Incidence of Surgical Site Infection Despite Preoperative Cefazolin Administration in Total Knee Arthroplasty Patients: A Tertiary Hospital Experience.

INTRODUCTION: Surgical site infection (SSI) is an infection that occurs after surgery on the incision site. Cefazolin is an old-generation antibiotic that decreases the risk of SSI. This study aimed to determine the relationship between the incidence of SSI, cefazolin administration, and the factors contributing to the relationship between them. METHODS: This is a retrospective study that used a data collection sheet to collect variables from the medical records of patients who underwent total knee arthroplasty (TKA) between 2016 and 2020. We looked mainly for the type of antibiotics given preoperatively, the number of doses given, discontinuation of antibiotics postoperatively, length of hospital stay, intensive care unit (ICU) admission, and SSI occurrence.  Results: A total of 195 patients were included. The majority (87.8%) were given two grams of cefazolin. Patients who have taken one gram of cefazolin had a slightly higher hospital stay than those who took two grams. However, all the patients did not develop an SSI. CONCLUSION: There was no incidence of SSI despite preoperative cefazolin administration in TKA patients. Patients who received higher doses of cefazolin had a shorter length of hospital stay.

Prevalence of Polypharmacy and Factors Associated with it Among Saudi Older Adults - Results from the Saudi National Survey for Elderly Health (SNSEH).

Background and Objectives: The percentage of Saudi older adults (SOA) is increasing over time. With advanced age, the prevalence of chronic diseases and multiple disabilities are increasing. This leads to increase utilization of multiple medications. The objectives of this study were to describe medication utilization, determine the prevalence of polypharmacy (PP) and factors associated with it among SOA. Methods: This cross-sectional study was conducted among community-dwelling SOA aged ≥ 60 years old using the Saudi National Survey for Elderly Health (SNSEH). The survey was conducted between 2006 and 2007 by the Ministry of Health on a nationally representative sample of SOA. The data included demographics, socioeconomic and health information such as diseases and medications. Polypharmacy was defined as the concurrent use of medications from ≥ 5 therapeutic classes. A modified Poisson multivariable regression was used to study factors associated with PP controlling for confounders. All analyses were done using STATA 14. Results: The study included 2,946 SOA; 50.4% were males, 60.9% were 60-70 years old, and 69.6% were illiterate. The most common medications used among SOA were: Paracetamol (67%), joint pain medications and NSAIDs (50% each), anti-diabetic and multivitamins and minerals (47% each). PP was identified in (51.5%) of participants. The most medication associated with PP were: Paracetamol (79.9%), multivitamins and minerals (71.6%), steroid and DMARDs (70.1%), NSAIDs (66.4%), anti-diabetic and anti-hypertensive (61.3%). Higher risk of PP was associated with diabetes (RR: 1.863; 95% CI: 1.686-2.059), hypertension (RR: 1.829; 95% CI: 1.624-2.060), having pain (RR: 2.282; 95% CI: 1.918-2.713), urinary incontinence (RR: 1.389; 95% CI: 1.238-1.560; ref: no urinary incontinence) or suggestive depression (RR: 1.379; 95% CI: 1.259-1.512). Similarly, compared to low income (<2500 SAR), higher incomes were more likely to have PP. On the other hand, compared to the central region, southern and northern regions were less likely to have PP (RR = 0.741; 95% CI: 0.652-0.843 and RR: 0.736; 95% CI: 0.596-0.908, respectively). Severe cognitive impairment was associated with a lower risk of PP (RR: 0.708; 95% CI: 0.501-1.000). Conclusion: The prevalence of PP among a nationally representative SOA was very high, i.e., 51.5%. Higher risk of PP was associated with many factors such as region, income, diabetes, hypertension, musculoskeletal pain, urinary incontinence, and depression. PP leads to many negative implications such as drug interactions, combined side effects, hospitalization, and death. Therefore, raising the knowledge of health care providers on the consequences of PP and providing medication therapy management services may help decrease the negative consequences of PP and improve therapy outcomes.

Community-Based Seroprevelance of SARS-CoV-2 in Saudi Arabia.

Introduction  The new coronavirus disease 2019 (COVID-19) is a major global concern. Due to the number of asymptomatic cases that go untested, the actual proportion of those who have been infected is likely to be higher than the reported prevalence. Thus, investigating the exact proportion of those who developed antibodies against the virus through serological surveys is crucial to identify the immune status of the population and direct public health decisions accordingly. Objectives The aim of this study is to estimate the seroprevalence of SARS-CoV-2 in the community and to describe the epidemiological characteristics of the discovered cases. Methods Between July and October 2020, a cross-sectional sero-survey was conducted including a total of 15,873 serum samples collected from seven regions within the kingdom. Using a multistage convenient sampling, people were invited to participate in an interviewer-administrated questionnaire. Afterward, blood samples were collected and seroprevalence was determined using the SARS-CoV-2 virus IgG/IgM antibody detection kits (ELISA). A p-value of <0.05 and 95% CI were used to report the significance. Results The overall seroprevalence of SARS-CoV-2 in the sample was 17.0%, and Makkah region constituted the highest number of reactive cases (33.3%). There was a significant association between all comorbidities and having symptoms except for diabetes. In addition, age, education, nationality, and region were all significant predeterminants of sero-result. Also, contact with a confirmed or suspected case increased the risk of being seropositive by nearly 1.5 times. Conclusion This study estimated the national seroprevalence of SARS-CoV-2 in Saudi Arabia to be 17%. At the time of this study, most of the population did not have the SARS-CoV-2 specific antibodies. This suggests that the population is still below the threshold of herd immunity and emphasizes the importance of mass vaccination programs and abiding by recommended prevention precautions.

The Characteristics of Clinical Studies Submitted to the Saudi Food and Drug Authority from 2009 until 2020.

BACKGROUND: Clinical trials are crucial in contemporary evidence-based medicine for discovering new treatments for diseases. Their registration in a registry increases the transparency in the dissemination of knowledge about clinical research. It is essential to understand the activity of clinical trials in a country, thus identifying research gaps. OBJECTIVE: This study, therefore, aims to describe the clinical trial activity since the inception of clinical trials' administration and national clinical trials' registry within the Kingdom of Saudi Arabia (KSA). METHOD: A descriptive study was conducted by reviewing all clinical studies that have been registered during 2009 and June 2020. The inclusion criterion was all phases of the clinical trials registered in the national registry during that period. Data analysis was done using descriptive statistics. RESULTS: Since 2009, 352 studies have been registered. However, a total of 333 studies with complete data was included in the analysis. A total of 80 sponsors funded the clinical studies in the KSA. The majority of the clinical studies are funded by multinational pharmaceutical companies. Oncology (13.81%) and diabetes (11.71%) were the most common therapeutic areas and constituted the largest proportion of the overall studies. 44% were phase 4 and 40% were phase 3 studies. CONCLUSION: With a population approaching 34 million, the number of clinical trials in the KSA is not sufficient. Since the inception of the clinical trial's administration and SCTR, the emphasis has been on phase 3 and phase 4 clinical studies. The most studied therapeutic areas were oncology and diabetes. Many clinical studies in the KSA were sponsored by multinational pharmaceutical companies.

Determining the prevalence of symptoms and risk of obstructive sleep apnoea among old Saudis.

OBJECTIVES: This study aimed to determine the prevalence of symptoms and risk of obstructive sleep apnoea (OSA) and to identify the risk factors associated with OSA among old Saudis. METHODS: In this population-based survey, we administered the Saudi National Survey for Elderly Health to old Saudis between 2006 and 2007. Symptoms of OSA and its associated risk factors were determined using the Berlin questionnaire. A multivariable logistic regression analysis was used to determine key factors associated with the risk of OSA. RESULTS: Out of 2946 participants, 1544 (52.4%) were at high risk of OSA, with women having a higher risk than men (60.8% vs. 44.2%, respectively; p-value <0.001). Obesity was higher among women than men (40.5% vs. 24.8%, respectively; p-value <0.001). Almost 56% of the participants reported snoring as a risk factor, but there was no statistical difference between women and men (57.3% vs. 53.5%, respectively; p-value = 0.317). The factors identified as independent predictors of a high risk of OSA were the female gender (OR 1.732, 95% CI [1.375-2.182]), living in rural areas (OR 1.384, 95% CI [1.094-1.750]), severe cognitive impairment (OR 2.709, 95% CI [1.350-5.436]), depression (OR: 1.432 95%CI [1.147-1.789]), and antidepressants usage (OR 2.959, 95% CI [1.402-6.244]). CONCLUSION: This study reported a 52.4% prevalence of a high risk of OSA. Women were more likely to be at high risk of OSA than men. In addition to the female gender, depression, antidepressant usage, severe cognitive impairment, and living in rural areas were main predictors of OSA.

The Utilization of Complementary and Alternative Medicine among Saudi Older Adults: A Population-Based Study.

BACKGROUND: Complementary and alternative medicine (CAM) is an integral part of patients' therapeutic experience worldwide. Among Saudi older adults, less is known about CAM utilization. OBJECTIVES: To determine the prevalence, patterns, and factors associated with CAM utilization among SOA. METHODS: In the Saudi National Survey for Elderly Health (SNSEH), subjects were asked about CAM use during the last twelve months before the interview. CAM use was defined as any use of herbal products, acupuncture, bloodletting, cauterization, medical massage, bones manual manipulation, honey, or religious rituals. Demographic characteristics included gender, age, marital status, region, educational level, and residence area. In addition, multiple comorbidities were included as possible factors that may be associated with CAM use. Multivariable logistic regression was used to explore factors associated with CAM utilization. All statistical analyses were done using STATA v.14. RESULTS: Out of 2946 respondents, 50.4% were males, the mean age was 70.3 ± 8.3 years, and 70% were illiterate. CAM use was prevalent (62.5%). The most common CAM types were herbal products (25.4%), acupuncture (21.2%), bloodletting (12%), honey (9.5%), cauterization (7.4%), medical massage and bones manual manipulation (4%), and traditional bone setting (2.1%). In the multivariable regression, age, gender, and marital status did not have an impact on the odds of using CAM. Subjects from rural areas were 2.92 times more likely to use CAM compared with subjects in urban areas (OR = 2.92; 95%CI: 2.28-3.75). Subjects with metabolic disorders (OR = 0.50; 95% CI: 0.42-0.60) or kidney disease were less likely to use CAM (OR = 0.30; 95%CI: 0.14-0.64). About pain, CAM is used more in neck pain (OR = 1.69; 95%CI: 1.30-2.21) and also used in back pain (OR = 1.22; 95%CI: 1.03-1.46). CONCLUSIONS: CAM use was very prevalent among SOA. Clinicians and pharmacists must ask about CAM use among older adults as many of CAM may interact with patients medications.

Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study.

BACKGROUND: The Global Burden of Disease Study (GBD) has historically produced estimates of causes of injury such as falls but not the resulting types of injuries that occur. The objective of this study was to estimate the global incidence, prevalence and years lived with disability (YLDs) due to facial fractures and to estimate the leading injurious causes of facial fracture. METHODS: We obtained results from GBD 2017. First, the study estimated the incidence from each injury cause (eg, falls), and then the proportion of each cause that would result in facial fracture being the most disabling injury. Incidence, prevalence and YLDs of facial fractures are then calculated across causes. RESULTS: Globally, in 2017, there were 7 538 663 (95% uncertainty interval 6 116 489 to 9 493 113) new cases, 1 819 732 (1 609 419 to 2 091 618) prevalent cases, and 117 402 (73 266 to 169 689) YLDs due to facial fractures. In terms of age-standardised incidence, prevalence and YLDs, the global rates were 98 (80 to 123) per 100 000, 23 (20 to 27) per 100 000, and 2 (1 to 2) per 100 000, respectively. Facial fractures were most concentrated in Central Europe. Falls were the predominant cause in most regions. CONCLUSIONS: Facial fractures are predominantly caused by falls and occur worldwide. Healthcare systems and public health agencies should investigate methods of all injury prevention. It is important for healthcare systems in every part of the world to ensure access to treatment resources.

The prevalence of benzodiazepines utilization and its association with falls among Saudi older adults; results from the Saudi national survey for elderly Health (SNSEH).

PURPOSE: First, to determine benzodiazepines prevalence (BDZs) among Saudi older adults (SOA); Second, to quantify the association between BDZs use and falls among SOA. Third, to determine falls effect on all-cause mortality among SOA. METHODS: This is a cross-sectional study that used the Saudi National Survey for Elderly Health; a nationally-representative, population-based survey. Participants were asked about BDZs use and falls history during the 12 months prior to the interview. Demographics, medications, comorbidities and housing conditions were used as covariates. Multiple imputation was used to impute missing data. Modified poisson multivariable regression was used to study the association between BDZs and falls. Cox- proportional hazard regression was used to determine falls effect on mortality over nine years period. RESULTS: Among 2946 SOA, BDZs prevalence was 4%. Around 13% reported falls. In the multivariable regression, relative risk (RR) of falls was 2 comparing BDZs users to non-users (95CI%: 1.02-3.99). Antidepressants (RR = 1.72; 95%CI: 1.10-2.74), laxatives (RR = 1.38; 95%CI: 1.11-1.7), low body mass index (RR = 1.94; 95%CI: 1.33-2.84), mild cognitive impairment (RR = 1.56; 95%CI: 1.21-2.03), high door steps (RR = 1.54; 95%CI: 1.23-1.93) and insufficient illumination (RR = 1.38; 95%CI: 1.11-1.71) increased falls risk. Lastly, the hazard ratio of falls on death was 1.48 (95%CI: 1.17, 1.89) over nine years. CONCLUSION: Despite the recommendation against BDZs use among older adults, still there were subjects who were prescribed these drugs. falls are common among SOA. Preventive strategies such medication therapy management, nutrition improvement, elderly-friendly housing structures can reduce the prevalence of falls and consequent increase in mortality among SOA.

Utilization of Colorectal Cancer Screening among Saudi Elderly Population: A Study from the Saudi National Survey for Elderly Health

Objective: The goal of this study was to measure colorectal cancer screening (CRCS) utilization in Saudi Arabia 's elderly population and to assess the factors associated with CRCS. Methods: The Saudi National Survey for Elderly Health was used to examine CRCS utilization. It is a nationally representative population-based cross-sectional survey that was conducted between 2006-2007. Utilization of CRCS was defined as any colonoscopy during the last five years or fecal occult blood test (FOBT) during the twelve months before the interview. Multivariable logistic regression was used to assess patients' demographics, co-morbidities, number of visits to primary health clinics, and hospital availability and accessibility impact on CRCS. Results: The prevalence of CRCS utilization among Saudi elderly population was 5.64%. The fecal occult blood test was done in 4.4% of subjects while scope use was performed in 0.55%. In addition, 0.69% of patients have gone through both FOBT and scope use. Having blood in stools (OR=2.80; 95%CI: 1.3-6.00), Self-drivers (OR= 2.52) private driver (OR=2.1; 95%CI: 1.15-3.7) having 4 or more visits to primary care centers 1.81 (95%CI: 1.14-2.86) were positively associated with CRCS utilization. On the other hand, being single was negatively associated with CRCS utilization. Conclusion: In this nationally representative sample CRCS prevalence was very low. According to our findings and in the context of the burden of colorectal cancer on the population, we recommend developing national evidence-based policies and programs that take in consideration easiness of transportation and the availability of primary care centers near to Saudi elderly population.

Measuring the health literacy level of Arabic speaking population in Saudi Arabia using translated health literacy instruments.

BACKGROUND: Health literacy is an essential predictor of health status, disease control and adherence to medications. OBJECTIVES: The study goals were to assess the health literacy level of the general population in Saudi Arabia using translated Gulf Arabic version of the short-version of the Test of Functional Health Literacy in Adults (S-TOFHLA) and Single Item Literacy Screener (SILS) tests and to measure the relationship between health literacy and education level. METHODS: The study was a cross-sectional with a convenience sample of 123 participants from the general population in Riyadh. Data were collected using the modified (Gulf) Arabic versions of both S-TOFHLA and SILS. Fisher's Exact test was used to measure the difference of the health literacy scores according to the education degrees and Cronbach's alpha was used to measure the internal consistency of the S-TOFHLA items. RESULTS: More than half (55.4%) of the participants were male, 50.4% had a middle school or less education level, and we found that 84.4% had adequate health literacy as measured by the S-TOFHLA, compared to 49.6% as measured by SILS. The Fisher's Exact test showed a significant difference (P<.05) in the S-TOFHLA and SILS scores according to education categories. CONCLUSIONS: The level of education has a significant positive association with S-TOFHLA and SILS results. The Gulf Arabic version of S-TOFHLA is a reliable test with a good internal consistency and a significant positive correlation between the two parts of S-TOFHLA. We recommend the use of S-TOFHLA or SILS at the first patient visit.

The health of Saudi older adults; results from the Saudi National Survey for Elderly Health (SNSEH) 2006-2015.

OBJECTIVES: To Describe the Saudi older adult (SOA) characteristics and Introduce the Saudi National Survey for Elderly Health (SNSEH). METHODS: The SNSEH, a population-based nationally-representative survey, was used. Subjects were included in 2006-2007, using random-cluster sampling utilizing probability proportional to size approach, and followed-up to determine their vital status until June 2015. In the analyses, survey weights were incorporated. Parametric, non-parametric and logistic regression were used. Cox-proportional hazard regression was used to determine gender effects on mortality. RESULTS: We included 2,946 SOA. The mean age was 70.1(SD = 0.3). Around, 70% were illiterate. Almost 50% had monthly income of 2500 (2007-Saudi-Riyals). The most reported diseases were hypertension, diabetes and joints pain. The most reported medications were over the counter, antidiabetics and antihypertensive. The nine-years age-adjusted death hazard was 42% higher in SOA males. CONCLUSION: This is an introductory paper for a series of papers that describe SOA health. These efforts will help in guiding the development of a national healthcare model for SOA, evidence-based health policies and public intervention programs that address SOA health-related issues.

Comparison of the application of treatment Panel III and American College of Cardiology/American heart Association guidelines for blood cholesterol treatment in Saudi Arabia.

BACKGROUND: One of the major risk factors for cardiovascular diseases is hyperlipidemia. The primary aim of this study was to estimate the proportion of individuals between 40-75 years old that would be eligible for statin therapy based on ACC/AHA guideline as compared to ATP-III guideline in a population of patients in Saudi Arabia. We also intended to extrapolate the results to the entire Saudi population, and estimate the cost implications of the ACC/AHA treatment guideline. METHODS: This study was a retrospective, observational study involving adult patients aged between 40-75 years old. The study was conducted at the primary health care clinics at King Abdul-Aziz Medical/Riyadh. The eligibility for statins use was assessed and compared for each patient based on both the recent 2013 ACC-AHA guideline and the 2002 ATP-III guideline. The cost implication of applying the ACC/AHA treatment guideline was estimated based on the average cost for 40 mg Atorvastatin in the Saudi Market. RESULTS: A total of 1005 patients were included in the study. Using the ATP-III guideline, there were 139 male (43.7%) and 279 female (40.6%) eligible to receive statin therapy. Based on the 2013 ACC/AHA guideline, treatment is recommended in 315 males (99.1%) and 564 females (82.1%). On the other hand, high-intensity statin was recommended in 302 male (95%) and 400 female (58.2%). Only 74 (10.5%) patients were prescribed high-intensity statin of the 702 eligible patients. Extrapolating the results to the entire Saudi population, 2.369 million additional patients would be eligible for statin therapy when applying the ACC/AHA guideline. Applying the new guideline would result in a cost increase of at least 4.318 billion SR per year. CONCLUSIONS: The eligibility for statin therapy was much higher when applying the ACC/AHA guideline as compared to ATP-III guideline. Applying the recent ACC/AHA dyslipidemia guideline increased the number of patients eligible for statin therapy to approximately two folds. This would be associated with a substantial increase in cost and possibly side effects. The concerns surrounding the ACC/AHA guideline should be addressed at the national level.

Measuring the health literacy level of Arabic speaking population in Saudi Arabia using translated health literacy instruments

Background: Health literacy is an essential predictor of health status, disease control and adherence to medications. Objectives: The study goals were to assess the health literacy level of the general population in Saudi Arabia using translated Gulf Arabic version of the short-version of the Test of Functional Health Literacy in Adults (S-TOFHLA) and Single Item Literacy Screener (SILS) tests and to measure the relationship between health literacy and education level. Methods: The study was a cross-sectional with a convenience sample of 123 participants from the general population in Riyadh. Data were collected using the modified (Gulf) Arabic versions of both S-TOFHLA and SILS. Fisher's Exact test was used to measure the difference of the health literacy scores according to the education degrees and Cronbach's alpha was used to measure the internal consistency of the S-TOFHLA items. Results: More than half (55.4%) of the participants were male, 50.4% had a middle school or less education level, and we found that 84.4% had adequate health literacy as measured by the S-TOFHLA, compared to 49.6% as measured by SILS. The Fisher's Exact test showed a significant difference (P<.05) in the S-TOFHLA and SILS scores according to education categories. Conclusions: The level of education has a significant positive association with S-TOFHLA and SILS results. The Gulf Arabic version of S-TOFHLA is a reliable test with a good internal consistency and a significant positive correlation between the two parts of S-TOFHLA. We recommend the use of S-TOFHLA or SILS at the first patient visit

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The Burden of Cardiovascular Diseases Among US States, 1990-2016.

Importance: Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes. Design, Setting, and Participants: Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017. Exposures: Residing in the United States. Main Outcomes and Measures: Cardiovascular disease disability-adjusted life-years (DALYs). Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors. Conclusions and Relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

Drug use patterns and demographic correlations of residents of Saudi therapeutic communities for addiction.

OBJECTIVES: This study describes the characteristics of residents in Saudi therapeutic communities (TCs), their patterns of drug use, and the correlations between these variables. METHODS: This retrospective study examined all Saudi TC residents admitted since the establishment of the first TC in 2000 until mid-2014. The TCs include three governmental and two non-governmental enterprises: two TCs in Dammam and one each in Riyadh, Jeddah, and Taif, with a total population of 2023 residents. RESULTS: All TC residents were adult males; 85.6% were Saudis, and almost all remaining residents were from the Gulf Cooperation Council countries. The mean age of residents was 33.9 years (±8.8 years), and their educational levels were mostly high school or lower; 25% were married, and 70.8% were jobless. The pattern of drug use indicated that 35.8% used opioids, 15% used hash, 11.9% used both hash and amphetamine, 11.1% used amphetamine, 7.9% used alcohol, and 10.9% used 3 or more drugs simultaneously. Amphetamine and hash dependencies were more prevalent among younger residents in comparison to opioids and alcohol, which were more common among older residents. Opioids were more used by the western region residents, while northern and southern regions residents preferred amphetamine. CONCLUSION: This study showed that the residents' drug use patterns are similar to those in other inpatient treatment services. However, opioid dependency is overrepresented. Furthermore, the type of drug used differs according to the residence region, which may warrant consideration when planning services for these regions.

Evaluation of the educational environment of the Saudi family medicine residency training program.

OBJECTIVES: The study was conducted to evaluate the educational environment (EE) in Family Medicine Training Programs. MATERIALS AND METHODS: A cross-sectional survey, The Postgraduate Hospital Educational Environment Measure (PHEEM), was distributed to all residents at the four training centers in the central region. Cronbach's alpha was used to test the reliability. The mean and standard deviation (SD) for each item, the overall score and the three domains were calculated. A multiple linear regression model was developed with PHEEM scores as an outcome. The Mann-Whitney-Wilcoxon test was used to compare each item based on the selected factors. RESULTS: The overall score was 67.1/160 (SD: 20.1). The PHEEM's domains scores: 24.2/56 (SD: 7.13) for perception of role autonomy; 25.3/60 (SD: 8.88), for perception of teaching; and 17/44 (SD: 5.6), for perception of social support. Training center and Level of training were the significant outcome predictors. Centre 1 (Joint Program) significantly had better scores than Centre 2. The instrument showed great reliability with a Cronbach's alpha of 0.92. CONCLUSIONS: There are many problems in the training program. Urgent actions are needed to improve the residents' learning experience particularly during rotations. Also, the curriculum should be restructured, and effective training methods introduced using the Best Evidence in Medical Education to meet the expectations and learning needs of family physicians.