دليل الرعاية الوقائية السريرية السعودية

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وقابه
هينه الصحه العامه
PUBLIC HEALTH AUTHORITY
Saudi Clinical Preventive
Guideline
Third Edition
1444H - 2023 G
Riyadh - KSA

CONTENT
<table><tr><td>Topic</td><td>Page</td></tr><tr><td>Chapter- I: Guideline Methodology</td><td>1</td></tr><tr><td>1.1 - Introduction</td><td>2</td></tr><tr><td>1.2- improve public health status</td><td>3</td></tr><tr><td>1.3 - Updating Methodology</td><td>4</td></tr><tr><td>1.4 - Guideline Milestones</td><td>5</td></tr><tr><td>1.5 - Methodology for Guideline Appraisal</td><td>6</td></tr><tr><td>1.6-Adaptation Phase</td><td>7</td></tr><tr><td>1.6.1- the clinical questions for searching</td><td></td></tr><tr><td>1.6.2- Searching engine for guidelines</td><td>8</td></tr><tr><td>1.6.3 - Grade Definitions After July 2012, USPSTF assigns one of five letter grades (A, B, C, D, or I)</td><td>9</td></tr><tr><td>1.7- Implementation Strategies</td><td>10</td></tr><tr><td>1.7.1- Implementation Phase</td><td></td></tr><tr><td>1.7.2- Expected barriers for implementation</td><td></td></tr><tr><td>1.7.3- Funding Body</td><td></td></tr><tr><td>1.7.4- Conflict of Interest</td><td></td></tr><tr><td>1.7.5- Update Process</td><td></td></tr><tr><td>Chapter-II: Guideline Content – Forms</td><td>11</td></tr><tr><td>1-(Under 6years) Check List</td><td>12</td></tr><tr><td>2-(6 - 17 Years old) Check List</td><td>16</td></tr><tr><td>3-(18 - 59 Years old) Check List</td><td>19</td></tr><tr><td>4-(60 years and above) Check List</td><td>23</td></tr><tr><td>Chapter-III: Counseling Skills</td><td>26</td></tr><tr><td>Chapter IV: Children and Adult Immunization</td><td>30</td></tr><tr><td>Abbreviations</td><td>33</td></tr><tr><td>References</td><td>34</td></tr></table>

Preface:
In accordance with the Kingdom's 2030 Vision to implement the health system aims to promote, protect and restore the health of both individuals and the society; meanwhile transforming the health system to be dynamic, technology enabled, as well as fosters both preventive and therapeutic health services for both individuals and the society. Public health Authority has the responsibilities of public health; commissioned the Saudi Clinical Preventive Guideline (Periodic Health Examination (PHE) previous.
And to ensure the continuity of keeping up with health global changes in many related health topics, this version (third virsion,2023) has been updated based on the latest evidence, hoping that this would help health practitioners to provide the best health services in a more efficient and beneficial way for the patients. Furthermore, to improving the quality of health services in the centers providing health care in the Kingdom of Saudi Arabia.
Dr. Abdallah R. Algwizani
Chief Executive Officer, Public Health Authority

Acknowledgment to third edition contributors:
Public Health Authority expresses its grateful to the contributors of the third edition of Saudi Clinical Preventive Guideline (SCP).
○ National committee of periodic health examination.
○ SHC National Heart Center (NHC): Dr. Adel Tash – Dr. Fawaz Almutairi – Dr. Jamilah Alrahimi.
○ SHC National Cancer Center (NCC): Professor Mushabbab AlAsiri.
○ SHC National Diabetes Center (SNDC): Dr. Suliman AlShehri – Dr.Mohammed Alharbi – Dr.Raed Aldahash – Ms.Saja Alhosan.
○ National Center for Mental Health Promotion (NCMH): Dr.Abdulhameed Alhabeeb.
○ Communicable Diseases Department (PHA): Ahmed Mohamad Hakawi - Omar Mohammed Khojah - Faten Jaber Althobaiti.
○ Healthy Environments and Communities department (PHA): Fatimah Hassan Alshehri.
○ National committee of Periodic Health Examination.
Special appreciation to Dr. Taghreed Mohammed Alghaith (PHA) for her valuable work in revising and following up the updating process, and Ms. Wala Bakri Almontashiri for her skillful work in collecting reviews and write the final update for this edition of guideline.

Third edition contributors:
○ Dr. Jaber Alshahrani
○ Dr. Raja Al-Raddadi
Second edition contributors:
Dr. Yassin H. Alsafi - Saudi Centre for Disease Prevention and Control
Dr. Zeinab A. Izzuldeen - Department of Public Health Jeddah
Dr. Eman M. Al-Salman - Department of Public Health - Eastern Province
Dr. Howaida A. Sonbol - Department of Public Health - Jeddah
Dr. Metrek A. Almetrek - Department of Public Health – Asir
Dr. Hassan H. AL-Saleem - Department of Public Health - Al-Hassa
Dr. Sami A. Alrohaly - Department of Public Health - Al-Madinah Al-Manawarah
Dr. Arwa A. AlSaiari - Department of Public Health - Jeddah
Dr. Thuraya A. Rumbo - Department of Public Health - Makkah Al-Mokarramah
Dr. Abduljabbar M. Alfetni - Department of Public Health - Makkah Al-Mokarramah
Dr. Hasan H. Al-Farra - Department of Public Health - Northern Province
Dr. Hanan H. Al-Muwllad - Department of Public Health - Jeddah
Dr. Ramadan M. Abdulhameed - Department of Public Health – Tabuk

First edition contributors:
○ Dr. Mohammed O. Basulaiman
○ Dr. Essam A. Alghamedi
○ Dr. Yassin H. Alsafi
○ Dr. Zeinab A. Izzuldeen
○ Dr. Eman M. Al-Salman
○ Dr. kholood M. Mugharbel
○ Dr. Hanan H. Al-Muwllad
○ Dr. Sami A. Alrohaly
○ Dr. Abduljabbar M. Alfetni
○ Dr. Howaida A. Sonbol
○ Dr. Hassan H. AL-Saleem
○ Dr. Metrek A. Almetrek
○ Dr. Arwa A. AlSaiari
○ Dr. Ramadan M. Abdulhameed
○ Dr. Hasan H. Al-Farra
○ Dr. Thuraya A. Rumbo

CHAPTER-I
Guideline methodology

1.1- Introduction
Healthcare providers are often faced with difficult decisions and considerable uncertainty while treating patients. They rely on the scientific literature, in addition to their background knowledge, skills, experience, and patient preferences, to inform their clinical decisions. This program aimed to create an efficient, easy-to-use memory aid that would remind family physicians evidence-based recommendations to use during periodic health examination. Such tool would offer family physicians rigorously evaluated task force recommendations in a format that would be easy to use in everyday practice.
Clinical Practice Guidelines (CPGs) are one of the tools that help to minimize inappropriate variation in clinical practice and to improve the effectiveness, efficiency and safety of clinical decisions. CPGs are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence based on assessment of the benefits and harms of alternative care options (1).
Recommendations for screening come from various organizations and are constantly changing, rendering health promotion and disease prevention a daunting task. Currently, navigating the plethora of available information in a search of prevention guidelines is overwhelming. There is a need for regular updates through systematic literature reviews. Piecing together these guidelines into a single summary table for practical use in a busy clinical setting simplifies access to information and allows practitioners to provide preventive care in an efficient, evidence-based practice.
Chronic diseases management is an economic burden to the health care system (2). Savings through prevention have been explored by several sources, with emphasis on quality of life and increase in years lived (3,4).
By facilitating opportunities for prevention through easy access to best-practice guidelines, the incidence of chronic disease might decrease, resulting in improved patient-centered care and reducing cost and economic burden on the health care system.

Adequately implemented, CPGs have the potential of reducing variability and translating scientific research into clinical practice and consequently improve the quality and safety of healthcare (5,6). However, scientific knowledge is in constant change; therefore, CPGs need to be updated regularly to maintain validity (7). The obsolescence of a CPG might occur because of new scientific research, including the development of new technologies in treatment, diagnosis, economic differences, or changes in values and preferences (8,9). Updating CPGs is therefore an essential matter to be addressed in order to ensure the validity and quality of CPGs recommendations.
1.2- Improving public health status:
The Saudi Clinical Preventive Guideline is an integrated tool to follow up the health status of community members, as it collects the most important international recommendations in the areas of counseling (such as breastfeeding, smoking, etc. etc.), and clinical examination (BMI measurement, blood pressure measurement, ... etc.), and immunizations in one package for health practitioners in primary care clinics, in addition to the ease of implementation and application of these recommendations and guidelines at a professional and elaborate level.
This leads to realizing the goals of the health Vision 2030 in strengthening prevention against health risks and contributing to reducing the burden of diseases and raising the level of health.

1.3 – Updating methodology:
Saudi Clinical Preventive Guideline (SCP) is updated every 3 years since it was published in 2015. In 2023 edition update, Public Health Authority (PHA), in cooperation with the relevant government agencies, reviewed the SCP in its second edition. The contributors involved have an experience in the medical topics that mentioned in SCP, in addition to their knowledge of new guides and global recommendations related to their specialties.
The relevant government agencies use the same previously adapted guidelines, United States Preventive Services Task Force (USPSTF), The Canadian Task Force on Preventive Health Care (CTFPHC) and Royal Australian College of General Practitioners (RACGP) which were used to fill the gaps.
Recommendations and notes were collected from the relevant government agencies, final review and validation of recommendations was done by assigned consultant and relevant team in PHA.

VISION:
To provide evidence-based preventive care to attain the highest possible level of health for all.
MISSION:
To provide gold standard evidence based, age appropriate, preventive and promotive health care through family practice in primary health care setting.
VALUES:
○ Holistic approach
- Respect and involvement
- Access of care
- Needs and preference
○ Empowerment
○ Justice and Equity
○ Quality and Excellence
Objectives:
To adapt an evidence-based guideline that focuses on comprehensive primary preventive care.
To implement the recommended screening and preventive services to all age groups at primary health care setting.
1.4 – Guideline milestone:
The General directorate of Health Centers Affairs and Health Programs in 2013 nominated a team to develop Saudi Clinical Preventive Guideline (SCP) program to be implemented in Primary Health Care centers.
The team had several meetings with the stakeholders to draw the road map for the program. The team selected a group of physicians who have an interest in evidence-based medicine and guideline adaptation. Two workshops were followed first situational analysis was done to clarify if the program is already implemented or not, secondly a group had been selected to search national and international guidelines regarding Saudi Clinical Preventive Guideline. Another workshop was attended after completing the task.
The main aim of the work group was:
- To produce an applicable, practical and friendly user guideline for health care professionals.
- To formulate an evidence based updated recommendations for SCP.
- To update this guideline every 2 years.

1.5 – Methodology for guideline appraisal:
Clinical practice guidelines (CPG) are systematically developed recommendations for appropriate health care for specific clinical circumstances. CPG reduces discrepancies between scientific evidence and clinical practice, have potential to improve the quality of care delivered.
Translating recommendations into practice require physicians 'adherence to the guideline. However, implementing guidelines is not without obstacles, patient preferences, inadequate facilities or resources, guideline complexity and physician preference and unfamiliarity are some of these. Many of these concerns may be minimized during development processes by adapting methodologies to achieve the appropriate standards of quality (15).
The clinical scope of services and purpose of the guideline and its relevance to practice was defined.
Stakeholders and professional group were involved in the process.
Piloting the guideline may ensure practicability and applicability including consideration of organizational barriers and cost implications. The credibility of guidelines also depends on editorial transparency and independence from funding bodies and in declaration of conflicts of interest by the developers.
The purpose of this document guideline is to provide an overview of the principles and methods of assessment and appraisal used within the context of the guideline's appraisal process.
Methodological process:
The appraisal of the SCP guideline was dependent on the tools for appraisal to assess the quality, consistency, applicability and accessibility.
Scope and purpose:
- To provide evidence-based approach to implement SCP in our community.
To reduce unnecessary interventions and use best health promotion activities.
- To improve quality of life to the community members.

1.6 - Adaptation process:
Preparation:
<table><tr><td>Guideline Adaptation</td><td>2013</td><td>2014</td><td>2019</td><td>2023</td></tr><tr><td>Forming SCP central committee</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Identify the need for implementing SCP guideline</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Meeting with stakeholders</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Proposed action plan (agreeing timelines, milestones)</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Selecting guideline adapting group</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Workshop for guideline appraisal and literature review</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Task distribution to the guideline adapting group</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Appraisal of the guidelines</td><td>√</td><td>--</td><td>--</td><td>--</td></tr><tr><td>Creating guideline recommendations</td><td>√</td><td>--</td><td>√</td><td>--</td></tr><tr><td>Guideline revision</td><td>--</td><td>√</td><td>√</td><td>√</td></tr><tr><td>Guideline editing</td><td>--</td><td>√</td><td>√</td><td>√</td></tr><tr><td>Internal reviewers</td><td>--</td><td>√</td><td>√</td><td>√</td></tr><tr><td>External reviewers</td><td>--</td><td>√</td><td>--</td><td>√</td></tr><tr><td>Guideline printing</td><td>--</td><td>√</td><td>Online</td><td>Online</td></tr></table>
1.6.1- The Clinical Question for Searching:
(P) Whole population.
(I) To prevent and promote health of the population by applying SCP.
(P) Family physicians, General practitioners, nurses, health educators.
(O) Improve quality of life and reduce the use of unnecessary intervention.
(H) Primary Health care settings.

1.6.2 - Searching Engine for Guidelines:
Based on the clinical question, database has been searched in the following sites: US National Guideline Clearinghouses, US Preventive Services Task Force (USPSTF), Guidelines International Network, MEDLINE search, Cochrane, National Institute of Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), The Royal Australian College of General Practitioners (RACGP) and Canadian Task Force on Preventive Health Care (CTFPHC).
Retrieved guidelines reviewed for date of publication, release and language. None English guidelines were excluded.
Ten guidelines retrieved and assessed by the panel; seven guidelines were excluded, as they were not relevant to the key question, currency and applicability in our community.
Critical appraisal using AGREE tool was performed to assess the quality, content, consistency, acceptability and applicability of these guidelines (16).
US Preventive Services Task Force rated high score; the panel decided to adapt this guideline as the main source. Gaps were identified; RACGP, and CTFPHC guidelines were used to fill the gaps. Strength was based on the stated recommendation grading criteria, the panel members reach a consensus after discussing the recommendations which fill the gap based on currency, applicability and prevalence of the condition in our setting.

1.6.3 - Grade Definitions After July 2012, USPSTF Assigns One Of
Five Letter Grades (A, B, C, D, Or I).
<table><tr><td>Grade</td><td>Definition</td><td>Suggestions for Practice</td></tr><tr><td>A</td><td>The USPSTF recommends the service. There is high certainty that the net benefit is substantial.</td><td>Offer or provide this service.</td></tr><tr><td>B</td><td>The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.</td><td>Offer or provide this service.</td></tr><tr><td>C</td><td>The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.</td><td>Offer or provide this service for selected patients depending on individual circumstances.</td></tr><tr><td>D</td><td>The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.</td><td>Discourage the use of this service.</td></tr><tr><td>I Statement</td><td>The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.</td><td>Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.</td></tr></table>

1.7- Implementation strategies:
○ Adapt the concept of SCP for health promotion.
○ Integrate SCP program in primary health care setting.
○ Implement recommendations for SCP based on scientific evidence.
○ Training and continuing medical education for end users.
1.7.1- Implementation phase:
<table><tr><td></td><td>2014</td><td>2015</td><td>2019</td><td>2023</td></tr><tr><td>Training of trainer&#x27;s workshops</td><td>√</td><td>--</td><td>--</td><td>√</td></tr><tr><td>Pilot phase</td><td>√</td><td>--</td><td>--</td><td>--</td></tr><tr><td>Evaluation of the pilot phase</td><td>√</td><td>--</td><td>--</td><td>--</td></tr><tr><td>Dissemination</td><td>--</td><td>√</td><td>Online</td><td>√</td></tr><tr><td>Evaluation</td><td>--</td><td>√</td><td>√</td><td>√</td></tr><tr><td>Updating the guideline</td><td>--</td><td>√</td><td>√</td><td>√</td></tr></table>
1.7.2- Expected Barriers for Implementation:
○ Limited resources at Primary Health Care Centers.
○ Lack of trained motivated staff.
○ unawareness of the community on preventive services.
○ Organizational barriers.
○ Ineffective referral system.
1.7.3- Funding Body:
Public Health Authority (PHA).
1.7.4- Conflict of Interest:
No financial or conflict of interest to disclose.
1.7.5- Update Process:
This guideline will be updated every 2 years unless new evidence emerges.

CHAPTER-II
Guideline content – forms

Saudi Clinical Preventive Guideline Checklist (Under 6 years)

User Guide:
*Counseling frequency will depend on doctor's clinical judgment and case assessment.
- Refer to index for counseling details and content.
- The above recommendations must be read along with the footnotes.
- The colored box means: The screening test is not recommended at this age and need to be performed only when clinically indicated.
- **For recommended immunization based on age refer to table(1)

Saudi Clinical Preventive Guideline under 6 years Foot Note
<table><tr><td>(1) Gaming and screen time limit:The American Academy of Pediatrics (AAP) released a set of guidelines for media use based on a child&#x27;s developmental stage which are highlighted below.Age 2 and under: avoid media use (except video chatting).Preschoolers: No more than one hour of high-quality programming per day.Grade-schoolers/Teens: Don&#x27;t let media displace other important activities such as quality sleep, regular exercise, family meals, &quot;unplugged&quot; downtime.All ages: Be a media mentor. Co-view media with your kids.</td><td>(8-2) The Corneal Light Reflex (Hirschberg Test): For testing eye alignment. When a light source is held directly in front of a patient who is staring straight ahead, normal eye alignment will reveal a symmetric reflex in the center of each pupil. If the light reflex in one eye is inwardly displaced, that eye is exotropic; if outwardly displaced, it is esotropic; and if inferiorly displaced, it is hypertropic.. The presence of an esotropia after the age of 2 months or an exotropia after the age of 6 months suggests an abnormality and needs ophthalmologist evaluation.</td></tr><tr><td>(8-3) The Cover-uncover Eye Test is a more accurate test for ocular alignment in the cooperative patient. Testing is done at 3 years of age with the patient looking first at a near object and</td><td></td></tr><tr><td>(2) developmental delays and disabilities:The American Academy of Pediatrics (AAP) recommends that all children be screened for developmental delays and disabilities during regular well-child doctor visits at:- 9 months- 18 months- 30 months</td><td>(8-4) Visual Acuity Testing: (eg, Snellen, Lea Symbols [Lea-Test], and HOTV [Precision Vision] charts)</td></tr><tr><td>(3) ADHD screening:The American Academy of Pediatrics (AAP) recommends an evaluation for ADHD for any child or adolescent age 4 years to the 18th birthday who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.</td><td>(9) Hearing: Evaluate gross hearing by observing an infants response to sound; a startle response, eye blinking and turning toward the sound is normal reaction.- Older children, whispering test can be used.Refer child at 3 years of age for standardize audiometric testing to ENT.- (Refer to Prevention of Hearing Impairment in PHC.</td></tr><tr><td>(4) Autism screening:all children should be screened specifically for Autism Spectrum Disorder ASD during regular well-child doctor visits at:18 months24 monthsA number of screening tools for autism spectrum disorder (ASD) have been developed and are commonly used.The American Academy of Pediatrics does not approve nor endorse any specific tool for screening purposes.</td><td>(10) Screening for developmental dysplasia of the hip (DDH)The American Academy of Pediatrics (AAP) recommends that all newborn infant&#x27;s hips should be evaluated by using the Barlow and Ortolani physical examination maneuvers.</td></tr><tr><td>(5) Sun Exposure &amp; Vitamin DCrecommended Dietary Allowance (RDAs) for Vitamin D:Age RDAs0-12 months 400 IU (10 mcg)1-13 years 600 IU(15 mcg)</td><td>(11) Sickling and G6PD tests: are requested if not done.Sickling test for Newborn should be done using thin layer isoelectric focusing (IEF) or high-performance liquid chromatography (HPLC). Sickling test can be performed at 9 months.</td></tr></table>

5–30 minutes of sun exposure between 10 AM and 3 PM at least twice a week to the face, arms, legs, or back without sunscreen.
(6) Developmental Milestones:
Denver Developmental Chart up to 6 years to assess child development.
Growth charts: use appropriate age-sex specific growth charts to monitor child growth. Use BMI charts from age 2 years. Use the following charts:
Infants to 36 months:
- Length-for-age and Weight-for-age
- Head circumference-for-age and Weight- for- length
Children and adolescents, 2 to 20 years
- Stature-for-age and Weight-for-age
- BMI-for-age
The Posterior Fontanelle: usually cannot be palpated after two months of age;
The anterior fontanelle generally closes between 10 - 24 months of age. The fontanelles of premature infants tend to close at a later time.
(12) Iron supplementation: The AAP recommends that full-term, exclusively breastfed infants start 1 mg per kg per day of elemental iron supplementation at 4 months of age until appropriate iron-containing foods are introduced. Formula-fed infants often receive adequate amounts of iron (average formula contains 10 to 12 mg per L of iron) and thus rarely require further supplementation.
(13) Vitamin K injection: A single dose (1.0 mg) of intramuscular vitamin K after birth is effective in the prevention of classic HDN. Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves biochemical indices of coagulation status at 1-7 days.
(7) Dental health:
Counseling and dental examination.
Dental referral from 12 months of age then annually. for Children from Birth Through Age 5 Years
primary care clinicians should refer the baby for topical fluoride like varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
(14) fluoride supplements
Prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride so ask about water source:
Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F
0-6 months 0 0 0
6 m- 3yrs0.25 mg 0 0
3-6 years0.50 mg 0.25 mg 0
Ref. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY2018.
(8) vision
(8-1) The Red Reflex Procedure:
-The red reflex is much easier to see in a darkened room, so switch off the lights,
-Use a direct ophthalmoscope with the lens power set at '0'.
-Sit about half a meter (50 cm) away. Hold the ophthalmoscope close to your eyes.
-Encourage the child to look at the light source and direct the light at the child's eyes individually and together. You should see an equal and bright red reflex from each pupil.
-Pay attention to the color and brightness of the red reflex. It should be identical in both eyes. Any difference between the eyes, an absence of the red reflex or an abnormal color may indicate a serious illness.
(15) Infants who are exclusively breastfed or receive less than 1 liter of formula daily should be supplemented with 400 IU of vitamin D daily, starting in the first few days of life
and continuing until they are 12 months of age.
Supplementation should continue until the baby is weaned to at least (1 L) of whole milk per day. Whole milk should not be used until after 12 months of age. Vit D supplement may be increased to 600 IU for age 1 year through adolescence.

Saudi Clinical Preventive Guideline Checklist (6-17 years)

User Guide:
Refer to index for counseling tips and content.
- The above recommendations must be read along with the footnotes.
*Counseling frequency will depend on doctors clinical judgment and case assessment.
**For recommended immunization based on age refer to table(1,2)

Saudi Clinical Preventive Guideline Checklist (6-17) Foot Note
<table><tr><td>(1) Sun Exposure and Vitamin D:5–30 minutes of sun exposure between 10 AM and 3 PM at least twice a week to the face, arms, legs, or back without sunscreen. Individuals with limited sun exposure need to include good sources of vitamin D in their diet or take a supplement to achieve recommended levels of intake.Recommended Dietary Allowance (RDAs) for Vitamin D3(cholecalciferol):</td><td>(6) 14-17 years This recommendation applies to who have ever are at increased risk</td></tr><tr><td>(2) Depression screening:The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.</td><td>(7) Folic AcidAll women planning or capable of pregnancy should take a daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid at least 1 month before conception and to continue daily supplements through the first 2 to 3 months of pregnancy</td></tr><tr><td>(3) ADHD screeningThe American Academy of Pediatrics (AAP) recommends an evaluation for ADHD for any child or adolescent age 4 years to the 18th birthday who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.</td><td>(8) Fluoride:Children aged &gt; 6 years are considered past the age that fluoride ingestion can cause cosmetically objectionable fluorosis because only certain posterior teeth are still at a susceptible stage of enamel development.Ask about water source:- If &lt;0.3ppm give fluoride 1 mg /day- If (0.3-0.6 ppm) give 0.5 mg /day- If (&gt; 6 ppm) no needs for fluoride supplement</td></tr><tr><td>(4) Oral Hygiene:Support tooth brushing in children.&amp; recommend personal tooth brushing and flossing in adults to prevent gingivitis- weak scientific evidence to recommend oral hygiene for the prevention of periodontitis</td><td></td></tr><tr><td>(5) BMI Plotting Charts: Children and adolescents, 2 to 20 years plot the following growth charts annually• Stature-for-age and Weight-for-age• BMI-for-age- Overweight: age and gender specific BMI at ≥85th to 94th percentile.- Obesity : age and gender specific BMI at ≥95th percentile</td><td></td></tr></table>

Saudi Clinical Preventive Guideline Checklist (18-59 years)

<table><tr><td rowspan="4"></td><td rowspan="4"></td><td>Hepatitis A</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Hepatitis B</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Haemophilus Influenzae Type b (Hib)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>National immunizations schedule**</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td>MOH Mother Health Passport.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="14">User Guide:- Refer to index for counseling tips and content.- The above recommendations must be read along with the footnotes.*Counseling frequency will depend on doctors&#x27; clinical judgment and case assessment.**For recommended immunization based on age refer to table(2)</td></tr></table>

Saudi Clinical Preventive Guideline Checklist (18-59 years) Foot Note
<table><tr><td>(1) Oral Hygiene: Adults good evidence to recommend personal tooth brushing and flossing to prevent gingivitis weak scientific evidence to recommend oral hygiene for the prevention of periodontitis</td><td>(9) Pap Smear: The USPSTF recommends screening for cervical cancer in women after starting sexual activity age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.</td></tr><tr><td>(2) screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use</td><td>(10) mammogram: locally The Saudi Expert Panel suggests screening with mammography in women aged 40–69 years every 1 to 2 years). (Conditional recommendation; low-quality evidence) (17) - Women aged 75 years or older, the evidence to recommend for routine screening is currently insufficient.</td></tr><tr><td>(3) Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions.</td><td>(11) Lung Cancer: The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.</td></tr><tr><td>(4) Depression Screening: Ask 2 simple questions about: Mood and loss of interest in the past 2 week.</td><td>(12) Colon Cancer Screening:The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years(A).The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years(B).- Locally based on American cancer society at the age 45 years (18)Screening methods: Choose one of the following tests:- FOBT=guaiac-based fecal occult blood test every year.- FIT=fecal immunochemical test every year.- Flexible Sigmoidoscopy(FSIG) every 5 years.- Colonoscopy every 10 years.- All positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.</td></tr><tr><td>(5) Check BMI &amp; Waist Circumference / 2 years in all adults aged over 18 years</td><td>(13) Perform DEXA Scan for:For postmenopausal women younger than 65 years who have at least 1 risk factor, a reasonable approach to determine who should be screened with bone measurement testing is to use a clinical risk assessment tool.- postmenopausal women younger than 65 years increased risk of:- osteoporotic fractures.- parental history of hip fracture- smoking.- excessive alcohol consumption- low body weight.No recommendation to screen asymptomatic men by USPSTF.</td></tr></table>

<table><tr><td>(6) Blood Pressure Recommendations: LOE: AScreen for high blood pressure in adults aged 18 years or older.Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment.Check BP annually for those who are at increased risk include:adults aged 40 years or older.persons with high-normal blood pressure.overweight or obese.Screening less frequently (ie, every 3 to 5 years) is appropriate for adults aged 18 to 39 years not at increased risk for hypertension and with a prior normal blood pressure reading.</td><td>(14) Aspirin 81 mg dailyThe decision to initiate low-dose aspirin use for the primary prevention of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit.</td></tr><tr><td>(7) Check Fasting Blood Sugar or Hb A1c or RBS starting at the age of 35 years every 3 yearsScreen all adults who are overweight (BMI ≥ 25 kg/ m2) and have additional risk factors:- Physical inactivity- First degree relative with DM- Women who delivered baby more than 4 kg or where diagnosed with GDM.- Blood pressure ≥ 140/90 or on therapy for hypertension.- HDL cholesterol level &lt; 35 mg/dl (0.9mmol/l) or TG &gt; 250mg/ dl (2.82mmol/l)- Women with polycystic ovary syndrome.- Impaired glucose tolerance test or impaired fasting glucose. OR HBA1C ≥ 5.7 %- History of CVD.</td><td>(15) Folic Acid: All women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid at least 1 month before conception and to continue daily supplements through the first 2 to 3 months of pregnancy. Women at high risk for neural tube defects (NTD) like epileptic or DM or previous baby with NTD should take 4mg per day.</td></tr><tr><td>(8) This recommendation applies to who have ever are at increased risk.</td><td>(16) STATIN-The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. (B)-The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia,dialbetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater.(C)</td></tr></table>

Saudi Clinical Preventive Guideline Checklist (60 years and above)
User Guide:
Refer to index for counseling tips and content.
- The above recommendations must be read along with the footnotes.
* Counseling frequency will depend on doctor's clinical judgment and case assessment.
**For recommended immunization based on age refer to table(2)

Saudi Clinical Preventive Guideline (60 years and above) Foot Note
<table><tr><td>(1) Fall Assessment and Prevention:Risk Assessment:-History of falls-Mobility problems-Poor performance on the timed Get-Up (up go test) Counsel for interventions to minimize risk of fall including:-Exercise therapy (working on gait, balance, and muscle strengthening in the legs),Diet, and vitamin D supplementation psychological health and cognition,vision, environmental conditions, diet.</td><td>(6) Lung CancerThe USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.</td></tr><tr><td>(2) Depression Screening: - Use Geriatric Depression Scale (short form)</td><td>(7) Colon Cancer Screening: Choose one of the following tests:The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years(A).Locally based on American cancer society at the age 45 years (20)Screening methods:gFOBT=guaiac-based fecal occult blood test every yearFIT=fecal immunochemical test every yearFlexible Sigmoidoscopy every 5 yearsColonoscopy every 10 years.All positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.</td></tr><tr><td>(3) Blood Pressure Recommendations:Annual screening for adults aged ≥ 40 years.- Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment.- Check BP annually for those who are at increased risk include:adults aged 40 years or older.persons with high-normal blood pressure.overweight or obese.</td><td>(8) Perform DEXA Scan:The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.No recommendation to screen asymptomatic men by USPSTF.</td></tr><tr><td>(4) Check Fasting Blood Sugar or Hb A1c or RBS starting at the age of 35 years every 3 years* Screen all adults who are overweight (BMI ≥ 25 kg/ m2) and have additional risk factors:Physical inactivityFirst degree relative with DMWomen who delivered baby more than 4 kg or where - diagnosed with GDMBlood pressure ≥ 140/90 or on therapy for hypertensionHDL cholesterol level &lt; 35 mg/dl (0.9mmol/l) or TG &gt; 250mg/dl (2.82mmol/l)Women with polycystic ovary syndromeImpaired glucose tolerance test or impaired fasting glucose.OR HBA1C ≥ 5.7 %History of CVD.</td><td>(9) Men Ages 65 to 75 Years who Have Ever Smoked The USPSTF recommends one-time screening forAbdominal Aortic Aneurysm (AAA) with ultrasonography in men ages 65 to 75 years who have ever smoked.</td></tr><tr><td>(5) Mammogram(Locally The Saudi Expert Panel suggests screening with mammography in women aged 40–69 years every 1 to 2</td><td>(10) Statin:-The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia,</td></tr></table>

<table><tr><td>years). (Conditional recommendation; low-quality evidence)(19)Women aged 75 years or older, the evidence to recommend for routine screening is currently insufficient.</td><td>diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. (B)-The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater.(C)</td></tr></table>

CHAPTER-III
Counseling skills

3.1- Counseling Skills:
3.1.1- Counseling is a systematic process which gives individuals an opportunity to explore and clarify the ways of living more resourcefully, with a greater sense of well-being.
The counselor's role is to facilitate the client work in a way that respect the client's values, personal resources and capacity for self-determination.
The following skills are necessary for counseling:
3.1.2- Attending Behavior:
Involves our behaviors which include paying full attention, in an acceptable and supportive way, to the client. An attempt to build a certain amount of rapport with their client but not to an extent that would allow them to become emotionally involved
3.1.3- Communication Skills:
Active listening is the most fundamental component of interpersonal communication skills, actively showing verbal and non-verbal signs of listening.
○ Effective questioning skills (open-ended questions).
○ Clarification: use of open questions to ensure the correct message has been received and to enable expanding on certain points as necessary.
- Paraphrasing (the counselor uses different words to restate in a nonjudgmental way what the client has said. Aiming to help the client to know that the counselor is aware of the client's perspective and has heard what he or she has said.
- Reflective responses (responds to feelings). Affective reflection in an open-ended, respectful manner of what the client is communicating verbally and nonverbally, both directly through words and nonverbal behaviors as well as reasonable inferences about what the client might be experiencing emotionally.
It is important for the helper to think carefully about which words he/she chooses to communicate these feelings back to the client.
- Empathetic response: Placing self in the client’s situation while remaining objective. Empathizing requires the counselor not to be judgmental and to be sensitive and understanding.
○ Negotiation skills (a process by which compromise, or agreement is reached while avoiding argument).
- Structuring and Summarizing: repeating a summary of what has been said back to client in their word.

3.1.4- Advice Skills:
The ability to give advice in a positive, constructive way is an art. Here are three points to help us offer advice with effectiveness and compassion.
Listen first While this rule is true for all good communication, it is doubly true when we wish to give advice.
By first listening, we open a space for the speaker to more fully describe the situation and for us to more fully understand it. In addition, when we listen first, it makes it more likely that the other will then listen to what we have to say.
Ask permission It can be experienced as un-welcome intrusion into personal business. It might also be seen disrespectful, as implying that a person is incapable of caring for himself and resolving his own issues. Asking if our advice is desired shows respect for others and prevents resentments.
Offer without insisting It is worth keeping in mind that even after we have listened, we can never know with certainty what is best for another person. By not insisting, we can increase the chances of our words being considered.

COUNSELING CHECK LIST
<table><tr><td rowspan="2">STEPS</td><td rowspan="2">SKILLS</td><td colspan="5">SCORING</td></tr><tr><td>1</td><td>2</td><td>3</td><td>4</td><td>5</td></tr><tr><td rowspan="7">Exploration of the problem</td><td>Establish good relationship: Welcome the client greets him, introduce yourself</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Call by name or the name he likes, marital status, job</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Use helpful non-verbal communication Suitable position posture and proper eye contact....</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Show welcoming and willing to help</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Attending behavior show interest, give attention, active listening</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Be sensitive to verbal and non-verbal cues</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Show empathy</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="6">Enable the client to explore the problem from his own Idea, Concern, Expectation and Effect (ICEE)</td><td>Open ended questions,</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Use paraphrasing,</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reflecting feelings</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Help the client to be specific</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Summarizing</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Acceptance &amp; non-judgmental attitude</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="5">Understanding &amp; defining goals</td><td>Help the client to recognize behavior pattern, inconsistency and feeling</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Appropriate sharing of the knowledge, experiences and feeling</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reach a new understanding of the problems, See the problem in a new perspective</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Focus on what to be done to enable the client to cope more effectively</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Define goals</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Action</td><td>Use creative thinking, problem solving and decision making</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Help the client to consider the action, consider its cost and consequences plan for it, implement it and evaluate it.</td><td></td><td></td><td></td><td></td><td></td></tr></table>

CHAPTER-IV
Child & Adult immunization
recommendations

Introduction:
The public health authority (PHA) recommends routine vaccination to prevent 17 vaccine-preventable diseases that occur in infants, children, adolescents and adults. Immunization process stimulate the body's own immune system to protect the person against subsequent infection or disease (WHO). Immunization is an important part of Saudi Clinical Preventive Guideline for both children and adults. (Table1) shows the National Immunization Schedule for ages from birth to 18 years in Saudi Arabia.
Table1: Recommended Vaccinations for Children and Adolescents Under 18

Table2: Recommended Vaccinations for adult from 18 and older
<table><tr><td rowspan="2">Vaccine*</td><td>\( Influenza^1 \)</td><td>\( Tdap or Td^2 \)</td><td rowspan="2">\( MMR^4 \)</td><td rowspan="2">\( Varicella^5 \)</td><td rowspan="2">Herpes zoster\( ^6 \)</td><td rowspan="2">\( HPV^7 \)</td><td colspan="2">Pneumococcal</td><td rowspan="2">\( Hep B^{10} \)</td><td rowspan="2">\( MCV4^{11} \)</td><td rowspan="2">Other Vaccinations</td></tr><tr><td>\( Adults^2 \)</td><td>\( Pregnant^3 \)</td><td>\( PPSV23^8 \)</td><td>\( PCV^9 \)</td></tr><tr><td>Date and signature</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table>
Timing / indication:
1- \( ^{1} \) dose annually.
2- \( ^{1} \) dose Tdap then Td booster every 10 years.
3- pregnant women (for each pregnancy between 27 & 36 weeks).
4- for unvaccinated individuals, premarital and post-natal women if no evidence of immunity or prior disease (1 or 2 doses depend on indication).
5- if no evidence of immunity or prior disease (2 doses 8 weeks apart).
6- 2 doses 2-6 m apart for adult age 50 years or older.
7- 3 doses (0, 1-2, and 6 m) from the first dose catch up immunization for female age 15-26 years.
8- 1 dose adults aged 65 years or older (1 year after PCV 13 dose) from the first dose.
9- 1 dose adults with comorbid/immunocompromised conditions and adults aged 65 years or older.
10- 3 doses (0, 1m, and 6m) if no previous immunization or no evidence of immunity.
11- 1 dose depending on indication, then booster every 5 years if risk remains.

ABBREVIATIONS
<table><tr><td>SCP</td><td>Saudi Clinical Preventive</td></tr><tr><td>PHA</td><td>Public Health Authority</td></tr><tr><td>PHC</td><td>Primary Health Care Center</td></tr><tr><td>CPG</td><td>Clinical Practice guidelines</td></tr><tr><td>USPSTF</td><td>united states Preventive Services Task Force</td></tr><tr><td>CTFPHC</td><td>US Capital Letters Canadian Task Force on preventive health care</td></tr><tr><td>NICE</td><td>National Institute of Clinical guidelines Network</td></tr><tr><td>SIGN</td><td>Scottish Intercollegiate Guidelines Network</td></tr><tr><td>RACGP</td><td>The Royal Australian College of General Practitioners</td></tr><tr><td>AGREE</td><td>The Appraisal of Guidelines for Research and Evaluation</td></tr><tr><td>RDA</td><td>Recommended Daily Allowance</td></tr><tr><td>IEF</td><td>Iso-electric focusing</td></tr><tr><td>HPLC</td><td>High performance liquid chromatography</td></tr><tr><td>DEXA SCAN</td><td>Dual energy x-ray Absorbtiometry</td></tr><tr><td>NTD</td><td>Neural tube defects</td></tr><tr><td>CVR</td><td>Cardiovascular risk</td></tr><tr><td>STI</td><td>Sexually transmitted infections</td></tr><tr><td>EPI</td><td>Expanded program of immunization practices</td></tr><tr><td>ACIP</td><td>The advisory committee on immunization practices</td></tr><tr><td>Tdap/ Td</td><td>Tetanus, diphtheria,a cellular pertussis Vaccine</td></tr><tr><td>DTaP</td><td>Diphtheria ,tetanus,acellular pertussis Vaccine</td></tr><tr><td>MCV4</td><td>Meningococcal Conjugate Quadrivalent Vaccine</td></tr><tr><td>PCV13</td><td>Pneumococcal Conjugate Vaccine</td></tr><tr><td>PPSV23</td><td>Pneumococcal Polysaccharide Vaccine</td></tr><tr><td>IPV</td><td>Inactivated Poliovirus Vaccine</td></tr><tr><td>OPV</td><td>Oral poliovirus Vaccine</td></tr><tr><td>CDC</td><td>Center for Disease Control and Prevention</td></tr></table>

References
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12. http://www.uspreventiveservicestaskforce.org/recommendations.htm
13. http://canadiantaskforce.ca.
14. https://www.racgp.org.au
15. https://www.sign.ac.uk/assets/sign50_2015.pdf
16. The ADAPTE Collaboration (2009). The ADAPTE Process Resource Toolkit for Guideline Adaptation, Version 2.0 http://www.g-i-n.net.
17. The AGREE II Instrument http://www.agreetrust.org
18. Clinical practice guideline on the use of screening strategies for the detection of breast cancer April 2014. the Saudi center for Evidence Based health care. available at: http://www.moh.gov.sa
19. American cancer society (cancer colon)
20. https://www.cdc.gov/vaccines/schedules/
Expanded Program of Immunization (National immunization Schedule).

وقابه
هينه الصحه الع川县
PUBLIC HEALTH AUTHORITY

SaudiCDC
www.cdc.gov.sa