Knowledge, Attitude, Reception, and Preventive Practices Towards Skin Photoaging Among the General Population in Jazan, Saudi Arabia

Introduction Skin photoaging is caused by prolonged exposure to sunlight, particularly ultraviolet rays (UV). High cumulative levels of UV radiation may cause burning, photoallergic or phototoxic reactions, pigmentary changes, photoaging, and even immunosuppression and skin cancers. Therefore, this study aims to assess knowledge, attitude, reception, and preventive practices towards skin photoaging among the Jazan general population in Saudi Arabia and its determinants. Methods A descriptive cross-sectional study was conducted among the general population of Jazan, Saudi Arabia, who were aged 18 years and above and agreed to participate in the study. The calculated minimum sample size was 385. An online, semi-structured, self-administered questionnaire was distributed conveniently in Google Forms through social media platforms. It included four sections: The first section was about sociodemographic characteristics. The second section assessed the smoking, exercise, and healthy diet behavior of participants and the use of sunscreen. The third section assessed the knowledge regarding the photoaging process and its preventive measures utilization using three-point Likert scale questions. The fourth section assessed attitudes towards the photoaging process and its preventive measures through three-point Likert scales. Results The study included 452, of which 243 (53.76%) were aged 18-30 years, 258 (57.08%) were females, and 272 (60.18%) had white skin color. Approximately 417 (92.26%) were nonsmokers. Sixty-eight percent (372) spent 1-3 hours in the sun. Social media was the primary source of information on photoaging 81 (17.92%). Around 234 (51.77%) defined photoaging correctly. Regarding sunscreen usage, 58 (12.83%) always use sunscreen, and 177 (39.16%) never use it. However, 191 (42.26%) recognized the correct sunscreen application. Approximately 233 (51.5%) and 240 (53.1%) of respondents had fair knowledge and a positive attitude regarding photoaging and sunscreen use. Being female, pursuing university and postgraduate education, and taking information on photoaging from a physician were linked to a higher knowledge of photoaging (p<0.05). Participants who never use sunscreen had lower knowledge than those who always use it (p<0.001). None of the demographic factors was associated with the attitude towards sunscreen use (p>0.05). Conclusion There is a substantial gap in knowledge and preventive practices related to skin photoaging among the Jazan general population in Saudi Arabia. Gender, education level, and information sources influence knowledge levels. Targeted educational interventions are needed to enhance awareness and promote healthier practices, particularly sun exposure and photoaging prevention.


Introduction
Skin aging is a dynamic and intricate process influenced by various internal and external factors that accumulate over time.Internal factors encompass genetic, hormonal, and natural skin aging changes.In

Study design, setting, and population
A descriptive cross-sectional study was conducted in Jazan, one of the 13 regions of Saudi Arabia that lie in the southwest corner directly north of the border with Yemen.We included the general population of Jazan, Saudi Arabia, who were aged 18 years and above and agreed to participate in the study.
The sample size was calculated using the Raosoft sample size calculator (Seattle, Washington, United States) [12] at a 95% confidence interval, 5% margin of error, 1.5 million population, and 50% anticipated proportion; the minimum required sample size was 385.

Data collection tools
An online, semi-structured, self-administered questionnaire was distributed conveniently in Google Forms through social media platforms.The questionnaire was adopted from previous studies [13,14].It was reviewed by five dermatologists, and consequently, a pilot study on 20 individuals was conducted to ensure the clarity and understandability of the questionnaire.
The questionnaire included four sections: The first section was about sociodemographic characteristics, such as age, gender, marital status, nationality, education, occupation, and skin color.The second section assessed the smoking, exercise, and healthy diet behavior of participants as well as knowledge of the term "skin photoaging," the source of information, and the use of sunscreen.The third section assessed the knowledge regarding the photoaging process and its preventive measures utilization using 13 questions coded on a three-point Likert scale (yes, no, I don't know).The fourth section contained 12 questions that assessed attitudes towards the photoaging process and its preventive measures.The questions were on a three-point Likert scale (0=disagree; 1=neutral; 2=agree).

Ethical consideration
Ethical approval was obtained from the Standing Committee for Scientific Research at Jazan University (HAPO-10-Z-001) (approval number: REC-45/04/831).Prior to the study, each patient was requested for their informed permission after being fully informed of its goals, risks, and advantages.The ability to withdraw from the study at any moment was made clear to participants.Additionally, participants are free to decline to take part in the study.Anonymity, privacy, security, and confidentiality were maintained.

Analytical plan
The data was collected, checked for completeness, and coded in an Excel sheet.The data was analyzed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States).Continuous variables were presented as a median and interquartile range, while categorical variables were expressed as numbers and percentages.Data normality was assessed using histograms and the Shapiro-Wilk test.For knowledge-related questions, the correct answers were coded 2, incorrect answers were coded 0, and unsure answers were coded 1, and the total knowledge score was calculated.Those scoring greater than or equal to the median were considered to have fair knowledge.The attitude score was coded as 0=disagree, 1=neutral, and 2=agree, and individuals scoring greater than or equal to the median were considered positive.The Kruskal-Wallis rank-sum and Wilcoxon rank-sum tests were employed to identify predictors of knowledge and attitude, with a significance level set at p<0.05.

Discussion
Knowledge, attitudes, and practices towards photoaging reveal important insights into public awareness and behaviors related to skin health.Skincare encompasses various practices.Skin issues significantly impact individuals' quality of life and health [15], particularly in older adults, due to structural changes in the aging skin [16].Essential skin functions include water conservation, electrolyte and protein retention [17], acting as a barrier between internal and external environments [18], sweat and vitamin D production, UV absorption, temperature regulation, and autonomic/immunologic actions [19].
This study explored the knowledge, attitudes, and practices of participants from Saudi Arabia regarding photoaging.The results show that much needs to be done to provide more education for individuals within these population groups that should help to improve their attitudes towards skincare and encourage them to institute practices that will offer them opportunities for healthier lives.
Four hundred and fifty-two participants were enrolled in this study, out of which 285 (57%) were females.Regarding daily sunlight exposure, 94 (21%) reported being not exposed, while 309 (68%) spent 1-3 hours in the sun.Skin damage from excessive sunlight can come in several forms: skin cancer, photoaging, rosacea, and chronic discoid lupus erythematosus [20].Studies have shown that adverse effects on skin health can result from exposure to 2,4-dichlorophenoxyacetic acid and paraquat [21] or organochlorine pesticides such as dichlorodiphenyltrichloroethane (DDT) [22].Such adverse effects can include the development of contact dermatitis, urticaria, erythema multiforme, ashy dermatosis, chloracne, hypopigmentation of the skin, and skin cancer [23].
In terms of knowledge, the findings suggest a varying degree of understanding among individuals regarding the impact of sun exposure on skin aging.Approximately 233 (51.5%) demonstrated a good level of knowledge about photoaging and sunscreen use.Analysis revealed that 325 (72%) of participants had never heard about photoaging.On the other hand, among those who were aware, social media was the primary source for the majority.Participants' understanding of skin photoaging varied, with 233 (52%) demonstrating a solid understanding of the connection between UV radiation and premature aging, highlighting the importance of education and awareness campaigns.
Regarding attitude, 240 (53.1%) of respondents showed a positive attitude regarding photoaging and sunscreen use.Attitudes towards photoaging appeared to be influenced by cultural perceptions and societal norms.While some individuals expressed a proactive attitude, adopting sun-protective measures, others displayed a more complacent approach, possibly due to misconceptions or a lack of perceived severity.
Sunlight and UV radiation are primary factors in skin problems [24].Protective measures, such as limiting outdoor activities during peak UV hours, seeking shade, wearing suitable hats and clothing and sunglasses, and using sunscreen, play a crucial role in preventing and safeguarding the skin against disorders [25,26].Practices related to photoaging varied widely, with 58 (13%) always using sunscreen, compared to 37 (8.2%) who use it on a usual basis.This is lower than the findings from a previous study in Peru, where of the total number of users of photoprotection, 38.4% used these products daily, while 61.6% used them only occasionally [27].This variation could be attributed to differences in socioeconomic status, level of education, and perception between the participants.Concerning proper sunscreen application, 191 (42%) recognized the need to apply at least 15 minutes before sun exposure and reapply every two hours.In contrast, 161 (36%) thought applying immediately before exposure and reapplying every four hours was suitable.This finding gives an insight into a notable discrepancy between knowledge and behavior.Despite knowing the harmful effects of sun exposure, many participants reported inconsistent sun protection practices.This suggests a potential gap between awareness and actual implementation of preventive measures.
Factors influencing knowledge, attitudes, and practices towards photoaging could include age, socioeconomic status, and access to information.Younger participants may exhibit a more carefree attitude, while those with higher socioeconomic status might prioritize skincare practices.Correlation testing revealed that females had higher knowledge of photoaging than their counterparts (p<0.001).A similar study revealed that women were more knowledgeable regarding sun protection (p=0.001)[27].Not only knowledge but also practice was influenced by gender, where a previous study conducted in Saudi Arabia found that females used sunscreen and protection methods more frequently than their male counterparts [28].This can also be attributed to the finding of a previous study where using skincare products was significantly associated with the female gender (p<0.001)[29].
Pursuing university and postgraduate education was linked to higher knowledge than earning less than a high school education (p=0.037).Participants taking information on photoaging from a physician had higher knowledge than those taking from social media (p<0.001).This is supported by the results of a previous study where knowledge regarding sun protection was more evident in individuals with university/college education (p<0.001)[27], indicating a positive correlation between educational level and knowledge regarding photoaging.
Addressing the gap between knowledge and practices is crucial for effective public health interventions.Educational campaigns targeting specific demographics and emphasizing the tangible benefits of sun protection could contribute to a positive shift in attitudes and behaviors towards preventing photoaging.Further research is needed to explore the long-term impact of interventions on knowledge, attitudes, and practices and ultimately reduce the prevalence of photoaging in the population.

Strengths of the study
A limited number of Saudi studies were published in this scope; hence, this study is considered a valuable base for evidence.Another strength of this study is that it included participants from variable demographic backgrounds and socioeconomic status, which would aid the authorities in dealing with the issue from all aspects.

Limitations of the study
The study was not without limitations.The fact that it was done within a specific setting may have determined a highly selected group of cases.It may, therefore, be difficult to generalize the findings to the total community in Saudi Arabia.Larger numbers of respondents would have improved the statistical significance of the results.

Conclusions
The study showed a good level of knowledge and favorable attitude towards photoaging and sunscreen use among half of the participants.A significant association between gender and knowledge was noticed, with females having a higher knowledge of photoaging.In addition, a high level of education was linked to a higher knowledge than those who earned less than a high school education.Serial and frequent studies on the issue should be conducted and funded to generate more evidence and data.In addition, educational campaigns, medical missions, and media recruitment should be held to increase community awareness of such issues, and attempts to enhance patients' practices should be arranged.Examples are offering skin care products for affordable prices or even setting shade umbrellas in public spaces.

TABLE 1 : General characteristics of the participants
n (%)

TABLE 2 : Sun exposure-related characteristics of the participants
n (%)