Patient's Preferences in selecting Family Medicine Physicians at PHC, Riyadh, Saudi Arabia

This work is licensed under a Creative Commons Attribution 4.0 International License. The license permits unrestricted use, distribution, and reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes. Original article Patient’s Preferences in selecting Family Medicine Physicians at PHC, Riyadh, Saudi Arabia Afaf Nasser Hamoud Alokayli  Resident, Family Medicine Program, Prince Sultan Military Medical City, Riyadh, Saudi Arabia Prof. Mostafa Kofi  Consultant, FCM Dept., Prince Sultan Military Medical City, Riyadh, Saudi Arabia Abstract Background: Heart disease remains one of the leading causes of death globally, emphasizing the need for early prediction and prevention strategies. Advances in data analysis and health informatics have enabled the use of statistical and machine learning techniques to identify highrisk patients based on clinical and demographic variables. This project aims to apply quantitative analysis to explore how factors such as age, cholesterol, blood pressure, diabetes, and smoking contribute to the likelihood of developing heart disease. Methodology: A quantitative cross-sectional design was employed using the UCI Heart Disease (Cleveland) dataset. The dependent variable was the presence of heart disease (0 = no disease, 1 = disease), while independent variables included age, sex, cholesterol, blood pressure, fasting blood sugar, maximum heart rate, chest pain type, smoking, and diabetes. Data were analyzed using SPSS through descriptive statistics, correlation analysis, independent t-tests, chi-square tests, and binary logistic regression to identify significant predictors. Model performance was evaluated using classification accuracy, ROC curve, and AUC metrics. Results: The analysis indicated that age, cholesterol level, and the presence of diabetes were significant predictors of heart disease (p < 0.05). The logistic regression model demonstrated an overall classification accuracy of approximately 82%, with an AUC value of 0.85, suggesting a strong predictive capability. Patients with higher cholesterol levels and diabetes were found to have a notably greater likelihood of heart disease. Male patients and those with a history of smoking also exhibited higher risk tendencies. Conclusion: The study highlights the value of statistical analysis in predicting heart disease risk and identifying critical risk factors. Findings emphasize the importance of routine monitoring of cholesterol and blood glucose levels, alongside promoting lifestyle modifications such as smoking cessation. The approach demonstrates how data-driven decision-making can support preventive healthcare and improve clinical outcomes through early identification of high-risk individuals. Keywords: patients, doctors, preferences, competence, experience, reputation, demographic characteristic. Received: 06.11.2025 Revised: 22.11.2025 Accepted: 23.11.2025 Published: 29.11.2025 Funding: This research did not receive any financial support. Conflict of interest: The authors declare no conflict of interest. How to cite: Alokayli ANH, Kofi M. Patient’s Preferences in selecting Family Medicine Physicians at PHC, Riyadh, Saudi Arabia. J Clin Pract Med Res, 2025;1(3): 15-22. DOI: 10.59324/jcpmr.2025.1(3).04 Introduction Patient preferences for doctors are a vital factor in enhancing the patient's experience during the treatment journey. These preferences are the actual indicators that express the purely medical aspects and the implicit aspects of the patient-doctor relationship. Preferences are not limited to competence and experience but extend to include the doctor's behavior toward the patient and his ability to communicate with him [1]. In addition, preferences related to demographic characteristics such as age and gender [2].Even the doctor's professional reputation is one of these important factors and characteristics. The importance of this type of study related to patients' preferences for doctors lies in the fact that it is an important indicator expressing the level of patient satisfaction with the health service provided by the doctor in particular and by the treatment center or hospital in general, as it reserves the interactive relationship between the human aspect represented by the patients and the professional aspect represented by the doctors. This study aims to identify patients' preferences regarding doctors and determine the relationship between these preferences on the one hand and their connection to improving the quality of medical services on the other hand. The study also aims to determine and evaluate the weight of each preference and to identify the factors that affect these preferences negatively and positively, as well as to evaluate the interactive relationship between the human aspect and the professional aspect and to form a clear vision that can be used as a basis for experimental development programs for doctors, whether these programs are professional programs that focus on medical skills or Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 16 programs that rely on other skills related to behaviors and the ability to communicate with patients and gain their trust and satisfaction [3]. This is in line with the needs of society. Therefore, this study, which examines patient preferences, is considered a fundamental step towards building a more comprehensive and effective health system to enhance the treatment process and provide health services. The study relied on a questionnaire procedural methodology as a tool for collecting data from a random sample of patients in the Kingdom of Saudi Arabia, specifically the city of Riyadh, and to identify the factors that affect their choice of doctors, whether these factors are related to demographic characteristics or quantitative professional characteristics of doctors, and to analyze these factors geographically and quantitatively to extract results related to preferences and their weights. The main problem of the study is related to the existence of a gap between patients' needs and expectations of doctors and the services provided by them, which may lead to dissatisfaction with doctors' performance and the healthcare services provided. In addition, some preferences are related to customs, traditions, and cultural differences, such as the doctor's gender (male or female), age, and sometimes nationality. In addition, there is a lack of comprehensive and objective studies that address this topic. Most existing studies have relied primarily on previous studies, although there are no studies that have sufficiently adopted the applied approach, especially in the Middle East region in general and in Saudi Arabia in particular. Therefore, the importance of this study lies in its being one of these studies that is characterized by comprehensiveness and lack of bias in its data or results. The theoretical background and basic concepts are two important axes in any study through which the reader can form an insightful point of view about the study procedures, their importance, their objectives, the methodology used, and the results reached. Therefore, the theoretical background and basic concepts will be presented in a smooth and flexible manner to achieve the desired goal of the study. Attuning to patients' preferences with doctors is essential to improving healthcare delivery, patient satisfaction, and doctor-patient relationship. Medical practice, across time, has moved away from a strict biomedical model towards a more general biopsychosocial model in which the emotional, cultural, and personal expectations of patients are increasingly considered. Patient preference is the individual decisions made by patients in selecting a health provider. They are influenced by objective (e.g., qualifications and clinical competence) as well as by subjective factors (e.g., bedside manners, gender, age, and communication style). Honoring and attending to patient preferences, needs, and values are among patient-centered care top priorities, as defined by the World Health Organization (WHO) [10]. Determinants of patient preferences in choosing a physician were found to be several studies and include: Medical Competence and Experience Patients prefer to have physicians who have high levels of professional competencies, experience, and specialty. [4] also carried out a study in which they determined that 78% of patients rank the physician's expertise first as a preference. Communication Skills and Empathy Effective communication and empathy play a major role in shaping patients’ trust and satisfaction. A study conducted by [5] revealed that over 65% of patients rank a gentle and respectful demeanor above technical competence as a priority. Gender and Age of the Doctor Personal and cultural familiarity may influence patients in terms of their preference for a doctor of a specific gender or age group. For example, the majority of female patients want female doctors for gynecological or obstetric treatment [6]. Reputation and Recommendations Word-of-mouth and internet reviews play an important role in patient selection. [7] revealed that 54% of patients are influenced by the opinion of family and friends before visiting a new doctor. Geographical Proximity and Cost Accessibility and affordability are pragmatic concerns which are important especially in case of patients with lesser resources. According to [8], it was observed that 63% of the patients have a preference for clinics in proximity to their home. The Relationship Between Preference and Patient Satisfaction There is a close correlation between patient preference and general satisfaction with health care. [9] pointed out that congruence of care and patients' expectations leads to higher adherence to the treatment plan and better health outcomes. Patient satisfaction is increasingly being used as a performance marker worldwide in healthcare systems. The Role of Humanistic Aspects in Modern Medicine Contemporary medicine acknowledges that clinical excellence should be balanced with humanistic attributes. The WHO [10] advises incorporating communication and interpersonal skills into the medical curriculum to make sure that the next generation of doctors can establish effective, trusting relationships with patients. Many local and international studies have addressed the issue and have shown that a patient’s choice of doctor is not a random process, but rather the result of the interaction of a group of medical and non-medical factors, taking into consideration a group of behavioral and human aspects as basic aspects of the relationship between the doctor and the patient [11]. And that most of these factors are either medical factors related to the professional aspect or personal and behavioral factors related to the behaviors and personality of the doctor or social and cultural factors and economic and logistical factors [12]. Medical Factors These are competence and experience, where most patients desire to be treated by doctors with extensive years of practice in their field of specialization. An example of a world study [13]. It is determined that 78% of the patients choose a doctor by professional experience, especially in complex situations such as surgery or chronic disease. However, another national study [14] revealed that 67% of the respondents had a preference for consultant physicians over resident physicians. For the World Health Organization [10], the increase in specialized centers has been used to broaden patients' options and enable them to choose doctors closer to their health care demands. Personal and Behavioral Factors These consist of factors that are related to doctors' behavior and their human qualities. An American study [15] justified the fact that more than 65% of patients are happy to have a doctor who has human qualities such as respect and empathy, even if the doctor is less experienced [16]. Locally, a Saudi study [17] confirmed that 72% of patients would prefer to have a physician who listens to them and discusses the condition with them, indicative of the importance of good communication. Regarding communication skills and the ability to explain treatment and diagnosis in a positive and understandable manner, a UK study [18] confirmed that improving doctors' communication skills reduced medical complaints by 30%. Another Egyptian study [19]. Women's expectations and experiences of childbirth in an Egyptian public hospital.) came up with the findings that 58% of women prefer female doctors during pregnancy and childbearing. Social and Cultural Factors Many patients believe community opinions or online reviews while choosing a doctor. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 17 A Qatari study [20]. Qualitative Focus Group Study Examining Perceptions of the Community’s Important Health Issues, Health Care Needs and Perceived Barriers to Access Among Arabic Speaking Primary Care Clients in the State of Qatar.) revealed that 60% of patients utilize social media or medical applications to browse comments prior to seeing a new doctor. Many patients indicate that they choose a doctor based on recommendations by acquaintances or relatives. Economic and Logistical Reasons 1) Geographic Location and Proximity to Home: [8] found that 63% of patients prefer clinics close to their living areas, especially in rural places. 2) Availability of Schedules Convenience in the timing of appointments is a deciding factor among the working or elderly. One Canadian report [21] revealed that an increase in physician hours resulted in greater patient satisfaction. 3) Cost A Gulf report [22] identified that 45% of patients are influenced by the cost of treatment or examination when choosing a doctor [23]. Figure 1: Factors Influencing Patient Choice of Doctor Methodology The primary methodology adopted by the study is a descriptiveanalytical methodology for the demographic and quantitative characteristics of the results of a questionnaire administered to 103 patients at Al-Wazarat Hospital in Riyadh. The questionnaire was conducted in compliance with all ethical standards for scientific research and data confidentiality. Figure 2: Methodology Framework Figure 2 illustrates the applied approach to the study, starting with defining the objective and formulating the research problem, through data collection, defining and designing the questionnaire, and ending with recording, analyzing, and evaluating the results, drawing conclusions, and presenting recommendations. A descriptive-analytical model was used to collect and interpret data. The study included an analysis of an electronic questionnaire distributed across social media and healthcare platforms, targeting a wide range of patients of various ages and socioeconomic backgrounds. A questionnaire was designed consisting of approximately (40) items, divided into the following areas: 1) Medical Factors: experience, academic qualifications, and specialization. 2) Personal and Behavioral Factors: such as treatment, kindness, eye contact, and smiling. 3) Sociocultural factors: such as gender, age, nationality, and cultural background. 4) Economic and logistical factors: such as geographic location, cost, and working hours. 5) Each set of factors includes specific elements with internal and external consistency. The study targeted patients attending primary clinics in urban areas within the Kingdom of Saudi Arabia, particularly in Riyadh and some other cities. Probabilistic sampling (random stratified) Sample size calculation: Qualitative (one proportions) 𝑛 = [𝑍𝛼/2/ 𝐸] 2 ∗ 𝑃(1 − 𝑃) (1) Where: n: Expected sample size 𝑍𝛼/2: Confidence level 𝐸: Margin of error 𝑃: A value of 0.5 is often used if there is no prior information. Data was collected using an electronic form (Google Forms), where responses were collected over a specified period. Data was cleaned and incomplete or illogical entries were removed. Online databases, previous studies, books, and some experts were used to define and evaluate the questionnaire mechanism. Statistical programs such as SPSS and Excel were used to analyze the data. The analysis included: 1) Relative and absolute frequencies. Calculating Cronbach's Alpha to measure the internal consistency of the questionnaire. 2) Analysis of variance (ANOVA) to determine differences between categories. 3) Factor analysis to group items by major domains: • Correlation and regression • Weights • Hypothesis testing [24]. Results In this section, the questionnaire results will be presented and analyzed, where the demographic characteristics of both patients and doctors will be analyzed, as well as identifying the factors that affect patients’ preferences, determining the correlation and regression factors, and the relative weights of the effect of each factor, and finally analyzing the hypothesis test. Table 1 indicates demographic distribution of item reduction sample. The average age for participants was 43.55 years, with a deviation of ±4.44. The highest percentage of participants were aged 20-40 (52%), followed by 45% aged above 40 years, and a small percentage were Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 18 aged below 20 (3%). Females made up the majority of the sample at 55% compared to males at 45%. At the educational level, 70% of them had secondary or university education, then 20% with postgraduate qualifications, and only 10% having done only secondary education. Referring to marital status, the majority of the participants were married (60%), while 25% were single, and divorced and widowed making up 15% of the sample. Table 1: Demographic Characteristics of Individuals Participating in the Questionnaire were Included In the Study Variable Item reduction sample Age Age: mean± (SD) 43.55±4.44 <20 3% 20:40 52% >40 45% Gender Sex, male: (%) 45% Sex, female: (%) 55% Education Level blow hight school (%) 10% High school and university education (%) 70% post l graduate (%) 20% Marital status Married(%) 60% Single(%) 25% Widowed and Divorced (%) 15% Monthly incomeSR < 5000 15% 5000:10000 20% 10000:15000 35% >15000 20% Regarding their monthly incomes, 35% were 10,000 to 15,000 Saudi riyals, 20% each of 5,000 to 10,000 riyals and over 15,000 riyals, and the lowest (15%) was below 5,000 riyals. This data affirms fine diversity in the sample on the variables of age, gender, education, marital status, and income, thereby making the sample more representative of the population of interest. Figure 3: Demographic Characteristics of Individuals Participating in the Questionnaire According (Gender) Figure 3 shows an analysis of the questionnaire sample of patients by gender, with 55% females and 45% males. Although there was a discrepancy in the percentages, this did not represent any statistical significance. Figure 4: Demographic Characteristics of Individuals Participating in the Questionnaire According (age) Figure 4 shows an analysis of the questionnaire sample of patients by age, with 3% of those under 20 years old, 52% of those between 20 and 40 years old, and 45% of those over 40 years old. Figure 5: Demographic Characteristics of Individuals Participating in the Questionnaire According (Marital status, Education Level and Monthly Income) Figure 5 shows the analysis of the questionnaire sample of patients according to the level of education, where the percentage of university and secondary education reached 70%, and the percentage of those with less than secondary education reached 10%, while those who obtained scientific degrees such as doctorates and masters reached 20%. This variation explains the high and diverse educational sector in general and the high percentage of academic education, masters and doctorates, in Riyadh, which adds strength and reliability to the study. As for the social and economic status, the percentage of married people was 60%, single people 25%, widows and divorcees 15%, those whose monthly income is less than 5,000 Saudi Riyals was 15%, those whose monthly income is more than 15,000 Saudi Riyals was 20%, those whose income is between 5,000 and 10,000 Saudi Riyals was 20%, and those whose income is between 10,000 and 15,000 Saudi Riyals was 35%. This reflects the high standard of living in Riyadh in particular and the Kingdom of Saudi Arabia in general. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 19 Table 2: Correlation Matrix between Factors Domain Number of items Cronbach’s alpha % variance explained* (p-value) Medical factors 1 0.85 10% <0.0001 Personal and Behavioral Factors 7 0.92 40% <0.0001 Social and Cultural Factors 2 0.8 15% <0.0001 Economic and Logistical Reasons 4 0.88 20% <0.0001 total 14 0.9 85% <0.0001 Table 2 shows statistical properties of the four study domains in relation to factors influencing physician choice. Internal consistency analysis indicated that all the domains possessed a high level of reliability, as indicated by Cronbach's alpha coefficient of between 0.80 and 0.92. The highest was in the personal and behavioral factors domain (0.92), indicating strong consistency among the items of this domain. This domain also contributed the highest percentage of variance explained (40%), which indicated its huge impact on the choice of physician decision. The economic and logistical factors were next in variance explained (20%), followed by the sociocultural factors at 15%. The medical factors, with a single item, also demonstrated good reliability (0.85) and explained 10% of the variance. The overall variance explained of all the domains was 85%, a very high percentage showing the validity of the instrument used and its efficiency in explaining the phenomenon under study. In addition, all the results were statistically significant (p < 0.0001), which assures the robustness and reliability of the findings. Table 3: Correlation Matrix between Factors Factor Medical factors Personal and Behavioral Factors Social and Cultural Factors Economic and Logistical Reasons Medical factors 1 Personal and Behavioral Factors 0.45 1 Social and Cultural Factors 0.2 0.3 1 Economic and Logistical Reasons 0.15 0.35 0.1 1 The table shows a correlation matrix between the four factors: medical, behavioral, economic, and social. The strongest correlation was between medical and behavioral factors (0.45), and the weakest correlation was between social and logistical factors (0.1). The factors are generally interconnected, but to varying degrees, indicating the importance of treating each factor relatively independently, while paying attention to minor overlaps. Figure 6 illustrates the correlation matrix for this heat map, which illustrates the relationships between the four factors influencing patients' choice of doctor. The closer the color is to dark red, the stronger the correlation between the two factors. The figure shows: • The highest correlation was between medical and behavioral factors (0.45). • The weakest correlation was between sociocultural and economic factors (0.1). • There were moderate correlations between behavioral and economic factors (0.35) and social factors (0.3). Figure 6: Illustrates the Correlation Matrix for This Heat Map Table 4: Factors Influencing Choice of Physician (% of Participants) Factor Number of Patients Percentage (%) Medical Experience and Competence 89 0.82 Kindness and Human Behavior (e.g., smiling) 84 0.78 Wearing the Medical Uniform 79 0.73 Eye Contact During Communication 70 0.65 Handshake at Greeting 54 0.5 Appropriate Age of the Doctor 43 0.4 Gender Preference (Male or Female Doctor) 49 0.45 Good Appearance (Clothes, Makeup, Hair) 38 0.35 Neat Hair and Grooming 32 0.3 Table 4 demonstrates the doctor choice factors by patients in terms of number of patients and percentage of each factor. Competence and experience in medicine were ranked first among all the factors at the total of 82%, indicating that it is the patients' number one criterion. This was followed by friendliness and humane attitude, such as smiling, at 78%, reflecting the importance of the human factor in medical encounters. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 20 Wearing medical uniforms also ranked high as an influential factor, 73%, and then eye contact at 65%. Physical and social factors were comparatively less important; 50% of the patients considered a handshake important, 45% desired a doctor of a particular gender, and 40% desired the age of the doctor to be important. The overall appearance of the doctor, i.e., clothes and hair style, had a limited impact (35% and 30%, respectively). The results indicate that patients place greater importance on professional competence and humane behavior, with appearance and courtesy being seen as add-on but not primary factors. Figure5: Factors Influencing Choice of Physician (% of Participants) Table 5: Relative weight (%) Factors Affect Patients' Preferences for Doctors Factor Relative weight (%) Medical Experience and Competence 17% Kindness and Human Behavior (e.g., smiling) 15% Wearing the Medical Uniform 14% Eye Contact During Communication 12% Handshake at Greeting 11% Appropriate Age of the Doctor 10% Gender Preference (Male or Female Doctor) 11% Good Appearance (Clothes, Makeup, Hair) 9% Neat Hair and Grooming 1% TotaL 100% Table 5 Relative weights of factors influencing the selection of a doctor. Professional competence and skill headed the list at 17%, as a reflection of the importance attached to professionalism by patients. Humane behavior and kindness was second at 15%, for the recognition of the importance of human touch in the relationship between doctor and patient. It also suggests medical uniform dress and eye contact were important factors, respectively accounting for 14% and 12%, and handshaking and doctor's gender preference, also being equally weighted (11%). The proper age of the doctor accounted for 10% of the relative weight. Conversely, the doc's hairstyle and style placed last, with a mere 9% and 1%, and formal traits being weaker than professional and humane ones. These results reflect a relative balance between the various factors, with a clear understanding towards professionalism and competence. Figure 6: Relative Weight (%) Factors Affect Patients' Preferences for Doctors Figure 6 shows that patients place a high priority on the doctor's medical experience and competence, at 17%, followed by the importance of kindness and humane behavior, such as smiling, at 16%. Wearing medical uniform was also an influential factor, at 14%, followed by eye contact during conversation, at 13%. The appropriate age for the doctor accounted for 12% of the relative weight, while gender preference (male or female) accounted for 10%. Handshaking when greeting received 9%, followed by elegant appearance, in terms of clothing and makeup, at 8%, and finally, cleanliness and styling of hair, at the same percentage. These figures demonstrate that the choice of doctor does not depend solely on medical skills, but is also influenced by human, social, and physical factors to varying degrees [1]. Table 6: Hypotheses Testing Hypotheses Βeta T-value P-value Result H1 There is huge impact of patients’s preferences on choosing their family physician. 0.3 4.22 <0.0001 Supported* H2 Patients’s preferences does not affect in choosing their family physician. 0.45 0.88 0.65 Not Supported* R1 for H1 0.67 Q1 H1 0.49 R2 H2 0.32 Q2 H2 0.16 Table 6 shows the result of the hypothesis testing. The first hypothesis (H1) was statistically significant, and it had a beta value (β) of 0.3 and a t value of 4.22 with very high statistical significance (P < 0.0001). This indicates a strong influence of patient preferences over family physician choice. The second hypothesis (H2), that patient preferences don't have an impact, was rejected on the basis of its t value being 0.88 and p value being 0.65, showing that it is not statistically significant. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 3 | November-December 2025 21 The determination coefficients showed the R1 for the first hypothesis to be 0.67, indicating that it explained the variance well, whereas that of the second hypothesis was much lower (0.32). The predictive values of Q1 = 0.49 to H1 and Q2 = 0.16 to H2 also proved the reliability of the model in validating the first hypothesis. [1]. Conclusions The following are the most important conclusions based on the table and graph: 1) The diversity in demographic characteristics in particular and in the data in general supports the reliability and accuracy of the results [25]. 2) Analysis of the questionnaire results showed that all domains enjoyed high reliability, with Cronbach's alpha values range from 0.80 to 0.92, with the highest being in the personal and behavioral factors. These factors also contributed the largest percentage of explained variance (40%), indicating their significant influence on the phenomenon studied. In contrast, medical factors contributed only 10%, despite their high reliability. The total variances explained for all factors was 85%, a high percentage that reflects the validity of the instrument used. All results were statistically significant (p < 0.001), enhancing the reliability and validity of the results [26]. 3) Medical competence was the most important factor for patients, as it received the highest relative weight, reflecting that patients are primarily concerned with the quality of the healthcare they receive. The most influential factor was the doctor's competence and experience (17%), followed by kindness and humane behavior (16%). Wearing a medical uniform (14%) and eye contact (13%) were also important. Age (12%) and gender preference (10%) had a moderate impact, while handshaking (9%) and elegant appearance (8%) were less influential. [27]. 4) Hypothesis tests supported hypothesis H1, which states that patient preferences support improved health service quality, and rejected the null hypothesis H2, which states that patient preferences do not contribute to improved health service quality. The most notable recommendations that might be made in light of the analysis and evaluation of survey results are the following: 1) The need for doctors to take more notice of patient preferences regarding professional skills and interpersonal behavior. 2) They need to teach doctors interpersonal techniques such as eye contact, smiling, and handshaking since they influence patient choices. 3) Enhancing the professional image of the physician via support for the medical dress code and personal cleanliness, as these have been found to play a role in the construction of the impression. 4) These factors should be part of the family physician selection and evaluation policies of health care organizations. 5) Conduct further studies in different cultural settings to affirm the generalizability of the results. The need for updating the selection policy and physician selection strategies to comply with patient needs and preferences. 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