The Effects of Predisposing, Enabling, and Need Factors on the Use of Health Services Among Noncitizen Employees in the Private Sector in Saudi Arabia

Abstract

Background: Saudi Arabia has more than 12 million noncitizen residents, accounting for 37% of the total population. In 2005, the country reformed its National Health System by enacting and implementing Compulsory Employment-Based Health Insurance. The law requires all employers in the private sector to provide health insurance coverage to noncitizen employees. Aims: This study has three aims: 1) assess the extent of health insurance literacy (HIL) among surveyed noncitizens; 2)assess the frequency of outpatient provider visits among noncitizens, and; 3) investigate relationships between predisposing, enabling, and need-based factors (identified by Anderson’s model of healthcare utilization) and Saudi noncitizen use of health services. Method: A cross-sectional survey was conducted through social media targeting noncitizen employees in the private sector in Saudi Arabia. A descriptive analysis was undertaken to identify participant characteristics and describe the frequency of outpatient provider visits and the prevalence of health insurance literacy by the sampled noncitizen employees. Logistic regression analysis was utilized to test associations between multiple predisposing, enabling, and need-based factors identified by the Anderson model and noncitizen use of outpatient health services. Factors investigated include age, gender, education, marital status, HIL score, monthly income, avoidance of healthcare visits due to worries about cost sharing, living area, regular source of care, perceived health, and chronic disease. Results: Among the 1039 participants, 80.3% had at least one outpatient visit in the past 12 months. Nearly 21.0% had one visit, 17.3% had two visits, 9.6% had three visits, 20.5% had between 4 to 9 visits and 11.9% had 10 or more visits. The average HIL score range was 21.2, with a standard deviation of 8.1. There are statistically significant associations between being married, having higher HIL, avoiding healthcare visits due to worries about cost sharing, having a regular source of care, and having a chronic disease, respectively, and an increased likelihood of outpatient visits in the past 12 months. Conclusions: This is the first study to use the Anderson Model in Saudi Arabia. In contrast to Alkhamis' previous study, this study is more comprehensive and addresses a broader array of noncitizen employees across the country. This study confirmed Alkhamis' findings on the impact of the HIL on the use of health services. In addition, the study identified additional factors that appear to influence health care utilization, including marriage, the presence of a regular source of care, avoidance of seeking medical care due to the concern over costs, and the presence of chronic diseases. Over time, the results of this study may lead to better implementation of evidence-based interventions and/or policies to encourage access to healthcare by noncitizen employees in Saudi Arabia.