Awareness of Urgent Care Services Among Primary Healthcare Center Patients in Al-Ahsa, Saudi Arabia

Background Urgent care clinics (UCCs) provide services for patients without the need to book an appointment in advance to treat acute diseases and injuries that do not need ED service and provide care for chronic conditions. This study aimed to assess the patients's level of awareness regarding UCCs in the Al-Ahsa region and provide information contributing to decision-makers' support about the urgent care services and their patterns of use within primary healthcare. Methods A descriptive cross-sectional study was conducted in the Al-Ahsa region from August 2023 to December 2023. A validated questionnaire was used. Cluster sampling was used to select three primary healthcare centers from four health sectors (southern cluster, middle cluster, northern cluster, and eastern cluster), and then simple random sampling was used to select participants. sample size calculated by Cochran's sample size formula, which estimated 377 participants. However, to accommodate a non-response rate of 10.0% and stronger statistical power and effect size, the final sample size was 469 participants. Data were analyzed by SPSS Statistics version 28 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp.). Both descriptive and inferential statistics were used. A p-value ≤0.05 is considered statistically significant. Results Of the 469 participants in the study, more than half (54.8%) were aged between 18 and 38 years old, and more than half (54.8%) were male. More than half (67.4%) reported having no chronic diseases, whereas the most common chronic diseases reported were diabetes mellitus (11.9%) and hypertension (14.3%). Most of the participants (84.9%) weren’t aware of UCCs. Among the participants who were aware of UCCs (n=71), 53.5% of them had visited a UCC in the last three months. The most common reasons for their visits were the common cold (40.8%), headaches (5.6%), and abdominal pain (5.6%). More than one-third of participants (38.6%) believed that UCCs provide services like those of the emergency center. According to patients' sex, there was a significant (0.031) difference in the awareness level; the highest was among females at 20.1% vs. 12.6%. Conclusion The study revealed that the majority of the participants were unaware of UCCs. Increasing patients' awareness of UCCs is necessary through different media to improve access to healthcare services and reduce overcrowding in the ED that is caused by non-urgent problems.


Introduction
An urgent care clinic (UCC) is defined by the American Academy of Urgent Care Medicine (AAUCM) as "the provision of immediate medical service offering outpatient care for the treatment of acute illness and injury" [1].UCCs consider walk-in clinics, which provide healthcare services for patients without booking an appointment in advance, for a variety of diseases and injuries that are not severe enough to require ED visits [2].In contrast, a primary healthcare center (PHC) is defined by the American Academy of Family Physicians as "the provision of integrated, accessible healthcare services by physicians and their healthcare teams who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community" [3].UCCs can deal with several diseases, including acute and chronic cases, through a patient-centered and comprehensive approach and in connection with another medical specialty [4].
ED demand has been increasing annually by about 3% to 6% in many countries, including the United States, Canada, Australia, and the United Kingdom [5][6][7][8].A previous study in Saudi Arabia showed increased emergency service utilization due to an increased number of patients [9,10].The increase in the number of ED visits led to increased waiting times and costs.ED crowding is considered a worldwide issue [11][12][13][14][15].A study showed that 10-60% of ED cases can be managed using lower acuity care services [16].It takes about one hour in a UCC to provide services for walk-in patients [17].A different study showed the main reasons for ED and UCC visits are lack of access to primary care, convenience in terms of better opening hours or being located closer to home than alternatives, and recommendations from a healthcare provider, relatives, or friends [18].
Literature shows unsatisfactory awareness regarding UCCs in Saudi Arabia.The most common cause of urgent care visits was the common cold (25.76%) [11].In Saudi Arabia, UCCs consider a new scope of services in the new healthcare transformation strategy, which is one of the strategic goals of the Saudi Vision 2030 [4].In Al-Ahsa, urgent care services are provided in many PHCs: Alsalhya PHC, Aljaber PHC, Eskan-Alhkabia PHC, Aloyun PHC, and Al Omran PHC.
This study aimed to assess the patients' level of awareness of UCCs in Al-Ahsa and identify the factors associated with patient awareness of UCCs.

Materials And Methods
This was a descriptive, cross-sectional, patient-based study.The study was conducted in the Al-Ahsa region, which accounts for about 20% of the Saudi Arabian area.It is considered the largest governorate in the Eastern Province of Saudi Arabia.It contains four major cities: Al-Hofuf, Al-Mubarraz, Al-Oyun, and Al-Umran.The total population of Al-Ahsa is about 1,369,338 people.Al-Ahsa is divided into four health clusters: the southern cluster, middle cluster, northern cluster, and eastern cluster, with a total of 66 PHCs, so cluster sampling was used to choose three PHCs from each sector randomly, and from each center, we selected the participants by using a simple random technique.The sample size was calculated by using a margin of error of 5%, a confidence level of 95%, and a response distribution of 50% through the following formula: where z represents the confidence level (95%), p represents the proportion of the dependent variable under study in the population (50%), and d represents the margin of error (0.05).
So, the sample size is 377.However, to accommodate a non-response rate of 10.0% and stronger statistical power and effect size, the final sample size was 469 participants.
All adult participants of Saudi nationality, older than 18 years, and not working in the health field were included in this study, while respondents were excluded if they were working in the health field, below the age of 18 years, and did not agree to participate.
Data was collected by a validated 16-item questionnaire that was used in a previous study [11].Permission to use the questionnaire was granted by the authors, Albalahi NM.Data was collected by a validated 16-item questionnaire that was used in a previous study [11].The questionnaire has two main parts: the first part is sociodemographic data (age, sex, marital status, educational level, employment status, family income, and history of chronic diseases); the second part is the extent of awareness and usage pattern of UCC.The participant who chose the aware option was considered aware, and those who were not were considered unaware.

Ethical considerations
The study was approved by the Institutional Review Board of King Fahad Hospital -Hofuf (approval number: 99-EP-2023).Informed consent was obtained from all the participants of the study, and the participants have the right to withdraw from the study at any time.All data remained confidential.The study shows no conflict of interest.

Results
Of the 469 participants in the study, more than half (54.8%) were aged between 18 and 38 years old, followed by 36.5% between 39 and 60, more than half (54.8%) were male, the majority (67.4%) were married, followed by single individuals (29.4%), about two-thirds had completed university education (66.1%), followed by high school graduates (22.6%).In addition, 44.6% identified as employees, followed by students (19.0%) and more than one-third (38.4%) of their family income between 6,000 and 12,000 SAR monthly, followed by more than 12,000 SAR (35.8%).A significant portion of participants (67.4%) reported having no chronic diseases, whereas the most common chronic diseases reported were hypertension (14.3%) and diabetes mellitus (11.9%).All details are shown in Table 1.The awareness and use of urgent care services are shown in Table 2. Most of the participants (84.9%) had not heard about UCCs; among the participants who were aware of UCCs (n=71), 46.5% reported not having visited a UCC in the last three months.Of those who did visit, 35.2% had one to three visits, 8.5% had four to six visits, and 9.9% had more than six visits.The most common reasons for their visit were the common cold (40.8%), followed by headaches (5.6%) and abdominal pain (5.6%).

Questions Answers Frequency (%)
Have you ever heard of the term urgent care clinics?The difference in awareness and utilization by participants' age is shown in Table 4.A study reported that individuals from different age groups had varying reasons for attending PHCs without a scheduled meeting.Among the age group of 18-38, a recent health problem was mentioned, whereas in the age group of 39-60, more than 60% reported having difficulty making appointments at 54.5% and 47.8%, respectively (p=0.009).
Regarding the groups allowed to attend UCCs, there were no significant differences observed among the age groups, except for pregnant women, people with special needs, health center employees, and males.The only statistically significant variation between income categories was observed in who was eligible to visit PHCs; pregnant women are the only group mentioned (Table 6).

Discussion
This is a cross-sectional study conducted in Saudi Arabia from August 2023 to December 2023.We aimed to evaluate patients' awareness of urgent care services and their patterns of use within primary healthcare.Our findings provide valuable insights into the current state of awareness regarding urgent care services.Saudi Arabia's healthcare system is undergoing a transformation in line with the country's 2030 vision, which aims to improve access to healthcare, modernize facilities and equipment, implement telemedicine consultations, utilize data-driven treatment plans, and enhance traffic safety to meet the needs of every member of society [4].
The present study reported that most of the participants (84.9%) had not heard about UCCs.More than half of the participants who were aware of UCCs (n=35, 53.5%) visited a UCC in the last three months.The most common reasons for visits to UCC were the common cold (40.8%), headache (5.6%), and abdominal pain (5.6%).These findings are consistent with a previous study in Saudi Arabia that reported that about threequarters (74.65%) of the patients were unaware of UCCs; 53.42% visited UCCs; and the common cold was the primary cause of the visits (25.76%) [11].The literature revealed that although there is access to free medical care through PHCCs throughout Saudi Arabia, the most common complaints to the ED were non-urgent problems such as abdominal pain (29%), ear, eye, nose, and throat pain (23.9%), limb/joint pain (17.7%), headache (13.5%), back pain (10.4%), cold and flu symptoms (9.4%), and fever (9.1%) [19].Insufficient community awareness of the role of the UUC and perceptions of its role lead to increased overcrowding in the ED.Increasing utilization of emergency care for non-urgent problems leads to overcrowding that is associated with increased waiting time, medical errors, patient mortality, and hospital length of stay, as well as reduced patient satisfaction and quality of care [20][21][22].
In the present study, 42.0% of participants visited PHCs without a scheduled visit.Having trouble scheduling appointments was the main cause of people attending PHCs without appointments (46.7%) and a recent health problem (48.2%).A study by Albalahi et al. found that almost half (45%) of patients visited PHCs without scheduling an appointment beforehand.The primary reason given for this was difficulty booking appointments (54.55%) [11].Urgent care services can play a significant role in supporting PHCs by addressing unscheduled patient appointments with the expectation that patients will subsequently follow up with their PHCs.This indicates that urgent care is fulfilling a need for convenience and may be supplanting primary care for specific acute concerns [2].
In the current study, more than one-third of participants (38.6%) thought that services offered by UCCs were equivalent to those of emergency centers.The majority believed that children (63.3%), the elderly (67.6%), pregnant women (50.3%), and people with special needs (50.7%) were permitted to attend UCCs.Most participants (61.0%) believed that UCCs are primarily for identifying medical conditions that require immediate care and treating acute symptoms that don't require visiting the ED (53.9%), treating chronic diseases (53.7%), and assisting individuals with challenges in obtaining appointments at public clinics (50.7%).The AAUCM defines urgent care medicine as the delivery of immediate medical services across all age groups, addressing both acute and chronic illness and injury.After initially diagnosing chronic conditions, patients are then referred to primary care for follow-up [1].
Our findings indicate that females have more awareness of UCCs than males.However, there were no significant differences between genders in terms of the frequency of visits to UCCs and reasons for visiting.A review revealed that women are more aware than men regarding UCCs as well as more likely to use health services [11,23,24].
It is worth mentioning that the participants with different personal characteristics mentioned the elderly, children, pregnant women, and people with special needs as the main groups allowed to attend UCCs.Urgent healthcare service delivery of immediate medical services for all age groups [1].

Limitation
This study offers valuable information on patients' understanding of urgent care.However, its generalizability is restricted due to the participants' specific geographic location, potentially leading to inaccurate representations of UCC usage in different areas.

Conclusions
The study concluded that most of the participants were unaware of UCCs.More than half of participants who were aware of UCCs visited a UCC in the last three months.The most common reasons for a visit to UCC were the common cold, headache, and abdominal pain.Females were more aware of UCCs than males.Further research is needed at the national level to explore the population's awareness of UCC.Focus awareness programs on simple language by different media are needed to improve access to healthcare services and reduce overcrowding in the ED that is caused by non-urgent problems.
Data were analyzed by SPSS Statistics version 28 (IBM Corp. Released 2021.IBM SPSS Statistics for Windows, Version 28.0.Armonk, NY: IBM Corp.).Categorical variables are presented as frequencies and percentages.The chi-square test was used for categorical variable comparison.A p-value ≤0.05 was considered statistically significant.

TABLE 2 : Usage and awareness of urgent healthcare services
When asked if they had ever visited PHCs without a prior appointment, 42.0% of participants responded affirmatively.The reasons for attending PHCs without an appointment were having trouble obtaining appointments (46.7%), developing a new health problem (48.2%), and other unspecified reasons (5.1%).More than one-third of participants (38.6%) believed that UCCs provide services like those of the emergency center.The majority believed that children (63.3%), the elderly (67.6%), pregnant women (50.3%), and people with special needs (50.7%) were allowed to visit UCCs.Other categories mentioned included males (32.0%), women (38.2%), domestic workers (23.2%), and health center employees (17.9%).A significant percentage (27.3%)respondedthattheydidnot know.The majority of participants (61.0%) believe that UCCs are primarily for detecting health conditions that require emergent intervention, treatment of acute symptoms that do not require going to the emergency center (53.9%), treatment of chronic conditions (53.7%), helping struggling cases get an appointment in public clinics (50.7%), refill medicine (26.0%), and follow-up (19.0%).Table3displays the awareness and use of UCC services by gender.The findings indicate that there is a significant variation in the awareness of UCCs between males and females, with 12.6% of males and 20.1% of females reporting awareness with a p-value of 0.031.However, there were no significant differences between genders in terms of the frequency of visits to UCCs and reasons for visiting or going to PHCs without making a reservation.Concerning those who are permitted to attend UCCs, females reported that the elderly (76.7% vs. 62.9%), children (76.1% vs. 56.8%),people with special needs (59.7% vs. 46.1%),and pregnant women (57.9% vs. 46.5%),respectively.Concerning the primary goal of UCCs, a higher percentage of females (69.8%) than males (56.5%) believed that UCCs identify medical problems that need emergency care, with a p-value of 0.005.2024 Almansour et al.Cureus 16(3): e57099.DOI 10.7759/cureus.570995 of 13

TABLE 4 : Utilization and awareness of urgent care clinics by age group
*: SignificantAs shown in
2024 Almansour et al.Cureus 16(3): e57099.DOI 10.7759/cureus.570998 of 13 Do you think that the urgent care clinics provide services similar to those of the emergency center?

TABLE 5 : Utilization and awareness of urgent care services correlated with level of education
*: Significant

TABLE 6 : Awareness and utilization of urgent care services by family monthly income
*: Significant