Is the Frequency of Postpartum Breastfeeding Counseling Associated with Exclusive Breastfeeding at Six Months? An Analytical Cross-Sectional Study.

Breastfeeding counseling is an essential public health tool in postpartum maternal and infant health. In this study, we aimed to explore the relationship between the frequency of postpartum breastfeeding counseling and the type of feeding outcome at six months. The study design was an analytical, cross-sectional study on mothers of 6-24-month-old children living in Riyadh, Saudi Arabia. We conducted an analysis with descriptive statistics as well as logistic regression models. The findings from our study can be summarized in the following points: First, only 31.9% of the women in our study received postnatal breastfeeding counseling in the first six months after delivery, with the majority receiving fewer than four sessions. Second, there seemed to be a drop in exclusive breastfeeding with time: from 35.3% in the first two months to 29.7% in the second two months and then 20.7% in the final two months. Third, previous exclusive breastfeeding increased the odds of exclusive breastfeeding in the proceeding delivery. Finally, exposure to one or more postnatal breastfeeding counseling sessions increased the odds of exclusive or predominant breastfeeding in the first six months. This study helps to guide decision makers in planning maternal child health services and relevant community-based efforts.

The Saudi Ministries Twitter communication strategies during the COVID-19 pandemic: A qualitative content analysis study.

Objectives: To understand government communication strategies during the COVID-19 pandemic by examining topics related to COVID-19 posted by Saudi governmental ministries on Twitter and situating our findings within existing health behavior theoretical frameworks. Study design: Retrospective content analysis of COVID-19 related tweets. Methods: On November 7th, 2020, we extracted relevant tweets posted by five Saudi governmental ministries. After we extracted the data, we developed and applied a coding schema. Results: A total of 3,950 tweets were included in our dataset. Topics fell into two groups: disease-related (49.2%) and non-disease related (50.8%). The disease-related group included seven categories: awareness (18.5%), symptom (0.6%), prevention (7.7%), disease transmission (1.9%), treatment (0.3%), testing (3.4%), and reports (16.7%). The non-disease related group included eight categories: lockdown (5.9%), online learning (12.8%), digital platforms (4.3%), empowerment (12.0%), accountability (1.1%), non-disease reports (2.1%), local and international news (10.8%), and general statements (1.9%). Based on the correlation analysis, we found that the top positively correlated categories were: "testing" and "digital platforms" (r = 0.4157), "awareness" and "prevention" (r = 0.3088), "prevention" and "disease transmission" (r = 0.3025), "awareness" and "disease transmission" (r = 0.1685), "symptom" and "testing" (r = 0.1081), "awareness" and "symptom" (r = 0.0812), "symptom" and "digital platforms" (r = 0.0645), and "disease transmission" and "digital platforms" (r = 0.0450), p-values < 0.01. Several health behavior theoretical constructs were linked to our findings. Conclusions: Integrating behavioral theories in the development of health risk communication should be taken seriously by government communication specialists who manage social media accounts, as these theories help underlining determinants of people's behaviors.

Complications of intravascular intrauterine transfusion for Rh alloimmunization.

BACKGROUND: Intravascular intrauterine transfusion (IUT) is considered a safe procedure, but complications still occur, including fatalities. OBJECTIVE: Review the outcomes of Rh alloimmunization, including indications and possible complications. DESIGN: Retrospective cohort (medical record review). SETTING: Tertiary care center. PATIENTS AND METHODS: We retrieved the records for all mothers who had an IUT for Rh alloimmunization between January 2009 and August 2019. We collected data on complications, post-transfusion hemoglobin and antibody combinations. MAIN OUTCOME MEASURE: Complications of IUT. SAMPLE SIZE: 119 mothers with 154 fetuses (154 different pregnancies). RESULTS: The 154 fetuses had 560 intrauterine transfusions. The median pre-IUT hemoglobin was a median of 8.0 g/dL while the median post-IUT hemoglobin 16 g/dL. Immediate procedure-related complications included fetal bradycardia in 2.7%, significant bleeding from the cord puncture site (for more than 2 minutes in 0.9%), and contractions in 0.9%. Eight (5.2%) were delivered by cesarean delivery due to IUT-specific complications such as post-procedure fetal bradycardia. Intrauterine fetal death complicated 8.4% of the pregnancies (13 fetuses). Phototherapy was required in 76 (49.4%), postnatal blood transfusions in 17 (11%), and exchange transfusion in 11 (7.1%). Neonatal death occurred 8 (5.2%). Data were insufficient to assess associations of complications with antibody combinations. CONCLUSIONS: Intrauterine transfusion is an effective treatment with high survival rates (around 90% for cases of Rh alloimmunization). LIMITATIONS: Case series. CONFLICT OF INTEREST: None.

Culture-Specific Observations in a Saudi Arabian Digital Home Health Care Program: Focus Group Discussions With Patients and Their Caregivers.

BACKGROUND: There is growing evidence of the need to consider cultural factors in the design and implementation of digital health interventions. However, there is still inadequate knowledge pertaining to the aspects of the Saudi Arabian culture that need to be considered in the design and implementation of digital health programs, especially in the context of home health care services for patients who are chronically and terminally ill. OBJECTIVE: This study aims to explore the specific cultural factors related to patients and their caregivers from the perspective of physicians, nurses, and trainers that have influenced the pilot implementation of Remotely Accessible Healthcare At Home, a connected health program in the Home Health Care department at King Saud University Medical City, Riyadh, Saudi Arabia. METHODS: A qualitative study design was adopted to conduct a focus group discussion in July 2019 using a semistructured interview guide with 3 female and 4 male participants working as nurses, family physicians, and information technologists. Qualitative data obtained were analyzed using a thematic framework analysis. RESULTS: A total of 2 categories emerged from the focus group discussion that influenced the experiences of digital health program intervention: first, culture-related factors including language and communication, cultural views on using cameras during consultation, nonadherence to web-based consultations, and family role and commitment and second, caregiver characteristics in telemedicine that includes their skills and education and electronic literacy. Participants of this study revealed that indirect contact with patients and their family members may work as a barrier to proper communication through the Remotely Accessible Healthcare At Home program. CONCLUSIONS: We recommend exploring the use of interpreters in digital health, creating awareness among the local population regarding privacy in digital health, and actively involving direct family members with the health care providers.

Caregivers' Sources of Information About Immunization as Predictors of Delayed Childhood Vaccinations in Saudi Arabia During the COVID-19 Pandemic: A Cross-Sectional Questionnaire Study.

PURPOSE: This study compared the most used sources of information by caregivers for scheduled childhood vaccination in Saudi Arabia before and during the COVID-19 pandemic and examined the effect of this decision-making. METHODS: An electronic survey was administered to 577 caregivers of children aged ≤2 years residing in Saudi Arabia during the COVID-19 pandemic curfew. The sources of information on childhood vaccination considered by the caregivers and their influence on the caregivers' decision to delay scheduled vaccination were assessed and statistically analyzed. RESULTS: Most participants (90.8%) were mothers aged 32.6 ± 5.7 years. Before the pandemic, most caregivers sought information about children's vaccinations personally from the healthcare workers, or trustworthy sources, including the Ministry of Health (MOH), MOH call center 937, and MOH Sehha app. However, during the pandemic, there was a noticeable decrease in the searches for health information through professional consultations (in person and health websites) and a significant increase in the use of social media platforms. Twitter was the most used platform (29.9%) and the use of Snapchat was significantly higher during the lockdown period compared to its use before the pandemic (21.9% vs 17.2%, P < 0.001). The use of social media not only increased the level of fear among the caregivers but also had a negative effect on their decisions about children's vaccinations. Searches on YouTube and Facebook particularly increased the odds of delaying vaccinations by 2.63 times (P = 0.008) and 3.66 times (P = 0.025), respectively. CONCLUSION: During the pandemic, caregivers' health-information seeking behavior was directed towards social media networking. In Saudi Arabia, YouTube and Facebook, in particular, played an important role in the caregivers' decision-making about childhood vaccinations. The results of this survey provide valuable information on how to reach the Saudi population and launch an effective awareness campaign using the most commonly accessed and influential sources of information.

Impact of the COVID-19 Pandemic Lockdown on Routine Childhood Immunization: A Saudi Nationwide Cross-Sectional Study.

Background: Routine childhood immunization is the most cost-effective method to prevent infection and decrease childhood morbidity and mortality. The COVID-19 pandemic has affected access to health care in Saudi Arabia, including mandatory vaccinations for young children. We aimed to assess the prevalence of intentionally delayed vaccinations in children aged ≤ 2 years during the COVID-19 pandemic curfew in Saudi Arabia, its relation to the caregivers' fear of infection, and identifying factors affecting the caregivers' decision. Methods: We conducted a cross-sectional study using a self-administered survey that targeted primary caregivers of children aged ≤ 2 years residing in Saudi Arabia during the COVID-19 pandemic curfew (March 4-July 6, 2020). Results: We received responses from 577 caregivers, of whom 90.8% were mothers. The prevalence of intentional vaccination delay was 37%. Upon adjusting the potential confounders, the odds of delaying scheduled childhood vaccination because of COVID-19 pandemic fears were greater among caregivers with higher levels of fear (OR 1.10, 95% CI 1.02-1.11). Common reasons for delaying vaccinations were COVID-19 infection and prevention of exposure to COVID-19 cases. Conclusion: Intentional vaccination delay leaves young children vulnerable to preventable infectious diseases. Identifying these children and offering catch-up vaccinations reduces this risk. Campaigns to increase awareness about the dangers of delaying vaccine-preventable diseases must be promoted to caregivers in addition to the promotion of home vaccination services. In preparation for future pandemics, we recommend countries consider interventions to control the level of fear and anxiety provoked by the pandemics and media, and interventions for improved access to vaccinations.

Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study.

BACKGROUND: Several factors influence patients' length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs). METHODS: This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units' leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days. RESULTS: Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million). CONCLUSION: If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.

Long-stay patients in pediatric intensive care units. Five-years, 2-points, cross-sectional study.

OBJECTIVES: To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources. METHODS: This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included. RESULTS: Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%). CONCLUSION: A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.

Digital Response During the COVID-19 Pandemic in Saudi Arabia.

BACKGROUND: The first case of COVID-19 in Saudi Arabia was confirmed on March 3, 2020. Saudi Arabia, like many other countries worldwide, implemented lockdown of most public and private services in response to the pandemic and established population movement restrictions nationwide. With the implementation of these strict mitigation regulations, technology and digital solutions have enabled the provision of essential services. OBJECTIVE: The aim of this paper is to highlight how Saudi Arabia has used digital technology during the COVID-19 pandemic in the domains of public health, health care services, education, telecommunication, commerce, and risk communication. METHODS: We documented the use of digital technology in Saudi Arabia during the pandemic using publicly available official announcements, press briefings and releases, news clips, published data, peer-reviewed literature, and professional discussions. RESULTS: Saudi Arabia's government and private sectors combined developed and launched approximately 19 apps and platforms that serve public health functions and provide health care services. A detailed account of each is provided. Education processes continued using an established electronic learning infrastructure with a promising direction toward wider adoption in the future. Telecommunication companies exhibited smooth collaboration as well as innovative initiatives to support ongoing efforts. Risk communication activities using social media, websites, and SMS text messaging followed best practice guides. CONCLUSIONS: The Saudi Vision 2030 framework, released in 2017, has paved the path for digital transformation. COVID-19 enabled the promotion and testing of this transition. In Saudi Arabia, the use of artificial intelligence in integrating different data sources during future outbreaks could be further explored. Also, decreasing the number of mobile apps and merging their functions could increase and facilitate their use.

Implementation of Cigarette Plain Packaging: Triadic Reactions of Consumers, State Officials, and Tobacco Companies-The Case of Saudi Arabia.

OBJECTIVES: In August 2019, Saudi Arabia started implementing plain packaging for cigarettes. Three months later, an opposing campaign on twitter using an Arabic hashtag "the new smoke" gained momentum amongst smokers. The purpose of this study is to document this opposing campaign's timeline and describe consumers, government, and tobacco industry rhetoric. METHODS: We created a timeline of the campaign events then performed online social listening of Arabic twitter hashtags related to the campaign. RESULTS: Campaigners mainly complained of an unfavorable new taste in cigarette packs with plain packaging. The messaging developed to accusations to government entities and neighboring countries, and then after threats to boycott tobacco companies. The campaign received a significant amount of media coverage and elicited an official response from a number of Saudi government bodies, such as the Saudi Food and Drug Authority and Ministry of Commerce and Investment. CONCLUSION: This case points at a need for risk communication training, possible tobacco industry manipulation, and a need to gain consumer trust with evidence-based messaging techniques. The case of cigarette plain packaging adoption in Saudi Arabia serves as an example to other countries of potential consumer interaction, tobacco industry interference, and state official counter-reactions.

Effectiveness of digital health using the transtheoretical model to prevent or delay type 2 diabetes in impaired glucose tolerance patients: protocol for a randomized control trial.

BACKGROUND: There is high prevalence of prediabetes and type 2 diabetes mellitus (T2DM) in Saudi Arabia that is still increasing. Early diagnosis of prediabetes, and immediate, effective intervention is yet unestablished. Conventional health promotion approaches are used to educate prediabetic patients. Behavior modification is very effective in prediabetics to delay T2DM. Thus, the main objective of this study is to examine the effect of the new behavioral model, the Transtheoretical Model short messages (text 4 change) to modify lifestyle to prevent or delay the onset of T2DM, through promotion of a healthy diet and increased physical activity, in impaired glucose tolerance patients. Another objective is to estimate the impact of this model on markers of cardiovascular and metabolic risks as T2DM is one of the modifiable risk factors to prevent cardiovascular diseases. METHODS: This is a randomized controlled trial. One thousand and sixteen, eligible Saudi adults will be recruited from the Heart Health Promotion study (HHP), which was conducted at the King Saud University from July 2013 to April 2014. These adults were at a higher risk of developing T2DM within 2-3 years. The research team's database has a contact list and they will recruit individuals over 6-8 weeks. All participants will be randomized at a 1:1 ratio into two groups, receive group education about lifestyle modifications and written information about diet and physical activity. Text 4 change SMS texts will be sent only to the intervention group. All participants will be assessed at baseline, 6, 12, 18, 24, 30, and 36 months for behavioral change using a World Health Organization (WHO) STEPS questionnaire and for glycated hemoglobin, biochemical and anthropometric measurements using standard methods. DISCUSSION: This new approach for promoting the importance of behavior modification in prediabetics is expected to delay and/or prevent the development of T2DM in Saudi Arabia, subsequently reducing the risk of cardiovascular morbidity and mortality too. Results from this study will promote an innovative and high-tech way to decrease the burden of cardiovascular diseases in Saudi Arabia. TRIAL REGISTRATION: International Standard Randomized Control Trial, registration number ISRCTN10857643. Registered 4 June, 2018.

Depression literacy in women attending university hospital clinics in Riyadh Saudi Arabia.

BACKGROUND: Depression literacy in general population constitutes an ability to understand depression, with knowledge of disease, its risk factors and symptoms. High levels of depression literacy promote early intervention, potentially reducing related disability. AIM: This study investigated the depression literacy in women visitors to clinics of a tertiary care hospital in Riyadh, Saudi Arabia. METHODS: Women of 18 and more years were surveyed during their visit to primary and other healthcare clinics of a public hospital in Riyadh. Knowledge on depression symptoms, causes and management approaches identified depression literate women scoring more than 30 points on a 42-item tool. RESULTS: Of the 409 participants, 65.5% were depression literate, 50% educated as college and above, 64.3% married, 50.7% housewives, 62.4% reported use of multiple information sources (range, 0-8) and had a mean age of 34.9 (standard deviation ( SD), 12.4) years. In a logistic regression model, participants scoring less than 30 for depression literacy were significantly associated with women having less than college-level education, divorced marital status and use of decreasing number of learning resources. CONCLUSION: Women with low education divorced; using fewer information sources need specific considerations by healthcare providers for assessment of depressive disorders in this setting.