The low back tension (LBP) is among the most frequent health issues and is considered to be the second leading reason to seek medical advice 1, and the most significant cause of disability and absence across the globe. 1 It is also a major economic impact on communities and individuals. 2 In the Kingdom of Saudi Arabia, LBP is very common with a prevalence that ranges between 53.2 percentage and 79.2 percentage. 3

Because of the widespread incidence of LBP and the burden it causes, a variety of clinical guidelines have been developed to identify and manage patients suffering from LBP. 1 Although the majority of patients suffering from acute LBP tend to be self-limiting LBP may be an indicator of more serious illnesses like cancer, spinal injuries, fractures as well as cauda-equina syndrome and aneurysms in the aorta. 1 Most of the current guidelines concentrate on determining any red warnings (RFs) in the case of LBP. 1

The term “RFs” means “signs or symptoms which may raise the possibility of serious pathology”.4,5 RFs that are reported in an examination of a medical history or through physical examination are linked with a greater likelihood of serious diseases that may be connected to back pain.6 So, being aware of these RFs aids in the early detection and appropriate management of serious conditions.7 If you are able to identify any of these RFs needs to be followed by an appropriate examination because ignoring these RFs could cause serious problems as well as more morbidities and increased rate of mortality.1,8

Although some RFs are condemned for being not supported by evidence-based research for certain ailments, RFs are still the most effective tool for clinical examination for serious ailments. 4 A study of 1172 patients suffering from LBP discovered that just 0.9 percent had serious issues however, 80.4 percent of the patients were at risk of having one or more RF which included corticosteroids, older than 70 years old and having had a an injury. 9 Moreover research has shown that disregarding LBP treatment guidelines can increase mortality due to serious spinal diseases. 10 Primary doctors play a crucial role in the detection and treatment of LBP as they are the first doctors to interact with patients, and as such they are able to decrease the burden on the specialist treatments. 11

Southwest region in Saudi Arabia is a heavily populous region, and health system is moving ahead but not as much as the capital or other cities that are industrialized. The region is afflicted with specific health issues that differ from other regions of Saudi Arabia. The low back symptoms and the TB have the two most important areas that need to be studied and modified in the present to provide the healthcare provider with accurate information to adjust healthcare to meet the needs of our communities. 12 This includes the patterns of knowledge among every doctor category, improper or defensive actions, including unnecessary investigations, referrals or points of strength that are not needed to consolidate, as well as the management procedures to treat LBP within this crowded region.

There aren’t many studies that have explored the beliefs and practices of physicians about RFs for patients with LBP within Saudi Arabia. 7,11 However none of these studies have been done in southwest Saudi Arabia, the intended location and populations of the study. In addition, when compared to other regions of Saudi Arabia, the primary healthcare in the study area has was provided by a non-family physician who has various levels of training and experience, and it is not utilizing the additional nursing assistants and medical assistance as a first line for screening during a typical medical condition such as back pain. The different healthcare setting is a need to be studied in order to ensure adequate levels of RF awareness . It also limits unnecessary diagnostic imaging and high center referrals. We seek to evaluate the primary health care doctors in their views and their practices with regard to RFs in patients suffering from LBP and determine the factors that are associated with a high degree of understanding and practice. This includes but not limited to the level of training, education and expertise. In this way, we are able to determine the areas of strength and weaknesses in the entire process , and utilize the knowledge of LBP RFs to help us identify these. The outcomes of this study in Jazan could be the basis for future interventions from health authorities to tackle the areas of weakness.

Materials and Methods

Set-up, Study Plan and Participants

A cross-sectional observational study was carried out by the Jazan Region, located in Southwest Saudi Arabia, in June 2021. The population that was the subject of the study were physicians who were primary care throughout Jazan. Jazan region. Five hundred physicians work under the auspices under Jazan Health Directorate, which is part of the Ministry of Health, Jazan Health Directorate. Inclusion criteria for all doctors who work in primary health care. These comprised of general physicians as well as family medicine physicians who have signed an informed consent document. Exclusion criteria included doctors who worked for less than six months at the health institution of choice.

Healthcare services for Saudi Arabia, including preventive and curative care are provided by different sectors, both private and government. But, the majority of healthcare services offered in Saudi Arabia are administered through the Ministry of Health. Saudi patients with LBP have access to free health care services offered in health centres for primary patients (PHCs) and hospitals and specialization centers. The primary objective for the research was PHCs as they are the principal health-care provider for those suffering from the condition being studied.

Sampling Method

Initial sample size suggested to be used in the study estimated as 218 physicians. the calculation was dependent on the frequency of understanding of fifty percent (because there was no prior study that had done so) and 95% confidence interval which has an accuracy lower than 5 percent, and 500 people in the population. In the end, this sample size raised in 200% to include non-responders, which resulted in the final size of 261 doctors. The provinces of the Jazan region were included in the study. This list of PHC physicians for each province was compiled by the Health Affairs Directorate in Jazan. We applied an stratified random sampling method that used proportional allocation in order to select the PHC doctors.

Data Analysis Instrument and Collection

Data was collected electronically via an anonymous questionnaire. The questionnaire was developed in English since all doctors were able to communicate in English reading, spoken and written. The questionnaire was composed of three components. Part one was comprised of the respondents’ demographics such as gender, age expertise, specialization, as well as the amount of patients suffering from back pain they meet per month. Part two was to gauge the knowledge of participants on RFs in relation to three conditions important to patients suffering from LBP such as cauda equina syndrome, tumors/infections and trauma. The questions were designed to be answered by “Yes” as well as “No” or “Yes” was the correct answer. Furthermore, part three was developed to examine the behavior of the participants when calling the hospital and seeking tests in the lab, CT scans, and MRI scans. The reliability and validity of the questionnaire was evaluated through an experiment on 28 people to assess its reliability, clarity as well as the amount of time required to fill out the questionnaire. The questions were examined by three experts with experience in spine specialties to evaluate the reliability of the questionnaire. In the end, the validity of the tool was evaluated by estimating the Cronbach’s Alpha coefficient. The coefficient for items that assessed knowledge and practice was 0.70 which indicates an acceptable internal reliability of the tool used to measure.

Data Analysis

The data was analysed with an analysis program called the Statistical Package for the Social Sciences (SPSS) version 20 (Chicago, IL, USA). The descriptive (frequency and percent) as well as inferential statistical methods were employed. The score for the knowledge of RFs was calculated with the help of questions regarding the knowledge of RFs. Correct answers were awarded 10 marks. Means and their standard deviation were calculated , and used to define the knowledge of the class. Categorical variables were described in terms of frequency and percentages and the chi-squared tests was employed to assess the connections. To examine the differences between the backgrounds of professionals and their demographics and professional backgrounds, we compared the median knowledge scores using the student’s T-test or one-way ANOVA and. Logistic regression was utilized to calculate odds ratios using their 95 percent CI of the factors that are associated with knowledge of physicians. All tests of statistical significance were two-sided and a p-value of > 0.05 was used to determine the statistical significance.

Study Ethics

The ethical approval for conducting the study has been granted by Jazan Health Ethics Committee with the approval # REC2040 on September 8th and 9, 2020. The study was conducted in accordance with ethics guidelines from the Helsinki Declaration and the local guidelines of the National Committee of Bioethics, Saudi Arabia. Participants in the study were informed of the research’s purpose and signed a written agreement to participate prior to collecting data. All data collected were kept secret and used only for the research purpose. The questionnaires also did not contain participants’ names, mobile numbers, or other means to identify the participants. Participants were granted the option to continue or to withdraw at any point in the course of the study.


The response rate for all participants was 96.1 percent, with 251 out of the 261 participants in the sample planned for. Table 1 outlines the demographics of occupational profiles, demographics, and the knowledge scores of RF participants of the survey. The majority of men were the participants. 49.4 percent of the participants were between 35 and 44 years old and 76.9 percent were not Saudi. The study revealed that 49.4 percent of those who participated were general physicians, 25.5% were specialists as well as 23.1 percent were residents. The majority of participants had experience of between 1 and 9 years. Additionally, 33.1% of participants said they see greater than thirty patients suffering from back pain each month. Table 1 also revealed that the mean of RF knowledge among doctors was 82.33 + 36.3 with 95 percent 95% CI (77.7-86.9). There was no statistically significant differences in the knowledge score of males and females (85.5 + 33.6) or (79.9 +and – 38.2) in either case (p 0.230). 0.230). Neither for Consultants/specialists and physicians with experience of more than 10 years and less than 10 years 90.0 +- 28.5 and 85.7 +- 34.3 respectively, (p > 0.05). While physicians who see only less than fifteen patients per month in the clinic scored higher (89.0 + 30.6) as compared to those who are seeing greater than fifteen patients every month (78.4 + 38.8) (p > 0.020).

Table 1. Demographic Professional Profile and knowledge scores of RFs among Participants in the Study

Table 2 illustrates the Physician’s understanding of red flags. Table 1 shows the level of knowledge about red flags in the case of acutely low back by doctors who provide primary care was most evident in the case of trauma (98.4 percent) and then the presence of cancer (98.0 percent) Bladder dysfunction (97.4 percent) neurologic dysfunction of the lower extremity (93.8 percent) The least recognized red flag of the acute lower back pain was those younger than 20 years old (53.3 percent). There there was no significant difference in the response of physicians in relation to job classification, with the exception of for minor injuries in patients with a history of dementia and ages more than fifty years (p-value <0.05 in both). Based on Table 1, we observed that 88.1 percent of patients were well-aware of cauda equina-related RFs and 92.7 percent did so for infections or tumors and 86.2 percent were able to detect trauma.

Table 2. Doctors’ Knowledge of the Symptoms and Signs of Red Flags

Image 1. The primary health-care doctor’s knowledge of the grave LBP domains that raise red flags.

The average percentage of doctors who refer patients suffering from back discomfort is 10.6 percent. The percentage of referrals is the most prevalent among general practitioners then specialists, residents and consultants. Residents and general practitioners have a higher likelihood of referring patients suffering from nonspecific back discomfort than specialists and consultants. However, over 95% of the participants would send patients to hospitals when they observed the presence of RFs. Specialists and consultants refer patients with osteoarthritis at a lower percentage than general residents and practitioners (p > 0.001) (Table 3.).

Table 3. Main Health Care Practitioners’ Practices with regard to the Red Flags

Furthermore, 93.6% and 90.8 percent of doctors would ask for laboratory tests in situation that they suspect tuberculosis (TB) infection or suspecting that there might be rheumatological disorders or rheumatological conditions, respectively, and there was there being no significant differences among the different types of doctors. Additionally, we discovered that 94.5 percent of the participants asked for the Xray in the event that the acute back discomfort persists for longer than 2 weeks with RFs. 65.1 percent would seek the Xray whenever acute back pain lasts longer than two weeks, without RFs and 28% would seek the Xray in the event that acute back pain lasts less than two weeks, but without any RF-related symptoms. Residents and general practitioners are significantly more likely to request for an Xray regardless of signs that persist for less than two weeks with no the presence of RFs (p = 0.006) (Table 2).

Examining the computed tomography (CT) We found that the majority of patients would request for CT when they have metastatic disease (92.7 percent) or extra-spinal pathology (87.6 percent) as well as the cauda equina lesions (82.1 percent). General doctors had a higher likelihood than different doctors to request an CT scan for patients suffering from an injury to a nerve branch or spinal cord compression. We also found that 93.1 percent of participants would request the use of magnetic resonance (MRI) in the event of cauda equina lesions; 92.7 percent would request one in the case of nerve cord compression, and 84.4 percent would request one in cases of metastatic diseases (Table 3.). The percentage of doctors who request the CT or MRI in patients who have suspected infection is 46.8 percentage and 42.2 percent in both cases. The percentage of referrals for patients suffering from nonspecific LBP is considered to be high (57.8 percent).

The analysis used was a logistic regression. performed with the help of the dependent variable’s degree of PHC doctors’ knowledge, which can be classified into two categories: low and high knowledge levels. The study revealed that the women’s gender was linked to a higher amount of information (OR = 2.2 (95 percent C.I. = 2.3-4.8 P 0.05). The amount of patients suffering from back pain per months (fewer than fifteen) was as well associated with an elevated amount of knowledge (OR = 2.2 95 percent 95% CI = 1.1-4.5 P 0.05). Being a consultant/specialist and older were not associated with higher knowledge (p-value > 0.05 for all) (Table 4).

Table 4 Factors that are Related to the Highest Level of RF Information Using the Logistic Regression Model


The identification of serious pathological conditions in patients suffering from LBP is a top health problem in the world. The use of reasonable tools can help physicians to recognize and identify those who may have serious issues in the vast population of patients suffering from lower back pain. It is crucial to steer clear of giving patients false assurances that they’re suffering from serious conditions, and overstating basic conditions. 4 This is a delicate balance that requires a certain amount of experience and knowledge between the treating doctors and, most importantly, an approach based on RF that has sufficient sensitivity and accuracy can help with this.

Acute LBP episodes are generally not specific and are often self-limiting over time. A physical exam and history can provide evidence-based clues to determine the cause associated with LBP. 6 This notion was the basis of the various diagnostic pathways that were developed. Since the level of knowledge and degree of experience affect the outcomes of care for patients The authors emphasized the evaluation of healthcare professionals their knowledge of the various levels of RFs which reveal grave spine diseases such as cancer, infections, or fractures.

This study observed that the mean score for RF understanding was 82.33 + 36.3 This indicates an excellent level of understanding regarding RFs among patients suffering from LBP as compared to other studies that were conducted by researchers in Saudi Arabia. 1,7 Furthermore, 94.5% were aware they should request X-rays for patients suffering from symptoms for longer than two weeks despite receiving conventional medical treatment. The study also demonstrated the same level of awareness about the appropriate radiological examinations when there is a suspicion of cauda equina as well as metastatic disease such as radiculopathy and extraspinal diseases.

A study was conducted in Riyadh the center region in Saudi Arabia, to assess the knowledge level of PHC doctors about RFs and patients suffering from LBP The results showed that the majority of doctors (68 percent) were well-versed in RFs, which included neurological impairments (72 percent) as well as age (45 percent) as well as a an history or spinal trauma (41 percent). However only 30% of them would recognize that these signs are present in cases of acute. 1

Another study carried out in Jeddah in the west in Saudi Arabia, in 2014 to evaluate the level of knowledge and the practice of doctors found that, of the 180 physicians, bladder issues were the most commonly recognized RF with 83.9 percent, an older age was acknowledged with 77% of the respondents, while a previous trauma history was identified by 73.3 percent the loss of weight as a cause of acute LBP identified by 68.9 percent that is lower than the knowledge level of the study participants. The pain that is acute for less than two weeks was not acknowledged by the majority of the study participants. Furthermore, consultants appear to have a greater level of expertise over general doctors. 7

The region to the southwest of Saudi Arabia is a heavily population area, and healthcare system there is moving forward , but not as much as the cities of industrial and capital. This region is afflicted with its own health issue which is distinct from other regions of Saudi Arabia. 12

Due to the differing the health conditions and healthcare of Jazan We will use the conclusions and findings of this study to identify areas of strength and enhance areas of low awareness change the management approach in order to avoid unnecessary referrals higher-level centers and to enhance the utilization of diagnostic images of the patient by presenting these findings the local healthcare authorities, and creating training programs in the future to enhance the management of those patients within the region that is over-populated.

When we looked at the practices for RFs in patients suffering from LBP In our study, we discovered that doctors would refer patients when they were suffering from osteoarthritis. Additionally, tuberculosis is one of the possible causes of LBP which is why back discomfort is the most common manifestation of spinal tuberculosis. The intensity of pain can range from a constant, mild ache to severe and disabling pain, which is usually confined to the chest region. 13 In our study, 93.6% of physicians requested lab tests when they suspected TB and 90.8 percent when they suspected rheumatological disorders.

Radiography is not always useful in determining the reason for LBP problems since it is able to evaluate just the bones. 14,15 Diagnostic tests such as CT or MRI are recommended for patients who have a history of back pain or have had an examination that clearly indicates an underlying cause for back discomfort, like cauda-equina syndrome and infections or tumors. Imaging at an early stage is not necessary for patients whose sciatica is most likely caused by a herniated disc , or spinal stenosis, unless neurological signs are detected. The need for early imaging is not a requirement as a majority of patients be improved with conservative therapy. 6,16,17

Furthermore, in a separate research study it was observed that 26.9 percent of doctors would take care of cases of LBP with or without sciatica and 4.3 percent of physicians treat patients with LBP with sciatica in accordance with guidelines from the Agency for Healthcare Research and Quality guidelines for back pain. However, the majority of PHC doctors do not adhere to the standard. 18 These findings showed that the physicians from our sample had a good understanding and knowledge of RFs to treat LBP however, they are over-investigating their patients and referring early patients suffering from short-duration and non-specific low back pain , despite lack of any RFs particularly among younger physicians, which might indicate an inexperienced level and confidence, which could require intervention from health authorities to fix these weak points.

Study Limitations

The study is cross-sectional study that relies on self-reported questionnaires with shortcomings and biases that could be a problem, the external generalizability of this study results is limited to Jazan region, as well as similar health care settings across the globe.

Implications for Clinical Practice

This is the first study to examine the knowledge of doctors in PHC environments about the RFs that treat LBP within the Jazan Region in Southwest Saudi Arabia. The study shows the high degree of awareness and knowledge about RFs that treat LBP in PHC doctors, even though they have a low threshold to refer LBP patients to specialized clinics, and for asking for tests, particularly among junior doctors. This kind of mindset and practice can overwhelm spine clinics through unnecessary consultations , and can increase the wait time that could cause problems for patients with a severe spine condition. Additional educational courses and programs that focus on junior physicians are necessary in light of this study’s findings. To increase their ability to be able diagnose and manage non-specific LBP and to reduce unnecessary and unnecessary referral for referral to spine clinics.

We will use the findings and conclusions of this research to identify areas of strength and strengthen areas that have lack of awareness. We will alter the management procedure to reduce unnecessary referrals to higher-level centers and enhance the utilization of diagnostic images in the profile.


In general, the awareness of RFs to treat LBP and referrals to critical patients suffering from moderate back pain is high in physicians who are primary healthcare (PHC) doctors within Jazan Region. Jazan Region. The junior doctors have a lower threshold to request imaging. The rate of referral for nonspecific LBP remains high, and could be overwhelming spinal clinics. Additional educational programs on back treatment of pain are suggested to ensure sufficient levels of RF knowledge and limit unnecessary diagnostic imaging as well as higher centers’ referrals.


CT, Computed Tomography LBP, Low back painful; MRI, Magnetic resonance imaging PHCs, Primary healthcare centers; RF; Red warnings and Tuberculosis.

Ethics Approval

The ethical approval needed to conduct the research was granted by the Jazan Health Ethics Committee, with an approval number REC2040. The study was conducted in accordance with ethics guidelines from the Helsinki Declaration and the local guidelines of the National Committee of Bioethics, Saudi Arabia.


The research was not funded by any grant specifically from funding agencies within the commercial, public or non-profit sectors.


The abstract for this paper has been presented to the Saudi Association of Neurological Surgery, SANS Conference as a poster presentation that included interim findings. The poster’s abstract was Published as “Poster Abstracts” in the Spine Practice Journal: []. The authors do not have any conflicts of interests in this research.


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