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PURPOSE The social impact of cancer on patients and their family is well known. Yet, unlike with physical and financial toxicities, no validated tools are available to measure this impact. This study aimed at developing, validating, and implementing a novel social toxicity assessment tool for patients with cancer diagnosis (STAT-C). METHODS Questions were generated through multiple steps including focus groups of patients, their families, and oncology care professionals. These steps along with relevant literature resulted in the development of an initial 20-item questionnaire. Content validity and relevance of the tool were assessed using Content Validity Index for individual items and Content Validity Index for the entire scale. Following expert examination, the constructed STAT-C tool consisted of 14 items grouped into three domains—social relations, social activities, and economic impact. Based on the total possible score for the survey in 150 patients for all the items, three levels of a socioeconomic toxicity were determined—severe social toxicity, mild social toxicity, and no social toxicity. RESULTS The 14 items were marked as relevant, and the Content Validity Index for individual items ranged between 0.80 and 1.00. An overall average Content Validity Index for the entire scale of 0.87 showed high content validity of the constructed tool. Exploratory factor analysis revealed retention of 13 items of the constructed STAT-C Tool, which loaded across three factors that mapped groupings into measures of social relations, social activities, and economic impact domains. CONCLUSION Our study revealed that STAT-C is a valid, reliable tool, and well captures and measures unique and pertinent social toxicity constructs for Arabic-speaking patients. The tool should enable oncology professionals to deliver better patient-centered care as a component of a comprehensive approach.

Background Chronic pain (CP) can be a symptom of many underlying health issues. The consequences of CP may vary from slight discomfort to disruption of quality of life and normal functioning. In this study, we aim to investigate the prevalence of CP and its associated factors in Al Kharj, Saudi Arabia. Methods This was a cross-sectional study conducted in Al Kharj, Saudi Arabia. We recruited 1031 participants for our study. Data was collected on socio-demographic, health predictors and anthropometric measurements (such as weight, height and waist circumference). The data analysis was performed on JMP®, Version 12. SAS Institute Inc., Cary, NC, 1989–2007. Results The prevalence of self-reported chronic pain in Al Kharj population was 19% with a mean age of 26.4 (SD = 8.6) years. The most common locations of pain included; back pain (30%), abdominal pain (26%), headache (13%), and any musculoskeletal pain (56%). Multiple logistic regression revealed that presence of a chronic disease (OR = 3.8; 95% CI = 2.3–6.2), psychological disease (OR = 2.3; 95% CI = 1.2–4.3), high General Health Questionnaire (GHQ)-12 score (OR = 1.06; 95% CI = 1.03–1.1), and pack-years of smoking (OR = 1.05; 95% CI = 1.01–1.08) were significantly related to chronic pain in Al Kharj population. Conclusions Our study results found a high burden of chronic pain in this selected Saudi population. The most prevalent pain was low back pain. The presence of chronic and psychological diseases were strongly related to chronic pain. Future prospective studies are needed to establish the temporal relationship of chronic pain with these factors.

Background HIV stigma and the resultant fear of being identified as HIV-positive can compromise the effectiveness of HIV programs by undermining early diagnosis and antiretroviral treatment initiation and adherence of people living with HIV (PLHIV). In the wake of the longstanding conflict in the country, little is known about the life experiences of PLHIV in Somalia. Methods A qualitative study using unstructured interviews was conducted in Somalia from September to December 2017. A convenience sampling approach was used to recruit 13 participants, including 10 persons who live with HIV and three senior officials who work for the HIV program at the Ministry of Health. Data were analyzed using a thematic analysis. Results Our findings show that PLHIV are alienated and prefer to isolate themselves due to widespread stigma subjected to them by their family members, society, employers, and health providers, which continue to undermine the scale-up of testing and treatment of PLHIV in Somalia. Consequently, they are reluctant to seek voluntary diagnosis and treatment of HIV. They often come to know about their status when their partners are found HIV positive, they are tested for other clinical purposes, or when an individual's health deteriorates, and all other means fail to work in improving his/her situation. The study also pointed out a shortage of facilities that provide HIV diagnosis, counseling and treatment in Somalia. Conclusion Addressing stigma and discrimination subjected to PLHIV are critical to a successful HIV response in Somalia. To successfully address stigma, HIV programs need evidence on effective interventions at individual, community, and societal levels in order to strategically incorporate stigma and discrimination reduction into national HIV programs.

Background The use of complementary and alternative medicine (CAM) is common among cancer patients and it may reflect the individual and societal beliefs on cancer therapy. Our study aimed to evaluate the trends of CAM use among patients with cancer between 2006 and 2018. Methods We included 2 Cohorts of patients with cancer who were recruited for Cohort 1 between 2006 and 2008 and for Cohort 2 between 2016 and 2018. The study is a cross-sectional study obtaining demographic and clinical information and inquiring about the types of CAM used, the reasons to use them and the perceived benefits. We compared the changes in the patterns of CAM use and other variables between the two cohorts. Results A total of 1416 patients were included in the study, with 464 patients in Cohort 1 and 952 patients in Cohort 2. Patients in Cohort 2 used less CAM (78.9%) than Cohort 1 (96.8%). Cohort 1 was more likely to use CAM to treat cancer compared to Cohort 2 (84.4% vs. 73%, respectively, p p Conclusion There is a significant change in CAM use among cancer patients over the decade, which reflects major societal and cultural changes in this population. Further studies and interventions are needed to improve the disclosure to physicians and to improve other aspects of care to these patients.

Background As increasing the number of organ donations presents a global challenge, Saudi Arabia is no different. Intensivists can play a major role in maximizing the organ donation process and minimize the challenges. The purpose of this study was to investigate Saudi pediatric intensivists’ comfort and importance levels of organ donation competencies. Methods We conducted a cross-sectional survey whose sampling frame included 100 pediatric intensivists. The pediatrician intensivists were identified through an updated list provided by the Saudi Critical Care Society. We assessed 14 competencies categorized into four domains: the general donation, donation after brain death (DBD), neurological determination of death, and medicolegal, religious, and ethical domains. Then we investigated the association between these competencies and physicians’ characteristics. Results With a response rate of 76%, we found that 40–60% of the surveyed pediatric intensivists rated their comfort in 6 out of 14 competencies as high or very high. There was a statistically significant gap in the intensivists’ rating of 10 competencies (i.e., high importance but low comfort levels). Ordinal regression showed that comfort levels with the general donation, neurological determination of death, and medicolegal, religious, and ethical domains were higher in intensivists who were frequently involved with DBD than those who had never been exposed. Conclusions Pediatric intensivists expressed low comfort levels to organ donation competencies that are essential for maximizing donation rates. Adapting mandatory comprehensive donation education programs and dedicated physician specialists may be beneficial in critical care units aiming to increase donation rates.

Background As increasing the number of organ donations presents a global challenge, and Saudi Arabia is no different, Intensivists can play a major role in the process. The purpose of this study was to investigate Saudi pediatric intensivists’ perception of their comfort and the importance of organ donation competencies. Methods We conducted a cross-sectional survey whose sampling frame included 100 pediatric intensivists. We assessed 14 competencies categorized into four domains: the general donation, donation after brain death (DBD), neurological determination of death, and medicolegal, religious, and ethical domains. Then we investigated the association between these competencies and physicians’ characteristics. Results With a response rate of 76%, we found that 40–60% of the surveyed pediatric intensivists rated their comfort in 6 out of 14 competencies as high or very high. There was a statistically significant gap in the intensivists’ perception of 10 competencies (i.e., high importance but low comfort levels). Ordinal regression showed that comfort levels with the general donation, neurological determination of death, and medicolegal, religious, and ethical domains were higher in intensivists who were frequently involved with DBD than those who had never been exposed. Conclusions Pediatric intensivists expressed low comfort levels with organ donation competencies. The pediatric intensive care community should invest in educational opportunities in the country to boost the low levels of organ donation.

Road traffic injuries (RTIs) are the second leading cause of death in Saudi Arabia. Their economic burden is significant but poorly quantified, as limited literature exists locally. We aim to estimate the impact of RTIs on healthcare costs.We included all patients from the hospital's trauma registry for the year 2017 (n = 381). Due to the availability of data, the analysis focused only on direct medical costs incurred during the hospitalization period. We computed the components of hospitalization costs and evaluated the association between patient and RTI characteristics and total hospitalization costs (the average and median) using quantile and log-linear regression techniques respectively.Patients were relatively young with an average age of 31 years (SD ± 14.6). Overall, patients treated for RTIs cost the hospital around 77,657 Saudi Riyal (SAR) on average. Pedestrian injuries incurred the highest costs. Motor vehicle injuries accounted for the highest procedure-related costs (SAR 19,537). The quantile regressions results suggest that Glasgow coma scale (GCS), admission to intensive care unit (ICU), and hospital length of stay were significantly associated with an increase in hospitalization cost. Hospital home disposition was however, associated with a decrease in cost. One additional day of stay in the hospital increases total hospitalization cost by SAR 3,508. Additionally, the log-linear showed injury severity score (ISS 16) was associated with a 20% decrease in the geometric mean of the hospitalization costs (p 0.001).This study underlines the economic burden of RTIs in addition to their impact on population health. The findings may be used to inform policymakers, researchers, and the public about the increasing burden of traffic crashes in the Kingdom. Public health interventions are warranted to reduce the severity and frequency of RTIs in order to improve traffic safety and reduce associated healthcare costs.

Minimizing the gap and ensuring agreement between patients’ perceptions and expectations is an indication of a better quality of hospital services. This study aimed to examine the agreement between patients’ perceptions and expectations of the quality of hospital services. A cross-sectional design was adopted, and quantitative methods were employed for data collection. The SERVAQUAL tool was used. The sample size was 415 participants. This study was conducted in Jordanian teaching hospitals. The study population was patients who used outpatient clinics in these hospitals. The study found that there is very low agreement between patients’ expectation and their perceptions. Overall, the perceived service quality was significantly lower than the expected service quality across all of the dimensions used to measure the service quality gap (reliability, responsiveness, assurance, empathy, and tangibles). The results suggest regional variation, where patients who sought care at hospitals in Amman have a four-fold higher perception of the quality of services than patients who visited Irbid hospitals. Also, patients who are more highly educated (Diploma, Bachelor, or Higher Studies) have a higher perception than patients who have less than secondary education. Age and gender were found to have no significant association with patients’ perceptions. The findings of this study suggest that there is a gap between patients’ perceptions and expectations. Thus, there is a need to close this gap by improving patient satisfaction with the quality of services.

e24115 Background: The social impact of cancer on patients and their family is well known. Yet, unlike with physical and financial toxicities, no validated tools are available to measure this impact. This study aimed at developing, validating, and implementing a novel social toxicity assessment tool for patients with cancer diagnosis (STAT-C). Methods: Questions were generated through multiple steps including focus groups of patients, their families, and oncology care professionals. Content validity, internal consistency, face validity and factor analysis were conducted. The questionnaire (in Arabic language) was administered to 150 patients with cancer served at King Abdulaziz Medical City, Riyadh, Saudi, Arabia. Results: STAT-C contains 14 items covering three domains: Social Relations domain (eight questions) related to relationship with parents, spouse, children, siblings, friends, members of congregation, and caregiver; Social Activities domain (two questions) measures participation in social events and leisure; and Economic Impact domain (four questions) related to standard of living, finances, and loss of job. The total possible score for each patient for the 14 items in the tool varied between -28 and +28 (Range = 56). Dividing the range by three levels of a socioeconomic toxicity yielded the length of each level, which effectively defined the categories as- Severe social toxicity (SST score: -28 to -9.3), mild social toxicity (MST: -9.2 to 9.5) and no social toxicity (NST: 9.6 to 28). Conclusions: Our study revealed that STAT-C is a valid and reliable tool in assessing the social toxicity of cancer in Arabic-speaking patients. Validating the tool in an English-speaking population is planned. The tool should enable oncology professionals to deliver better patient-centered care as a component of a holistic approach.

e19361 Background: This study computed and analyzed aggregate and sub-aggregate healthcare costs of lung cancer care by demographic profiles, resource utilization, clinical conditions, and target therapy. Methods: This is a retrospective chart-review and descriptive analysis of resource use and direct medical cost for lung cancer care had at the Oncology Department, King Abdulaziz Medical City for the period 2016-2018. The cost difference between patients receiving targeted therapy (TT) and those with wild-type tumors and the incremental cost-effectiveness ratio (ICER) was performed. The relationship between aggregate cost and demographic profiles, resource utilization, clinical conditions, and treatment therapies using multivariate regression technique was conducted. Results: A total of 35 patients of lung cancer patients with non-small cell lung cancer were analyzed, of which, 34% received targeted therapy; the median age was 62 years (29-84), 43% were ≥ 65 years, 20% were alive; 74% were in stage IV, 69% had visited ED more than twice, and 69% were admitted for non-ICU-related issues. The mean aggregate cost for all patients was USD 197,300 and it was USD 176,000 for TT patients compared with USD 210,600 for non-TT patients. The mean cost for targeted patients was higher for medication components, which accounts for 87.8% of all the costs. On average, the targeted group had USD 34,600 less cost compared with wild type. At least in terms of non-ICU admissions, both groups had on average two admissions. Thus, in terms of ICER, the targeted therapy dominates as it shows lower average aggregate cost for a given level of effectiveness. While longevity (survival) was associated with a higher cost, having stage IV was associated with lower cost for the targeted group compared with wild-type. Generally, being female, > 65 years of age, non-Saudi, and insurance eligibility were associated with lower costs. Conclusions: TT patients had a lower aggregate average cost in spite of expensive medications treatment. This lower aggregate cost presents an added value to the known advantages of patient survival and quality of life.

Breast cancer is classified as the most frequently diagnosed cancer site among women in Saudi Arabia [1-3], with its incidence continuing to increase rapidly during recent decades [2,4], and it can occur in women at an early age [2,3,5-7].

Background Cancelation of same-day surgery is a common global problem, wasting valuable hospitals’ operating room (OR) times and imposing significant economic costs. There is limited evidence to support the association between frequency of same-day surgery cancelation and patient demographics, time-related variables, healthcare provider reasons for cancelation, and clinical procedures in Saudi Arabia. The aim of this study was to explore this relationship, providing an understanding of the local context. Methods A retrospective cross-sectional study that retrieved medical records to examine the association between the frequency of same-day surgery cancelation and covariates including patient demographics, time-related variables, healthcare provider reason for cancelation, and clinical procedures. The data covered from January 2014 to December 2014 at King Fahad National Guard Hospital in Riyadh. We considered 440 patients that met the inclusion criteria for final analysis. The cancelation was regarded less frequent if a patient canceled once in the12 months and more frequent if a patient canceled two times or more in the same period. We used descriptive statistics to summarize data and employed a probit regression to estimate the association of frequency of same-day surgery cancelation and covariates via maximum likelihood method. King Abdullah International Medical Research Center granted the institutional approval. Results Our study suggests that while reasons of unavailability of OR time were associated with less frequent same-day surgery cancelation, scheduling issues were linked to more frequent cancelations, compared with reasons for patients being unwell on the day of surgery. Waiting time of more than six hours and morning sessions were associated with less frequent cancelations compared to shorter waiting time and afternoon sessions. Compared to general procedures, specialized clinical procedures were associated with cancelations that are more frequent. Further, female patients were more likely to have more cancelations. Finally, being married was associated with the less frequent cancelation of same-day surgery. Conclusion Our findings provide evidence of determinants of the frequency of same-day surgery cancelations. This study draws several important implications for hospitals, especially on optimal utilization of resources and minimization of same-day surgery cancellations. The study also offers several recommendations that we believe will spur future research.

Background The risk of getting cancer before full life expectancy and mortalities per year are on the rise in Saudi Arabia. Yet, evidence of economic burden of cancer in the country remains largely unknown. In order to provide evidence, we attempted to estimate the economic burden in terms of indirect cost associated with premature cancer deaths among the active or potentially economically active population aged 15–60 years in Saudi Arabia. Method Within the framework of the World Health Organization guide of identifying the economic consequences of disease and injury, our method employs cost-of-illness approach. This approach is based on a macroeconomic model that estimates the indirect cost of cancer in terms of total non-health gross domestic product resource loss associated with a disease. We used epidemiological, health system, and macroeconomic data for our estimation. We discounted the net loss at 3% and computed an extension of the loss with a finite and stable upper limit proxied by non-health gross domestic product per capita. We carried out separate analyses for male and female. We conducted sensitivity analyses to account for uncertainties of epidemiological and economic factors on the robustness of the estimated economic burden. We varied the proportion of total cancer deaths, discount rate, and value of health expenditure per capita by ±20%. We further determined which of these factors or parameters had the greatest uncertainty or variation on the net present value total non-health gross domestic product resource loss per Capita. Results Our results indicate the indirect cost associated with cancer deaths among Saudi population aged 15–60 years to be Int$ 2.57 billion of which Int$ 1.46 billion (57%) was accounted for by females. The total indirect loss of cancer deaths increased by 8% to Int$ 2.77 billion when the loss is allowed to grow with a finite and stable upper limit proxied by non-health gross domestic product per capita over the discounted years of life lost per a death among female and male respectively. Much of the uncertainty in the determination of the value of the loss was accounted for by the proportion of total cancer deaths and discount rate, while health expenditure per capita was responsible for the least variability. Conclusion Our findings reveal evidence of indirect cost associated with cancer premature deaths in Saudi Arabia. In order to develop cancer control actions, the results of this study can inform health system policymakers not only of the extent of the enormous economic burden but also drawing attention to epidemiological and economic factors that explain the variability of the burden.

Background: The recent outbreak of bubonic plague in Madagascar reminds us of the continuing public health challenges posed by such deadly diseases in various parts of the world years after their eradication. This study examines the role of Twitter in public health disease surveillance with special focus on how Twitter intensity, time, and location issues explain Twitter plague message delay. Method: We retrospectively analyzed the Twitter feeds of the 2014 bubonic plague outbreak in Madagascar. The analyses are based on the plague-related data available in the public domain between November 19th and 27th 2014. The data were compiled in March 2015. We calculated the time differential between the tweets and retweets, and analyzed various characteristics of the Tweets including Twitter intensity of the users. Results: A total of 6873 Twitter users were included in the study, of which 52% tweeted plague-related information during the morning hours (before mid-day), and 87% of the tweets came from the west of the epicenter of the plague. More importantly, while session of tweet lease and relative location had effect on message lapse, absolute location did not. Additionally, we found no evidence of differential effect of location on message lapse based on relative location i.e. tweets from west or east nor number of following. However, there is evidence that more intense Twitter use appears to have significant effect on message lapse such that as the number of tweets became more intense, time differential between the tweets and retweets increased while higher number of retweets diminished message lapse. Conclusion: This study affirms that Twitter can play an important role in ongoing disease surveillance and the timely dissemination of information during public health emergencies independent of the time and space restrictions. Further ways should be explored to embed social media channels in routine public health practice. Keywords: Twitter, Social media, Bubonic plague, Madagascar, Outbreak, Surveillance, Public health

Background As primary health care (PHC) centers in Saudi Arabia provide standardized preventive and curative oral health care (OHC) services, challenges remain. In addition, evidence of determinants of OHC seeking behavior is unknown. The aim of this study was to identify common challenges faced by patients seeking OHC in PHC centers and assess determinants of demand for OHC in Riyadh. Methods After institutional approval and piloting, 320 adult patients were sampled at two large PHC centers in October 2015. Using a modified version of General Practice Assessment (GAPQ) and New York State Department of Health (NYSDOH) Questionnaires, information about cumulative number of visits to a dentist, patient profiles, provider characteristics, and challenges were collected. We used descriptive statistics to summarize data and employed ordinal regression for analyzing extent of effects of challenges and determinants of demand for OHC. Results Oral health condition was reported to be good in 31 % of the patients, very good in 25 % of the patients, and fair in 20 % of the patients. More than half (53 %) of patients visited a dentist in the past 12 months once, 20 % twice, and 25 % at least three times. High cost of private clinic and unavailability of dentists were reported as the most common difficulties in seeing a dentist. Patients who were very satisfied with dental care and treatment plan, those with less than excellent oral health conditions and male patients had less number of cumulative visits to a dentist compared with patients with less satisfaction, patients with perceived excellent oral health, and female patients respectively. Conclusions Our findings provide a strong evidence of challenges faced by patients and determinants of demand for OHC seeking behavior. The findings can inform policy maker not only in patient satisfaction of OHC, but also implications on facilities and health care systems. We conclude with recommendations for future research, especially on oral health preventive measures in PHC centers that correct inherent dental problems and other underlying challenges.