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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 2085-2091  

Diabetes-care practices and related awareness amongst type-2 diabetes patients attending diabetes OPD at a tertiary care hospital in southwestern Saudi Arabia


1 Department of Medicine/Critical Care, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Assistant Professor, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
3 Department of Medicine, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
4 College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia

Date of Submission07-Dec-2019
Date of Decision16-Dec-2019
Date of Acceptance07-Jan-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Ali Al Bshabshe
Department of Medicine/Critical Care, College of Medicine, King Khalid University, PO. BOX 25216, Abha
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1120_19

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  Abstract 


Background: Diabetes is the most prevalent disease in Saudi Arabia having vast health and economic implications. Hence, it is important that all measures must be undertaken to prevent and control the disease. Objectives: This study was performed to assess the diabetes-care practice and related awareness of patients of type 2 diabetes attending the outpatient department of a diabetes care center at a tertiary care hospital in southwestern Saudi Arabia. Methods: A descriptive cross-sectional approach was used wherein patients attending the outpatient department of the diabetes treatment center of a tertiary hospital in the southern region of the Kingdom of Saudi Arabia were surveyed, using a predesigned pretested questionnaire covering the study variables. Results: The study included 287 individuals with type 2 diabetes in the age range 25 years to 90 years (mean age = 55.5 years). Around 57% of the participants were females while the rest were males. Conclusion: The present study showed that awareness about diabetic complications among the study population is good, especially among young educated patients who adhere to regular medical follow-up. Attending physicians were a major source of awareness for the patients.

Keywords: Behavior, complications, diabetes-care, diabetes complications, knowledge, prevention, type 2 diabetes mellitus


How to cite this article:
Al Bshabshe A, Ahmad MT, Assiri OA, Assery AA, Aljadhaa GA, Al Aslai SA, Alamri ZS, Khan MA, Asiri LS. Diabetes-care practices and related awareness amongst type-2 diabetes patients attending diabetes OPD at a tertiary care hospital in southwestern Saudi Arabia. J Family Med Prim Care 2020;9:2085-91

How to cite this URL:
Al Bshabshe A, Ahmad MT, Assiri OA, Assery AA, Aljadhaa GA, Al Aslai SA, Alamri ZS, Khan MA, Asiri LS. Diabetes-care practices and related awareness amongst type-2 diabetes patients attending diabetes OPD at a tertiary care hospital in southwestern Saudi Arabia. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 26];9:2085-91. Available from: https://www.jfmpc.com/text.asp?2020/9/4/2085/283388




  Introduction Top


With changing lifestyles the prevalence of diabetes mellitus (DM) has been rising worldwide over the past few decades. According to a recent estimate by the International Diabetes Federation, the age-adjusted prevalence of diabetes in Saudi Arabia is 17.7%.[1] In another study conducted by Al-Daghri,[2] the prevalence of T2DM was found to be 31.6%. According to a report by the Ministry of Health, Saudi Arabia, there has been a 2.7 times rise in the incidence rate of diabetes in the two decades between 1990 and 2010.[3] This rapid rise in the burden of diabetes has been largely attributed to the rising obesity rate as well as an aging population.[4] Diabetes is the most prevalent disease in the Kingdom of Saudi Arabia and has vast human resources and economic implications for the government. Hence, it is imperative that all measures must be undertaken for the prevention and control of the disease.[5]

DM is a potentially debilitating chronic disease that is characterized by a lack of insulin secretion or an anomaly in insulin action. Based on the underlying pathology, diabetes has been classified into three types, namely, type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM). T1DM is due to the autoimmune destruction of insulin-producing beta cells in  Islets of Langerhans More Details leading to low levels of insulin and its consequences. T2DM, on the other hand, is due to increased resistance of body tissues to insulin which results in diminished metabolic action of insulin. GDM is defined as any degree of hyperglycemia, which occurs during pregnancy.[6],[7]

Poorly controlled diabetes can lead to many complications ranging from microvascular to macrovascular complications such as coronary artery disease, renal failure, stroke, blindness, skin ulcers especially in foot, and so on which can lead to serious morbidity and mortality.[8],[9]

The quality of life of patients with diabetes can be improved if complications of the disease are detected early. Thus, training of the individual is an integral part of the self-management of diabetes.[10] Optimum management of the problem requires an individual to be aware of the nature and consequence of the disease, its risk factors, treatment, and its complications. Hence, an attempt has been made to study the knowledge of complications of diabetes in patients with diabetes attending tertiary care center. Knowledge and awareness of diabetes care and lifestyle management are an essential component of the strategy to prevent diabetes complications. Worldwide different studies have assessed awareness among diabetic patients regarding the complications of diabetes.[11],[12],[13],[14],[15],[16],[17],[18].[19]

Due to the paucity of studies in southern Saudi Arabia regarding awareness and diabetes care practices amongst diabetes patients, this study was conducted amongst type 2 diabetic patients attending the outpatient's department in Aseer Central Hospital (ACH), which is one of the largest tertiary care centers in southern Saudi Arabia.

In the majority of times, diabetic care especially types -2. DM is provided by family physicians in most countries. Diabetic patients care plans are usually followed and subjected to changes by primary healthcare practitioners.


  Methodology Top


A descriptive cross-sectional approach was used in which patients with type 2 DM attending the outpatient department of the diabetes center of Aseer Central Hospital were requested to provide information based on a predesigned and pretested questionnaire. The study was conducted from November 2017 to December 2018.

The first part of the questionnaire contained items dealing with the sociodemographic characteristics of the patients, namely, age, gender, educational status, occupation, and socioeconomic status. The second part of the questionnaire contained items to assess the awareness about common diabetic complications and diabetes care practices of the patients.

After data were collected it was coded and fed to statistical software IBM SPSS version 20. Graphs were made using Microsoft Excel software. All statistical analysis was done using two-tailed tests (alpha error of 0.05.). A P value less than or equal to 0.05 was considered to be statistically significant. Chi-square/Mont Carlo exact test and Fishers exact test were used to test for the association between different patients' factors with their knowledge level. Exact tests were used in case of small frequencies where Chi-square was invalid. The research was approved from the ethics committee of King Khalid university number: (REC#2018-02-51), date of approval: 19-3-2018 and from the research committee of Aseer central hospital booth copies attached.


  Results Top


The study included 287 diabetics with ages ranged from 25 years to 90 years old (mean age = 55.5 years). Around 57% of the participants were females, rest males. Rural residence was found in 41.5% of the patients and the rest resided in urban areas. Education status was recorded and it was found that 23.3% had attended university, while 33.8% of the patients did not have any formal education, rest had obtained education ranging from primary to secondary school level. Most of the subjects (76.3%) were not in any full-time employment. Based on BMI figures, 74.2% of the patients were classified as obese, 18.1% overweight, and 7.7% normal. Smoking history was elicited 13.2% of subjects reported being smokers. Three quarters (75.6%) of the participants reported the presence of at least one another family member with diabetes [Table 1].
Table 1: Biodemographic characteristics of the study patients, Aseer, Saudi Arabia

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Nearly 46% of the subjects reported having suffered from diabetes for more than 10 years, while only 7.3% had the disease for less than a year [Table 2]. With regard to diabetes control, 42.9% mentioned that their HBA1c was measured within the past 1 month while 5.2% recalled having had it measured around a year back. Poor diabetic control was recorded among 64.8% of the patients even though 82.1% of the patients reported that they visit the hospital regularly.
Table 2: Diabetes data of the study patients, Aseer, Saudi Arabia

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Information measuring the subjects' knowledge about diabetes and its complications was sought and it was found that [Table 3], 41.8% of the patients were aware of the neurological complications of diabetes, while the awareness regarding renal complications, cardiac complication, stroke, and dermatological complications was seen in 45.6%, 42.9%, 39.7%, and 36.9%, respectively. Regarding patient practices for diabetes control, 86.8% of the participants have glucose meter at their homes for a periodic checkup, while 44.9% follow a specified dietary routine. Moreover, 57% of the subject perform daily care of their foot and 38.7% reported practicing sports daily. Around 57% of the respondents reported getting their triglyceride level measured in the past 5 years [Table 4]. Overall, a high level of awareness was observed in 50.5% of the participants while 9.8% had poor awareness [Figure 1].
Table 3: Knowledge regarding DM and its complications of the study patients, Aseer, Saudi Arabia

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Table 4: Patients practice regarding DM of the study patients, Aseer, Saudi Arabia

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Figure 1: Overall awareness of sampled patients regarding DM and its complications

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With regard to treatment methods, 43.9% of the patients know that diabetes medicines are effective, 14.98% mentioned that insulin was the best treatment for diabetes while 35.5% mentioned dietary control as the best way to control diabetes. Just 1.05% believed that herbal medicines are effective for diabetes treatment. On the issue of preventive methods against complications, 51.2% of the patients knew about the importance of medication adherence while 50.52% responded that regular exercise is important for protection against complications. The subjects were asked about the source of knowledge regarding DM and its complications; 90.2% of the patients responded that the treating physicians were the main source, followed by internet (33%), social media (31.5%), and television (24.5%) [Figure 2].
Figure 2: Source of knowledge regarding DM and its complications among the sampled population

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It was observed that [Table 5], 60.6% of those aged below 50 years had a good awareness level compared to 32.4% of those who were aged 70 years or more. However, this was not found to be significant. (P =0.015). With regard to education, 73.1% of university graduated patients had a good level of awareness compared to 28.9% of those who received no formal education (P =0.001). Considering the residence area, residents of urban areas had better knowledge; 59.5% compared to 37.8% amongst those living in rural areas (P =.001). Patients with regular hospital visits recorded a high level of awareness in 56.8% of the subjects as compared to 23.5% in those not visiting the hospital regularly (P =.001). Gender, career, and family member with DM or DM duration not significantly related to diabetes-related awareness.
Table 5: Relation between patients' biodemographic characteristics and their DM awareness level

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  Discussion Top


This study was conducted to assess diabetes-related awareness and practices of patients suffering from diabetes. This is the first such study conducted in the Aseer region. Hopefully, this study would serve as a guide for physicians and public health practitioners to deal with the public health problem of diabetes in a more effective manner.

All our 287 study subjects comprised of patients of diabetes attending the Diabetes Clinic at Aseer Central Hospital. Patients were well represented from rural as well as urban areas, both males and females were represented in a proportionate manner. We had a good mix of subjects ranging from university-educated to those not formally educated. Different age-groups were well represented in our study.

Obesity which is one of the major risk factors for diabetes was present in 74.2% of the patients as per their BMI figures. A similar study conducted in Tabuk found that high BMI and fast food consumption were found more frequent diabetes patients (P < 0.05).[20] Our survey also found that around 50% of the patients were aware that exercise is a good way to prevent diabetic complications. Our survey also found that just 38.7% of the patients practiced sports daily. This is one area in which more awareness needs to be cultivated among diabetics as well as the general population. In a study conducted in KSA by Midhet et al.[21] it was found that lack of exercise and bad dietary practices were significantly related to the development of diabetes.

Based on BMI figures, 74.2% of the patients in our study were classified as obese. Obesity has been closely linked to diabetes in studies around the world.[22],[23],[24] A study by Daousi et al. found that obesity was present in 80 to 90% of type 2 diabetes patients.[25] Further in our study, it was found that 37.8% of the subject reported practicing sports on a daily basis while 44.9% of the subjects followed a prescribed dietary routine [Table 4] Hence, efforts to ensure exercise and healthy eating could be a major intervention for prevention and control of diabetes in our setting as well.

With regard to diabetes control, 42.9% mentioned that their HBA1c was measured within the past 1 month while 5.2% recalled having had it measured around a year back.

Poor diabetic control was recorded among 64.8% of the patients and 82.1% of them visit the hospital regularly.

About 50.5% of the participants recorded a high level of awareness regarding DM and its complication while only 9.8% had poor awareness [Figure 1].

Self-management of diabetes which is based on regular monitoring of blood sugar is important for achieving successful outcomes. In our study, 86.8% of the participants reported owning a glucose meter at home for a periodic checkup of their blood glucose level [Table 4]. This was similar to another study in the USA, which found the glucose meter ownership of 85% amongst diabetes patients.[26]

Foot-related complications are quite common in patients of diabetes. In a study conducted in Saudi Arabia, it was found that 11.4% of the patients of diabetes had diabetes foot complications.[27] In our study, it was found that 57% of the subjects care for their foot and nail. This was higher than the findings of a study in Iran where 60% of the patients failed to inspect their feet and patients, in general, were found to have poor knowledge of foot self-care.[28]

Diabetes management requires a high level of awareness and motivation on part of the patients regarding self-care. We compared the awareness level of patients with other characteristics. It was found that 73.1% of university graduated patients had a good level of awareness as compared to 28.9% for noneducated patients (P =0.001). Similarly, residents of urban areas had a better knowledge-59.5%, compared to those who live in rural areas-37.8% (P =0.001). In addition, it was found that 56% of those visiting the hospital regularly recorded a good level of awareness as compared to 23.5% for those who did not (P =.001). Gender, age, career, and family members with DM or DM duration were statistically insignificant [Table 5]. Hence, these findings underline the need for focused awareness efforts especially amongst lesser-educated, rural residents, having difficulty accessing healthcare services.

Knowledge regarding complications of diabetes is important to ensure that the patients are motivated to take care of their health and undertake preventive checks as advised. In our study, 45.6% of the subjects were aware of the renal complications of diabetes. Around 45.6% of the patients were aware of the renal complications of diabetes. The awareness was 42.9% for cardiac complications, 41.8% for renal complications, 39.7% for stroke, and 36.9% for dermatological complications [Table 3].

Trust in the therapy is important for maintaining compliance. Diabetes requirement a lifelong intake of medications and hence it is essential that the patient is informed enough to believe in the effectiveness of the therapy. It is also important to know whether the patients find the treatment effective or not. In our study, 43.9% of the patients believed that diabetes medicines are effective, 14.98% mentioned that insulin was the best treatment for diabetes while 35.5% mentioned dietary control as the best way to control diabetes. Around 1% believed that herbal medicines are effective for diabetes treatment. (There is some discrepancy with the headings in [Table 3]). A study [29] conducted in Mecca found that 15.6% of the studied subjects believed that traditional medicines were safe and effective which is much higher as compared to our findings.

Responses were also elicited about the subjects' views on preventive measures for control of diabetes. We found that 51.2% of the patients knew about the importance of medication adherence while 50.52% responded that regular exercise is important for protection against complications. There appear some gaps in the knowledge of the subjects regarding the effectiveness of the diabetic medication. A detailed study may be able to guide in planning an effective campaign to remove these gaps.

We also asked about the source of the subjects' knowledge about diabetes and its care. Around 90% of the patients responded that the treating physicians were the main source of their information. This was followed by the internet (33%), social media (31.5%), and television (24.5%). In studies, healthcare staff including doctors have been found to have gaps in their knowledge regarding diabetes.[30],[31] Hence there is a need for capacity building of the staff to make them more equipped to communicate essential information to promote diabetes care amongst the patients.


  Conclusions and Recommendations Top


The present study showed that awareness about diabetic complications among the study population is good especially among young educated patients who adhere to regular medical follow-up. Healthcare providers' role in increasing awareness about diabetic complications need to be emphasized more. Health education sessions regarding the prevention of diabetic complications can be organized regularly in clinics and primary health centers to sensitize and create awareness among the general population. Mass media and other voluntary organizations can also be involved in creating awareness and screening for these diabetic complications can be held regularly at primary health centers to detect these complications earlier and provide optimal management to stop their progress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Diabetes Federation. IDF diabetes atlas-2017 Atlas. Available from: http://www.diabetesatlas.org/resources/2017-atlas.html. [Last accessed on 2017 Dec 30].  Back to cited text no. 1
    
2.
Al-Daghri NM, Al-Attas OS, Alokail MS, Alkharfy KM, Yousef M, Sabico SL, et al. Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (Riyadh cohort 2): A decade of an epidemic. BMC Med 2011;9:76.  Back to cited text no. 2
    
3.
The Ministry of Health. Statistics report 2015 [cited 2015 Nov 05]. Available from: http://www.moh.gov.sa/en/Ministry/Statistics/book/Pages/default.aspx.  Back to cited text no. 3
    
4.
Kearns K, Dee A, Fitzgerald AP, Doherty E, Perry IJ. Chronic disease burden associated with overweight and obesity in Ireland: The effects of a small BMI reduction at population level. BMC Public Health 2014;14:143.  Back to cited text no. 4
    
5.
Alanazi FK, Alotaibi JS, Paliadelis P, Alqarawi N, Alsharari A, Albagawi B. Knowledge and awareness of diabetes mellitus and its risk factors in Saudi Arabia. Saudi Med J 2018;39:981-9.  Back to cited text no. 5
    
6.
American Diabetes Association. Complications. [Internet]. Available from: http://www.diabetes.org/living-with-diabetes/complications/. [Last accessed on 2018 Jan 15].  Back to cited text no. 6
    
7.
Monitoring and follow up of people with Diabetes. Guidelines for Management of Type 2 Diabetes: Indian Council of Medical Research; 2005. Available from: http://www.icmr.nic.in/guidelines_diabetes/section5.pdf. [Last accessed on 2018 Jan 13].  Back to cited text no. 7
    
8.
O'Sullivan EP, Bhargava A, O'Callaghan M, Buckley U, De Faoite T, Moynihan K, et al. Awareness of diabetes complications in an Irish population. Ir J Med Sci 2009;178:401-6.  Back to cited text no. 8
    
9.
Sabri AA, Qayyaum MA, Saigol NU, Zafar K, Aslam F. Comparing knowledge of diabetes mellitus among rural and urban diabetics. Megill J Med 2007;10:87-9.  Back to cited text no. 9
    
10.
Songer TJ, Ettaro L. Studies on the Cost of Diabetes. Atlanta, USA: Centers for Disease Control and Prevention; 1998.  Back to cited text no. 10
    
11.
Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, et al. Nutrition therapy for adults with diabetes or prediabetes: A consensus report. Diabetes Care 2019;42:731-54.  Back to cited text no. 11
    
12.
Hossein-Nezhad A, Larijani B. Cost analysis of screening and diagnosis methods in gestational diabetes. Iran J Diabetes Lipid Disord 2001-2002;1:31-40.  Back to cited text no. 12
    
13.
Meck Higgins ML. Diabetes Awareness and Management, Promot Healthier and Safer Lives. Kansas State University, are available on the World Wide Web at: http://www.oznet.ksu.edu; 2000.  Back to cited text no. 13
    
14.
American Diabetes Association. 5. Lifestyle management: Standards of medical care in diabetes-2019. Diabetes Care 2019;42(Suppl 1):S46-60.  Back to cited text no. 14
    
15.
Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014;37(Suppl 1):S120-43.  Back to cited text no. 15
    
16.
American Diabetes Association. 13. Children and adolescents: Standards of medical care in diabetes-2019. Diabetes Care 2019;42(Suppl 1):S148-64.  Back to cited text no. 16
    
17.
Vankudre AJ, Padhyegurjar MS, Jennifer HG, Padhyegurjar SB. A study to assess awareness regarding diabetes mellitus and factors affecting it, in a tertiary care hospital in Kancheepurum District. Healthline 2013;4:44-9.  Back to cited text no. 17
    
18.
Menezes SA, Bava MM, Roshan M. A study on awareness of diabetic complications among type 2 diabetes patients. IOSR J Dent Med Sci 2015;14:13-6.  Back to cited text no. 18
    
19.
Bodunde OT, Odusan O, Ogunsemi O, Ajibode HA, Raimi TH. Awareness of ocular complications of diabetes among diabetic patients in a tertiary hospital in Western, Nigeria. IOSR J Dent Med Sci 2014;13:9-12.  Back to cited text no. 19
    
20.
Al-Mountashiri NA, AL-Zhrani AM, Ibrahim SF, Mirghani HO. Dietary habits, physical activity and diabetes perception among patients with type 2 diabetes mellitus in Tabuk City, Saudi Arabia. Electron Physician 2017;9:5179-84.  Back to cited text no. 20
    
21.
Midhet FM, Al-Mohaimeed AA, Sharaf FK. Lifestyle related risk factors of type 2 diabetes mellitus in Saudi Arabia. Saudi Med J 2010;31:768-74.  Back to cited text no. 21
    
22.
El-Hazmi MA, Warsy AS. Prevalence of obesity in the Saudi population. Ann Saudi Med 1997;17:302-6.  Back to cited text no. 22
    
23.
Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003;289:76-9.  Back to cited text no. 23
    
24.
Hossain P, Kawar B, El Nahas M. Obesity and diabetes in the developing world -- A growing challenge. N Engl J Med 2007;356:213-5.  Back to cited text no. 24
    
25.
Daousi C, Casson IF, Gill GV, MacFarlane IA, Wilding JP, Pinkney JH. Prevalence of obesity in type 2 diabetes in secondary care: Association with cardiovascular risk factors. Postgrad Med J 2006;82:280-4.  Back to cited text no. 25
    
26.
Bell RA, Arcury TA, Stafford JM, Golden SL, Snively BM, Quandt SA. Ethnic and sex differences in ownership of preventive health equipment among rural older adults with diabetes. J Rural Health 2007;23:332-8.  Back to cited text no. 26
    
27.
Hu Y, Bakhotmah BA, Alzahrani OH, Wang D, Hu FB, Alzahrani HA. Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia. Diabetes Res Clin Pract 2014;106:286-94.  Back to cited text no. 27
    
28.
Khamseh ME, Vatankhah N, Baradaran HR. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J 2007;4:298-302.  Back to cited text no. 28
    
29.
Al Saeedi M, El Zubier AG, Bahnassi AA, Al Dawood KM. Patterns of belief and use of traditional remedies by diabetic patients in Mecca, Saudi Arabia. East Mediterr Health J 2003;9:99-107.  Back to cited text no. 29
    
30.
Khan AT, Lateef NA, Khamseen MA, Alithan MA, Khan SA, Ibrahim I. Knowledge, attitude and practice of ministry of health primary health care physicians in the management of type 2 diabetes mellitus: A cross sectional study in the Al Hasa District of Saudi Arabia, 2010. Niger J Clin Pract 2011;14:52-9.  Back to cited text no. 30
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31.
Al Rasheed R, Al Adel F. Diabetic retinopathy: Knowledge, awareness and practices of physicians in primary-care centers in Riyadh, Saudi Arabia. Saudi J Ophthalmol 2017;31:2-6.  Back to cited text no. 31
    


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