Title: Causal explanations for patient engagement with primary care services in Saudi Arabia: A realist review

Abstract

Introduction: Primary healthcare (PHC) in Saudi Arabia (SA) has lagged behind secondary care, and evidence suggests that up to 65% of the cases seen in emergency departments (ED) are non-urgent and more appropriately managed in primary PHC settings. Previous research has focused on patient satisfaction with PHC services in SA. However, engagement with PHC services is a more complex process that goes beyond satisfaction level. Yet, uncertainty still exists about causal explanations for patient engagement with PHC services and what refinements are needed for PHC. This review aims to understand the causal explanations for patient engagement with PHC and generate theories of how patient engagement with PHC in SA might be achieved through identified contexts and mechanisms. Methods and Analysis: A realist approach was used for evidence synthesis, including peer-reviewed and grey literature relevant to Saudi PHC delivery and patient engagement with PHCs. A realist analysis was used to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes of patient engagement with PHCs in SA. Results: 27 documents were used to collect the data. The decision to seek PHC help is impacted by patient's awareness of PHCs' role. Socio-cultural factors and religious beliefs have an impact on patient access to PHCs. Concerns about professionalism at PHCs, particularly staff education and skills, have an impact on patient trust and interaction with PHCs. Organisational factors such as infrastructure and PHC resources might help or hinder patient engagement with PHC. Gaps in continuous care at PHCs have explained the presence of patients with non-urgent chronic conditions in EDs instead of PHCs. Implications: Patient engagement with PHC in SA is multifactorial and influenced by local, contextual, and social circumstances, as well as organisational processes and available resources. The findings of this review have informed an empirical study to explore further current patient engagement with PHC in SA, disentangling healthcare wants and needs. This will support a better understanding of the factors that lead to patient engagement and inform recommendations to support PHC development within the Saudi context, which might also be useful in any PHC system.