Knowledge, Awareness, and Attitude Regarding Obstructive Sleep Apnea Among Primary Healthcare Physicians in the Al-Baha Region of Saudi Arabia

Introduction: Obstructive sleep apnea (OSA) is a clinically significant disorder that requires attention from healthcare professionals. This study aimed to assess the knowledge, awareness, and attitude of primary healthcare physicians regarding OSA in Saudi Arabia. Methodology: A cross-sectional observational study design was employed from January 18, 2023, to August 18, 2023, focusing on primary healthcare physicians practicing in the Al-Baha region of Saudi Arabia. The survey included questions related to knowledge, awareness, and attitudes toward OSA, using the Obstructive Sleep Apnea Knowledge and Attitude (OSAKA) questionnaire for OSA, and demographic information. Descriptive statistics and chi-square tests were used to analyze the data. Results: A total sample size of 174 primary health care physicians was collected, where the majority of participants were male (101, 58.0%), and the mean age of the participants was 32.73 years (SD = 9.14). The item with the most correct answers was "The majority of patients with obstructive sleep apnea snore" (150, 86.2%). On the other hand, the item with the lowest number of correct answers was "Laser-assisted uvulopalatoplasty is an appropriate treatment for severe obstructive sleep apnea" (17, 9.8%). The majority of participants agreed that it is essential for physicians to know about OSA as a clinical disorder (161, 92.5%). However, when it came to screening all patients for possible OSA, there was a higher proportion of participants who disagreed or strongly disagreed (111, 63.8%). In general, the majority of participants had a low level of knowledge (109, 62.6%). Gender was significantly associated with both knowledge (p = 0.021) and awareness (p = 0.039), as well as nationality (knowledge (p = 0.012) and awareness (p = 0.039)), and specialty training, which was significantly associated with both knowledge (p = 0.000) and awareness (p = 0.002). Conclusion: Although all participants acknowledged that OSA is a clinical disease, their perspectives on screening and levels of confidence in utilizing screening techniques varied. While the participants exhibited commendable understanding in the majority of domains, there were some facets of OSA in which they lacked expertise.


Introduction
Sleep apnea and hypopnea are common chronic conditions in the general population, and they are characterized by repeated episodes of apnea and hypopnea during sleep.It can manifest as obstructive sleep apnea (OSA), central sleep apnea (CSA), or a combination.When OSA disorder is combined with daytime sleepiness, the condition is known as obstructive sleep apnea-hypopnea syndrome [1,2].
Obstructive sleep apnea is a common sleep disorder among middle-aged adults.It is defined as a sleeprelated disorder in which airflow is significantly reduced due to complete or partial upper airway obstruction, resulting in oxygen deficiency and disrupted sleep [3,4], and it is characterized by nocturnal symptoms such as snoring and witnessed apneas.Sleep disruption can lead to impairment of emotional, marital, social, and occupational health and increase accident risk because of excessive daytime sleepiness [4][5][6].There are a lot of risk factors associated with OSA, such as obesity, male sex, older age, adenotonsillar hypertrophy, and smoking, which are established risk factors for OSA, with the additional risk associated with race/ethnicity and family history.The risk of OSA correlates with body mass index, and obesity remains the one major modifiable risk factor for OSA [7,8].
Obstructive sleep apnea is a growing public health issue, particularly in developing countries, as it affects 3% to 7% of men and 2% to 5% of women [9][10][11] and may be associated with serious complications such as systemic hypertension, pulmonary hypertension, coronary artery diseases, heart failure, arrhythmias, stroke, and neurocognitive disorders [11,12].Obstructive sleep apnea has recently been identified as one of the most common undiagnosed chronic diseases, accounting for more mortality and morbidity than any other sleep disorder [11,13].It is important to recognize that untreated OSA has an independent impact on morbidity and mortality [14].
Primary care physicians can help ensure that OSA is properly diagnosed and treated by becoming more aware of the disorder and its impact on their patients' general health.Patients who are obese or snore should be suspected of having OSA [14].
This study aims to assess general practitioners' knowledge, awareness, and attitude regarding OSA in primary care in the Al-Baha region of Saudi Arabia, and the findings will help to write recommendations to primary care physicians regarding OSA.

Study design
A cross-sectional observational study design was employed from January 18, 2023, to August 18, 2023, focusing on primary healthcare physicians practicing in the Al-Baha region of Saudi Arabia.

Sample size calculation
The required sample size was determined using the Yamane formula, considering a confidence level of 95% and a margin of error of 7%.Adjusting for a 10% non-response rate, the final sample size was determined to be 161 primary healthcare physicians.

Yamane formula: (
where n = number of samples; N = total population; e = error tolerance

Sampling method
A convenience sampling method was utilized to select participants from the sample frame of primary healthcare physicians practicing in the Al-Baha region.

Inclusion and exclusion criteria
Primary healthcare physicians working in the Al-Baha region were included in the study.Those who were not primary healthcare physicians or worked in secondary or tertiary hospitals, those with incomplete questionnaires, and those who refused to participate were excluded.

Data collection
Data were collected through phone interviews with primary healthcare physicians.The Obstructive Sleep Apnea Knowledge and Attitude (OSAKA) questionnaire was utilized.The questionnaire consists of three sections: a knowledge section with 18 questions scored from 0 to 18, an attitude section with five items significantly correlated with each other, and a section focusing on sociodemographic factors such as age, gender, specialty, subspecialty (if applicable), seniority, and workplace.Further, a prepared questionnaire to assess awareness was used, consisting of 18 questions with true, false, and I do not know options.Knowledge and awareness scores were further classified into low (<60% of the overall score), average (60% to 79% of the overall score), and high (>80% of the overall score).This category was included according to Bloom's criteria and has been used by several studies in the past [15,16].

Ethical considerations
Verbal consent was obtained from each participant at the beginning of the questionnaire.Participants were informed about the aims, methods, and anticipated benefits of the study.The study is self-financed, and the researchers are affiliated with the Faculty of Medicine at Al-Baha University, Al-Baha, Saudi Arabia.Potential risks are deemed minimal.Participants had the right to withdraw without reprisals, and they were offered a copy of the informed consent.The study did not impose any financial burden related to investigations or treatment.This research study was approved by the Committee of Research Ethics, Deanship of Scientific Research at Al Baha University, Kingdom of Saudi Arabia (approval number: REC/SUR//BU-FM/2023/05).

Data analysis
Data were entered into Microsoft Office Excel 2023 (Microsoft Corp., Redmond, WA) and analyzed using IBM Statistical Package for the Social Sciences (SPSS) software version 26 (IBM Corp., Armonk, NY).A descriptive analysis was performed to report sociodemographic information.A contingency table analysis (chi-square test) was conducted to compare the rates of unmatched samples.Independent t-tests were used for analyzing continuous variables.

Frequency (n=174) Percentage
In Table 2, the knowledge of the participants regarding OSA using the OSAKA questionnaire and the correct answer rates for each item are reported.

Frequency (n=174) Percentage
Women with obstructive sleep apnea may present with fatigue alone.103 59.2% Uvulopalatopharyngoplasty is curative for the majority of patients with obstructive sleep apnea.28 16.1% The estimated prevalence of obstructive sleep apnea among adults is between 2% and 10%.92 52.9% The  The item with the highest correct answer rate was "The majority of patients with obstructive sleep apnea snore" (150, 86.2%).This indicates that the participants had good knowledge of the association between snoring and OSA.On the other hand, the item with the lowest correct answer rate was "Laser-assisted uvuloplasty is an appropriate treatment for severe obstructive sleep apnea" (17, 9.8%).This suggests a lack of awareness among the participants regarding the appropriate treatment for severe OSA.Furthermore, it is noteworthy that the participants demonstrated relatively good knowledge regarding symptoms, diagnosis, and some aspects of the treatment of OSA.They correctly identified that OSA is associated with fatigue (103, 59.2%), hypertension (70, 40.2%), and cardiac arrhythmias (111, 63.8%).They also recognized the importance of overnight sleep studies for diagnosis (136, 78.2%) and continuous positive airway pressure (CPAP) therapy for nasal congestion (83, 47.7%).However, there were knowledge gaps in understanding the prevalence of OSA (92, or 52.9%) and the appropriate treatment options for severe OSA, such as uvulopalatopharyngoplasty (28, 16.1%) and laser-assisted uvulopalatoplasty (17, 9.8%).
Figure 1 provides insights into the attitudes of the participants toward OSA.The majority of participants agreed that it is essential for physicians to know about OSA as a clinical disorder (161, 92.5%).However, when it came to screening all patients for possible OSA, there was a higher proportion of participants who disagreed or strongly disagreed (111, 63.8%) compared to those who agreed or strongly agreed (63, 36.2%).Additionally, there was a relatively equal distribution of opinions regarding confidence in using OSA screening tools, with 85 (49.3%) agreeing and 89 (50.7%) disagreeing.Regarding the presence of a distinct referral protocol in their workplace to collaborate with the sleep medicine department, there was a higher proportion of participants who disagreed or strongly disagreed (105, 60.7%) compared to those who agreed or strongly agreed (69, 39.3%).
In Table 3, the participants' level of awareness regarding various aspects of OSA is presented.

Frequency (n=174) Percentage
In Saudi Arabia, the overall prevalence of OSA, as defined by the American Academy of Sleep Medicine, was  The correct answer rates for each item are reported.Overall, the participants demonstrated good awareness in most areas, with correct answer rates ranging from 62 (35.6%) to 153 (87.9%).However, there were certain items where awareness was relatively lower, such as the prevalence of OSA in Saudi Arabia (65, 37.4%), the fact that OSA is more common in women than men (66, 37.9%), and the association of orofacial pain and bruxism with OSA (73, 42.0%).
Figure 2 illustrates the level of knowledge and awareness of the participants toward OSA.

FIGURE 2: The level of knowledge and awareness of OSA (N=174)
OSA: obstructive sleep apnea In terms of knowledge, the majority of participants had a low level of knowledge (109, 62.6%), followed by a moderate level (62, 35.6%), and a small proportion had a high level of knowledge (3, 1.7%).Regarding awareness, a similar pattern was observed, with 63 (36.2%) having a low level of awareness, 86 (49.4%) having a moderate level of awareness, and 25 (14.4%)having a high level of awareness.Several demographic factors showed significant associations with knowledge and awareness.Gender was significantly associated with both knowledge (p = 0.021) and awareness (p = 0.039), with a higher proportion of females having moderate knowledge and awareness levels compared to males.Nationality also showed a significant association with both knowledge (p = 0.012) and awareness (p = 0.039), with a higher proportion of non-Saudi participants having moderate knowledge and awareness levels.Specialty training was significantly associated with both knowledge (p = 0.000) and awareness (p = 0.002), with participants specializing in internal medicine, pediatrics, and otolaryngology demonstrating higher knowledge and awareness levels.Years of experience showed a significant association with awareness (p = 0.011), with participants having less than 10 years of experience showing higher awareness levels.The current job title was significantly associated with both knowledge (p = 0.004) and awareness (p = 0.004), with specialists and consultants demonstrating higher knowledge levels, while residents showed higher awareness levels.

Discussion
Obstructive sleep apnea is a medical condition of considerable clinical importance, necessitating the involvement of primary care physicians and other healthcare practitioners [17].The purpose of this research was to determine the knowledge, awareness, and attitudes of primary care physicians in Saudi Arabia regarding OSA.Our findings provide insights into the participants' attitudes, level of knowledge, and awareness regarding OSA, as well as the relationship between these variables and a variety of demographic parameters.
A significant proportion of the participants in our research acknowledged the criticality of physicians possessing an understanding of OSA as a clinical condition.This is consistent with prior studies that emphasize the importance of OSA to the well-being and overall livability of individuals [18].However, regarding the screening of all patients for potential OSA, a significant majority of respondents were opposed or extremely opposed.The aforementioned finding gives rise to apprehensions over the inadequate diagnosis and treatment of OSA, given the critical nature of early detection in facilitating successful management [19].This implies that additional awareness campaigns and educational initiatives may be required to underline the significance of OSA screening in primary care settings.
Numerous existing texts suggest that self-confidence is an essential feature of a great physician, including primary care physicians [20,21].In terms of their confidence in utilizing OSA screening techniques, the participants' viewpoints were comparatively balanced.This result may be attributable to the absence of universally acknowledged and standardized screening instruments for OSA in primary care settings [22].
Similar to this study's findings, another study by Chang et al. compared primary care physicians' attitudes toward OSA in three African regions, and they reported that their study participants had low confidence in caring for OSA patients [23].Hence, it is imperative to prioritize the development and validation of dependable and user-friendly screening instruments that can be efficiently integrated into primary care environments.
Concerning awareness and understanding, our research unveiled a spectrum of accurate response rates for different facets of OSA.Although the participants generally exhibited a high level of awareness, there were specific items for which their level of awareness was comparatively lower.An example of the participants' poor knowledge pertains to the prevalence of OSA in Saudi Arabia, the gender-based disparity in OSA prevalence between men and women, and the correlation between OSA and bruxism and orofacial pain.The aforementioned knowledge gaps align with prior research that has documented inadequate levels of awareness among healthcare workers concerning diverse facets of OSA [15].In line with the research conducted by Embarak et al. [17] and Corso et al. [16], our study's findings revealed a substantial range of variation in the knowledge questionnaire items, from 35.6% to 87.9%.This result indicates that understanding OSA is insufficient and requires curriculum-appropriate instruction.According to our research, the item about snoring received the highest proportion of accurate responses from primary care physicians.This discovery is consistent with the results of a study conducted in Egypt in 2020 [17].The majority of participants in this survey (150, 86.2%), concurred that the majority of patients with OSA snore.
The participants exhibited a low to moderate degree of overall knowledge and awareness, with just a minority displaying a high level of knowledge and awareness.Similar results were reported by recent studies conducted in Saudi Arabia and Ecuador, which revealed that the mean score of the respondents was approximately 10 out of 18 [22,24].On the contrary, a few alternative studies have documented somewhat higher average knowledge scores among the participants [16,25].This finding underscores the necessity for focused educational efforts aimed at enhancing primary healthcare practitioners' comprehension of OSA.
Prior research has demonstrated that educational initiatives and interventions might efficaciously augment the understanding and consciousness of OSA in healthcare [26].Hence, the integration of OSA education into medical school curricula and the provision of ongoing professional development opportunities for practicing physicians may contribute to the resolution of the knowledge deficit.
Our study offers useful insights into the correlation between demographic characteristics and knowledge and awareness of OSA.The variables of gender, nationality, current job title, specialist training, and experience duration showed strong correlations with levels of knowledge and awareness.Higher levels of knowledge and awareness were observed among females, non-Saudi participants, those who specialized in internal medicine, pediatrics, and otolaryngology, persons with fewer than 10 years of experience, and specialists and consultants.The results of this study align with prior research that has demonstrated discrepancies in OSA knowledge and awareness according to demographic attributes [22,27].The authors emphasize the need to take into account these variables during the development of training interventions and customize them to suit the particular requirements of distinct healthcare professional cohorts.
Several limitations of our research should be duly recognized.To begin with, it should be noted that the sample size was very small, which raises concerns over the representativeness of primary healthcare providers in Saudi Arabia as a whole.Furthermore, the research was executed exclusively within a certain geographic area, thereby constraining the applicability of the results.Furthermore, self-reported data, which are susceptible to recall and social desirability biases, were utilized in the study.Further investigation utilizing more extensive sample sizes and a broader range of participants is imperative to authenticate and broaden the scope of our findings.

Conclusions
In conclusion, although all participants acknowledged that OSA is a clinical disease, their perspectives on screening and levels of confidence in utilizing screening techniques varied.While the participants exhibited commendable understanding in the majority of domains, there were some facets of OSA in which they lacked expertise.The prevailing levels of knowledge and awareness were primarily moderate to low, underscoring the criticality of implementing focused educational interventions.A correlation was seen between demographic variables and levels of knowledge and awareness, underscoring the criticality of customizing educational interventions to suit certain cohorts of healthcare professionals.By enhancing the expertise and consciousness of primary care physicians, it is possible to improve the detection and treatment of OSA, thereby leading to enhanced patient outcomes and quality of life.

TABLE 2 : Knowledge of the participants toward obstructive sleep apnea using the OSAKA questionnaire. (N=174)
OSAKA: Obstructive Sleep Apnea Knowledge and Attitude

TABLE 3 : Awareness of the participants regarding OSA (N=174)
OSA: obstructive sleep apnea

Table 4
examines the relationship between demographic factors and the participants' knowledge and awareness of OSA.