Knowledge and Attitudes Regarding Cataracts and Their Associated Factors Among Hail Region Residents in Saudi Arabia

Background Cataract is a condition that affects the lens, causing separation and/or aggregation of proteins and disrupting the regular alignment of cell fibers. Cataracts have many known risk factors contributing to their development, such as diabetes, oral steroid therapy, smoking, and high body mass index. Good knowledge about cataracts may improve the quality of treatment through early diagnosis. Unfortunately, poor knowledge is still a significant barrier to reducing blindness caused by cataracts in developing countries. Methodology This cross-sectional study was conducted using a pre-validated questionnaire and online questionnaires. Participants were approached through multiple social media platforms from June 2022 to August 2022. Results Of the 307 participants, with a mean age of 32.4 ± 12.8 years, 51.5% had good knowledge of cataracts and their related risk factors, while 28.7% had a favorable attitude about cataracts. Of all participants, 50.5% reported a diagnosis of cataract. The majority of participants, 58.6%, who did not have cataracts, had good knowledge versus 44.5% of others with (p = 0.014). Moreover, 75% of participants aged 50 years or older had good overall cataract knowledge levels compared to 38.9% of others aged 30-39 years (p = 0.002). Conclusions Cataracts are a preventable cause of blindness that can be corrected by surgery. In this study, we discovered extremely concerning rates of knowledge, awareness, and attitudes regarding cataracts among the populations of Hail City. More educational programs should be directed toward spreading knowledge about cataracts to patients and the public.


Introduction
Cataract affects the lens, causing the usually transparent lens to cloud.Depending on the location of the clouding, it can affect vision to varying degrees.It is believed that the most plausible cause for lens cloudiness is the separation and aggregation of proteins; another reason is the disruption of the regular alignment of cell fibers [1].According to the World Health Organization, cataracts are one of the leading causes of blindness worldwide, causing 94 million people to have moderate or severe distance vision impairment or blindness [2].In a Saudi study, the prevalence of visual impairment was 13.9% (95% confidence interval = 11.4%-16.9%),and cataract was the underlying cause for 29.1% of cases [3].
Many risk factors play a role in the development of cataracts, such as diabetes, oral steroid therapy, current smoking, high body mass index, occupational exposure to sunlight, gout medications, family history, and use of eyeglasses by age 20 years [4].According to the Ministry of Health, the most reported symptoms of cataracts are gradual and painless weakening of vision, sensitivity to bright lights, formation of halos around lights, struggle to see clearly at night, and the lens gradually changing its color to white or brown as cataract advances [5].The public needs to be wary of these symptoms and seek ophthalmologist advice.Regarding cataract intervention, cataract surgery has developed into a small-incisional procedure with quick vision recovery, positive visual outcomes, and few complications in most patients because of advancements in surgical technology and techniques.The treatment of cataracts with astigmatism, presbyopia, or both is now achievable because of advances in intraocular lens technology [6].As a variation of extracapsular cataract surgery, manual small-incision cataract surgery also has similar intraoperative and postoperative problems, according to studies on its effectiveness and safety for cataract surgery.Therefore, the risk of iris damage, striate keratitis, and posterior capsular rupture is increased by the significant handling that occurs inside the anterior chamber during nucleus administration [7].In addition to the complication of cataract surgery, posterior-capsule opacification is considered a primary cataract surgery complication that occurs the most frequently [8]; hence, the rectangular, sharp-edged optic design, which produces a sharp capsular bend, is the fundamental cause of the effectiveness of the sharp-edge foldable intraocular lens types in preventing posterior capsule opacification [9].
A cataract is a condition influenced by an individual's occupation, lifestyle, and general health.Therefore, awareness should be raised, and the public should be educated.Multiple studies conducted in different regions in Saudi Arabia have shown poor knowledge and understanding regarding cataracts [10][11][12][13]; however, none of these studies assessed the awareness and knowledge of the Hail population.Therefore, conducting such research in the Hail region would be needed to understand and measure the public's awareness of cataracts and their factors.

Objectives
This study aimed to explore the knowledge, attitudes, and awareness of Hail region residents regarding cataracts and their causes, associated risk factors, and treatment options.

Study design
This cross-sectional study was conducted using a validated questionnaire after the approval of the Institutional Review Board (approval number: H-2022-273).A total of 307 participants aged 18 and above and residing in the Hail region were included.Participants were recruited using an electronic online questionnaire through multiple social media platforms (e.g., WhatsApp, Twitter, Telegram) from June 2022 to August 2022 in the Hail region of Saudi Arabia.The agreement to participate in the study was considered proof of consent.The demographic data of the participants were recorded and analyzed.

Content of the survey instrument
A 24-item questionnaire was developed to assess the knowledge, attitudes, and awareness of cataracts and their associated risk factors in the Hail region.Initially, items one through six were about participants' data.Participants' knowledge about cataracts and their consequences was tested using 15 items.One item was used to assess participants' source of information and where they received their knowledge of cataracts.Finally, five items were designed to assess participants' attitudes and awareness regarding cataracts.

Sample size
In total, 307 participants were needed to estimate the knowledge, attitudes, and awareness of cataracts and their associated risk factors in the Hail region.The sample size calculated for this cross-sectional study used the following formula = Z 1-ᾳ/2 2 SD2/d2, where Z1-α/2 is the standard normal variate (5% type 1 error) and a confidence level of 95%.SD is the standard deviation of the variable and d is the absolute precision.

Statistical analysis
The data were collected, reviewed, and fed to SPSS version 21 (IBM Corp., Armonk, NY, USA).All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if the p-value was less than or equal to 0.05.A descriptive analysis was done, and the knowledge and attitude of adult participants regarding cataracts, risk factors, and treatment were tabulated.Participants' awareness regarding cataract prevention and their source of information on cataracts were graphed.Pearson chi-square test for significance and exact probability test were used to determine small frequency distributions in participants' overall knowledge level by their data and source of information, as well as testing the distribution of participants' attitudes by gender using the latter test.
Overall knowledge level regarding cataracts was assessed by summing up discrete scores for multiple correct knowledge items.The general knowledge score was categorized as poor if the participant's score was less than 60% of the overall score and good if the participant's score was 60% or more.

FIGURE 1: Cataract prevention methods reported by study participants,
Hail, Saudi Arabia.
The most reported source of information among study participants was doctors (45.9%) (Figure 2).As shown in  In total, 158 (51.5%) participants had good knowledge of cataracts and related factors, while 149 (48.5%) had a poor knowledge level (Figure 3).As shown in Table 4, 75% of participants aged 50 years or older had an excellent overall cataract knowledge level compared to 38.9% of others aged 30-39 years (p = 0.002).Moreover, 64.7% of unemployed/retired participants had a good knowledge level compared to 30% of healthcare staff (p = 0.007).Furthermore, 58.6% of participants with no cataract history had good knowledge versus 44.5% of others (p = 0.014).

Discussion
Study participants aged 20-29 years scored 60 points, with seven participants showing a good knowledge of cataracts, while those aged 30-39 years demonstrated the opposite.However, another study in southern Ethiopia showed that adults (≥40 years) were twice more likely to have good knowledge about cataracts than younger individuals [14].Of the study respondents, most students had more knowledge about cataracts than healthcare staff.Despite that, our study included all students, including medical students, so it is possible that their percentages were high.The study showed that participants complained of poor cataract knowledge.To enhance awareness regarding cataracts, it is imperative to intensify health education efforts, explain the condition to patients, and conduct community-wide awareness campaigns.
Regarding the attitudes toward cataracts, 29% of the participants showed a positive attitude, which is slightly less compared to a study done in southern Ethiopia (37.9%) [15], with both showing a low positive attitude.Moreover, males had more positive attitudes than females.
On the contrary, two recent studies from Saudi Arabia about the attitudes toward diabetes mellitus, one among diabetic patients in Jazan [16] and another among university students in Jeddah [17], showed a highly positive attitude.We can speculate the difference between the attitudes toward cataracts and diabetes mellitus is because of two main reasons.First, diabetes is prevalent in the community, and the fact that having relatives with the same condition enhances an individual's attitude and knowledge about the condition.Second, the large number of awareness campaigns that are implemented in public places and schools help improve attitudes.The importance of assessing attitude is because the study population's positive attitude toward cataracts can raise awareness regarding the causes, prevention, and treatment of cataracts [14].
The majority of participants did not know the correct definition of a cataract, as in a study in Gondar town, northwest Ethiopia, with about 51% of participants answering incorrectly [18].
Most participants knew that cataracts reduce peripheral vision, while more than half stated that cataracts induce blindness.A previous study showed that participants knew that blurred vision was the most common symptom, while less than half of the participants knew that cataracts can lead to blindness [14].The same study showed that more than half of the participants learned about the risk factors of cataracts, and more than half knew about surgical treatment and extraction of cataract lenses [14].The result of our study and the comparative analysis are favorable regarding treatment awareness.In our study, about 50% agreed that surgery is the treatment for cataracts, which is consistent with two studies from Nepal [19] and Gondar town, northwest Ethiopia [18].The percentage of those who agreed was 64% and 67%, respectively in these studies [18,19].Compared to the awareness regarding other chronic diseases in the Hail region, when asked about the treatment of glaucoma, some studies found that less than half of the participants selected eye drops to treat glaucoma, less than half chose surgery, and more than half chose both [20].As a result, most of the participants had poor knowledge about glaucoma.Therefore, local health authorities must implement glaucoma awareness programs to change public perception and behavior.Another study that aimed to assess general knowledge in the Hail region found that regardless of education level, residence, or employment status, most participants (82%) had a high level of diabetes knowledge and were aware that physical activity can positively affect or prevent diabetes [21].

Limitations
Cataract is a diagnosis that largely affects the elderly population.Given that we collected our data using an online questionnaire which is harder for people with cataracts to fill out, it can be considered a limitation.If they were able to participate, they would have had better knowledge and understanding of cataracts.

Conclusions
Cataracts are a preventable cause of blindness that can easily be corrected by surgery.In this study, we discovered extremely concerning rates of knowledge, awareness, and attitudes regarding cataracts among the population of Hail City.What is more concerning is the poor knowledge and understanding observed among participants diagnosed with cataracts.More educational programs should be directed toward cataracts for patients and the public.

FIGURE 2 :
FIGURE 2: Source of information about cataracts and consequences among adults, Hail, Saudi Arabia.

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growing over the eye • A lens change where the lens becomes opaque • An age-related process leading to a decrease in vision • Is it possible to get back vision from cataract blindness?• Yes 2024 Alanazi et al.Cureus 16(5): e60444.DOI 10.7759/cureus.60444•Can age be a risk factor for cataracts?Can vision problems (such as myopia) be a risk factor for cataracts?that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

TABLE 1 : Demographic data of study participants, Hail, Saudi Arabia.
A total of 112 (36.5%) study participants reported that cataracts are lens changes where the lens becomes opaque, while 58 (18.9%) said that cataracts are an age-related process leading to a decrease in vision.

Table 3
, 84 (27.4%) study participants agreed that a person with a cataract should seek eye treatment, 83 (27%) agreed that cataract is a serious health problem, 26.1% agreed that a person with a cataract needs an eye examination, and, surprisingly, 215 (70.0%) disagreed.The majority of participants, 219 (71.3%), had negative attitudes and awareness regarding cataracts.

TABLE 4 : Distribution of participants' knowledge of cataracts by their related factors and source of information.
P: Pearson chi-square test; $: exact probability test; *: p < 0.05 (significant).

Table 5 ,
Approximately 18.9% of female participants agreed that a person with a cataract needs an eye examination versus 34.8% of male participants (p = 0.004).Furthermore, 26% of female participants agreed that a person with a cataract gets appropriate care in a healthcare institution compared to 38.4% of male participants (p = 0.047).