden associated with mental disorders  , ease of access to mental health services and treatment  , early detection and prevention of mental conditions  , and reduction of chronic recurrent course of mental illness  . Furthermore, the integration of psychology into PHC settings could help in predicting new definition, explanation, and concept of PHC in the future of the health-care system structure  . For instance, to further their ability to collaborate with medical practitioners, psychologists can offer a biopsychosocial explanation and detection of mental illness to patients and their family caregivers  . In view of this, some scholars    particularly emphasized the availability and timely access to PHC settings to provide psychological services to at-risk populations, such as underserved rural dwellers, victims of abuse, and those with low socioeconomic status.
A few studies have been conducted on patient’s satisfaction in Saudi PHC settings   . However, no published studies to date have investigated comparing patients’ satisfaction and QOL at PHC settings with that of psychiatric hospitals. Therefore, the primary objective of this study was to compare satisfaction and QOL between two groups of participants who received mental health treatments at PHC setting (group1; G1) and psychiatric hospitals (group 2; G2), and also to compare the findings to a healthy control group (G3) recruited from general population.
This research study highlighted the important association between the PHC organizational model and health-related QOL and client satisfaction in persons with mental illness. It was carried out in the Eastern Province (EP) of KSA and hypothesized that participants at PHC would report higher satisfaction and QOL regarding their mental health than participants treated at psychiatric hospitals.
Participants from group 1 (G1; PHC attendees) were recruited from three PHC in Dammam and Khobar in KSA. They included 14 males (M = 32.71 years in age, SD = 5.9) and 22 females (M = 32.77 years in age, SD = 8.21) who were regularly receiving mental health services from the clinics.
Group 2 (G2; hospital attendees) participants were recruited from outpatient psychiatric departments at King Fahad University Hospital (KFUH) in Khobar city and Al Amal Complex Hospital (ACH) in Dammam city, KSA. They included 45 males (M = 36.63 in age, SD = 12.84) and 13 females (M = 34.36 in age, SD = 10.34) who were consecutively receiving mental health services from the hospitals. Two participants did not indicate their gender.
Group 3 (G3; control) served as a healthy control and included 39 males (M = 37.47, SD = 15.14) and 24 females (M = 28.89, SD = 7.55) who were recruited from public locations such as schools, universities, lecture halls, supermarkets, and mosques. One participant did not specify his or her gender.
Permission was granted to carry out the study from authorities of each clinical setting. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of General Directorate of Health Affairs (GDHA) in Khobar, EP of KSA. Eligibility criteria included being native Saudi participants of both genders, literate, aged 18 years or older, currently using PHC or psychiatric hospital services and having met the ascertained diagnostic criteria for mental disorders according to the Diagnostic and Statistical Manual of Mental Disorder, 5th ed. (DSM-5)  .
Participants were consecutive attendees at the PHC and psychiatric hospital settings who fulfilled the study’s inclusion criteria. They were approached by the primary investigator (OAA) who used the direct enrollment strategy by approaching each participant individually and asking him or her of whether he or she would be interested in take part in the study. Illiterate or those who were unable to answer questions were excluded. An IRB-approved letter of the study was presented to the treating healthcare providers who assisted in referrals of eligible and interested participants. A considerable care was taken that no participant contacted would feel obliged or pressured to participate. Also, all participants were informed that they had the right to withdraw from the study. Thereafter, OAA visited each facility and handed the measures to each participant after explaining the purpose of the study and confidentiality, responding to their questions effectively and receiving their verbal consent to participate. The questionnaires were completed at the facility while the investigator was waiting in a separate room. Participants returned the anonymously filled questionnaires to the investigator. In addition, healthy control participants were approached in classrooms, supermarkets, and mosques. No identifying information was collected.
Two assessment instruments were used in the present study: the validated Arabic version of the World Health Organization Quality of Life-short version (WHOQOL-Bref)  and the translated Arabic version of the Client Satisfaction Questionnaire (CSQ)  .
The Arabic WHOQOL-Bref is a 26-item, self-administered questionnaire, a short version of the WHOQOL-100 scale used for assessing participants’ subjective responses rather than their objective life conditions     . The questionnaire captures four domains of QOL. They are physical health, psychological health, social relations, and environment. The rating uses a five-point scale ranging from “dissatisfied” (a score of 1) to “highly satisfied” (a score of 5). The scores are scaled in a positive direction (i.e., higher scores denote higher quality of life)  . Individual item ratings are based on transforming raw scores into scores ranging from 4 - 20 to align with WHOQOL-100 instruments  . The items are then summed to provide an overall index of satisfaction level  . Two additional stand-alone domains that are of particular relevance to an individual’s Overall Quality Of Life (OQOL; Q1) and General Health (GH; Q2) facets were assessed separately, as recommended by the WHOQOL Group (  . They are used to constitute the general facet of OQOL and health. The test-retest and the internal consistency reliability for the questionnaire and the domains had an acceptable Cronbach’s alpha of ≥0.7. Internal consistency reliability on each domain (Cronbach’s alpha) was 0.80 for physical health, 0.77 for psychological health, 0.69 for social relations, and 0.83 for environment  . Similarly, our current study showed a high reliability for the full questionnaire (alpha = 0.95) and adequate to high levels for its four domains: 0.89, 0.84, 0.84, 0.76, and 0.87 respectively.
Client Satisfaction Questionnaire
Larsen, Attkisson, Hargreaves and Nguyen (  first developed the CSQ, a self-report measure designed to assess the degree of clients’ satisfaction with service and elicit their perspective on the value of services received. It is an 8-item measure with rating response options based on a 4-point scale with scores ranging from 1 (quite dissatisfied) to 4 (very satisfied), easily scored by summing the individual item scores to produce a range of 8 to 32, with high scores indicating greater satisfaction   1979). An example of the eight different components that the questionnaire measured is “how satisfied are you with the amount of help you have received?” for which the response options are 1 = quite dissatisfied, 2 = indifferent or mildly satisfied, 3 = mostly satisfied, and 4 = very satisfied  . Unlike WHOQOL-Bref, CSQ has no subscales and tends to report a single dimension of overall general satisfaction with services  . The internal consistency of the original CSQ-8 was high, with Cronbach’s alpha coefficients ranging from 0.84 to 0.93  . A similar result of high reliability was reported by the present study (alpha = 0.89). The questionnaire has been translated into different languages, including Arabic  , and has been used in a wide spectrum of clinical and human services, educational and governmental programs, legal and police services, and administrative and research settings      .
2.4. Data Analysis
PSPP statistical software version 0.10.2  was used for the data analysis. Means, standard deviations and frequency data were calculated to describe participants’ sociodemographic and clinical information in each group. Comparisons among the three groups for each of four domains and two facets of WHOQOL-BREF were done using one-way ANOVA, followed by post hoc t-tests with Bonferroni corrections. Similarly, One-way ANOVA was used to compare CSQ scores among three groups with post hoc t-tests.
Table 1 shows the characteristics of the study population. The study had the total of 160 participants (n = 96; 60%) and controls (n = 64; 40%). Participants aged between 18 and 79 years, with the majority (73.9%) of them young adult native Saudis aged between 18 and 40 years. They were predominantly married
Table 1. Sociodemographic and clinical characteristics of participants and control group (N = 160).
(61.5%), educated at a high school or college level (89.6%), employed at a professional or technical level (42.4%) and more than one-third (42.7%) had a history of comorbid disorder. Likewise, majority of healthy controls were young adults between 18 and 40 years (69.8%), predominantly married (64.1%), educated at a high school or college level (95.3%), employed (62.6%) and nearly one-third (32.2%) had reported having a disease.
Table 2 shows the means and standard deviations of WHOQOL-BREF scores of participants in G1, G2 and G3. One-way ANOVAs found significant differences among three groups in each domain and overall QOL scores. Post hoc comparisons of groups on each domain were calculated with Bonferroni corrections. The results of the multiple comparison tests showed no significant differences on the QOL level between G1 and G2 across all four domains and General Health (GH) whereas participants in G3 reported significantly higher QOL than G1 and G2 in all domains and GH. The only significant result for overall QOL is that G3 scored significantly higher than G2. There was no difference between G1 and G2, nor was there between G1 and G3 on overall QOL.
Table 3 shows a One-Way ANOVA on CSQ scores which showed significant difference across groups, F (2, 157) = 9.45, p < 0.01. The post hoc analyses indicated that participants in G1 reported significantly higher satisfaction than G2 (t = 2.38, p < 0.019) and G3 (t = 4.55, p < 0.01). G2 participants reported significantly higher client satisfaction than participants in G3 (t = 2.05, P < 0.042).
Table 2. WHOQOL-BREF means and standard deviations across settings.
Note. * = p < 0.05, ** = p < 0.01, *** = p < 0.001 Standard deviations appear in parentheses after means.
Table 3. CSQ means and standard deviations across settings.
Note. ** = p < 0.001.
This study was conducted in one of the 13 provinces of KSA with the aim to compare mental health participants’ reported levels of satisfaction and QOL in mental healthcare between PHC and hospital settings. It used validated Arabic instruments to assess the participants’ ratings of their own subjective experiences, which proved to be more accurate measures than clinicians’ ratings  . It also incorporated a healthy control group recruited from corresponding communities for comparative rating. However, the study was limited by its small sample size which may have reduced power to detect meaningful differences among the groups. Also, the study population was sampled from an urban province (i.e.; EP) that hosts large universities and hospitals, thus the findings cannot be extrapolated to the Saudi rural areas. Future research using more diverse and larger groups of mental patients is needed to establish whether the differences reported herein can be further generalized to other Saudi PHC settings. Despite such limitations, the present findings were in accordance with previous studies  that urbanized countries with a well-established PHC system showed significant results in favor of PHC program over hospitals.
The results did not show significant differences in participants’ QOL in all four domains and GH between PHC and hospital settings. As expected, the healthy control population reported significantly higher QOL than participants in both settings, as seen in other studies  . With regard to participants’ satisfaction, the results showed that participants at PHC settings were significantly satisfied compared to participants seen at the hospital settings and among controls. Some possible explanations for higher satisfaction reported by Alshammari  included patients’ exhibiting less severe diagnoses, quality of clinicians and empathic communication. Prior studies have pointed to these explanations as strongly correlated to patient’s satisfaction with favorable outcomes   . The higher level of satisfaction shown by the study among hospital group more than control group may be influenced by the new changes and recent advances in Saudi mental health system adopted from WHO  quality rights and aimed at promoting quality of mental care such as ease of referrals to mental or general hospitals and improvement in detection of undiagnosed mental conditions  .
Certain factors could possibly explain poor overall QOL in our clinical sample. Physical and psychological variables such as comorbidities, distressed mood, and lack of occasional assistance in self-care in clinical population have been found to be significantly associated with poor QOL   . For instance, Fu et al.  reported comorbidities as negatively associated with QOL of chronically ill survivors whereas lower severity in terms of having fewer co-morbid conditions was associated with higher QOL  . Our study showed that more than one-third (42.7%) of participants had a history of comorbid disorder. Hence, further research considering the combined influence of comorbidity and mental illness on participants’ QOL is needed. When investigating Saudi conservative society, still, it is important to mention the fear of confidentiality breaches and feelings of guilt and shame arising from social stigma of seeking mental health services  . To reduce such ingrained fears, integrated behavioral services within PHC can provide the needed confidentiality for people who require mental healthcare. Literature showed that mental health culture strictly values confidentiality as opposed to medical culture that is organized around referrals and consultation with others  . Hence, the patients’ bill of rights (PBR) publicized by the Saudi Ministry of Health (MOH)  has led to a stronger call for providing an insight into awareness and knowledge of patient’s rights such as right to confidentiality and privacy  . To reduce stigma, Angantyer et al.  perceived brief therapy at PHC as less stigmatizing for clients, especially when it is conducted by a qualified psychotherapist  . Other programs to fight against negative attitudes and beliefs about mental illness can be implemented via public awareness campaigns, media messages targeting documented stigma and discrimination  , and well trained psychologists who have knowledge of PHC strategies and all techniques important for providing effective psychotherapy  .
While there has been remarkable progress in Saudi mental health system and the number of psychologists is rising  , PHC system still lacks a well-established program based on psychosocial intervention and precise detection of mental health problems by PHC providers   . The present findings encourage the primary care community to put more effort into improving mental illness detection by qualified clinicians in KSA, pay attention to mental conditions that might be manifested by or mixed with medical conditions  , use routine self-reporting instruments by PHC service providers to accurately assess patient’s mental status    and make referrals to mental health professionals accessible. Furthermore, programs are necessary to develop a system to keep pace with global improvement of mental health services. Such a change requires mental health professionals’ willingness to take an active stance in the movement. Larger scale studies in various provinces are recommended. Also, other variables such as influence of comorbidity, psychiatric diagnoses, client support system in preventing relapse, and skills and experiences of clinicians should be evaluated in future studies.
We are grateful to the authorities at KFUH and ACH in Khobar and Dammam for their valuable assistance in consenting to and facilitating data collection. Our thanks also go to the participants for their valuable cooperation and contributions to our study.
Declaration of Authorship
OAA initiated the idea of the study and collected the data. AWA supervised the study and contributed to data interpretation. HA analyzed and interpreted the data. All authors contributed equally to writing the manuscript, and all read and approved the final manuscript.