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Family physicians health‐related absenteeism at the Al‐Wazarat Healthcare Center

Background: In general, physicians and family physicians more specifically tend to treat themselves in an informal matter. The evidence suggests that family physicians have a tendency not to consult other physicians while they are sick and tend to self‐treat. Health‐related absenteeism among family physicians in primary care settings is an issue that needs to be addressed. Aim: The aim of this study is to identify the prevalence of health‐related absenteeism among family physicians in Al‐Wazarat Health Center and to investigate the medical causes associated with sickness absence. Methods: The study used cross‐sectional design to investigate the prevalence of health‐related absenteeism among family physicians in a primary care setting. Results: The study included 108 physicians from the Al‐Wazarat Healthcare Center in Riyadh, KSA. On average, the physicians were absent for 2 days over the last year with 53.3% (64/108) have no health‐related absence days. The most common recorded reasons for work absence are the severity of illness 75.0% (81/108) and workload 63.0% (68/108). Influenza was the most common health condition that causes absenteeism 60.2% (65/108). The attitude toward working while ill scored 2.3 ± 2.5, being responsible for affecting the patients if working while ill 8.0 ± 2.8, physicians with chronic diseases should stay away from work 3.7 ± 3.7, and the quality of healthcare service could be affected by the physician’s illness 7.5 ± 2.5. Conclusions: Further investigations are needed for more understanding of the physicians’ tendencies and casual approach toward working with illness. Such understanding will help to formulate better guidelines for medical practices.

Introduction physicians rejected the idea of attending work while ill. [9] The mean score for the question related to physicians' responsibility about infecting their patients while ill was 7.4 out of 10. The study did not find differences in the attitude between "older" >45 years and "younger" <45 years toward health-related absence. [9] Sickness absence and "working through" illness: a comparison of two professional groups is a study published in 1997. [7] This study reported casual attitude of physicians when they are ill toward having an absence day. The study reported that 88% of the physicians come to work or try to continue working. [7] The study concluded that the reasons behind such attitude are the sense of the importance of their job and the desire to not put their colleagues under further work pressure. [7] A 1994 report by the national health service in the United Kingdom reported that among healthcare workers, physicians are the least absent due to health related problems than any other job. [10] The report showed that the percentage of doctors and general physicians admitted in hospitals because of sickness was 13.5%. [10] However, most of them either are self-treated or asked fellow physicians informally. [10] A review study by Baldwin reported young doctors' attitudes when they are sick to contact with their friends informally or self-prescribed medication. The majority refused to do a full investigation in appropriated doctor setting. Baldwin reported that such behavior does not convey with the guidelines of preventive medicine. [11] Furthermore, the review showed that approximately 52% of the resident and young physicians ignore their sickness and continue to work. [11] A study conducted in Finland among physicians reported that health status of female doctors has been better than other female health staff. The female doctors are the highest rate of taking a rest-off day compared with male doctors. The study reported that health status of male doctors was the same as other male health staff. However, the study showed that male and female doctors had the lowest rates in taking a rest-off day compared with other health staff. [12] Also, the study reported that male doctors are the highest rate of suffering from a chronic disease compared with other health staff. Moreover, the study showed that the male and female doctors had the lowest rate of seeing other health specialty providers and they process their recovery by taking self-prescribed medications. [12] Several studies concluded that physicians, in general, and family physicians, in particular, tend to self-treat in an informal manner. Additionally, a study showed that upper respiratory tract infection is the most cause of sickness among young doctors. [13] This study will assess the physician's attitude toward health-related absenteeism. This is the first study as far as our research is concerned that tried to investigate the matter of health-related absenteeism in physicians in Saudi Arabia.

Study Area
Cross-sectional study was conducted at the Al-Wazarat Health Centre (WHC). The center is one of 18 primary healthcare centers operated by Prince Sultan Military Medical City (PSMMC) in the Saudi, capital city of Riyadh. Around, 124 family physicians are registered on the center's working rota. All family physicians working at WHC that agreed to fill the questionnaire are included. Non-family physicians and other healthcare workers are excluded. We conducted a convenient survey of all the included family physicians.

The research tool
The questionnaire is self-administrated. The questions in the questionnaire were adopted from the literature, especially the study conducted by Khalaila. [9] The questionnaire also accounted for certain areas in the Saudi community, such as absenteeism related to religious occasions, Ramadan, and social occasions and obligations. The questionnaire was validated using two stages. The first stage used a face validation by two consultants and a biostatistician.
The second phase used statistical reliability and validity tests. The questionnaire was distributed to 18 family physicians from a different primary healthcare center operated by the military. The physicians were asked to re-do the questionnaire after 2 weeks. The reliability was measured using the inner consistency of the questionnaire using Cronbach's Alpha with the minimum level accepted is 0.7. [14] The test resulted in an overall Cronbach's Alpha = 0.84, which indicates satisfactory level of inner consistency. The second test called intraclass correlation was tested using kappa coefficient using SPSS ® 22 software package. [15] The agreement between the first and second time in filling the questionnaire yielded kappa coefficients between 0.61 and 1.00. All the coefficients were statistically significant indicating agreement between the test and retest phases.
The data collection phase started on 2017 March 03 and finished by 2017 June 01. The author distributed the questionnaire to 112 family physicians to ensure the minimum sample size is achieved. This accounts for approximately 96.4% response rate.

Statistical Analysis
The statistical analysis in this study used descriptive statistics to answer the questions related to the study objectives. Tables of frequencies and percentages are produced with graphical representation. The analysis was conducted using SPSS ® 22 software (IBM Corporation, IBM SPSS, Chicago, US).

Results
In Table 1, the sample is described. The final sample size consisted of 108 completed questionnaires out of the 112 distributed.
This accounts for 96.4% response rate. The average age of the physicians participated was 30.7 ± 6.9 years. The majority of the respondents were male physicians 57.4% (62/108). The share of married physicians was slightly higher than the unmarried physicians 53.7% (58/108). Most of the participants are national Saudis 88.0% (91/108). The residents formed the biggest portion of the sample 75.0% (81/108). The prevalence of chronic diseases was 10.2% (11/108).

Attitudes Toward Physicians' Work Absenteeism
The answers to the questions of the health-related absenteeism questionnaire are presented in Table 2. The mean score for the question about the belief that physicians should come to work while ill was 2.3 ± 2.5 on a scale from 1 (not at all) to 10 (definitely believe so). On the other hand, the mean score for the question as to whether physicians may infect their patients was 8.0 ± 2.8. The mean result for the physicians' believe that physicians with chronic diseases should stay away from work was 3.7 ± 3.7. The attitude in the question about the quality of healthcare while ill shows different direction than the previous question with an average was 7.8 ± 2.5. The severity of illness was the most cited factor that affects the decision as to whether to come to work or not 75.0% (81/108), in the second rank was workload 63.0% (68/108), followed by lack of available physicians 38.0 (41/108) and workload (N = 83, 77.6%). Working while having acute illness was the answer observed from 57.4% (62/108) of the answers.
When asked their opinion about the most common cause for not attending work due to health-related factor, the physicians' answers ranked influenza as the most common factor 60.2% (65/108). The list of the causes, frequencies, and percentages is presented in Table 3.
The average number of days the physicians reported for not attending work due to health-related reasons in the last years  was 2 days. More than half of the physicians reported perfect attendance 59.3% (64/108). Figure 1 shows the distribution of the number of days for absenteeism due to health-related reasons.

Discussion
This cross-sectional study aimed at the present study was to estimate the prevalence of health-related absenteeism in a primary care setting in Riyadh, KSA. Despite the evidence in the literature about the casual attitude of physicians toward illness and working, this study shows contrasting results. The results of our study indicate a negative attitude toward work with illness in the sample of the family physicians questioned. The average of 2.7 reflects a tendency to reject the notion of working while being ill. Second, the average of 8.0 for the statement about the physician's responsibility in affecting the patients while being ill reflects a strong opinion on the matter. These results conform to the results obtained by Khalaila in the Negev study. [9] Another interesting result is that 57.4% of the physicians stated that they attend work while having an acute illness. This result is not surprising as the literature provides considerable evidence that physicians, especially family physicians, tend to work while being ill. [3,12,16] Our result percentage is comparable with studies in the literature [3,16] but slightly higher than Khalaila's study. [9] Considering Influenza and upper respiratory as the main health-related causes of absence is consistent with the other study findings. [9,17] Infectious diseases can potentially infect some of the patients as well as fellow medical staff. The physicians recognize this issue; however, as pointed out in one study, the decision of absenting from work can be very complex. [6] Even with chronic or noninfectious diseases, the repercussions of working without the necessary medical supervision cannot be without risk. The self-assessment and treatment without proper medical monitoring can lead to delay in diagnosis and affect the physician's health and performance. [6,18,19] This study tried to assess the prevalence and health-related factors associated with absenteeism among family physicians. Despite the cross-sectional nature of the study, it is the first study as far as our search is concerned to tackle this issue in Saudi Arabia.
The importance of this study is shedding light on an overlooked matter in health management.

Conclusions
Family physicians tend to come to work while being ill. While the severity of illness can restrict this matter, it is noted that even with acute illness some physicians keep attending work. The positive aspects of keeping the health service running smoothly reduce the burnout and pressure on colleagues and promote dedication. However, many potential negative aspects are to be investigated: the lack of adherence to preventive medicine practice and potential risk to patients and staff.

Recommendations
1. Further investigations in this area as there is lack of studies that discuss the physicians' behavior and attitude toward working with illness.
More investigations and discussions to formulate better guidelines in this area of behavioral medicine.
Further discussion with the physicians to raise awareness about the potential risks accompanying these tendencies.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.