Abstract
Introduction:
Peptic ulcer disease (PUD) is a condition characterized by discontinuity in the gastrointestinal (GI) tract’s inner lining, often caused by factors such as Helicobacter pylori infection and NSAID consumption. PUD can lead to various symptoms, but up to 70% of patients may not experience any symptoms. Diagnosing PUD can be challenging due to the unreliability of individual symptoms and signs. PUD can have serious complications if left untreated. Despite its significance, there is a lack of studies measuring the awareness of PUD among the population in Al-Ahsa, Saudi Arabia. Therefore, this study aimed to assess the level of awareness of PUD among the general population in Al-Ahsa.
Methodology:
A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia, from September to December 2023. The study included 399 adult residents of Saudi Arabia who agreed to participate. A convenient nonprobability sampling technique was used to collect data. An online self-administered questionnaire, distributed through social media platforms, was used to gather information on participants’ awareness of PUD. The questionnaire included sociodemographic characteristics and questions related to PUD awareness. Data were analyzed using SPSS, and qualitative data were presented as numbers and percentages. The Chi-square test was used to examine qualitative data between the two groups.
Results:
Of the 399 participants, 71.4% demonstrated a good level of knowledge regarding PUD, whereas 28.6% had a low level of knowledge. The sample consisted of nearly equal numbers of males and females, with participants aged 18–55+ years. The majority of participants had attained a bachelor’s degree and were employed. The findings suggest a relatively high level of education among the study population.
Conclusion:
The study highlights the need for increased public awareness of PUD in Al-Ahsa, Saudi Arabia. While some participants showed good knowledge of PUD, a significant number had low awareness. Educational initiatives are essential to improve understanding and knowledge of PUD among the community. By enhancing awareness, early detection and appropriate management of PUD can be promoted, resulting in improved health outcomes for individuals in Al-Ahsa.
Keywords: Al-Ahsa, peptic ulcer disease, Saudi Arabia
Résumé
Introduction:
La maladie ulcéreuse peptique (MUP) est une affection caractérisée par une discontinuité de la muqueuse interne du tractus gastro-intestinal (GI), souvent causée par des facteurs tels que l’infection à H. pylori et la consommation d’anti-inflammatoires non stéroïdiens (AINS). La PUD peut entraîner divers symptômes, mais jusqu’à 70 % des patients peuvent ne ressentir aucun symptôme. Le diagnostic de l’ulcère peptique peut être difficile en raison de l’irréliabilité des symptômes et des signes individuels. Le PUD peut avoir des complications graves s’il n’est pas traité. Malgré son importance, il y a un manque d’études mesurant la sensibilisation à la DPU parmi la population d’Al Ahsa, en Arabie Saoudite. Par conséquent, cette étude visait à évaluer le niveau de sensibilisation à la DPU parmi la population générale d’Al Ahsa.
Méthodologie:
Une étude transversale a été menée à Al Ahsa, en Arabie Saoudite, de septembre à décembre 2023. L’étude a inclus 399 résidents adultes d’Arabie Saoudite qui ont accepté de participer. Une technique d’échantillonnage non probabiliste pratique a été utilisée pour collecter des données. Un questionnaire auto-administré en ligne, distribué via les plateformes de médias sociaux, a été utilisé pour recueillir des informations sur la sensibilisation des participants à l’UPD. Le questionnaire comprenait des caractéristiques socio-démographiques et des questions liées à la sensibilisation à la DUL. Les données ont été analysées à l’aide de SPSS, et les données qualitatives ont été présentées sous forme de chiffres et de pourcentages. Le test du chi carré a été utilisé pour examiner des données qualitatives entre deux groupes.
Résultats:
Parmi les 399 participants, 71,4 % ont démontré un bon niveau de connaissance concernant l’UPD, tandis que 28,6 % avaient un faible niveau de connaissance. L’échantillon se composait d’un nombre presque égal de mâles et de femelles, avec des participants âgés de 18 à 55 ans et plus. La majorité des participants avaient obtenu un diplôme de licence et étaient employés. Les résultats suggèrent un niveau d’éducation relativement élevé parmi la population étudiée.
Conclusion:
L’étude souligne la nécessité d’une sensibilisation accrue du public concernant la maladie ulcéreuse peptique (MUP) à Al Ahsa, en Arabie Saoudite. Bien que certains participants aient montré une bonne connaissance de l’UPD, un nombre significatif avait une faible sensibilisation. Les initiatives éducatives sont essentielles pour améliorer la compréhension et les connaissances sur les DPU au sein de la communauté. En renforçant la sensibilisation, la détection précoce et la gestion appropriée des DPU peuvent être favorisées, ce qui entraîne une amélioration des résultats de santé pour les individus à Al Ahsa.
Mots-clés: Al ahsa, arabie saoudite, maladie ulcéreuse peptique
INTRODUCTION
Peptic ulcer disease (PUD) is defined as a discontinuity in the gastrointestinal (GI) tract’s inner lining driven by pepsin or gastric acid release. It could penetrate the stomach epithelium’s muscularis propria layer. Usually, the stomach and proximal duodenum are affected. It affects the distal duodenum, jejunum, or lower esophagus as well.[1] PUD can be further subdivided into two separate subtypes, including stomach and duodenal ulcers, depending on where the lesion development took place. As it becomes apparent from their names, duodenal ulcers relate to lesions that arise in the walls of the upper section of the small intestine, whereas gastric ulcers refer to lesions that develop in the mucosal lining of the stomach.[2] Helicobacter pylori infection and NSAID consumption are the two primary risk factors for PUD, however, not everyone with these conditions will ultimately develop the condition. A lower socioeconomic status, poor sanitation, or overcrowding are risk factors for acquiring the infection. H. pylori is more prevalent among several ethnicities and is more prevalent in poorer nations. In the mucosal layer, H. pylori induces an inflammatory response that includes neutrophils, lymphocytes, plasma cells, and macrophages and results in epithelial cell degeneration and damage. In the antrum, gastroenteritis is typically more severe. All patients found to have peptic ulcers should be tested for H. pylori.[3] On the other hand, NSAIDs are the second-most common factor in the development of peptic ulcers in the upper GI tract, beneath H. pylori infection. Inhibition of cyclooxygenase-1 results in mucosal injury because it reduces the production of cytoprotective mucosal prostaglandins and a protective bicarbonate mucus barrier in the stomach and small intestine.[4]
Up to 70% of patients with PUD have no symptoms and this is seen more in people with a higher body mass index (BMI), tea users, alcohol and coffee consumers, and smokers.[5] The most prevalent presenting complaint in symptomatic individuals with PUD is epigastric discomfort, which may be accompanied by dyspepsia, bloating, abdominal fullness, nausea, and early satiety.[6] PUD is often diagnosed based on clinical manifestations along with specific tests, although it is crucial to note that individual symptoms and signs are relatively unreliable.[7] In patients who have dyspepsia and other alarm symptoms (e.g., age more than 60 years, family history of upper GI tract malignancy, weight loss, early satiety, dysphagia, GI bleeding, iron deficiency anemia, or vomiting), upper endoscopy can be used to diagnose PUD and is especially urgent in those patients.[8] In addition, urea breath testing, stool antigen testing, fast urease testing, histology of stomach samples collected during upper endoscopy, and serologic testing are all used to diagnose H. pylori infection.[9]
PUD affects 5%–10% of the world’s population and causes 8 million deaths each year worldwide.[10] The incidence rate of PUD is estimated to be between 0.1% and 0.19%; however, several studies have observed a decreasing trend in incidence worldwide in recent years. In addition, the risk of PUD increases with age and is therefore less common in children. Certain factors, such as smoking, male gender, underlying chronic diseases, and unhealthy lifestyles, are associated with a higher incidence of PUD.[11] Serious complications can occur if early symptoms are ignored, for example, scar penetration, bleeding due to perforation of underlying blood vessels, penetrating wounds to adjacent organs, and gastric blockage due to obstruction by fibrous structures.[11] In 2020, a cross-sectional study was conducted to assess the awareness level of the general population in Jeddah, 620 randomly recruited participants in Jeddah, Saudi Arabia, the general awareness level of PUD in the general population is low which confirms the need for increasing public awareness.[11] A 2019 Indian study examining people’s knowledge of peptic ulcer risk factors found that 81% of 100 pretested samples lacked adequate knowledge, which emphasizes the need to increase public awareness.[12] Similarly, an Egyptian study found that of 150 adults diagnosed with PUD, only 9.3% correctly identified the causes of PUD. On the other hand, 40% did not know the causes and 50% only partly knew.[13] To our knowledge, despite the importance of PUD, no previous study has measured the awareness of PUD among the Al-Ahsa population. Therefore, this study aims to measure the level of awareness among the general population of Al-Ahsa, Saudi Arabia about PUD.
METHODOLOGY
A cross-sectional study was carried out in the Alahsa region in Saudi Arabia from September to December 2023. The study population was recruited from the general population. The study included adult residents of Saudi Arabia who agreed to participate, regardless of gender, nationality, or age above 18, as long as they could read and had a social media account. Participants who were not residents of Saudi Arabia did not have a social media account or declined to participate were not included in the study. The sample size was calculated using the statistical package for the social sciences (SPSS) version 27.0. (IBM Corp., Armonk, NY). info program. Based on the total population of Saudi Arabia, 5% margin of error, and 95% confidence interval, the sample size was estimated to be 384, which was adjusted to 399 to compensate for the 10% nonresponse rate. An online self-administered questionnaire was utilized for the study, with the help of Google Forms. The link generated for the survey was randomly distributed on social media platforms like WhatsApp. The survey interface clearly provided a detailed explanation of the study’s objective. A validated questionnaire was used based on previous studies. The questionnaire contained sociodemographic characteristics of the participants such as age group, sex, nationality, and residence. The questionnaire also included questions about the awareness of the general population in Saudi Arabia about PUD. The questionnaire used a standardized grading system, in which two points were assigned to the correct option, whereas zero points were given for incorrect answers and one point for a neutral response. Upon completion of data collection, participants who scored 30 or more points out of 36 were considered to have a good understanding and practice of PUD. The questionnaire was pretested using a sample of 25 participants in a pilot study. The results of the pilot study were not included in the study. However, some modifications were accordingly done to ensure easy understanding and clarity of the questions. A convenient nonprobability sampling technique was used to collect the data from the participants. The collected data were coded, entered, and analyzed using SPSS. Qualitative data were expressed in the form of numbers and percentages. The Chi-square test was used to examine qualitative data between two groups.
RESULTS
The study aimed to determine the awareness of PUD within the general population of Al-Ahsa, Saudi Arabia achieved a total of 399 eligible subjects to be enrolled. The majority of them reported a good level of knowledge regarding PUD accounting for 285 (71.4%), whereas 114 (28.6%) were classified as having a low level of knowledge. The participants elucidated a comprehensive sociodemographic landscape of the participants. As shown in Table 1, the study consisted of 399 individuals, with a nearly even gender split of 203 males (50.9%) and 196 females (49.1%), ensuring a balanced gender perspective in the findings. Age wise, 43.1% of the sample was of the 18–25-year age group, followed by 26–35 and 36–45 categories, each comprising 20.1% of participants, while those in the 46–55 range represented a smaller fraction at 11.3%. The senior-most group, aged 56 and above, was the least represented at 5.5%. Marital status varied across the sample, with more than half of the participants being married (57.4%), and single subjects at 40.9% of the whole sample, whereas divorced and widowed individuals were relatively few, making up 0.8% and 1.0%, respectively. Education levels among the participants were notably high, with an overwhelming majority having attained a bachelor’s degree (71.4%), indicative of a well-educated sample. Those with secondary education formed (17.3%), but only a minuscule number reported primary (0.3%) or middle education (3.8%). An additional (7.3%) identified with education categories outside the conventional spectrum, labeled as “other.” Occupational profiles revealed that half of the participants were employed (50.1%). Students made up a significant proportion (30.8%), whereas unemployment and retirement were present but less common conditions, affecting 9.5% and 5.5% of the sample, respectively, and a small fraction fell into other occupational categories (4.0%). The income analysis reported 35.1% earning below 3000, whereas the higher income groups exceeding 15,000 were reported by 19.3% of the participants. The middle-income ranges from 3000 to 14,000 were variably represented, with a diverse economic demographic.
Table 1.
Sociodemographic data of the study participants
| Item | n (%) |
|---|---|
| Gender | |
| Male | 203 (50.9) |
| Female | 196 (49.1) |
| Age | |
| 18–25 | 172 (43.1) |
| 26–35 | 80 (20.1) |
| 36–45 | 80 (20.1) |
| 46–55 | 45 (11.3) |
| 56 or above | 22 (5.5) |
| Marital status | |
| Single | 163 (40.9) |
| Married | 229 (57.4) |
| Divorced | 3 (0.8) |
| Widowed | 4 (1.0) |
| Education level | |
| Primary | 1 (0.3) |
| Secondary | 15 (3.8) |
| Higher secondary | 69 (17.3) |
| Bachelor | 285 (71.4) |
| Other | 29 (7.3) |
| Occupation | |
| Employed | 200 (50.1) |
| Unemployed | 38 (9.5) |
| Retired | 22 (5.5) |
| Student | 123 (30.8) |
| Other | 16 (4.0) |
| Income | |
| <3000 | 140 (35.1) |
| 3000–4999 | 23 (5.8) |
| 5000–9999 | 59 (14.8) |
| 10,000–14,000 | 100 (25.1) |
| >15,000 | 77 (19.3) |
As shown in Table 2, regarding the awareness of PUD among the general population of Al-Ahsa, the study revealed that a significant majority were familiar with PUD (68.9%), whereas a smaller yet notable proportion reported personal or known cases of PUD diagnosis (21.8%). When inquired about the nature of PUD, a large majority correctly identified it as a digestive disease (90.5%). Misconceptions about PUD being related to the heart or liver were minimal, and a small percentage was unsure of the disease’s classification. Recognition of the initial red flags for PUD suspicion was high, with the majority correctly reporting epigastric pain as a key warning sign (78.9%), whereas other symptoms such as chest pain and headache were less frequently misidentified as initial PUD symptoms. The most commonly observed symptom of PUD was regurgitation (50.1%). A significant number was unsure about the common symptoms of PUD, indicating a knowledge gap that could be addressed in educational outreach. In terms of treatment approaches for PUD, the majority correctly understood that a combination of antibiotics and acid-suppressive medications is typically employed (38.8%). However, there was a significant degree of uncertainty regarding treatment modalities among the respondents (30.8%). With regard to the recommended age for endoscopy, a critical diagnostic tool for PUD was not well-known, with a large number of respondents unsure about when it is advised (38.1%). Only a small proportion correctly identified when endoscopy is generally recommended (19.3%). Furthermore, a minority of the respondents believe PUD is a genetic disease, whereas a majority disagree, and a significant number are unsure. When it comes to asymptomatic cases of PUD, a substantial portion of respondents think PUD can affect a person without visible symptoms (44.1%), which shows a recognition that the disease may not always manifest with clear signs. However, some disagree, and others do not know, indicating a degree of uncertainty or lack of knowledge about the condition. Further details are in Table 2. The role of psychological stress as a risk factor for PUD is widely acknowledged, with a large majority agreeing (76.9%), suggesting a common belief in the connection between stress and GI health. Only a small fraction disagrees (5.5%), and others are not sure (17.5%). Regarding the influence of other diseases such as liver cirrhosis on PUD risk, opinions were more divided: some agree (37.8%), but there is a significant number of unsure responses (53.9%). With respect to the symptoms of PUD, many recognize vomiting as a typical symptom (56.4%). On the preventive side, an overwhelming majority believe that a healthy lifestyle and eating habits can reduce the risk of PUD (85.7%), indicating a strong belief in the effectiveness of lifestyle modifications for disease prevention. Furthermore, when investigated about their perspective toward the efficacy of home remedies for treating PUD, some respondents believed that home remedies can solely treat the disease (22.3%); however, a larger group disagrees (42.6%) and a considerable number are unsure (35.1%). Smoking’s impact on PUD risk was significantly unrecognized by the participants. Only a small portion agreed that it can increase risk (8.5%), whereas a significant majority disagreed (60.2%), and others did not know (31.3%) about the impact of smoking. Exploring the study participant’s opinion on community awareness of PUD, community awareness about PUD a majority of the respondents (69.7%) believed it to be insufficient, and some believe there should be more focus on increasing public awareness about the disease (34.6%), whereas a substantial number do not know if the current focus is adequate (47.4%).
Table 2.
Awareness of peptic ulcer disease among the general population of Al-Ahsa
| Question | Responses |
|||
|---|---|---|---|---|
| Yes, n (%) | No, n (%) | Not sure, n (%) | ||
| Have you ever heard about PUD? | 275 (68.9) | 76 (19) | 48 (12) | |
| Did you or someone you know ever diagnosed with PUD? | 87 (21.8) | 272 (68.2) | 40 (10) | |
|
| ||||
| Question | Responses | |||
|
| ||||
| PUD is a disease?, n (%) | Heart | Digestive | Liver | I don’t know |
| 0 | 361 (90.5) | 8 (2) | 30 (7.5) | |
| What is initial red flag for PUD suspicion?, n (%) | Chest pain | Headache | Epigastric pain | I don’t know |
| 10 (2.5) | 2 (0.5) | 315 (78.9) | 72 (18) | |
| What is the most commonly observed symptom of PUD?, n (%) | Nausea | Regurgitation | Low BP | I don’t know |
| 90 (22.6) | 200 (50.1) | 6 (1.5) | 103 (25.8) | |
| Mostly, the treatment approach used for PUD is?, n (%) | Antibiotics | Acid suppression | Both | I don’t know |
| 48 (12) | 73 (18.3) | 155 (38.8) | 123 (30.8) | |
| At what age endoscopy is recommended?, n (%) | 18–40 | 41–54 | 55 or older | I don’t know |
| 100 (25.1) | 77 (19.3) | 70 (17.5) | 152 (38.1) | |
|
| ||||
| Question | Responses | |||
| Agree, n (%) | Disagree, n (%) | I don’t know, n (%) | ||
|
| ||||
| Do you think PUD is a genetic disease? | 49 (12.3) | 202 (50.6) | 148 (37.1) | |
| Do you think PUD can affect a person without any visible symptoms? | 176 (44.1) | 97 (24.3) | 126 (31.6) | |
| Do you think psychological stress can be a risk factor of PUD? | 307 (76.9) | 22 (5.5) | 70 (17.5) | |
| Do you think other diseases such as liver cirrhosis can increase risk of PUD? | 151 (37.8) | 33 (8.3) | 215 (53.9) | |
| Vomiting is a typical symptom of PUD | 225 (56.4) | 38 (9.5) | 136 (34.1) | |
| Do you think healthy lifestyle and eating habits can reduce risk of PUD? | 342 (85.7) | 8 (2) | 49 (12.3) | |
| Do you think home remedies can solely treat PUD? | 89 (22.3) | 170 (42.6) | 140 (35.1) | |
| Do you think smoking can increase the risk of PUD? | 34 (8.5) | 240 (60.2) | 125 (31.3) | |
| Do you think old age can increase the risk of PUD | 348 (87.2) | 6 (1.5) | 45 (11.3) | |
| Do you think your community has enough awareness about PUD? | 278 (69.7) | 13 (3.3) | 108 (27.1) | |
| Do you think there should be more focus on increasing the public | 138 (34.6) | 72 (18) | 189 (47.4) | |
PUD=Peptic ulcer disease, BP=Blood pressure
Table 3 demonstrates an association analysis between sociodemographic data and the level of awareness regarding PUD among the general population of Al-Ahsa. The P values listed in the table are all above the conventional threshold for statistical significance. This indicates that there are no statistically significant differences in the awareness levels across the different categories of gender, age, marital status, education level, occupation, and income.
Table 3.
The association between sociodemographic data and the level of awareness regarding peptic ulcer disease among the general population of Al-Ahsa
| Item | Good | Poor | P |
|---|---|---|---|
| Gender | |||
| Male | 51 | 152 | 0.374 |
| Female | 57 | 139 | |
| Age | |||
| 18–25 | 57 | 115 | 0.154 |
| 26–35 | 19 | 61 | |
| 36–45 | 15 | 65 | |
| 46–55 | 12 | 33 | |
| 56 or above | 5 | 17 | |
| Marital status | |||
| Single | 52 | 111 | 0.183 |
| Married | 55 | 174 | |
| Divorced | 1 | 2 | |
| Widowed | 0 | 4 | |
| Education level | |||
| Primary | 0 | 1 | 0.691 |
| Secondary | 3 | 12 | |
| Higher secondary | 18 | 51 | |
| Bachelor | 82 | 203 | |
| Other | 5 | 24 | |
| Occupation | |||
| Employed | 47 | 153 | 0.176 |
| Unemployed | 9 | 29 | |
| Retired | 4 | 18 | |
| Student | 42 | 81 | |
| Other | 6 | 10 | |
| Income | |||
| <3000 | 42 | 98 | 0.460 |
| 3000–4999 | 5 | 18 | |
| 5000–9999 | 16 | 43 | |
| 10,000–14,000 | 30 | 70 | |
| >15,000 | 15 | 62 |
DISCUSSION
PUD is defined as a discontinuity in the GI tract’s inner lining driven by pepsin or gastric acid release.[1] PUD affects 5%–10% of the world’s population and causes 8 million deaths each year worldwide.[1] The incidence rate of PUD is estimated to be between 0.1% and 0.19%.[11] H. pylori infection and NSAID consumption are the two primary risk factors for PUD.[3] The most prevalent presenting complaint in symptomatic individuals with PUD is epigastric discomfort, which may be accompanied by dyspepsia, bloating, abdominal fullness, nausea, and early satiety.[6] Up to 70% of patients with PUD have no symptoms and this is seen more in people with a higher BMI, tea users, alcohol and coffee consumers, and smokers.[5] In this study, the awareness of the general population regarding PUD was investigated. Findings showed that the majority of the participants had a good level of knowledge regarding PUD accounting for 71.4%. This level is higher than the level of awareness that was reported by Perez Quarte et al.,[14] who reported that the Physician Assistantship students and the Nursing students had an “average or moderate” knowledge (with a percentage of 64.0% and 53.5%), respectively. In contrast, a study was conducted in Jeddah, Saudi Arabia by Dafalla et al. wherein only 38.4% of participants were recognized with a good level of awareness.[15] Lower levels of awareness were highlighted in a national study in Saudi Arabia by Jaddoh, which reported that only 26.5% of participants had good awareness about PUD.[2] The current results revealed that educational level did not have any significant impact on awareness about PUD, as the calculated P values were recorded as 0.322. This is in accordance with the findings of the study conducted by Abukanna et al.[16] which recorded P = 0.827. The current results contradict the findings of the study that was conducted by Jaddoh et al.[12] who demonstrated that the awareness level was found to be associated with bachelor and other educational qualifications holders. The results were also contrary to the results previously reported by Dafalla et al.[15] as the calculated P values were recorded as 0. 010. This study included a total of 399 participants, most of whom were males (50.9%). Two age groups were equally active in this study, 26–35 and 36–45 with a percentage of 20.1% each. Concerning the level of awareness toward PUD in different age groups, in the current study, age is not considered to be causing statistically significant variations. In contrast to Jaddoh,[2] in 2021, highlighted the increased level of awareness in higher age groups. In comparison to Khaity, et al.,[10] 2023, concluded the need for a larger sample size within Sudan due to the variations in awareness levels among the population. Eldeen Dafalla et al.,[11] in 2021, highlighted the higher rate of awareness within 25–34 age group. Concluding that the level of awareness is insufficient among the Jeddah population. According to Shamseya et al.,[13] in 2015, 81.3% of the participants were found to have minimal overall knowledge scores. Age and the patient’s level of knowledge were found to differ by a significant margin, with patients between the ages of 20 and 30 years. Regarding gender and its effect on PUD awareness, Jaddoh,[2] in 2021, revealed that gender, nationality, and residency did not have any significant impact on awareness about PUD. On the contrary, Eldeen Dafalla et al.,[11] in 2021, observed a significantly higher level of awareness within males. In the current study, there were no drastic variations of level awareness with different genders. Regarding participants’ awareness of risk factors for PUD, 76.9% believed that PUD can be caused by psychological stress and only 37.8% knew that other diseases such as liver cirrhosis could increase the risk of PUD, whereas a higher fraction of participants (97.8%) were aware of the risk factors of PUD as reported in a study conducted by Jaras et al.[17] In addition, the current study shows that an overwhelming majority believe that a healthy lifestyle and eating habits can reduce the risk of PUD (85.7%). The current result was also similar to a study conducted among the Saudi general population by Jaddoh,[2] who reported that a large percentage of participants (82%) think that a healthy lifestyle could reduce the risk of PUD.
CONCLUSION
The current study showed that the majority of participants had a good awareness of PUD. However, there are gaps in knowledge about the common symptoms of PUD, the age at which endoscopy is recommended, and the effect of smoking on PUD. There was no significant relationship between gender, age, and education level. Health authorities should make special efforts to raise awareness of PUD, thereby improving patient self-awareness and recognition of early signs and symptoms, preventing further deterioration, and improving the quality of life for PUD patients.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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