Studying the behaviors and habits of individuals in order to find the most appropriate preventive strategies for the Saudi society

1. Introduction

The evaluation of health phenomena is a fixed necessity all over the worldwide[1]. Achieving and maintaining healthy status in Kingdom is a collective and context-specific endeavor[2]. There are substantial studies and research on Saudi health risk factors to guide health intervention plans[3]. While these previous research offer valuable insight, it is limited to quantitative findings without the concern of the consideration to the context in which health attitude and behavior occur. The healthcare system in the Kingdom is undergoing rapid changes to confront the new health issues and challenges. The government increased the health sector budget to support the development of healthcare facilities for its citizens[4]. The government planned and implemented a variety of strategies that’s: (1) provided health education campaigns to promote public awareness, (2) increased the number of screening clinics to detect a diagnosis early and (3) controlled risk factors to reduce the incidence of chronic disease.

The main causes of diseases and disabilities are mostly preventable. Their prevention is largely based on interventions targeting health determinants in some major areas: diet, physical exercise, protection of moral health to which can be added the early detection of certain diseases[5].

A very large part of these acts and interventions are not carried out by the actors of the health care system but by the individuals themselves who, through their behavior and habits, can prevent many probable health problems.

It is from this vision that the concept of prevention is a major axis of any health system it not only guarantees the good state of health of the population but also the reduction of the costs of care resulting from the spread of diseases and epidemics. Prevention concerns in many ways the State and public health and therefore the financing of the health system[6].

In this context Saudi Arabia like any other country in the world must implement prevention strategies against all risks of diseases and epidemics. The question that arises is: what strategies should we adopt? And do these strategies help reduce the costs of care and hospitalization?

It is from there that this study seeks to determine what strategies can be considered to achieve the two objectives: improvements in the quality of health of individuals and minimization of the costs of care and hospitalization[7].

Determining types of strategies must begin with studying the behavior and habits of Kingdom individuals in order to find strategies best suited to our society.

Two measures can be considered:

M1: preventive measures must be initiatives of the individuals themselves.

M2: preventive measures must be guided by the health system through strategies focused mainly on awareness.

Determining types of strategies must begin with studying the behaviors and habits of

Kingdom individuals in order to find strategies best suited to our society.

Two hypotheses can be considered:

M1: preventive measures must be initiatives of the individuals themselves.

M2: preventive measures must be guided by the health system through strategies focused mainly on awareness.

A survey was conducted of (764) Kingdom individuals with the objective of determining the types of strategies most suitable for the Saudi Arabia health context.

2. Theoretical framework of the "economics of prevention" study:

A closely related study in Saudi Arabia reported that COVID-19 curfew has an effect on the eating habits among the population[8]. The social isolation was associated with increased number of meals consumed daily and the consumption of sweets. As a result, COVID-19 curfew led to a rapid weight gain for many Saudis. Furthermore, a number of studies have begun to examine the effect of “stay-at-home” orders on physical activity practices[9]. The curfew has limited access to community services and therefore enforced a sedentary behavior such as prolonged sitting and watching TV, playing online games, and not participating in physical exercise. [10]Argued health consciousness is an important element to enforce healthy attitudes and behaviors and adopt healthy lifestyles through the pandemic.

[11]Prevention is designated by the World Health Organization (WHO) as any act intended to avoid expected phenomena. Economists distinguish two families of prevention: self-protection and self-insurance[12].

Self-protection corresponds to the actions taken to reduce the probability of a loss; self-insurance covers actions whose objective is to limit the extension of the loss if it occurs[13].

In this context, prevention is defined as "all the actions carried out with the aim of preparing or preventing the occurrence of certain risks but also of minimizing the negative consequences induced by their occurrence. Prevention therefore has two objectives, either to reduce the occurrence or occurrence of a risk, or to adapt behavior in the presence of the realized risk[14].

From a public health approach, three categories of preventive actions can be distinguished:

- Primary prevention: which represents the set of actions that reduce the incidence of a disease (vaccination for example);

- Secondary prevention: which represents actions aimed at reducing the consequences of a disease when it has appeared (for example cancer screening);

- Tertiary prevention: This represents actions aimed at reducing disability associated with chronic diseases.

Prevention expenditure is by nature difficult to apprehend, the part that can be counted includes the consumption of preventive medicine, collective prevention and health control:

- Preventive medicine covers the cost of the services involved in: occupational medicine, school medicine, maternal and child protection, missions provided by the state such as the fight against infectious diseases and vaccination;

- Collective prevention and health control which cover the cost of preventive actions for: water control, health information and education campaigns, actions and programs of the Ministry of Health, hygiene expenditure and other[15].

But there is part of the prevention expenditure that is difficult to account for, and these are awareness campaigns guided by the state or by other civil society associations or even by private companies as part of their social responsibility. Corporate social responsibility (CSR) can go well beyond the framework of awareness-raising to go further in helping and supporting various activities related to the prevention of diseases and epidemics[16].

There is a plurality of prevention actors: individuals, doctors, firms, local communities, the state, civil society associations and others, but individuals constitute the most important nucleus of the whole chain[17].

3. Method:

In this study, the author describes the research approach and design used to achieve the study objectives. The author also described the research methods and tools used for data collection, the process of qualitative data collection and analysis, reliability, challenges and limitations, and issues related to ethical considerations of research study.

In order to determine the appropriate prevention strategies against diseases and pandemics, an empirical approach focusing on the study of the habits of individuals was adopted.

The study was conducted using an inductive methodology involving a survey of a sample of (764) individuals representing the whole Saudi Arabia population.

The questionnaire was distributed on the various social networks and the sample was chosen by simple random drawing under a probabilistic method in which the probability of leaving the sample was equal for all individuals in the population.

Our sample was therefore made up of 764 respondents of different age categories (four categories were made up: less than 30 years old, between 30 and 40 years old, between 41 and 50 years old, 50 years old and over) belonging to the four corners of the country, (East, west, Center and South) and with different educational levels (high school student, bachelor's degree, master, doctorate) which gives this sample a large representative capacity (see table1). The survey was conducted during the month of June 2021.

Table 1: Age category, Scientific level, and Regions of the country
Age category
	Frequency	Percent	Valid Percent	Cumulative Percent
	246	32.2	32.2	32.2
	372	48.7	48.7	80.9
	114	14.9	14.9	95.8
≥ 50 years	32	4.2	4.2	100.0
Total	764	100.0	100.0
Scientific level
High school student	16	2.1	2.1	2.1
Bachelor's degree	52	6.8	6.8	8.9
Master	120	15.7	15.7	24.6
Doctorate	576	75.4	75.4	100.0
Total	764	100.0	100.0
Regions of the country
West	274	35.9	35.9	35.9
East	256	33.5	33.5	69.4
Center	200	26.2	26.2	95.5
South	34	4.5	4.5	100.0
Total	764	100.0	100.0

The questionnaire was composed of 08 questions (see Appendix) where each question represented a variable.

RDV: Regular doctor's visit

TCD: Take care of your diet

UPS: Usual practice of sport

KHP: Knowledge of health potential

MPP: Monitoring of prevention programs

ACO: Awareness campaign for the organization

UDP: Use of disinfectant products

MDO: Municipality disinfection operation

The analysis of the results was done by the segmentation method. The segmentation in our case was based on variables and not observations. It is useful to point out that this method is widely used for data analysis, it allows categorization or taxonomy. That is to say, bring out groups of individuals or variables and the assignment of different variables to different groups[18].

This method makes it possible to simplify the reading of data by grouping them into categories having common characteristics[19]. Segmentation can be defined as follows: "given a set of objects (or individuals) described by a certain number of characteristics (or variables), to constitute groups (or types) of objects such that the objects are the most similar possible within a group and that the groups be as dissimilar as possible; the resemblance or dissimilarity being measured on all the variables describing the objects "[20]. In our case the objective is to determine from these groups suitable prevention strategies against diseases and epidemics.

The construction of the categories (groups) was made by one of the hierarchical classification methods which are the “ascending hierarchical classification” which consists in establishing an ascending tree structure[21].

The aggregation algorithm used was Ward's algorithm which calculates the means for all the variables of each group then, for each individual, the square of the Euclidean distance to the center of the class[22]. Since the data are measured on different scales we have standardized them using the standard deviation.

4. Results

Data processing produced the “dendrogram” shown in Figure1. The “dendrogram” reads as follows: vertical axes represent groupings of segments; horizontal axes represent distances between segments. The goal is to keep the most distant segments and aggregate the closest.

By reading the “dendrogram” from right to left we can define the groups. We see that there is a very important jump between (25) and (5) which separates the variables into two main categories. The first category brings together the variables (KHP, knowledge of health potential, MPP monitoring by prevention programs, TCD Take care of your diet, UDP use of disinfectant products, RDV Regular doctor's visit, UPS usual practice of sport) and the second category brings together the variables (ACO, awareness campaign for the organization, MDO the municipality's disinfection operation).

The first category encompasses two subcategories, the first is made up of variables (KHP, MPP, TCD, and UDP) and the second is made up of variables (RDV and UPS).

Regarding the chain of aggregation (see table3), the aggregation coefficient makes a very significant jump (more than double) between steps (6 and 7) (from 2003.667 to 5600.637). So two-group segmentation is quite appropriate.

Fig.1. Dendrogram using Ward's distance (Distance resize combined cluster)

Source: Produced by the author

Source: Produced by the author

Regarding the KMO test which is a generalized measure of the partial correlation between the study variables, it is equal to 0.761 (see table2 and table3) which indicates medium validity. Bartlett's test tells us that the measures M1 must be rejected (the test result must be equal to or less than 0.05 in our case the value is 0.00) so the search for the components is justified.

Table 2 : Planning agglomerations 4: Planning agglomerations
Combined Cluster	Coefficients	Cluster Step of first appearance
Step	Cluster1	Cluster2	Cluster1	Cluster2	Next Step
1	4	5	250,975	0	0	2
2	2	4	539,591	0	1	5
3	6	8	880,346	0	0	7
4	1	3	1221,823	0	0	6
5	2	7	1578,861	2	0	6
6	1	2	2003,667	4	5	7
7	1	6	5600,637	6	3	0

Table 5: Bartlett's Test and KMO
KMO measure of sampling adequacy.	0,761
Bartlett's Test of sphericity approx. Chi-Square	223,353
Deference	28
Significant.	0,000

Source: Produced by the author

5. Discussion

The author has identified many challenges in the country's health system that need to be addressed over the next decade. These challenges fit into existing models of care for key patient pathways within the country. There are a number of high-priority pathways with specific challenges, including the maternity pathway, chronic illness, planned care, and urgent care[23]. To address these challenges, the Ministry of Health has developed a program to design, pilot and implement a program of new patient-centered models of care.

Figure.2. New Models of Care Program

Private

20%

Governmental

Healthcare

System

MOH

60%

Others

20%

-Teaching and University Hospitals

-Armed Forces Medical Services

-National Guards Medical Services

-Security Forces Medical Services

-Aramco Medical Services

Tertiary Care

Secondary Care

Primary Care

Source: Ministry of Health, Healthcare-Transformation-Strategy-2022

This study provides an overview of the digital transformation of the health system in the kingdom, setting out the underlying objectives in the clearest and most coherent way possible. Implementing the strategy will be more complex and will only work if we can effectively mobilize and coordinate large numbers of highly educated and skilled people effectively[24].

The empirical study showed two main groups of variables. The first group represents individual prevention measures and the second group represents collective prevention measures. These two types are actually complementary.

Individual preventive measures represent initiatives made by individuals voluntarily and individually, they are distinguished by primary and secondary preventive measures.

Primary preventive measures are taken before the onset of the disease to prevent its onset. Secondary prevention measures which are used when the disease has already occurred. The aim is to save time in the course of the disease or epidemic, which makes care more effective because it is earlier.

Collective prevention measures are acts carried out by the State or by its bodies or also by civil society associations. These acts aim to propagate a health culture through the organization of disinfection operations and awareness campaigns against various diseases and epidemics[25].

The conclusion is that the two hypotheses of the study are true because preventive measures must be initiatives of individuals but also must be guided by the health system through national and local actions.

All these measures have a single objective: to minimize the costs of care, also called non-prevention costs, because the cost of applying these measures is much lower than the cost of care or hospitalization in the event of complications. The principle is simple; it is to implement prevention strategies based first and foremost on sensitizing individuals.

Awareness can be guided by several means, including:

The introduction of the subject of "prevention" in the teaching programs of primary school pupils as well as the organization of awareness campaigns throughout the year within the various national education establishments. Raise awareness and encourage individuals to follow a healthy diet; enact laws to control the components of food products in order to protect the health of the population.

All this will make it possible to eliminate some bad habits and replace them with healthy practices allowing better prevention against various diseases and epidemics.

6. Conclusion

Prevention interventions call for comprehensive policies that combine several dimensions: health, economic, social and above all educational. The effectiveness of preventive measures comes from the combination of actions at national level and local actions as well as individual actions.

Individual actions are strongly requested, it is a question of promoting a health culture. In this context, the role of the national education sector is major; implementing preventive habits seems a requirement in a world where the spread of disease is so great and so rapid.

Beyond emerging infectious diseases, the health challenges of tomorrow also concern chronic diseases: cardiovascular diseases, cancers and the consequences of accidents and their risk factors. These factors are for the most part linked to the lifestyle and behavior of individuals.

APPENDIX:

Appendix: the questionnaire

1. Do you regularly visit a doctor for a check-up or routine check-up? RDV (regular doctor's visit)

1. Are you taking care of your diet? TCD (take care of your diet)

1. Do you usually play sports? UPS (usual practice of sport)

1. Do you know the health potential of the country? KHP (knowledge of health

potential)

1. Do you follow programs and documentaries concerning health and prevention?

MPP (Monitoring by prevention programs)

1. Does your organization regularly organize awareness and prevention campaigns?

OAC (organization's awareness campaign)

1. Do you use disinfectants? UPD (use of disinfectant products)

1. Does the municipality of your residence organize disinfection operations? MDO

(municipal disinfection operation)

References

1.1 World Health Organization, Modes of transmission of virus causing COVID 19: implications for IPC precaution recommendations, Scientific brief, World Health

Organization, Modes of transmission of virus causing COVID-19: implications for

IPC precaution recommendations, Scientific brief, World Health Organization, Geneva, Switzerland, 2020.

2.2 Saad Alflayyeh. The Privatization of Healthcare in selected First-world Countries and its Implications in the Kingdom of Saudi Arabia: A Descriptive Comparative

Study. Majmaah Journal Health Sciences. 2017; 5(2): 113

127. doi:10.5455/mjhs.2017.02.012

3.3 Ministry of Health, Health Statistical Year Book. Riyadh: Ministry of Health Press.2014

4.4 Unaib Rabbani, Abdullah Mohammed Al Saigul. Knowledge, Attitude and

Practices of Health Care Workers about Corona Virus Disease 2019 in Saudi Arabia, Volume 11, Issue 1, 2021, p. 60 – 68.

5.5 Ehrlich,I. and Becker, G. Market Insurance, Self-Insurance And Self Protection.

Journal of Political Economy (80), 2016, p. 623-649.

6.6Haseebullah et al., The Impact Of Coronavirus (Covid-19) Pandemic On Retail

Business In Saudi Arabia: A Theoretical Review, European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 1, p. 3547-3554.

7.7Lamoureux, P. Économie De La Prévention. Dans P.-L. Bras, Traité D'économie Et De Gestion De La Santé. Paris: Presses De Sciences Pol.2009.

8.8 Lebart, L., Morineau, A., and Piron, M. Statistique Exploratoire Multidimensionnelle. Paris: Dunod.2015

9.9 Lorenzoni L, Belloni A, Sassi F. Healthcare expenditure and health policy in the

USA versus other high-spending OECD countries. The Lancet. 2014 Jul 11; 384(9937):83 92.

10.10 Majnoni D‟intignano, B. Economie De La Santé. Paris: Presse Universitaires De France.2011.

11.11Malhotra, N., Decaudin, J.-M., & Bougerra, A. Etudes Marketing Avec Spss (Ed. 5). Paris: Pearson Education. 2017.

12.12Tuffery, S. Data Mining Et Statistique Décisionnelles (Ed. 5e). Paris: Edition Technip. 2017.

13.13S.Alflayyeh. Theoretical Perspective Of Unusual Purchasing Tendencies During

Pandemic Situation of Covid-19, European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 1, Pages 3475-3482.

14.14 Squires DA.Explaining high health care spending in the United States: an international comparison of supply, utilization, prices, and quality. New York, NY:

Commonwealth Fund, 2012.

15.15World Health Organization (WHO). Health expenditure database 2004-2016.

Available: http://apps.who.int/nha/database (accessed September 11, 2017).

16.16Aljuaid M. et al. Quality of care in university hospitals in Saudi Arabia: a systematic review. BMJ Open. 2020 ;(6):008988.

17.17Almalki M.. Health care system in Saudi Arabia: an overview. East Méditer Health J. 2019;17(10):784–93.

18.18KSA Ministry of Health, VRO, Business Case for the Health System Reform

Component of the Kingdom of Saudi Arabia‟s Vision 2030 Program, Version 2.0, 31 May 2017.

1. 1. Brower V.(2003). Health is a global issue. EMBO reports, 4(7), 649–651.Journal of Advocacy,Research and Education,2(1).https://doi.org/10.1038/sj.embor.embor892 ↑

1. 2. Almutairi KM, Moussa M. Systematic review of quality of care in Saudi Arabia. a forecast of a high quality health care. Saudi Med J. 2014;35 (8):802–9. ↑

1. 3. Khan, A.R., AL-Abdul Lateef, Z.N., AlAlthan, M.A., Bu-Khamseen, M.A. (2017). Factors contributing to non-compliance among diabetics attending primary health centers in the Al Hasa district of Saudi Arabia. Journal of Family and Community Medicine, 19(1): 26-32. ↑

1. 4. Alfaqeeh G, Cook E J, Randhawa G, Ali N. Access and utilisation of primary health care services comparing urban and rural areas of Riyadh Province, Kingdom of Saudi Arabia. BMC Health Serv Res. 2017; 17-106. ↑

1. 5. World Health Organization, Modes of transmission of virus causing COVID 19: implications for IPC precaution recommendations, Scientific brief, World Health Organization, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations, Scientific brief, World Health Organization, Geneva, Switzerland, 2020. ↑

1. 6. Saad Alflayyeh. The Privatization of Healthcare in selected First-world Countries and its Implications in the Kingdom of Saudi Arabia: A Descriptive Comparative Study. Majmaah Journal Health Sciences. 2017; 5(2): 113 127. doi:10.5455/mjhs.2017.02.012 ↑

1. 7. Ministry of Health, Health Statistical Year Book. Riyadh: Ministry of Health Press.2014 ↑

1. 8. Mumena, W. (2021). Impact of COVID-19 Curfew on eating habits, eating frequency, and weight according to food security status in Saudi Arabia: A retrospective study. Progress in Nutrition, 22(4): 2020075. https://doi.org/10.23751/pn.v22i4.9883 ↑

1. 9. Knell, G., Robertson, M. C., Dooley, E. E., Burford, K., & Mendez, K. S. (2020). Health Behavior Changes During COVID-19 Pandemic and Subsequent "Stay-at-Home" Orders. International journal of environmental research and public health, 17(17): 6268. https://doi.org/10.3390/ijerph17176268 ↑

1. 10. Pu, B., Zhang, L., Tang, Z., & Qiu, Y. (2020). The relationship between health consciousness and home-based exercise in China during the COVID-19 Pandemic. International journal of environmental research and public health, 17(16):5693. https://doi.org/10.3390/ijerph17165693 ↑

1. 11. Unaib Rabbani, Abdullah Mohammed Al Saigul. Knowledge, Attitude and Practices of Health Care Workers about Corona Virus Disease 2019 in Saudi Arabia, Volume 11, Issue 1, 2021, p. 60 – 68. ↑

1. 12. Ehrlich,I. and Becker, G. Market Insurance, Self-Insurance and Self Protection. Journal of Political Economy (80), 2016, p. 623-649. ↑

1. 13.Haseebullah et al., The Impact Of Coronavirus (Covid-19) Pandemic On Retail Business In Saudi Arabia: A Theoretical Review, European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 1, p. 3547-3554. ↑

1. 14.Lamoureux, P. Économie De La Prévention. Dans P.-L. Bras, Traité D'économie Et De Gestion De La Santé. Paris: Presses De Sciences Pol.2009. ↑

1. 15. Lebart, L., Morineau, A., and Piron, M. Statistique Exploratoire Multidimensionnelle. Paris: Dunod.2015 ↑

1. 16. Lorenzoni L, Belloni A, Sassi F. Healthcare expenditure and health policy in the USA versus other high-spending OECD countries. The lancet. 2014 Jul 11; 384(9937):83 92. ↑

1. 17. Majnoni D’intignano, B. Economie De La Santé. Paris: Presse Universitaires de France.2011. ↑

1. 18.Malhotra, N., Decaudin, J.-M., & Bougerra, A. Etudes Marketing Avec Spss (Ed. 5). Paris: Pearson Education. 2017. ↑

1. 19.Tuffery, S. Data Mining Et Statistique Décisionnelles (Ed. 5e). Paris: Edition Technip. 2017. ↑

1. 20.S.Alflayyeh. Theoretical Perspective Of Unusual Purchasing Tendencies During Pandemic Situation of Covid-19, European Journal of Molecular & Clinical Medicine, 2020, Volume 7, Issue 1, Pages 3475-3482. ↑

1. 21. Squires DA.Explaining high health care spending in the United States: an international comparison of supply, utilization, prices, and quality. New York, NY: Commonwealth Fund, 2012. ↑

1. 22.World Health Organization (WHO). Health expenditure database 2004-2016. Available: http://apps.who.int/nha/database (accessed September 11, 2017). ↑

1. 23.Aljuaid M. et al. Quality of care in university hospitals in Saudi Arabia: a systematic review. BMJ Open. 2020 ;(6):008988. ↑

1. 24.Almalki M.. Health care system in Saudi Arabia: an overview. East Méditer Health J. 2019;17(10):784–93. ↑

1. 25.KSA Ministry of Health, VRO, Business Case for the Health System Reform Component of the Kingdom of Saudi Arabia’s Vision 2030 Program, Version 2.0, 31 May 2017. ↑