Knowledge, Attitudes, and Practices With Regard to Cosmetic Procedures Among the General Population in the Western Region of Saudi Arabia: A Cross-Sectional Study

Background One of the most frequently carried out medical procedures is an aesthetic procedure. These procedures have become increasingly popular in our country due to various factors, such as body image dissatisfaction, the desire for perfection, and the expanding influence of social media. The aim of our study is to assess the knowledge, attitudes, and practices with regard to cosmetic procedures among the general population in the western region of Saudi Arabia. Methods This population-based cross-sectional study uses a self-report questionnaire distributed via social media platforms with randomized sampling between March and April 2023. The target population of this study is the general population in the western region of Saudi Arabia who are 18 years old and above from both genders. All participants who have congenital anomalies or mental disorders, are non-Arabic speakers, and refuse to participate in the study are excluded. Our data collected via an online self-administrated translated questionnaire survey was designed using a Google Forms questionnaire template. Results The study questionnaire was completed by 477 individuals in total. The mean age of the participants was 27.4±12.9 years, with ages ranging from 18 to over 60. A total of 190 individuals (39.8%) had prior knowledge of cosmetic procedures, and 338 (70.9%) were female. Of the non-surgical cosmetic treatments that people are most familiar with, 37.9% mentioned filler injections. Additionally, the most popular surgical cosmetic surgery was rhinoplasty (73.6%) and liposuction (22%). 85.7% of respondents said social media impacts people's decisions to undergo cosmetic treatments, while 86.8% of respondents said women do more cosmetic procedures than males. Of the participants, only 40 (8.4%) had previous cosmetic procedure done before. Rhinoplasty was the most common undergone surgical treatment (15.4%). In terms of non-surgical treatments, hair removal accounted for the majority (51.3%). Conclusion This study revealed that 39.4% of the study population, the majority of which are young individuals, females, and singles, have a good knowledge with regard to cosmetic procedures due to many factors such as culture diversity among generations, distribution of the social media, and interest differences. We conclude that the social media factor can significantly influence the practice of cosmetic procedures.


Introduction
One of the most frequently performed medical procedures is aesthetic surgery.These procedures have gained increasing popularity in our country due to various factors, including dissatisfaction with one's body image, the pursuit of perfection, and the growing influence of social media [1].Cosmetic procedures are defined as "treatments designed to enhance a person's appearance" [2] and are categorized into surgical and non-surgical options [3].Surgical procedures encompass rhinoplasty, breast augmentation, and blepharoplasty [4], while non-surgical procedures include botulinum toxin injections, chemical peels, filler treatments, vein removal, laser skin resurfacing, and laser hair removal [5,6].
According to the American Society of Plastic Surgeons, there has been a significant global increase in the number of cosmetic procedures performed over the past two decades, with a remarkable growth rate of 169% between 2000 and 2019.Notably, the majority of these procedures were minimally invasive, and women have shown a greater willingness to undergo these minimally invasive procedures, as they offer a more natural appearance with minimal recovery time [7].
Several epidemiological variables, social factors, and psychological traits, including self-esteem, body image, and other personality characteristics, as well as specific psychopathologies have been associated with an interest in cosmetic surgery.These variables can predict an individual's inclination to pursue or avoid cosmetic procedures [8].
It is worth noting that Saudi Arabia ranks 22nd among the top 25 nations in the world with the highest rates of cosmetic surgery, according to a study conducted by the International Society of Aesthetic Plastic Surgery [9].Numerous studies have also explored surgical and non-surgical procedures in various cities and regions across Saudi Arabia.However, there has been a notable absence of prior research specifically addressing the western region of the country.Hence, our study aims to evaluate the knowledge, attitudes, and practices with regard to cosmetic procedures among the general population residing in the western region of Saudi Arabia.

Materials And Methods
This is a population-based cross-sectional study conducted at Umm Al-Qura University, Makkah, Saudi Arabia, from March to April 2023, employing a self-report questionnaire distributed via social media platforms with randomized sampling.The study's target population comprises adults aged 18 and above from the western region, including both genders.Individuals with congenital anomalies and mental disorders, who are non-Arabic speakers, or who decline to participate are excluded from the study.The questionnaire comprises five sections: a consent form, sociodemographic data, an assessment of knowledge regarding cosmetic procedures, an evaluation of attitudes toward cosmetic procedures, and an assessment of the practice of cosmetic procedures.The selection of items for the questionnaire was informed by a thorough literature review [10].The questionnaire was distributed in Arabic language.Our data were collected through an online, self-administered, translated questionnaire survey created using a Google Forms questionnaire template.It was accompanied by information about the survey's objectives and the target population and a request for voluntary participation, with the assurance of maintaining the confidentiality of all responses.

Sample size determination
The minimum required sample size for this study was determined using OpenEpi Version 3.0, taking into account the following factors: a population size estimated at approximately 8,325,304 individuals (as reported by the General Authority for Statistics), a confidence interval (CI) level of 95%, and an anticipated frequency of 50%.The calculated sample size came out to be 385 participants.To account for potential data loss, the total sample size was increased to 400 participants.This study received approval from the Biomedical Research Ethics Committee of Umm Al-Qura University, with the approval number HAPO-02-K-012-2023-03-1519.

Data analysis
The data were collected, reviewed, and subsequently input into IBM SPSS Statistics for Windows, Version 21.0 (Released 2012; IBM Corp., Armonk, New York, United States).All statistical methods employed were two-tailed, with a significance level (alpha) set at 0.05, considering results as significant if the p-value was less than or equal to 0.05.Descriptive analysis involved the presentation of frequency distributions and percentages for various study variables, including participants' personal information and cosmetic procedures undergone personally and within their families.Additionally, data pertaining to knowledge, attitudes, and practices with regard to cosmetic procedures were tabulated.
Cross-tabulation was utilized to display factors associated with participants' knowledge of cosmetic procedures, and statistical significance was assessed using the Pearson chi-squared test.In cases where small frequency distributions were observed, an exact probability test was applied.

TABLE 2: Participants' awareness and perception regarding cosmetic procedures in the western region of Saudi Arabia
The study declared that about 418 (87.6%) of the participants think cosmetic procedures are common, 414 (86.8%) stated that women undergo more cosmetic procedures than men, 409 (85.7%) believe that social media influences the decision to have a cosmetic procedure, and 373 (78.2%) agreed that low self-esteem causes people to undergo cosmetic procedures, while 354 (74.2%) indicated that they would feel intimidated if they decided to do cosmetic procedures (Table 3).

TABLE 4: Self-practice regarding cosmetic procedures among study participants in the western region of Saudi Arabia
A total of 208 (43.6%) reported that one of their relatives had undergone cosmetic procedure.Among these, 53 (25.5%) mentioned siblings, 22 (10.6%)mentioned parents, and the majority 125 (60.1%) mentioned other relatives.The most commonly undergone non-surgical procedures among relatives were filler injections 120 (57.7%),Botox 97 (46.6%), hair removal 72 (34.6%), and non-surgical liposuction 51 (24.5%).As for surgical procedures, rhinoplasty 62 (29.8%) and liposuction 41 (19.7%) were the most commonly mentioned, while other procedures accounted for 54 (26%) (Table 5).To the best of our knowledge, this study represents the first attempt to assess the knowledge, attitudes, and practices with regard to cosmetic procedures among the general population in the western region of Saudi Arabia.We discovered that 39.6% of the participants display a solid understanding of aesthetic procedures, a significantly higher proportion compared to a previous local study conducted in Al-Majmaah in 2020, which reported that only 18% possessed a good knowledge base [10].Globally, a different study conducted in 2016 among undergraduates studying basic sciences at a Nigerian university found that only 4.2% of the respondents had a reasonably good level of knowledge [11].This variance can be attributed to various factors, including cultural diversity and the widespread use of social media within our local society.
Among the three categories examined, namely, young individuals, females, and single participants, we observed the highest perception of cosmetic procedures.This outcome aligns with expectations, given the heightened sociocultural pressures exerted on women to conform to certain standards of physical appearance.Such pressures may explain the observed gender disparity.Similarly, previous studies conducted locally in Riyadh [12] and globally by Markey and Markey and Swami et al. [13,14] also found that women are more likely to embrace cosmetic surgery.
In terms of the acceptance of aesthetic procedures, only 158 (33.1%) of the survey participants expressed approval, a notably lower figure when compared to two studies conducted in other regions of Saudi Arabia [10,12].This outcome aligns with expectations, considering that our western region is known for its conservative societal norms.Interestingly, 418 (87.7%) of the 477 participants acknowledged that cosmetic procedures are indeed prevalent in our society.
Among our participants, only 40 (8.4%) had undergone prior aesthetic procedures.In contrast, in the United States, the rate of cosmetic surgery among women stands at 24.1% [15], whereas a substantial 55.4% of Saudi women have undergone such procedures [16].This significant disparity can be attributed to the preference among American women for invasive treatments like liposuction and breast augmentation [15].
Another notable finding in our study is that the majority of respondents use the internet as their primary source of information about cosmetics (76.7%).This discovery aligns with a local study conducted in Al-Taif City among female university students, which reported that the internet was the most prominent source of information for cosmetics (79.1%) [17].Furthermore, most of our participants believe that social media exerts the greatest influence on their decision to undergo cosmetic procedures.Surprisingly, these findings diverge from a study conducted in the United Kingdom that examined factors influencing the likelihood of undergoing cosmetic procedures.This UK study found that individuals with lower self-ratings of attractiveness were more likely to opt for cosmetic surgery [18].

Strengths and limitations
This research represents the first conducted study in the western region of Saudi Arabia aimed at assessing the knowledge, attitudes, and practices with regard to cosmetic procedures among the general population.
The sample encompassed a diverse range of age groups, genders, and social networks.
The first notable limitation of this study is its reliance on a cross-sectional survey design and self-reported data, which may not fully capture the dynamics of cosmetic trends accurately.Additionally, the study's sample was confined to individuals encountered within the western region, limiting the generalizability of the findings to the entire Saudi Arabian population.We recommend conducting further research in other regions of Saudi Arabia among the general population, as cultural and traditional differences may yield varying results.

Conclusions
Our findings revealed that 39.4% of the study population, the majority of which are young individuals, females, and singles, have a good knowledge with regard to cosmetic procedures due to many factors such as culture diversity among generations, distribution of the social media, and interest differences.There was a significant association between the young age group individuals and increased knowledge and awareness of cosmetic procedures; the rise in awareness in young people is most likely due to social media usage as it is the most reported source of information in our study.We conclude that the social media factor can significantly influence the practice of cosmetic procedures.

TABLE 1 : Sociodemographic data of study participants in the western region of Saudi Arabia
SR: Saudi riyalAs for participants' awareness and perception regarding cosmetic procedures, the current study showed that 190 (39.8%) had previous knowledge about cosmetic procedures.With regard to the most common nonsurgical cosmetic procedures they were aware of, 181 participants (37.9%) spoke of filler injection, 145 (30.4%) reported for hair removal, and 85 (17.8%) told about botulinum toxin A. In addition, when it came to surgical cosmetic procedures, rhinoplasty and liposuction were the most well-known surgical cosmetic procedures, with 351 (73.6%) of participants recognizing rhinoplasty, followed by liposuction 105 (22%) and breast augmentation 22 (4.4%).As for reason that motivates people to undergo cosmetic procedures, 324 (67.9%) cited the influence of social media, and 319 (66.9%) mentioned a desire for better appearance.Additionally, 199 (41.7%) mentioned other factors, and 173 (36.3%) reported for personal desire.The most reported sources of information included the internet 366 (76.7%), friends 160 (33.5%), and physicians 145 (30.4%) (Table2).

TABLE 5 : Family history of undergoing cosmetic procedures in the western region of Saudi Arabia
Factors Do