Background: Keratoconus (KC) causes visual disability in young adults. To improve its early detection and compliance, improving the awareness of patients and their relatives is crucial. We present the level of awareness about KC among the adult population of western Saudi Arabia and its determinants. Methods: This web-based survey was carried out from June to August 2020 in urban and semi-urban areas in western Saudi Arabia. Demographic and eye ailment profiles were collected. To generate responses on the presentation, causes, management and prevention of KC, a five-point Likert scale was used. The logit values were calculated and graded into good and poor awareness. Awareness was associated with other determinants. Results: We surveyed 420 Saudi adults. The median logit score of awareness about KC among participants was 2.86 (inter quartile range (IQR) 0.86; 2.95). The median score of knowledge about the causes and presentation of KC was 2.86 (IQR 1.1; 2.86) and for management, it was 0.00 (IQR 0.00; 0.18). The level of awareness was good in 286 participants (68.1%) and poor in 134 (31.9%). Residents of major cities (P < 0.04) and women (P < 0.001) had significantly better awareness about KC. Knowledge about KC mainly came from friends and reading about it. The mass media and social media were rarely used to seek knowledge. Conclusions: Awareness about the presentation, causes and management of KC was good in two-thirds of adults but with some variation. Strategies to involve the community and stress health education need to be urgently implemented. Campaigns should target the male and semi-urban population in western Saudi Arabia.
Keratoconus (KC) is an ectatic disease characterized by the mainly bilateral but occasionally unilateral progressive thinning and protrusion of the cornea, resulting in irregular astigmatism and sometimes scarring and thereby leading to significant visual impairment [
High quality eye services are available free of charge to the Saudi population. To further reduce visual disabilities, strategies such as health promotion, local organ donation and improved compliance should be planned. Both service providers and eye patients are stakeholders in this task. KC management includes periodic eye checkups, prescriptions for spectacles and contact lenses, collagen cross-linkage, refractive surgery and keratoplasty [
The western region, one of five regions in Saudi Arabia, has large cities such as Jeddah, Makah and Medina as well as many small but well-developed semi-urban areas. The total population of this region is around 9.5 million. Nearly 187 ophthalmologists provide secondary and tertiary eye care to this population [
To the best of our knowledge, there is limited information on awareness among the general Saudi population about KC, which is a disease mainly affecting young adults in their productive life. To provide effective and timely intervention for KC, it is essential to support the population and encourage KC patients to comply with eye professionals’ advice. We discuss the awareness of KC of adults in western Saudi Arabia as well as its prevention and management and the source of their information.
The ethical and research committee of our university approved this survey-based cross-sectional study. Given the Covid-19 pandemic, the responses of participants were collected using Google between June and August 2020. Written informed consent was obtained. Adults aged 18 years and older agreeing to participate were included. They were approached through social media, personal contacts and WhatsApp groups. Those not consenting to participate were requested to leave the survey. Participants were requested to complete all the survey questions. The questionnaire was prepared in the local language. To ensure translation consistency, reverse translation and a pilot of the survey tool was undertaken. The tenets of the Helsinki Declaration were strictly abided by during all stages of the research.
We assumed that the level of awareness among the five million Saudi adults in western KSA was 57% [
Five medical students were involved in the study. They approached the adult population in three major cities and semi-urban areas using social media to encourage them to participate and then sent a link for the web-based questionnaire.
The demographic information collected included age group, sex, occupation, literacy rate and social status. Information on KC among participants and relatives, other eye medication, surgeries and systemic ailments were collected. Residents of Makkah, Medina and Jeddah were considered urban and the rest were grouped as semi-urban dwellers.
Sixteen questions were related to KC grouped as 1) KC as a disease (11 questions), 2) treatment of the condition (4) and 3) prevention of KC (1) (Appendix: 1). We had undertaken quality control measures like pilot of the measurement tool, reverse translation, monitoring of the data collection. We also performed Cronbach alpha test (>0.75) to study internal reliability of the questionnaire for awareness. Participants responded using a five-point Likert scale [
The collected data were entered into a Microsoft Excel spreadsheet. After cleaning the data and undertaking consistency checks, they were transferred into the Statistical Package for Social Studies (SPSS 25) (IBM, NY, USA). Univariate analysis was performed using the parametric method. The continuous outcome variable (logit score of awareness) was plotted to study the distribution. For normally distributed variables, the mean and standard deviation were calculated. For non-normal variables, the median and inter quartile range (IQR) were estimated. The qualitative data were presented as the number and percentage. The comparison of good and poor awareness was associated with the determinants. Two-sided P values were calculated for statistical significance. A P value of <0.05 was considered statistically significant.
We surveyed 420 adult residents of western Saudi Arabia. Their profile is given in
The source of their information included friends (42; 9%), social media (49; 11.7%), relatives with KC (28; 6.7%), lectures (14; 3.3%) and reading (52; 12.4%). The median logit score of awareness about KC among participants was 2.86 (IQR 0.86; 2.95)
The logit score of three sub-groups of awareness cause and presentation of KC, management and prevention were also analyzed separately. The median logit score of knowledge about cause and presentation of KC among adult population of western Saudi Arabia was 2.86 (IQR 1.1; 2.86). The median logit score of knowledge about management of KC among adult population of western Saudi Arabia was 0.00 (IQR 0.00; 0.18). The median logit score of knowledge about prevention of KC was 0.00 (IQR 0.00; 0.00)
Number | Percentage | ||
---|---|---|---|
Age group | 18 to 25 | 98 | 23.3 |
26 to 30 | 65 | 15.5 | |
31 to 40 | 106 | 25.2 | |
More than 40 | 151 | 36.0 | |
Gender | Male | 202 | 48.1 |
Female | 218 | 51.9 | |
Residence | Makkah (city) | 39 | 9.3 |
Jeddah (city) | 143 | 34.0 | |
Madina (city) | 34 | 8.1 | |
Taif (semi-urban) | 114 | 27.1 | |
Yanbu (semi-urban) | 60 | 14.2 | |
Khulayas (semi-urban) | 30 | 7.1 | |
Literacy | Elementary | 2 | 0.5 |
Middle school | 3 | 0.7 | |
High school | 77 | 18.3 | |
University | 308 | 73.3 | |
High education | 30 | 7.1 | |
Occupation | Student | 79 | 18.8 |
Employed | 206 | 49.0 | |
Housewife | 33 | 7.9 | |
Retired | 66 | 15.7 | |
Unemployed | 36 | 8.6 | |
Social status | Married | 255 | 60.7 |
Single | 148 | 35.2 | |
Divorced | 10 | 2.4 | |
Widow | 7 | 1.7 |
The level of awareness was good in 286 (68.1%) and poor in poor in 134 (31.9%) participants. Of the former, only 6 (1.4%) participants had an excellent grade of awareness.
The good and poor grades of awareness of participants were associated with different independent variables (
Number | Percentage | |
---|---|---|
Using spectacles for distance viewing | 136 | 32.4 |
Using contact lens for viewing | 55 | 13.1 |
Refractive surgery done | 51 | 12.1 |
Eye allergy | 105 | 25 |
Taking eye medication | 19 | 4.5 |
Other Eye surgery in past | 16 | 3.8 |
Systemic health ailment | 96 | 22.9 |
Diagnosed with keratoconus | 9 | 2.1 |
Keratoconus in other family member | 24 | 5.7 |
Good awareness of KC (n = 286) | Poor awareness of KC (n = 134) | Validity | ||||
---|---|---|---|---|---|---|
Gender | Male | 131 | 45.8 | 87 | 64.9 | OR = 2.2 (95% CI 1.4; 3.3) P < 0.001 |
Female | 155 | 54.2 | 47 | 35.1 | ||
Age group | 18 to 30 | 118 | 41.3 | 45 | 33.6 | OR = 0.7 (95% CI 0.5; 1.1) P = 0.1 |
31 and more | 168 | 58.7 | 89 | 66.4 | ||
Residence | Major city | 157 | 54.9 | 59 | 44.0 | OR = 1.5 (95% CI 1.0; 2.3) P = 0.04 |
Semi urban | 129 | 45.1 | 75 | 56.0 | ||
Occupation | Students | 51 | 17.8 | 28 | 20.9 | c2 = 0.1 Df = 4 P = 0.8 |
Housewife | 22 | 7.7 | 11 | 8.2 | ||
Employed | 146 | 51.0 | 60 | 44.8 | ||
Retired | 43 | 15.0 | 23 | 17.2 | ||
Unemployed | 24 | 8.4 | 12 | 9.0 | ||
Literacy | Not school graduates | 58 | 20.3 | 24 | 17.9 | OR = 0.85 (95% CI 0.5; 1.5) P = 0.6 |
College & higher | 228 | 79.7 | 110 | 82.1 | ||
Social status | Married | 167 | 58.4 | 88 | 65.7 | OR = 0.7 (95% CI 0.5; 1.1) P = 0.2 |
Not married/single | 119 | 41.6 | 46 | 34.3 | ||
KC status | With KC in family | 6 | 2.1 | 3 | 2.2 | OR = 0.9 (95% CI 0.2; 3.8) P = 0.9 |
No KC in family | 280 | 97.9 | 131 | 97.8 | ||
Eye allergy | Yes | 67 | 23.4 | 38 | 28.4 | OR = 0.8 (95% CI 0.5; 1.2) P = 0.3 |
No | 219 | 76.6 | 96 | 71.6 | ||
Eye surgery | Yes | 9 | 3.1 | 7 | 5.2 | OR = 0.6 (95% CI 0.2; 1.6) P = 0.3 |
No | 277 | 96.9 | 127 | 94.8 |
The level of awareness about KC was good in two third of the surveyed adult population of Western Saudi Arabia. One in seventeen surveyed participants had KC in family. Females and residents of the major cities had better awareness about KC compared to males and residents of semi-urban population. The awareness about prevention and management were less compared to the knowledge about causes and presentation. The source of knowledge about KC was mainly through friends and reading about it. Mass media, social media and interaction with health personnel were not the main source of information about KC.
This is perhaps the first such survey in Saudi Arabia inquiring adult Saudi population about keratoconus. There was a good representation of both genders, age groups and urban and semi-urban population. There seems to be a strong need for health education using population preferred mode of delivering these messages. The score system used in the present study for evaluating five graded response seems to be better than qualitative method of describing the responses of participants. This was because there was a wide variation in non-response for individual questions related to awareness.
Two thirds of participants had a good level of awareness about KC in present study. This matched with the level of awareness among non-medical students of Abha province of Saudi Arabia [
The rate of KC in participants of present study and their family was 5.7%. This was close to 4.8% in pediatric age-group noted in Saudi Arabia [
Health promotion to improve awareness among patients, their relatives and population at large has been advocated in Brazil and then globally by Violet June [
There was wide difference in level of awareness among urban (city dwellers) compared to other participants in present study. This was also noted by Dondana et al. [
In our study, females had better knowledge than males about KC. This was in contrast to the less awareness about blinding eye diseases in females compared to males noted in the developing country like Nepal and Pakistan [
There were a few limitations in the present study. Use of web-based survey tool during Covid Pandemic perhaps could have resulted in a bias population that was smartphone computer users in the study area. Therefore, extrapolating the study results to the entire population especially adult semi-urban population not well versed with digital knowledge seeking tools should be done with caution.
We thank the people of Saudi Arabia for participating in this survey. We thank Dr Rajiv Khandekar for guiding and giving inputs to improve research.
The authors declare no conflicts of interest regarding the publication of this paper.
Alzuhairy, S., Hamza, R., Alharbi, M., Alqadi, M., Alharthi, A., Alzahrani, K.T. and Alshehri, A.H. (2020) Web Based Survey of Adult Population of West and Central Saudi Arabia about Cause and Management of Keratoconus. Open Journal of Ophthalmology, 10, 341-350. https://doi.org/10.4236/ojoph.2020.104037