ASSESSMENT OF MULTIPLE SCLEROSIS AWARENESS: KNOWLEDGE AND ATTITUDE AMONG SAUDI POPULATION IN TAIF CITY, KSA

Mona G Amer 1,2 , Wejdan A AlZahrani* 3 , Asma’a A AlZahrani 3 , Fatimah A Altalhi 3 , Seham S Alrubaie 3 , Rawan A Alsini 3 , Sara H AlZahrani 3 and Samaher H Altowairqi 3 . 1. Anatomy & histology department college of Medicine, Taif University, KSA. 2. Histology & Cell Biology department, Faculty of Medicine, Zagazig University, Egypt. 3. Medical Intern, College of Medicine, Taif University, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


Materials & Methods:-
Study design: A community based cross sectional study was conducted in different public areas (university, and shopping malls of different regions of Taif city, KSA). The study was approved by the Ethics Committee of College of Medicine, Taif University.
Target population: The sample was derived from the general population with varying age groups and locations from March, 2014 to May, 2014. Participants were selected randomly without age or gender criteria. Adult Saudis were included and all health professionals/students and subjects diagnosed with MS were excluded. All participants in the study voluntarily gave their consent before being enrolled. Randomly selected men and women aged 18 years and above participated in the study.Knowledge and attitude toward MS was assessed by using a pre validated questionnaire.
Sampling methods:-A structured questionnaire was generated and distributed. The questions were about knowledge, sources of knowledge on MS and attitude toward the disease were administered by an interview. Face, content and convergent validity of the questionnaire was performed. The questionnaire was piloted with 30 respondents for its acceptability and consistency. Little modification was needed after the pilot testing. Data from the pilot study was not included in the final analysis. As the consistency and validity of the study questionnaire was stabilized, the instrument was made available for data collection. The questionnaire was divided into three sections. The first part was for demographic characteristics for respondents, second includes knowledge questions and the third was for attitude.
The knowledge section include 15-item Arabic, closed-ended questions to collect information about familiarity, knowledge about MS etiology, risk factors and perception of perceived seriousness of the disease in Taif city. An additional question was added on the source of the information: social media, newspaper, TV or radio. For every question, the participant is given a choice of answering by yes or no. Table 2 summarizes the questions.The scoring range of the questionnaire was 15 (maximum) to 0 (minimum). A cut off level of ≤ 8 was considered as poor whereas > 8 was considered as adequate knowledge about MS. Knowledge scores for individuals were calculated and summed up to give the total knowledge score.
Attitude towards MS was assessed by asking seven questions (table 3). Each question was labeled with positive or negative attitude. A score of 1 was given to positive while 0 was given to negative attitudes with a score range of maximum of 7 to a minimum of 0. The scale classified attitude as positive with score > 4 and negative ≤ 4.

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Statistical analysis:-Descriptive statistics such as frequency distributions and means ± SD were used to evaluate perception variables. Categorical variables were measured as percentages while continuous variables were expressed as mean ± standard deviation. Statistical differences were assessed by one-way Analysis of Variance (ANOVA) followed by Post Hoc multiple comparison tests (least significant different test; LSD) and paired sample t-test to detect the significance of difference from the SPSS statistical package (version 17; Chicago, IL, USA) to compare changes among individual. The significance level was set at (P ≤ 0.05) for all statistical procedures.
Relationship between the knowledge and attitude scores was done by Pearson correlation (r) analysis and the correlation coefficients (r) were tested. P < 0.05 was considered statistically significant.

Results:-
A total of 900 questionnaires were distributed and 715 were completed the questionnaire with a response rate of 79.0%.

Demographic characteristics (table 1):-
The mean ± SD of age of the study respondents was 27.4±10.8 with more female than males; 35% of respondents were male (n=248) and 65% were female (n=467). About 55% of respondents had secondary school education and 28% had high level of education. 51% of respondents were unemployed including house wives and students. The major source of information regarding MS was from family/friend/neighbors (31%), followed by (26%) getting their information from social media. Health workers as a source of information was the least percentage (5%). Table (2) describes the responses of the participants towards MS knowledge. Mean knowledge for all participants was 5.74 ± 1.7, range = (3-13). Out of the 715 participants, 528 (74%) were within the poor knowledge range whereas 187 (26%) showed adequate knowledge about MS. Table (3), majority of the respondent 567 (79%) believed that they can never get affected with MS. About 37% of respondents stated that they will be ashamed to get the disease. Respondents were ready to disclose their disease to their family (43%) and friends (29%). However, 28% agreed to consult a physician as their first choice of treatment. Four hundred (56%) of the study respondents were of opinion to go to traditional healer in case of MS. In addition, over all the respondents had a negative attitude towards MS with mean score of 2.91 ± 1.8.

Assessment of attitude towards MS table (3):-As shown in
Data analysis comparing demographic characteristics with knowledge and attitude scores revealed that age or sex weren't significantly affect both scores of participants p >0.05. However, education level significantly affects knowledge and attitude scores. High level of education was associated with higher scores. Also, employment significantly increases the scores.
There was a significant difference between mean scores of knowledge and attitude and having someone with MS in the respondents' family; having persons with MS recorded 10.9 ±1.9 as mean knowledge score and 3.9±0.8 as mean attitude score versus 4.9 ±0.8 and 1.8±1.2 mean values of knowledge and attitude scores of persons who don't have someone with MS. The persons with MS relative or friend performed better in the knowledge and attitude toward MS.
Scatter plots of knowledge score against attitude score revealed a significant correlation (Fig. 1). Significant Positive linear correlation was found between both scores (P = 0.0001 and r value = 0.87). The attitude score was decreased significantly with the decrease in knowledge score and vice versa.   Note: Attitude was assessed by giving 1 to positive and 0 to negative attitude. The scale classified attitude as positive with score >4 and negative ≤4. Over all the respondents had a negative attitude towards MS with mean score of 2.91 ± 1.8.

Fig. 1:-Correlation between knowledge and attitude scores
Pearson's correlation coefficients (r) were used to evaluate simple linear relationship between variables.

Discussion:-
Multiple sclerosis is an immune-mediated demyelinating disease of the central nervous system [11]. This treatable but incurable degenerative disease affects approximately40/100,000 Saudis in 2008. Although it used to be thought that MS is not common in Saudi Arabia, it is now clear that it is fairly prevalent, under-diagnosed and in increase [2]. The average age of onset of MS is 30 years. Because this is the age when individuals may be beginning a family and workers have not typically reached their full earning potential, it has a particularly devastating impact on family, social, and professional relationships. Early diagnosis and early treatment are critical to prevent irreversible longterm sequelae in patients with MS [12; 13).
The current study sought to evaluate knowledge and attitude towards MS among healthy individuals in Taif, Saudi Arabia. Results of this study revealed poor knowledge and attitude towards MS. The mean knowledge score among the study cohort was 8.74 ± 2.7 and the mean attitude score was 2.19± 1.8 with no significant variation regarding age and sex of participants.

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A small percentage of respondents actually heard about MS. Lack of knowledge about risk factors, presentations and complications of MS were evident with our study participants. Only 29% of the participant believed that MS can cause disability complications, which is a major sign of concern [14]. MS is most commonly first diagnosed between the ages of 20 to 40 years, and over time, it results in varying levels of progressive mobility and sensory functional limitations affecting not only function but also appearance [15]. A lack of knowledge about the disease symptoms may cause patients to present late and miss the opportunity to reap the benefits of early intervention [16].
The study participants reported "people around them" as a significant source of information about MS. Also, those who reported knowing someone with MS showed significantly higher scores for knowledge and attitude. These results are in line with the findings from studies reported from other parts of Saudi Arabia where the overall knowledge of the general population regarding MS was reported low [17]. Reliance on family, friends and neighbors in MS knowledge may indicate shortage in the available information about the disease in the internet or TV. However, Arhan et al. [18] stated that written materials, can be an effective, inexpensive, and easy-to-implement strategy to improve popular understanding of a condition or its treatment especially for patient's family.
As expected and previously reported with other neurological diseases, people with higher education especially those who employed were more well-informed about the disease compared to those with lower level of education. Diagnosing MS can be a challenging process. In early MS, symptoms may be non-specific and suggestive of several disorders of the nervous system. Early symptoms that come and go may be ignored.
The positive correlations between knowledge-attitude, in this study reaffirm the relationship between them with disease prevention. It is concluded that adequate knowledge can lead to positive attitude resulting in good practices. The findings are in line with the results presented by Abolfazli et al. [26].
An early recognition of the inflammatory process enables patients to begin treatment with an immunomodulatory agent even before the technical diagnosis of definite MS so that the degenerative progression of MS can be retarded. Public awareness of MS is generally poor, and this limited understanding delays the early diagnosis and treatment of patients. [6] Helping others better understand the disease is critical to fueling the progress that changes lives for people affected by it and ultimately will increase quality of life and end the disease complications and disability forever [18]. Therefore, extensive popularization should be implemented to raise awareness of these diseases, thus contributing to the efficient treatment of MS and reducing the burden of these diseases.

Conclusion and Recommendations:-
These findings indicate a lack of understanding of the basics of MS with poor knowledge and attitude scores. Learning from surrounding people was the only source of information with significantly high knowledge and attitude score. Also, participants who recorded knowing someone with MS was significantly had higher knowledge and attitude scores. Most respondents in our sample suffered from deficiency of background information about MS 1765 and health education. Therefore, more intensified awareness programs among population are necessary to ensure reliable information reach the public in order for early detection and management of this serious disease. Also, further researches are needed to identify causes of inadequate knowledge and attitude of MS among Saudi population. More utilization of Media as an important source of MS is important to improve awareness among the community.

Limitations:-
The study was conducted in one city and therefore results of the research are not representative of the entire population of Saudi Arabia.