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Journal of Multidisciplinary Healthcare logoLink to Journal of Multidisciplinary Healthcare
. 2024 Oct 24;17:4851–4861. doi: 10.2147/JMDH.S490128

Comparative Analysis and Spatial Distribution of the Primary Health Care Centers and Health Manpower Across Saudi Arabia Using Shapiro–Wilk Test

Ashraf A’aqoulah 1,2, Samir Albalas 3, Mustafa Albalas 4, Raghad Abdullah Alherbish 5, Nisreen Innab 6,✉
PMCID: PMC11514713  PMID: 39469290

Abstract

Background

Due to the growing demand for better health services by the population pressure, Saudi Arabia is facing challenges in providing the required coverage in primary health care over all regions.

Study Objectives

The study aims to do a comparative analysis of the spatial distribution of the primary healthcare centers and health manpower across Saudi Arabia.

Study methods

This study deals with the analysis of the spatial distribution of the PHCCs and health manpower in Saudi Arabia regions during the period 2017–2021 by applying the Shapiro–Wilk test. This study relied on a dataset issued by the Ministry of Health (MoH). The variance of the spatial distribution of the dataset was also analyzed using the T-student and Binomial tests.

Results

This study found that PHCCs of 2020; the dentists of 2021; and Allied Health Personnel of 2017, 2020, and 2021 were normally distributed. However, the distribution of the population and all datasets of the other health indicators is a non-normal distribution. In addition, the correlation between the number of PHCCs and regions based on population is significant in all the regions. Moreover, The number of dentists showed a significant correlation with the population in most regions, except Riyadh, Makkah, and Jazan. However, the number of physicians, allied health personnel, nurses, and family medicine practitioners generally did not correlate significantly with the population, with exceptions for nurses in Tabuk and family medicine in the Northern Borders. Finally, the spatial distribution of the population shows the concentration in three major regions which are Riyadh, Makkah, and Eastern Province.

Conclusion

Despite the expansion in the number of PHCCs and health workers and spread in all regions of Saudi Arabia, their spatial distribution still requires the establishment of more of them to provide the basic health services necessary to cover the actual needs of the population.

Keywords: primary health care centers, systems of care, public health, knowledge, statistical analysis, Saudi Arabia

Introduction

In line with the Alma Ata Declaration of 1978, Saudi Arabia has placed great importance on health care through primary health care centers (PHCCs). By 2021, the Ministry of Health regulates many PHCCs throughout the kingdom. These PHCCs provide primary services to all citizens of Saudi Arabia. With the growing demand for better healthcare services due to population pressure, Saudi Arabia faces the challenges of the required coverage in primary healthcare in all regions.1 Over many decades, Saudi Arabia has implemented a number of development plans, centered on infrastructure development, as well as many ambitious development plans and initiatives, particularly in the field of health of.2 Infrastructure plays a vital role in enhancing the health sector.3 These plans led to remarkable achievements in the field of health indicators, which reflect the progress in the health sector, and have a significant impact on the health and well-being of the population.

Regional disparities in Saudi Arabia involve the distribution of infrastructure, resources, and services across different regions. Major cities like Riyadh, Dammam, and Jeddah have advanced education, healthcare, and economic opportunities, while rural areas, particularly in the northern and southern regions, face challenges in accessing these services. These disparities are rooted in geographical, historical, and economic issues. The Saudi government’s Vision 2030 seeks to create equitable and improved access to services in all regions.4,5 Many studies have focused on the major cities to improve healthcare services.5–9 Almujadidi et al mentioned that there is a shortage of labor especially in rural areas of Saudi Arabia.9 Jamjoom, Gahtani, and Sharab found that medical personnel in Saudi Arabia are distributed differently.5

The strategic interest in developing primary health care has been one of the main pillars of successive development plans for Saudi Arabia. This stems from of the importance of providing healthcare components to support the development of the health levels and health capabilities of citizens across Saudi Arabia. Preventive, curative and rehabilitative healthcare services in Saudi Arabia are provided by a network of healthcare facilities headed by PHCCs. These centers are the main institution entrusted with providing integrated and comprehensive healthcare services to all regions of Saudi Arabia.10

The number of PHCCs reached 2121 centers in 2021.11 These centers are spread across the regions of Saudi Arabia and linked to general and specialized hospitals. The services of PHCCs are integrated with hospitals through referrals and therapeutic care, starting from the first level to the specialized level.

The primary health care centers provide various integrated services such as maternal and child health care through follow-up during pregnancy, during and after delivery. They implement immunization programs for mothers and children against infectious diseases, in addition to the programs for prevention of communicable and endemic diseases. The primary health care centers also take care of people with non-communicable diseases, especially chronic diseases such as blood pressure and diabetes, to reduce their complications.1

It is expected that the population per center will improve in all regions once the implementation of the PHCCs is completed. Saudi Arabia’s various development plans have prioritize, social development needs in order to provide basic services to the population, including PHCCs. The Ministry of Health made more efforts to provide PHCCs and their operations by constructing many centers and attempting to develop them and continuously improve their services.12 Therefore, two main objectives are being pursued. The first objective is to determine the adequacy of PHCCs and health personnel (doctors, nurses, pharmacists, dentists, allied health professionals, and family medicine doctors). This selection is usually based on their role in patient care, their impact on healthcare outcomes and their fulfillment of the needs of the population in the different regions of Saudi Arabia. The second objective is to identify the differences in the spatial distribution of the services of PHCCs and health manpower.

The Shapiro–Wilk test is a useful test. Many disciplines, including the social sciences and healthcare, have adopted it. It assesses the kurtosis and skewness of a data set. For small- datasets, the Shapiro–Wilk test is a very useful tool for detecting deviations from normality. The disadvantage of the Shapiro–Wilk test is that it can lead to an unnecessary rejection of the normality assumption for large data sets and is limited to continuous data. This study relies on the Shapiro–Wilk test to assess the normality of spatial distribution of primary healthcare centers and health workers across Saudi Arabia.

Methods

Saudi Arabia is located in south-west Asia. The country is characterized by arid climatic conditions. Consequently, human life is severely affected by the dry and dusty climatic conditions. This study included some comparisons and focused on selected key indicators. The study is based on secondary data. The dataset is available in the statistical yearbooks published by the Ministry of Health for the period 2017–2021.11 This study covers six of the most important health and demographic indicators in Saudi Arabia. These indicators were carefully selected from a set of health indicators available in the statistical yearbooks of the period 2017–2021.11

The data were organized and tabulated using the SPSS package, version 23, and used to analyze the descriptive statistics of the selected indicators. These data were processed and tested using the Shapiro–Wilk test to determine the normality distribution of the data. In addition, a correlation coefficient was used between the regions in Saudi Arabia (independent factors) and the number of PHCC, doctors, nurses, allied health professionals, dentists, and family medicine doctors (dependent factors).

Results

Table 1 shows the population, area and density in the regions of Saudi Arabia in 2021.13 The area of Saudi Arabia is administratively divided into 13 provinces. The population distribution is mainly concentrated in three provinces: Riyadh (capital city), Makkah Al Mukarramah and the Eastern Province. The population in these areas is 8,175,378; 7,692,188; and 4,879,962 respectively.

Table 1.

Population, Area, and Density in the Saudi Region in 2021

Region Population (People) Area (km2) Density (People/km2)
Riyadh 8,175,378 382,027 21.4
Makkah 7,692,188 139,351 55.2
Eastern Province 4,879,962 536,259 9.1
Madinah 2,053,240 144,594 14.2
Aseer 1,943,532 78,685 24.7
Jazan 1,355,099 13,430 100.9
Qaseem 1,289,032 69,302 18.6
Tabuk 850,859 137,235 6.2
Ha’il 715,422 127,753 5.6
Al Jouf 574,894 85,805 6.7
Najran 567,533 128,984 4.4
North Borders 359,411 92,156 3.9
Al Bahah 327,833 11,227 29.2
Total 30,784,383 1,948,378 15.8
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Note: Statistical Database, General Authority for Statistics.13

Table 2 shows the distribution of health workers in the Saudi Arabia region. The table shows that in most regions, the number of PHCCs, doctors, nurses, allied health professionals, dentists, and family medicine doctors increased between 2016 and 2018. However, between 2019 and 2021, there was a decrease or stability in the same variables in the regions of Saudi Arabia.

Table 2.

Distribution of PHCCs and Health Manpower in PHCCs in the MoH in All Regions

Year 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021
Region PHCCs Physicians
Riyadh 436 447 415 415 390 1931 2489 2568 2463 1416
Makkah 340 344 324 335 322 2050 1808 2007 2868 1485
Madinah 159 159 149 156 144 772 776 752 1023 701
Qaseem 181 183 156 155 155 691 717 760 989 466
Eastern Province 255 255 244 240 218 1372 1794 1673 1956 1035
Aseer 339 339 334 316 277 1122 1289 1476 1371 1268
Tabuk 87 96 96 94 90 249 263 381 580 297
Ha’il 110 111 109 110 109 371 350 371 459 255
Northern Borders 47 48 43 42 41 244 251 284 381 262
Jazan 170 170 168 168 155 688 732 769 842 532
Najran 69 68 69 69 68 270 269 307 395 206
Al-Bahah 108 108 94 94 94 363 302 357 464 316
Al-Jouf 60 62 60 63 58 289 281 316 403 238
Region Nursing Allied Health Personnel
Riyadh 3595 2725 3484 3417 2894 2203 3059 3042 2417 1499
Makkah 3181 1854 3328 3287 2739 2009 2501 2376 2699 1814
Madinah 1657 1024 1611 1362 1675 966 1297 1091 1312 1080
Qaseem 1244 944 1454 1102 990 869 1181 1075 1036 798
Eastern Province 2595 2840 3166 2710 2474 1602 2467 2182 1962 1580
Aseer 1816 1484 2237 1737 2216 826 1345 1317 1118 1304
Tabuk 676 459 828 794 882 313 375 366 426 357
Ha’il 930 593 869 725 687 390 484 472 479 366
Northern Borders 423 283 477 444 408 118 260 194 202 122
Jazan 1184 1059 1434 1103 1184 894 1108 1080 1041 1135
Najran 529 273 557 477 497 677 561 578 648 525
Al-Bahah 639 359 585 317 546 331 407 368 379 355
Al-Jouf 788 426 796 358 783 366 463 423 360 268
Region Dentists Family Medicine
Riyadh 253 274 268 534 218 875 1308 1451 1206 761
Makkah 285 298 349 579 413 832 725 799 1250 721
Madinah 150 138 146 197 246 253 258 244 432 306
Qaseem 140 148 169 209 181 229 259 268 450 195
Eastern Province 248 334 343 462 385 452 578 573 801 484
Aseer 193 197 282 340 337 362 365 380 420 374
Tabuk 47 55 89 106 99 123 102 181 245 158
Ha’il 58 66 96 116 124 117 113 101 139 89
Northern Borders 30 32 42 58 44 52 60 57 94 98
Jazan 1000 97 127 175 194 313 315 317 344 284
Najran 38 38 71 72 69 103 95 88 136 77
Al-Bahah 43 43 94 109 112 94 85 87 103 101
Al-Jouf 36 50 83 86 106 87 82 82 120 100
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Table 3 shows the Shapiro–Wilk test of health indicators to determine the significance of the health indicators dataset. The results of the test show that the PHCCs of 2020, the dentists of 2021, and the Allied Health Personnel of 2017, 2020 and 2021 were normally distributed. However, the distribution of the population and all datasets of the other health indicators is a non-normal distribution with degree of freedom of 13 and a p-value of 0.05.

Table 3.

The Shapiro–Wilk Test of the Health Indicators

Health Indicators Period (Year) Statistic D.F P-value Null Hypothesis (H0) Distribution
Population 2017 0.733 13 *0.023 Rejected Non-Normal
2018 0.789 13 *0.003 Rejected Non-Normal
2019 0.732 13 *0.021 Rejected Non-Normal
2020 0.754 13 *0.042 Rejected Non-Normal
2021 0.783 13 *0.002 Rejected Non-Normal
PHCCs 2017 0.816 13 *0.012 Rejected Non-Normal
2018 0.805 13 *0.014 Rejected Non-Normal
2019 0.810 13 *0.032 Rejected Non-Normal
2020 0.892 13 0.104 Accepted Normal
2021 0.853 13 *0.016 Rejected Non-Normal
Physicians 2017 0.821 13 *0.022 Rejected Non-Normal
2018 0.807 13 *0.045 Rejected Non-Normal
2019 0.809 13 *0.032 Rejected Non-Normal
2020 0.822 13 *0.002 Rejected Non-Normal
2021 0.844 13 *0.024 Rejected Non-Normal
Nurses 2017 0.857 13 *0.001 Rejected Non-Normal
2018 0.802 13 *0.023 Rejected Non-Normal
2019 0.816 13 *0.005 Rejected Non-Normal
2020 0.817 13 *0.002 Rejected Non-Normal
2021 0.867 13 *0.048 Rejected Non-Normal
Dentists 2017 0.857 13 *0.014 Rejected Non-Normal
2018 0.822 13 *0.011 Rejected Non-Normal
2019 0.818 13 *0.002 Rejected Non-Normal
2020 0.877 13 *0.039 Rejected Non-Normal
2021 0.913 13 0.201 Accepted Normal
Allied Health Personnel
(AHP) 		2017 0.062 13 0.875 Accepted Normal
2018 0.861 13 *0.025 Rejected Non-Normal
2019 0.865 13 *0.045 Rejected Non-Normal
2020 0.895 13 0.916 Accepted Normal
2021 0.890 13 0.885 Accepted Normal
Family Medicine 2017 0.805 13 *0.032 Rejected Non-Normal
2018 0.741 13 *0.007 Rejected Non-Normal
2019 0.732 13 *0.011 Rejected Non-Normal
2020 0.824 13 *0.042 Rejected Non-Normal
2021 0.826 13 0.014 Rejected Non-Normal
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Notes: *P-value < 0.05 indicates that the health indicators are not normally distributed.

Table 4 shows the correlation between the health indicators and the regions based on population. The correlation (ratio) between the number of PHCCs and the region is significant in all regions, as shown by the “tr” values, which are greater than the critical value of 2.13 at degrees of freedom 4. Moreover, the correlation between = dentists and = region was significant in all = regions= except Riyadh, Makkah and Jazan. In contrast, the correlations between the number of doctors and allied health professionals and the region were not significant in the regions. The correlations between the number of nurses and the region were also not significant in all regions except Tabuk. The correlation between the number of family medicine doctors and the region was also not significant in all regions, with the exception of the northern borders at degree of freedom 4.

Table 4.

Correlation Between Health Indicators and Regions Based on Population

Region PHCC Physicians Nursing
R2 tr Ho df R2 tr Ho df R2 tr Ho df
Riyadh 0.86 4.95 *Reject 4 0.06 0.54 Accept 4 0.33 1.41 Accept 4
Makkah 0.87 5.29 *Reject 4 0.23 1.09 Accept 4 0.07 0.56 Accept 4
Madinah 0.91 6.52 *Reject 4 0.04 0.01 Accept 4 0.01 0.25 Accept 4
Qasim 0.87 5.25 *Reject 4 0.28 1.27 Accept 4 0.33 1.42 Accept 4
Eastern Province 0.53 2.18 *Reject 4 0.21 1.06 Accept 4 0.00 0.16 Accept 4
Aseer 0.80 4.12 *Reject 4 0.08 0.60 Accept 4 0.45 0.81 Accept 4
Tabuk 0.08 2.62 *Reject 4 0.38 1.58 Accept 4 0.56 2.26 *Reject 4
Ha’il 0.84 4.58 *Reject 4 0.25 1.18 Accept 4 0.20 1.02 Accept 4
Northern Borders 0.92 7.06 *Reject 4 0.26 1.20 Accept 4 0.36 1.51 Accept 4
Jazan 0.93 2.73 *Reject 4 0.25 1.18 Accept 4 0.26 1.19 Accept 4
Najran 0.96 8.21 *Reject 4 0.11 0.71 Accept 4 0.23 1.10 Accept 4
Al Bahah 0.87 5.41 *Reject 4 0.01 0.24 Accept 4 0.03 0.03 Accept 4
Al Jouf 0.78 3.83 *Reject 4 0.02 0.31 Accept 4 0.14 0.839 Accept 4
Region Dentists Allied Health Personnel Family Medicine
R2 tr Ho df R2 tr Ho df R2 tr Ho df
Riyadh 0.03 0.39 Accept 4 0.13 0.79 Accept 4 0.04 0.09 Accept 4
Makkah 0.29 1.29 Accept 4 0.22 1.06 Accept 4 0.07 0.57 Accept 4
Madinah 0.59 2.44 *Reject 4 0.25 1.17 Accept 4 0.36 1.52 Accept 4
Qasim 0.63 2.62 *Reject 4 0.08 0.61 Accept 4 0.03 0.03 Accept 4
Eastern Province 0.64 2.72 *Reject 4 0.02 0.34 Accept 4 0.01 0.07 Accept 4
Aseer 0.84 4.64 *Reject 4 0.41 1.70 Accept 4 0.11 0.70 Accept 4
Tabuk 0.89 5.84 *Reject 4 0.42 1.71 Accept 4 0.38 1.59 Accept 4
Ha’il 0.86 5.14 *Reject 4 0.03 0.40 Accept 4 0.29 1.29 Accept 4
Northern Borders 0.73 3.33 *Reject 4 0.02 0.31 Accept 4 0.83 4.46 *Reject 4
Jazan 0.05 0.49 Accept 4 0.17 0.69 Accept 4 0.30 1.31 Accept 4
Najran 0.60 2.47 *Reject 4 0.05 0.49 Accept 4 0.10 0.68 Accept 4
Al Bahah 0.81 4.16 *Reject 4 0.15 0.84 Accept 4 0.34 1.46 Accept 4
Al Jouf 0.64 2.69 *Reject 4 0.02 0.18 Accept 4 0.25 1.17 Accept 4
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Notes: *There is a correlation between health indicators and regions based on population.

Table 5 shows the spatial distribution of the population, PHCCs and health personnel in 2021. The spatial distribution of the population shows a concentration in three major regions, namely Riyadh (26.5%), Makkah (25%) and the Eastern Province (15.8%). The spatial distribution of health indicators is related to the spatial distribution of the population.

Table 5.

Spatial Distribution of the Population and Health Indicators Among Regions During 2021

Region Population % PHCCs % Physicians % Nursing % Dentists % Allied Health Personnel % Family Medicine %
Riyadh 26.5 19.3 16.7 16.2 8.6 13.4 20.3
Makkah 25 15.9 17.5 15.3 16.3 16.2 19.2
Eastern Province 15.8 5.9 12.2 13.8 15.2 14.1 12.9
Madinah 6.7 7.1 8.3 9.4 9.7 9.6 8.2
Aseer 6.3 13.7 15.0 12.4 13.3 11.6 10.0
Jazan 4.4 7.7 6.3 6.6 7.7 10.1 7.6
Qaseem 4.2 7.7 5.5 5.5 7.2 7.1 5.2
Tabuk 2.8 4.5 3.5 4.8 3.9 3.2 4.2
Ha’il 2.3 5.3 3.0 3.7 4.9 3.3 2.4
Al-Jouf 1.9 2.9 2.8 4.3 4.3 2.4 2.7
Najran 1.8 3.4 2.4 2.7 2.8 4.7 2.1
Northern Borders 1.2 2.0 3.1 2.3 1.7 1.1 2.6
Al-Bahah 1.1 4.6 3.7 3.0 4.4 3.2 2.6
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Table 6 shows the distribution of health indicators in groups based on concentration. The spatial distribution of health indicators can be divided into 3 groups. The first group consists of 3 regions (Riyadh, Makkah and Eastern Province) with a total of 67.3% of the population served by 41.1% of PHCC, 46.4% of doctors, 45.3% of nursing, 40.1% of dentists, 43.7% of allied health professionals, and 52.4% of family medicine doctors. The second group consisted of 4 regions (Madinah, Asser, Qaseem and Jazan) with a total of 21.6% of the population served with 36.2% of PHCC, 35.1% of doctors, 33.9% of nursing, 37.9% of dentists, 38.4% of allied health professionals, and 31% of family medicine doctors. The third group was composed by 6 regions (Tabuk, Ha’il, Al-Jouf, Najran, Northern Borders, Al-Bahah) with a total of 11.1% of the population served with 22.7% of PHCC, 18.5% of doctors, 20.8% of nursing, 22.0 of dentists, 17.9% of allied health professionals, and 16.6% of family medicine doctors.

Table 6.

Spatial Distribution of Health Indicators into Groups Based on Concentration

Groups Population % PHCCs % Physicians % Nursing % Dentists % Allied Health Personnel % Family Medicine % Concentration
Group 1 (Riyadh, Makkah, and Eastern Province). 67.3 41.1 46.4 45.3 40.1 43.7 52.4 High
Group 2 (Madinah, Asser, Qaseem, Jazan). 21.6 36.2 35.1 33.9 37.9 38.4 31 Moderate
Group 3 (Tabuk, Ha’il, Al-Jouf, Najran, Northern Borders, Al-Bahah). 11.1 22.8 18.5 21.2 21.8 17.9 16.7 Low
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Discussion

This study found that the PHCCs of 2020, the dentists of 2021; and allied health professionals of 2017, 2020 and 2021 were normally distributed. However, the distribution of the population and all data sets of the other health indicators is a non-normal distribution with the degree of freedom 13 and p-value 0.05. In addition, the correlation (ratio) between the number of PHCCs and the regions based on population is significant in all regions. Moreover, the correlation between the dentists and population was significant in all regions except Riyadh, Makkah and Jazan. In contrast, the correlations between the number of doctors and allied health professionals and the population were not significant in all regions. It The correlation between the number of nurses and the population was also not significant in all regions except Tabuk. The correlation between family medicine doctors and the population were also not significant in all regions, with the exception the northern borders. Finally, the spatial distribution of the population shows a concentration in three major regions, namely Riyadh (26.5%), Makkah (25%) and the Eastern Province (15.8%). The spatial distribution of health indicators is related to the spatial distribution of the population.

Primary health care is the cornerstone of any health care system as it provides vital services such as general medical care, early diagnosis, chronic disease management and preventative care.14 The majority of PHC facilities in Saudi Arabia are under the Ministry of Health (MoH). Although significant progress has been made in improving access to healthcare services, there are still large disparities in the number and distribution of PHC centers across the country.15

Due to geographic differences, rural and remote areas are underserved as primary healthcare facilities are concentrated in urban areas. Due to longer traveling times to health facilities, people in rural areas have less equitable access to care. The lack of PHC facilities in the less populated regions of Saudi Arabia, where a large proportion of the population lives, exacerbates health inequities, especially for the elderly and people with chronic diseases.16

There is a shortage of healthcare workers in Saudi Arabia, particularly doctors, nurses, and allied health professionals. This shortage affects access to and quality of healthcare. The shortage of PHC facilities and medical staff affects access to and quality of healthcare both directly and indirectly by increasing the burden on hospitals, limiting access to healthcare, and jeopardizing health outcomes.17,18 In addition, we need to retain qualified professors in universities to ensure that graduates in healthcare fields have sufficient skills to improve the healthcare sector.19

There are several levels of health assessment in the PHCCs. Experts agree that there are three main levels proposed by Donabedian, namely structure, process and outcome.20 The evaluation’s structure level components emphasize the significance of health staff, facilities, and equipment.21,22 However, many research studies conducted in different countries have shown that there are significant differences between PHCCs in terms of in the health personnel and equipment. This fact can be seen as the primary hindrance to the successful delivery of healthcare services by PHCCs. The process evaluation depends on (a) the way resources can be utilized to improve the interaction between patients and health workers; (b) the care goals achieved by the scope of health services provided by PHCCs; (c) the specific technique and procedures used in responding to people’s demand in primary care; and (d) the good coordination between health workers of PHCCs.23 Quality of care with higher validity of process measures are the most important practices of outcome evaluation.

A study by Al Fraihi, Famco and Latif (2016) concluded that the quality of care gap model is valid and needs to be prioritized and addressed through targeted health management improvement efforts.24 In addition, the results of the evaluation of PHCCs in Riyadh based on users’ views show the patient satisfaction due to the good order in health care.12

Conclusion

Although the number of PHCCs and health workers has increased and is spread across all regions of Saudi Arabia, more PHCCs need to be established to meet the actual needs of the population for basic health services. In addition, there are differences in the spatial distribution of PHCCs services and health personnel across Saudi Arabia.

Healthcare decision-makers need to not only increase the number of healthcare providers and PHCCs, but also focus on a more equitable distribution. Strategic, data-driven resource allocation is essential to ensure that underserved regions receive adequate healthcare support. Eliminating these disparities will be critical to achieving equitable healthcare across the country and meeting healthcare goals.

Acknowledgments

The authors would like to express sincere gratitude to Almaarefa University, Riyadh, Saudi Arabia, for its scientific support of this research. The authors would like to express sincere gratitude to King Saud bin Abdulaziz University for Health Sciences, for its scientific support. The authors would like to express sincere gratitude to King Abdullah International Medical Research Center, for its scientific support. The authors would like to express sincere gratitude to Yarmouk University for its scientific support. The authors would like to express sincere gratitude to the Office of Research at King Saud bin Abdulaziz University for Health Sciences and in particular Reem Alamr and Atika Al Sudairi who have assisted us with editing and proofreading this research paper.

Funding Statement

No funding was obtained to conduct this research.

Ethical Approval

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (IRB) at King Abdullah International Medical Research Centre (KAIMRC). The study approval number is MJ/EJ/WS/056.

Disclosure

The authors report no conflicts of interest in this work.

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