 |
|
ORIGINAL ARTICLE |
|
| Year : 2023 | Volume
: 18
| Issue : 1 | Page : 15-22 |
|
| Measurement of the awareness of venous thromboembolism in the Saudi population |
|
|
Ali Alaklabi1, Shouq Mohammed AlNujaim2, Sarah Mohammed Alghaihab2, Sadeem Ahmed AlDakhil2, Obeid Mohammed AlKethami2, Rajkumar Rajendram1
1 Department of Medicine, King Abdulaziz Medical City, National Guard Health Affairs; College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| Date of Submission | 13-Apr-2022 |
| Date of Acceptance | 18-Jun-2022 |
| Date of Web Publication | 25-Jan-2023 |
Correspondence Address:
Dr. Shouq Mohammed AlNujaim
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/atm.atm_147_22
|
|
 Abstract | | |
BACKGROUND: Venous thromboembolism (VTE) causes significant morbidity and mortality. International studies have suggested poor public awareness of VTE, with a few data from Saudi Arabia. The aim of this study was to investigate the knowledge and awareness of VTE in the Saudi population. Awareness of other important diseases was also investigated to allow contextualization.
METHODS: A cross-sectional survey study was conducted throughout Saudi Arabia from April to June 2021. A nonprobability, purposive, social media-driven, snowballing sampling technique was used to distribute a validated online questionnaire to Saudi adults (aged over 18 years) from the general population.
RESULTS: Of 1226 respondents, 214 were excluded as they were health-care professionals. The majority of the participants were unaware and unconcerned about VTE. They were more aware of other medical conditions such as hypertension. Immobility and old age were frequently recognized as risk factors for VTE. While less than half of the participants were aware that thrombosis is the cause of VTE, most participants correctly identified leg pain and tenderness as symptoms of deep venous thrombosis. The majority of the participants identified chest pain and breathlessness as symptoms of pulmonary embolism. However, leg paralysis and slow, shallow breathing were frequently identified as symptoms of VTE. The majority of subjects disagreed with the statement, "having a blood clot is not considered a medical emergency." Awareness of VTE varied significantly with age.
CONCLUSION: In Saudi Arabia, the public awareness of VTE is poor. To improve outcomes, public health initiatives must increase awareness, introduce preventive measures, encourage early diagnosis, and ensure compliance with treatment.
Keywords: Awareness, knowledge, public, Saudi Arabia, venous thromboembolism
How to cite this article:
Alaklabi A, AlNujaim SM, Alghaihab SM, AlDakhil SA, AlKethami OM, Rajendram R. Measurement of the awareness of venous thromboembolism in the Saudi population. Ann Thorac Med 2023;18:15-22 |
How to cite this URL:
Alaklabi A, AlNujaim SM, Alghaihab SM, AlDakhil SA, AlKethami OM, Rajendram R. Measurement of the awareness of venous thromboembolism in the Saudi population. Ann Thorac Med [serial online] 2023 [cited 2023 Mar 29];18:15-22. Available from: https://www.thoracicmedicine.org/text.asp?2023/18/1/15/368492 |
Venous thromboembolism (VTE; i.e., deep vein thrombosis [DVT] and pulmonary embolism [PE]) causes significant morbidity and mortality. The annual incidence of VTE is 1–2 per 1000 adults worldwide.[1] Several international studies have reported poor public awareness of VTE.[2],[3],[4]
In Riyadh, Saudi Arabia, a survey found that only 18.6% and 38.7% of respondents were aware of DVT and PE, respectively.[5] Other studies conducted in Saudi Arabia reported similar outcomes.[6],[7],[8] Since the majority of the previous studies were done in a single city or a population group, the present study aimed to investigate public awareness of VTE throughout Saudi Arabia. For contextualization, public awareness of other important diseases was also investigated.
| Methods | |  |
Study design
This cross-sectional, online, validated questionnaire-based study of awareness of VTE was performed among Saudi adults (over 18 years of age) with access to social media from April to June 2021. Health-care professionals were excluded. The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia. Informed consent was obtained from each participant.
Survey development
The preexisting literature describing public awareness of VTE was reviewed.[1],[2],[3],[4],[5],[6],[7],[8] These data were used to develop a validated questionnaire investigating the knowledge, understanding, and awareness of VTE among the general public throughout Saudi Arabia. To facilitate regional, national, and international comparisons, the questionnaire used in the studies conducted by Wendelboe et al., 2015,[2] was modified and translated into Arabic using the Brislin back-translation method.[9]
The survey instrument had two sections with a total of 17 closed questions. Free text answers were not allowed. The first section collecting demographic data was modified to include three questions on variables of interest to our study. These were age (range, 18–39 years, 40–64 years, or over 65 years), sex, and country of residence (Saudi Arabia or other).
The second section contained 14 questions assessing participants' awareness of VTE and other medical conditions. Questions 1–10 were similar to those in the questionnaire designed by Wendelboe et al., 2015.[2] The first question asked whether the respondents had heard of any of a range of common medical conditions. Question 2 asked about respondents' level of concern about the medical conditions listed in question 1. Question 3 assessed respondents' knowledge of the cause of DVT. Questions 4–7 asked about the symptoms and signs of DVT and PE. Question 4 asked if the participant knew what a clot in the leg felt like. Those who answered yes, moved to question 5. Those who answered no, skipped to question 6. Question 5 asked about the signs and symptoms of DVT. Question 6 asked if the participant knew what a blood clot in the lung felt like. Those who answered yes, moved to question 7. Those who answered no, skipped to question 8. Question 7 asked about the signs and symptoms of PE. Questions 8 and 9 explored participants' perceptions of the potential risk factors and complications of VTE. Questions 1–8 included some incorrect answers to prevent subjects from predicting answers. Question 10 asked participants to select the statement that most closely describes the urbanization of their residence (e.g., living in or near a major city).
However, questions 11–14 were designed to extract further data relevant to the present study. Question 11 asked participants to select their region of residence within Saudi Arabia (e.g., central or northern region). Questions 12 and 13 explored previous personal history of PE, DVT, or both and history of VTE in the participant's acquaintances. Question 14 asked about whether the participant was involved in the medical field.
The versions of the survey instrument in English [Appendix 1] and Arabic [Appendix 2] were converted to an online survey using Google Forms (Google, LLC, Mountain View, California, United States of America [USA]). The aim of the study, expected time required to complete the questionnaire (approximately 5 min), consent form, and choice of language (Arabic or English) were provided at the start of the questionnaire.
[Additional file 1]
[Additional file 2]
After obtaining ethical approval, 6 health-care professionals pretested the English and Arabic versions of the online survey and provided input on survey length, content, and clarity. Following the pretest, it was universally agreed that the English and Arabic versions of the survey instrument were unidimensional and no changes to the online form were required. The data from the pretest were excluded from the final analysis.
Distribution of the survey instrument
The authors initially distributed the link to their contacts via WhatsApp (Facebook, Inc., Menlo Park, California, USA). Those invited to complete the questionnaire by the authors were also asked to distribute the link to their contacts. Participants could use any social media platform to forward the link. No data on the distribution of the link was collected. Therefore, the response rate cannot be calculated.
Sample size and technique
Assuming a response distribution of 50%, it was estimated that at least 385 responses would be required to obtain a result with a 5% error margin at a confidence level of 95%. After ethical approval, a nonprobability, purposive sampling technique was used to obtain a sample of Saudi adults with access to social media by distributing the survey through social networks. Informed consent was obtained before participation in the survey. No incentives were provided.
Outcome measures
Answers to most of the questions on awareness of the selected medical conditions, clinical features of VTE, and risk factors for VTE were chosen from prepopulated lists of binary options which allowed the selection of only one option. Two questions allowed the selection of more than one option. The first multiple choice question investigated awareness of selected medical conditions. The listed options included the statement "I am not aware of any of these conditions." The second multiple choice question asked about VTE risk factors. The listed options included the statement "none of the above."
Answers to the question on the cause of DVT were chosen from a prepopulated list which allowed the selection of only one option. Agreement with statements on the complications of VTE was rated on a 5-point Likert scale labeled only at the extremes (i.e., 1: completely disagree and 5: completely agree). When analyzing these data, scores of 1 and 2 on this scale were considered to represent "disagreement," 3 was considered to represent "neither agree nor disagree," and 4 and 5 were considered to reflect "agreement." Concern about the selected medical conditions was rated on a semantic differential scale labeled only at the extremes (i.e., 1: not at all concerned and 5: extremely concerned). On this scale, any response >1 represented some degree of concern, while 4 and 5 reflected high levels of concern.
Ethical approval
Ethical approval for this study (RC20/448/R) was obtained from the Institutional Review Board of KAIMRC, Riyadh, Saudi Arabia.
Statistical analysis
The data were analyzed using standard descriptive statistical techniques. The final analysis included all responses. Responses were stratified by sex, age range, and region of residence. Categorical data were presented as frequency and percentage with a 95% confidence interval (CI). Continuous data, described on a scale, were presented as mean and standard deviation. The interval data were compared using Student's t-tests or analysis of variance as appropriate. Categorical data were compared using McNemar's, Chi-squared, or Mann–Whitney U tests. All data analyses were carried out using Statistical Package for the Social Sciences (SPSS; version 21, IBM Corporation, Armonk, New York, USA).
| Results | | |
Demographic data
The survey was completed by 1226 adults. However, 214 (17.5%) were health-care professionals, and so did not meet the inclusion criteria. The demographic data of the remaining 1012 adults are presented in [Table 1]. Most of the samples were women (748, 73.9%; men 264), between 18 and 39 years old (839, 82.9%), resident in the central region (728, 71.9%), and lived in or near a major city (902, 89.1%). Eight participants (0.8%) were resident outside Saudi Arabia at the time of the survey. Only 16 participants (1.6%) had a previous PE, DVT, or both. Most (839, 82.9%) of the participants had neither experienced VTE nor knew anyone who had.
Public awareness of the specified medical conditions
Participants' self-reported awareness of the selected medical conditions is presented in [Table 2]. The statement "I am not aware of any of these conditions" caused some confusion. Forty-six participants answered no to this question, but had stated that they were not aware of any of the conditions specified in the preceding questions. Four other participants answered yes to this question, but had stated that they were not aware of any of the conditions specified in the preceding question. Furthermore, 406 people answered no to this question, yet had stated that they were aware of at least one of the conditions specified in the preceding questions. The answers to this question were therefore excluded from the analysis.
Awareness of a fictitious condition (i.e., hemodistension syndrome) was reported by 125 participants (12.4%; male 35, female 90; 3 English, 122 Arabic; 107 aged 18–39 years, 18 aged 40–64 years). The majority self-reported awareness of hypertension (912, 90.1%), acquired immunodeficiency syndrome (884, 87.4%) and breast cancer (879, 86.9%). However, while 884 (87.4%) reported being aware of thrombosis; the awareness of arterial thrombosis (i.e., heart attack {843, 83.3%} and stroke {791, 78.2%}) was far greater than that of VTE (i.e., DVT {470, 46.4%} and PE {360, 35.6%}).
Participants concern about specific conditions
Participants' concern about the specified medical conditions is presented in [Table 3]. The sample was most concerned about either breast or prostate cancer {530, 52.4%}. However, while 457 (45.2%) reported being concerned about thrombosis; the concern about arterial thrombosis (i.e., heart attack {449, 44.4%} and stroke {450, 44.5%}) was far greater than their concern about VTE (i.e., DVT {297, 29.3%} and PE {323, 31.9%}).
Perception of the cause of deep vein thrombosis and the risk factors for venous thromboembolism
Only two fifths of the sample (434, 42.9%) were aware that thrombosis is the primary cause of DVT [Table 4]. Participants' perception of the risk factors for VTE is presented in [Table 5]. The majority of the sample correctly reported that age >65 (86.8%), immobility (84%), estrogen-based medications (67.1%) cancer (66.4%), surgery (62.5%), and family history of VTE (60%) were risk factors. There was less appreciation that admission to hospital (20.7%) and pregnancy (50.5%) were risk factors. The majority also erroneously perceived that hyperlipidemia (83.4%) and hypertension (72.1%) were risk factors. A minority of the sample erroneously believed that excessive physical exercise (10.8%) and donating blood (8.6%) were also risk factors.
In relation to the risk factors for VTE, the statement "none of the above," caused some confusion. Two hundred and eight people answered yes to this question, but had stated that one or more of the situations specified in the preceding questions were risk factors for VTE. However, of the 804 participants who answered no to this question, only 12 had stated that none of the conditions specified in the preceding questions were risk factors. The answers to this question were therefore excluded from further analysis.
Knowledge of symptoms and signs of venous thromboembolism
Participants' knowledge of symptoms and signs of DVT is presented in [Table 6]. Few participants reported that they knew what a DVT or a PE would feel like (DVT: n = 150, 14.8%, 95% CI: 12.6%–17%; PE: n = 132, 13%, 95% CI: 11%–15.1%). However, most participants correctly identified swelling of the leg (80.7%) and pain and tenderness (78%) as symptoms of DVT. However, similar numbers also believed that paralysis of a leg was also a symptom of DVT (71.3%).
Participants' knowledge of the symptoms and signs of PE is presented in [Table 7]. Nearly all participants identified chest pain (90.9%) and breathlessness (92.4%) as symptoms of PE. However, a large proportion of the samples (81.8%) also incorrectly believed that slow, shallow breathing was also a symptom of PE.
Perceptions of the prevention, treatment, and urgency of venous thromboembolism
Participants' perceptions of the prevention, treatment, and urgency of VTE are presented in [Table 8]. Just over half (54.9%) of the participants agreed or strongly agreed with the statement, "a blood clot can cause death." Over two-thirds (71.1%) disagreed or strongly disagreed with the statement "having a blood clot is not considered a medical emergency." About half (50.5%) of the participants disagreed or strongly disagreed with the statement "most blood clots cannot be prevented." A minority (18.6%) agreed or strongly agreed with the statement "if untreated, it is unlikely that a blood clot in a vein of the leg can travel to the lungs." | Table 8: The distribution of responses to statements about venous thromboembolism
Click here to view |
Participants' characteristics and self-reported awareness of selected medical conditions
The awareness of the selected medical conditions within select strata of the samples is presented in [Table 9]. There were a few participants aged over 65 years of age to draw meaningful conclusions about that stratum. However, awareness of PE was greater in those who were 40–64 years old than those in the 18–39 years old age group. There were no other significant differences in awareness of PE or DVT. | Table 9: Awareness of various medical conditions stratified by age group, sex and residence
Click here to view |
| Discussion | | |
Our data reveal that the awareness of VTE is poor throughout Saudi Arabia. This observation reinforces the findings of previous studies.[2],[5],[6],[7],[8] While 87.4% of participants self-reported that they were aware of thrombosis, less than half were aware of DVT and PE. In contrast to previous reports, there was no significant difference in the awareness of DVT and PE in the present sample.[2]
A Saudi study conducted in Aseer found that awareness of PE and DVT was comparable to that of other medical illnesses (such as heart attack and breast cancer).[6] This relatively higher knowledge of VTE may reflect the younger age and high level of education of the participants.[6]
In the present study, fewer respondents were concerned about VTE than many other medical conditions. Alarmingly, 49.3% and 52% of participants stated that they were not concerned about DVT or PE, respectively. This may be because participants were not aware of the high morbidity and mortality associated with VTE.[10]
The lack of concern about VTE may also reflect limited awareness of the cause and risk factors of VTE. Only 42.9% of the samples were aware that thrombosis is the primary cause of DVT, while 35.3% of participants were unsure of the exact etiology. The ability to correctly identify the cause of DVT by two fifths of the participants could be attributed to the self-explanatory name of the disease "DVT" and not because of real awareness.
However, it is reassuring that immobility and old age were the often correctly identified as risk factors for VTE. Pregnancy and hospitalization were not recognized by some respondents. Unfortunately, a considerable number of respondents incorrectly reported that hyperlipidemia and hypertension were risk factors for VTE. Our observations on the awareness of risk factors for VTE are consistent with the findings of previous studies.[1],[2],[5],[11],[12],[13],[14],[15],[16],[17]
The majority of respondents correctly identified symptoms and signs of VTE. The signs and symptoms that were most commonly incorrectly associated with VTE were leg paralysis and slow, shallow breathing. These observations are consistent with the findings of previous studies.[1],[5],[14],[15],[16],[17] However, awareness of symptoms of PE was significantly lower in two other studies.[6],[18]
In our cohort, the awareness of PE was greater in the 40–64 years' age group than in those between 18 and 39 years of age. There were no other significant differences in gender, region, or urbanization of residence in the awareness of PE or DVT. Jarab et al.[11] also reported that those in the 40–64-year-old age group were significantly more aware of VTE. However, they did not find any association of gender with awareness.[11]
The 40–64 years' age group is probably more knowledgeable of VTE because they are more likely to have comorbidities and are relatively at higher risk.[19] Of the selected medical conditions, those which the sample was most aware of (e.g., heart attack and stroke) have been the subject of major public health campaigns.[2]
Interestingly, one international study which included nine countries found that the UK's general public had the highest awareness of thrombosis, DVT, and PE. This is thought to reflect the benefit of public awareness campaigns which had occurred in the UK.[2] As 60% of the disease burden can be attributed to hospital associated VTE, key public health messages should include that hospitalization, pregnancy, and surgery are major risk factors.[2]
The survey instrument used closed questions. As a result, some subjects could have anticipated the correct answers. The incorporation of incorrect responses into the survey instrument may have mitigated against this. Since the questionnaire used in the present study had previously been used in local and international studies, translation of this validated questionnaire into Arabic allowed comparison with the preexisting literature. Confusion about the statements "I am not aware of any of these conditions" and "none of the above" required removal of the responses to these questions prior to analysis. However, this is unlikely to have affected the interpretation of the responses to other questions.
The limitations of our study include its cross-sectional nature and the use of an online questionnaire disseminated via social media. This resulted in overrepresentation of those residents in the central region and underrepresentation of some vulnerable subgroups of the community (e.g., the elderly and those without access to social media). The use of social media for snowball sampling precluded calculation of the response rate.
| Conclusion | | |
The public awareness and knowledge of VTE in Saudi Arabia is poor. As the morbidity and mortality associated with VTE is high, these observations reinforce the need for campaigns to educate the public about VTE. These initiatives should encourage preventive measures, early diagnosis, and treatment. Further studies are needed to determine the most appropriate methods to raise awareness and disseminate health-related education in Saudi Arabia.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Cushman M, Creager MA. Improving awareness and outcomes related to venous thromboembolism. JAMA 2015;314:1913-4.  |
| 2. | Wendelboe AM, McCumber M, Hylek EM, Buller H, Weitz JI, Raskob G, et al. Global public awareness of venous thromboembolism. J Thromb Haemost 2015;13:1365-71. |
| 3. | |
| 4. | Okoye H, Nwagha T, Ezigbo E, Nnachi O, Obodo O, Nnachi O, et al. Low awareness of venous thromboembolism among the general population: A call for increased public enlightenment programs. J Prev Med Hyg 2021;62:E704-8. |
| 5. | Alyahya KI, Alangari FS, Saja DK, Alothaim LO, Albugami SJ, Alharbi SO. Public awareness of venous thromboembolism in Riyadh, Saudi Arabia. Int J Adv Appl Sci 2020;7:125-9. |
| 6. | Al Bshabshe A, Mousa WF, Alshehri MS, Saeed Alshahrani MM, Alamri OM, Alshehri FS, et al. Awareness, knowledge, and attitude toward venous thromboembolism among Aseer Population, Saudi Arabia. J Family Med Prim Care 2021;10:2411-5. |
| 7. | Alnaser AR, Khojah AA, Hashemi AS, Alsabban B, Musa AY, Albasheer EA, et al. Knowledge of and attitude toward venous thromboembolism among professional drivers in Saudi Arabia. Arch Environ Occup Health 2022;77:396-402. |
| 8. | |
| 9. | Brislin RW. Back-translation for cross-cultural research. J Cross Cult Psychol 1970;1:185-216. |
| 10. | Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: A public health concern. Am J Prev Med 2010;38 4 Suppl:S495-501. |
| 11. | Jarab AS, Al-Azzam S, Badaineh R, Mukattash TL, Bsoul R. Awareness and perception of thromboembolism and thromboprophylaxis among hospitalized patients in Jordan. Curr Clin Pharmacol 2020;15:72-80. |
| 12. | Almodaimegh H, Alfehaid L, Alsuhebany N, Bustami R, Alharbi S, Alkatheri A, et al. Awareness of venous thromboembolism and thromboprophylaxis among hospitalized patients: A cross-sectional study. Thromb J 2017;15:19. |
| 13. | Le Sage S, McGee M, Emed JD. Knowledge of venous thromboembolism (VTE) prevention among hospitalized patients. J Vasc Nurs 2008;26:109-17. |
| 14. | Aggarwal A, Fullam L, Brownstein AP, Maynard GA, Ansell J, Varga EA, et al. Deep vein thrombosis (DVT) and pulmonary embolism (PE): Awareness and prophylaxis practices reported by patients with cancer. Cancer Invest 2015;33:405-10. |
| 15. | Kingman CE, Economides DL. Travel in pregnancy: Pregnant women's experiences and knowledge of health issues. J Travel Med 2003;10:330-3. |
| 16. | Ahmed R, Almodaimegh H. Pregnant and the postpartum women's knowledge and awareness of venous thromboembolism. Int J Med Res Health Sci 2019;8:15-21. |
| 17. | Kamel H, Navi BB, Sriram N, Hovsepian DA, Devereux RB, Elkind MS. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014;370:1307-15. |
| 18. | Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Arch Intern Med 2007;167:1471-5. |
| 19. | Zöller B, Li X, Sundquist J, Sundquist K. Age- and gender-specific familial risks for venous thromboembolism: A nationwide epidemiological study based on hospitalizations in Sweden. Circulation 2011;124:1012-20. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9] |
|
|
|
|
|
|
|
|
|
|
|
|
| Article Access Statistics | | | Viewed | 1155 | | | Printed | 50 | | | Emailed | 0 | | | PDF Downloaded | 162 | | | Comments | [Add] | | |
|
|
