key: cord-0912302-1068z7pk
authors: Almutairi, Abdulhakeem N.; Altuaysi, Abdullah M.; Alwhaid, Mohammed S.; Alhasson, Muath A.; Alharbi, Meshari A.; Alsalam, Hawra’a A.; Almazyadi, Hashim A.; Almuqbil, Abdulrahman Ahmed
title: Knowledge and attitude of the general population regarding infant hearing loss in Saudi Arabia
date: 2022-02-16
journal: J Family Med Prim Care
DOI: 10.4103/jfmpc.jfmpc_1399_21
sha: 9e657db3abb919f43ae1ea2f658b2fafffebb048
doc_id: 912302
cord_uid: 1068z7pk

BACKGROUND: Ear health and hearing loss (HL) among infants has devastating outcomes. With most HL being deemed preventable, the assessment of one’s knowledge and attitude regarding this impairment is important. In Saudi Arabia, the state of the general population’s knowledge on infant HL remains unknown. OBJECTIVES: To determine and further elucidate the general population’s knowledge and attitude with regard to HL in Saudi Arabia. METHODS: This is a cross-sectional survey-based study conducted on the general population of Saudi Arabia. A predetermined questionnaire was translated into Arabic. This was distributed among the targeted participants in several provinces of Saudi Arabia (central, northern, eastern, western, and southern) by using an online survey via social media. The data were collected and analyzed via the SPSS program. RESULTS: The knowledge with moderate, poor, and good was determined among 60.9%, 29.6%, and 9.4% of the participants, respectively. The participants with positive and negative attitudes were detected among 92.6% and 7.4% of respondents, respectively. Increasing age was associated with better attitude, while increased knowledge was directly related to higher educational attainment. Those who have a child with HL had nearly twice as poor knowledge as those who do not have a child with HL (P < 0.001). CONCLUSIONS: Although most of the respondents possessed a positive attitude toward infant HL, their knowledge about it seems to be lacking. Thus, there is a need to address these knowledge gaps regarding infant HL.

Meanwhile, hereditary HL has been noted to be a significant contributor to congenital HL. In more than 50% of all cases, autosomal recessive, autosomal dominant, and x-linked can be a mode of inheritance. In prenatal mothers, factors such as infections with cytomegalovirus, herpes simplex virus, or German measles have been identified. Moreover, being born to diabetic mothers, toxemia, rhesus incompatibility complications, and premature birth injuries were all considered as causes of congenital HL. Meanwhile, it was determined that acquired HL can present at a later stage of children's life as a result of many causes such as certain chronic ear infections, infectious diseases, use of particular drugs, and exposure to excessive noise. [5] [6] [7] Furthermore, HL can result in a significant disability among children in four ways. First, it delays language and speech development. Second, it directly contributes to learning ability, leading to general reduced academic achievements. Third, the children's ability to communicate effectively is compromised, resulting in isolation, frustration, and poor self-concept. Lastly, it can affect vocational choices. Previous studies have suggested that early identification and intervention can minimize or even prevent such devastating consequences. [8, 9] Previous studies have emphasized that support from family, friends, and family physicians has been shown to impact hearing help-seeking. [10] In an Australian population-based cohort research, less than 50% of people seeking assistance from their physicians received a referral for treatment or support services for HL. [11] Pediatricians and other general practitioners understand the importance of early detection and intervention for deafness in infants. Physician responsibilities will be supported by the provision of action-oriented tools that educate parents about the significance of follow-up and equip clinicians to implement proper surveillance methods into everyday practice. [12] Despite the availability of effective therapies, several hurdles limit the chance of screening in the primary care environment. The majority of patients are hesitant to disclose their hearing impairment. However, studies have reported that patients are usually not reluctant to discuss such issues with their family physician. Moreover, they follow the advice or referral recommendation that are proven to be beneficial. [13] Understanding the causes of this dysfunction has been determined crucial to inhibit it. [14] Evaluating parents' understanding of HL and audiology services is critical for establishing appropriate and comprehensive hearing programs for children. [15] Previous research has shown that parents highly favor early identification and treatments for hearing impairments. [16] The current study aimed to determine and further elucidate the knowledge and attitude of Saudi Arabia's general population with hearing loss.

This is a cross-sectional study targeting the general adult population in different provinces around Saudi Arabia (central, northern, eastern, western, and southern) in the period from July 21, 2020 to August 8, 2021 to assess the knowledge and attitude toward infant HL. With the COVID-19 pandemic, an online survey via SurveyMonkey was used as a safe alternative to paper surveys, and these were distributed via social media. We assured a 100% response rate with only one response per device by allowing non-repeated internet protocol (IP); we included the adult population, excluding physicians, medical staff, and participants under 18 years of age. The sample size was calculated using the OpenEpi program, version 3. The estimated sample size was 9462, which was based on a confidence level of 99%. We then increased the sample size by 30% to cover the non-response rate. The questionnaire was adapted from the questionnaire designed by Olusanya as well as Parving; [3, 14] this was translated into Arabic by a professional translator.

With 18 and 11 questions directed to assess the knowledge of the risk factors, four questions were intended to evaluate the knowledge of identification and intervention, and three questions were regarding the participant's attitude. The questionnaire comprised three categories, answerable as "yes," "no," or "not sure," in addition to the items pertaining to the participants' demographic data. A pilot study was performed to ensure the questions' efficiency and clarity, and the time required to complete the questionnaire was calculated. Ethical approval was obtained from Qassim Regional Research Ethics Committee Registered at National Committee of Bio & Med, Ethics (ECBE) Registration No. H-04-Q-001. The participants provided consent at the beginning of every survey. Data were elaborated with numbers (percentages) for all qualitative variables, while mean, standard deviation, and median (min-max) were used to elaborate all quantitative variables. Using the Chi-square test, we compared the participants' knowledge and attitude toward infant HL based on their respective sociodemographic characteristics. Multivariate regression was also conducted to determine the independent factor associated with poor knowledge and a negative attitude. Simultaneously, correlation procedures were used to determine the linear relationship between knowledge and attitude scores. All statistical data were analyzed using Statistical Packages for Software Sciences (SPSS) version 21 (Armonk, New York, IBM Corporation).

In total, we recruited 13837 respondents coming from different provinces in Saudi Arabia. As described in Table 1 , most of the participants were aged around 21-30 years (37.5%); the majority of them were females (68.4%), and more than half (53%) were married, while 40.3% had a bachelor degree.

As presented in Figure 1 , the most frequently cited province was the Eastern Province (38.8%), followed by Riyadh Province (20.8%) and Makkah Province (19.5%). In comparison, the Northern Border and Jawf Province were the least mentioned (0.3% each, respectively). In the assessment of attitude regarding infant HL, as presented in Figure 3 , we learned that nearly all of them would let their baby use a hearing aid if necessary (94.6%), while the proportion of respondents who would like their baby tested or those concerned about their child's hearing and need more information were 91.7% and 48%, respectively.

In Table 2 , the top three statements where respondents exhibited better knowledge were as follows: "children with HL can attend school" (84.5%), "babies can be born with HL" (78.4%), and "children with HL can have similar educational opportunities as hearing peers" (75.1%). On the other hand, respondents had less knowledge on the following statements: "jaundice can cause HL" (9.6%), "Putting a baby under mechanical ventilation is a risk factor of HL" (12.7%), and "having an underweight born baby is a risk factor of HL" (13%).

The descriptive statistics of the respondents' knowledge and attitude regarding infant HL are well elaborated in Table 3 . Based on these results, the total mean knowledge score was 12.4 (SD 4.98) out of 28.5 points, where the majority were determined to have moderate knowledge (60.9%) on infant HL, while the rest had either poor (29.6%) or good knowledge (9.4%). Concerning their attitude, the total mean score was 2.34 (SD 0.69), with nearly all having a positive attitude (92.6%) toward infant HL, with only 7.4% negative.

In Figure 4 , the correlation between knowledge and attitude scores was positively statistically significant (r = 0.208; P < 0.001), suggesting that a positive attitude toward infant HL is also likely to increase as one's knowledge increases.

Measuring the relationship between the level of knowledge and attitude based on the participants' sociodemographic characteristics, we determined that increasing age can significantly influence both knowledge (χ 2 = 112.283; P < 0.001) and attitude (χ 2 = 40.701; P < 0.001). We also observed that educational attainment was significantly associated with both knowledge (χ 2 = 270.351; P < 0.001) and attitude (χ 2 = 29.605; P < 0.001), while participants' province also showed a significant connection to either knowledge (χ 2 = 23.972; P = 0.021) or attitude (χ 2 = 32.563; P = 0.001). Furthermore, gender (χ 2 = 102.120; P < 0.001) and marital status (χ 2 = 19.043; P < 0.001) showed significant difference with attitude but not with knowledge (both P > 0.05); further, having a child with HL has also been determined to significantly influence one's knowledge level χ 2 = 12.758; P < 0.001) on infant HL, but not on the level of attitude (χ 2 = 2.213; P = 0.0137). [ Table 4 ] In a multivariate regression model, we learned that there is a chance that females' attitude toward infant HL would significantly improve in as much as 70% compared to males (AOR = 0.345; CI = 0.345-0.487; P < 0.001). Those in the age group of 21-30 years were also found to have significantly better knowledge than those who were 20 years or below (AOR = 0.404; CI = 0.278-0.588; P < 0.001). In terms of attitude toward infant HL, it was predicted that the increase in positive attitude is associated with increasing age, which was confirmed by our findings: age group of 21-30 years (AOR = 0.302; CI = 0.180-0.506; P < 0.001), Table 5 ].

This study examined the knowledge and attitude of the public regarding infant HL. Our findings would be essential to the best of our knowledge as it involves a large community in Saudi Arabia. Studies have reported that parental knowledge regarding hearing loss is essential to enable auditory access and support language development to ensure the maximum outcomes for children.

Studies have suggested that early detection of hearing impairment is beneficial for future outcomes in speech. Moreover, parents with proper knowledge can detect such deformities sooner than anyone else. [17] Similarly, knowledge regarding hearing loss and its mode of treatment is also important for general practitioners. Most individuals feel comfortable discussing their and their family issues with their family physician and follow their advice. [13, 18] Previous findings also revealed that perceived knowledge and confidence levels are related to self-reported action levels and hearing device use. [19] As per our findings, the overall mean knowledge score was 12.4 (SD: 4.98) out of 28.5 points, with moderate knowledge observed among 60.9% of the respondents, and the rest were either poor (29.6%) or good knowledge (9.4%). In the Qassim region, Saudi Arabia, Alsudays et al. [20] measured the knowledge and attitude to childhood HL and hearing services among parents who attended well-baby and ear nose throat (ENT) clinics between August 2018 and September 2018. Based on their accounts, poor knowledge was found in more than half of the respondents (57.6%), while the remaining 42.4% were considered good knowledge, although the findings in our study showed otherwise. However, the criteria of classification need to be considered as in our study, we classified the level of knowledge into three categories: poor, moderate, and good. Similarly, in Egypt [13] , nearly half of the parents (48.4%) exhibited poor knowledge, while good knowledge was found among 51.6%, which did not seem to agree with our results.

On the other hand, in India, [21] nurses had better viewpoints regarding infant hearing impairment. According to their findings, HL -Hearing Loss 64% of nurses were aware of infant hearing impairment, with only 36% not aware, which is higher than our results. However, it is understandable that nurses' perceived awareness was likely to be higher than the general population as they are members of public health institutions. Furthermore, we learned that having a child with HL was an independent risk factor of poor knowledge. In some studies, age showed a significant association with awareness or knowledge. For instance, Al Shehri et al. [21] found a significant association between age and level of awareness, explaining that the level increased as the age increased, while Alsudays et al. [20] found a significant association between knowledge and age group. This was also consistent with our findings as age group was determined to significantly influence one's level of knowledge.

In addition, we determined that educational level was also an influential factor of knowledge. In the multivariate regression model, we hypothesized that respondents' knowledge increased as the educational attainment increased.

In the specific assessment of knowledge toward infant HL, respondents showed high scores on the following statements: [16, 20, 21] For example, Alsudays et al. [20] documented that parents agreed that "children with HL can attend school," which was also consistent with the papers published in India and South Africa. [16, 22] In contrast, respondents showed less knowledge on the following statements: "Jaundice can cause HL" (9.6%), "Putting a baby under mechanical ventilation is a risk factor of HL" (12.7%), and "having an underweight born baby is a risk factor of HL" (13%). A study published in South Africa and the Solomon Islands [22, 23] also does not agree that jaundice was a risk factor for HL, which is consistent with our study findings.

Moreover, we measured the attitude of respondents toward infant HL via three statements discussed in Figure 3 . Based on the given criteria, the total mean attitude score was 2.4 (SD: 0.69) out of 3 points, wherein nearly all (92.6%) respondents exhibited positive attitudes toward infant HL, with only 7.4% negative. These results seem to coincide with other papers, [22, 24] which mainly reported that nearly all participants exemplified a positive attitude toward infant HL. We also examined which factors are associated with attitude, and based on our assessment, female gender and higher educational attainment (college students/ graduates) were more associated with a better attitude. On the other hand, being married and being divorced or widowed had a significant impact on poor attitude, which is contrary to the findings of Alsudays et al. [20] as the latter did not find any significant association between the level of attitude among the age group, gender, and educational attainment. Similarly, we hypothesized that increasing age was associated with increasing positive attitude toward such impairment; this was consistent with the findings of Elbeltagy et al., [24] who documented that parents' age has a significant association with a child's attitude in terms of wearing a hearing aid.

Moreover, in the thorough assessment of attitude toward infant HL, respondents mostly expressed positive attitude in the following statements: "Would let their baby use hearing aid if necessary" (94.6%) and "Would like their baby tested soon after birth" (91.7%). However, the percentage of respondents who would like to know more about infant HL was only 48%.

In South Africa and the Solomon Islands, [22, 23] the proportion of respondents who would like to know more about infant HL was relatively higher than our results, which indicated 96.7% and 98.7% each, respectively. In India, a significant number of mothers (84.9%) expressed willingness to have their child tested after birth, which was also in line with our results. [16] Limited knowledge and less interest in gaining awareness regarding HL among the Saudi population may lead to a grave outcome.

Although most of the respondents exhibited a positive attitude regarding infant HL, their knowledge seems lacking. Having a child who is suffering from HL greatly improved their awareness on such impairment. Moreover, increasing age positively impacted attitude while being married or had been married had a negative impact on attitude. As per our findings, increasing the knowledge level on infant HL among the general population should be a priority; thus, more educational campaigns should be conducted to address these knowledge gaps, with the government institutions playing a vital role in this process.

Ethical approval was obtained from Qassim Regional Research Ethics Committee Registered at National Committee of Bio & Med, Ethics (ECBE) Registration No. H-04-Q-001.

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Nil.

There are no conflicts of interest.

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