Knowledge and confidence regarding pressure ulcer prevention among caregivers of high-risk individuals: A pre- and post-education assessment in a single-center

Abstract

Objective

We aimed to measure the effect of implementing a pressure ulcer (PU) educational program on the knowledge and confidence of caregivers taking care of bedridden patients or patients with limited mobility.

Methods

This study included caregivers of immobile or bedridden patients in our center from 23 April 2023 to 13 May 2023. A pre-assessment questionnaire to assess knowledge about PUs was provided. After this, an educational session was implemented. Thereafter, a post-assessment questionnaire was provided to measure the education outcomes.

Results

A total of 98 caregivers were included in the study; the majority were females (n = 69, 70.4 %) and were family members of the patient (n = 89, 90.8 %). Most have never received education on PUs and their prevention (n = 63, 64.3 %). The education sessions significantly affected the level of knowledge, as the scores were significantly higher post-education compared to pre-education (16.96 ± 2.73 vs. 11.06 ± 3.71, p < 0.001).

Conclusion

Overall, we found that education sessions on PUs using different visual and audio aids could significantly increase caregivers' knowledge of PU prevention.

Innovation

We adopted a multi-faceted approach by developing original educational materials tailored to non-professional caregivers, including videos, booklets, and brochures in Arabic and English. This helped ensure accessibility and enhance the potential for widespread applicability in diverse home settings.

Highlights

• •Pressure ulcers were reported to be among the top seven causes of short-term mortality.
• •Providing educational materials to caregivers significantly increased their knowledge about pressure ulcer prevention.
• •Only 35.7 % of caregivers reported that they received proper education regarding pressure ulcer prevention previously.
• •After education, 95.9 % of caregivers were confident in preventing bedsores.
• •Caregivers who received prior education on pressure ulcer prevention scored better than those who did not.

1. Introduction

Pressure ulcers (PUs), also known as decubitus ulcers, are defined as localized damage of the skin and underlying soft tissue over a bony prominence or in relation to a medical device, resulting from prolonged pressure, shearing, and friction [1]. Risk factors for PUs include the following: immobility, urinary or fecal incontinence, decreased sensation, malnutrition, dehydration, and medical conditions impairing blood flow. Areas frequently involved are the sacrum, heels, ischial tuberosities, greater trochanters, and lateral malleoli. The most common consequent complication is infection, which can potentially be life-threatening [2]. Frequent assessment of ulcer susceptible points and awareness of the different stages of PU aid in early detection and prompt intervention [3]. More importantly, knowledge and application of preventative methods are extremely critical given the slow healing time and frequent recurrence of PUs [4]. The action is best initiated at home by actively involving caregivers of predisposed individuals [5].

PUs were listed as one of the top seven causes of short-term mortality in a systematic review [6]. One study conducted among home caregivers evaluated their knowledge of PU prevention through a questionnaire and found that 50 % had poor knowledge while only 10 % had good knowledge [7]. Another similar study revealed that most patients claimed not to have received adequate education regarding PUs while in hospital [8]. In Saudi Arabia, one study estimated that the prevalence and incidence of overall inpatients with PUs were 5.7 % and 1.6 PU/1000 cases, respectively [9]. Furthermore, another Saudi study conducted exclusively among ICU patients has reported a PU incidence of around 39 % in the intensive care unit [10].

There is a scarcity of research regarding knowledge of PU prevention among home caregivers, as most studies targeted healthcare workers instead. Moreover, the majority of programs conducted in the past were dedicated to preventing hospital-acquired PUs by educating nurses rather than involving home caregivers. This sheds light on the significance of targeting greater efforts toward preventing such a prevalent and debilitating problem, primarily focusing on the role caregivers play at home. Implementing a PU prevention educational program would significantly contribute to the overall quality of patient safety in terms of reducing PU occurrence and complications, as well as improving the quality of life of patients and their caregivers. Therefore, through this study, we aimed to assess the difference in knowledge among caregivers before and after implementing educational sessions regarding PU care and prevention among home caregivers of high-risk individuals.

2. Materials and methods

2.1. Study design, setting, and population

A cross-sectional study was conducted between April 2023 and January 2024. Caregivers and families of individuals who are bedridden, wheelchair-bound, or moving with assistance were recruited from our tertiary center. Eligible patients were identified by reviewing the records in the hospital's electronic database of those admitted to the surgical and medical wards at the time of the study. Caregivers of these patients were then approached during the hospital's visiting hours and invited to participate in the study. We used a consecutive sampling approach, including all eligible participants who met the inclusion criteria and were present in the wards during the study team's visits. Those who had no caregivers around as companions and those with language barriers were excluded, as our assessment questionnaires and educational material were only available in English and Arabic.

2.2. Data collection

During three weeks between 23rd April 2023 and 13th May 2023, caregivers of patients who were bedridden or with limited mobility were visited in the hospital to be assessed. Our study involved three phases: knowledge and confidence pre-assessment phase, educational material delivery phase (intervention), and knowledge and confidence post-assessment phase. Each participant completed the pre-assessment questionnaire prior to providing our educational material. The educational material comprised a variety of videos, booklets, brochures, and flyers, available in both the Arabic and English languages [supplementary materials and videos]. These contained information regarding the definition of bedsore (pressure ulcer), etiology, risk factors, complications, prevention methods, repositioning techniques, grading, examination steps, and common misconceptions. Then, the post-assessment questionnaire, which reassessed the same items, was completed two to four days later. The pre- and post-assessment surveys, created using Google Forms, included items from two validated questionnaires in the English language, one assessing knowledge and the other confidence and attitude toward PU prevention. The knowledge part included information regarding pressure ulcer risk factors and prevention practices [8], while the confidence and attitude part explored the level of self-confidence with regard to preventing the occurrence of pressure ulcers [11]. These questionnaires were translated into Arabic by two authors and then back-translated into English by two different authors. The two English versions were compared to ensure both accuracy and consistency with the original questionnaires. No further validation was performed post-translation, as the original versions were already validated, and the items were deemed culturally appropriate for an Arabic-speaking audience. The knowledge assessment questionnaire items with the correct answer for each question are demonstrated in Table 1.

Table 1.

Knowledge assessment questionnaire items.

	Yes	No	I do not know
1. If a seated person does not change his position, pressure injury may occur.	✔
2. The skin should be moisturized after cleansing.	✔
3. It is appropriate not to change the position of areas with reddened skin.		✔
4. Dry skin prevents the occurrence of pressure injury.		✔
5. The use of any type of alcohol-containing product, such as rosemary oil, can help prevent the occurrence of pressure injury.		✔
6. The use of Talcum powder on the skin prevents the occurrence of pressure injury.		✔
7. In people with delicate and fragile skin, it is easier for pressure injury to appear.	✔
8. Moisture from urine and sweat may lead to the occurrence of pressure injury.	✔
9. If we see a reddened area in the skin of the patient that does not bleach when touched, we must inform the nurse as it may be a pressure injury.	✔
10. Massage of reddened areas helps prevent the occurrence of pressure injury.		✔
11. The application of soap and very strong detergents to wash a bedridden patient who has bladder and bowel incontinence, is helpful in the prevention of pressure injury.		✔
12. The use of any kind of soap, gel, or detergent is good for cleaning a bedridden person.		✔
13. The use of dressing on areas susceptible to pressure injuries can reduce the risk of the occurrence of pressure injuries.	✔
14. A diet rich in fats (oils, meats, eggs) helps prevent the occurrence of pressure injury.	✔
15. A diet rich in protein (meat, fish, and eggs) and vitamins (fruits and vegetables) helps prevent the occurrence of pressure injury.	✔
16. Poor nutrition increases the risk of the occurrence of pressure injury.	✔
17. The use of soft cushions under the patient's feet while sitting can help prevent the occurrence of pressure injury.		✔
18. Placing the patient's feet on a small chair or footstool, if they do not reach the ground, can be helpful in the prevention of pressure injury.	✔
19. It is better to use the pillow or blanket that is under the bedridden patient in order to move them in bed.	✔
20. For complete bed rest, it is better to raise the head of the bed up to 30 degrees to prevent the occurrence of pressure injury.		✔
21. Putting enough blankets and sheets under the bedridden patient can help prevent the occurrence of pressure injury.		✔

Notes: correct answers are indicated with ✔.

A point was scored for every correct answer the caregiver got, and no points were given if the answer was either incorrect or if the caregiver answered with “I do not know.” a score out of 21 was then calculated pre- and post-education. Other data collected consisted of demographic information of both the caregiver and the patient.

2.3. Data analysis

Microsoft Excel 2021 (Microsoft Corporation, Redmond, WA) was used for data entry, and IBM SPSS Statistics version 27 (IBM Corp., Armonk, NY) was used for data analysis and coding. Categorical data, such as those regarding sex, caregiver type, and education level, are expressed as frequencies, whereas continuous data, such as that of age, are expressed as means and standard deviations. Cronbach's α Test was used to determine the internal consistency of the Knowledge Score Questionnaire, and it was deemed reliable with a score of 0.731 for the pre-test and 0.694 for the post-test. Paired Sample T-Test was used to determine whether there was a statistical significance between the pre and post-education knowledge scores. An Independent t-test was performed to analyze whether the pre-education scores differed significantly based on the caregiver's demographic characteristics, years of caregiving, and prior learning. Statistical significance was set at p < 0.05.

2.4. Ethical approval

This study was approved by our center's Research Biomedical Ethics Committee (reference no. 125-24). The participants filled in their agreement electronically before filling out the questionnaire. They were informed that data may be used for research; however, that shouldn't affect their answers. Additionally, all patients' personal data were kept anonymous, and the research variables were only accessible to the research team.

3. Results

3.1. Details regarding caregivers and patients

This study included a total of 98 caregivers of patients who developed or were at high risk of developing bedsores; the mean age of the caregivers was 39.99 ± 12.56 years (Range: 18–65), and the majority were females (n = 69, 70.4 %). 90.8 % of the caregivers were family members, 7.1 % were housemaids, and 2.2 % were home nurses. Most family member caregivers were either the patients' children (n = 48, 53.9 %) or parents (n = 18, 20.2 %). The majority of caregivers have heard about bedsores before (n = 73, 74.5 %). However, only 35.7 % reported that they had received proper education about it, and the most reported sources for that education were the internet or social media (n = 13, 37.1 %) or the hospitals' homecare team (n = 12, 34.3 %). Regarding the patients, their mean age was 66.30 ± 22.78 years, and 38.9 % have had a bed sore at some time in their lives. Table 2 demonstrates the sociodemographics and details regarding the caregivers and patients.

Table 2.

Caregivers and patients' sociodemographic characteristics and details.

	Caregivers Mean ± SD	Patients Mean ± SD
Age (years)	39.99 ± 12.56	66.30 ± 22.78
	Caregiver N (%)	Patients N (%)
Sex
Male	29 (29.6 %)	44 (44.9 %)
Female	69 (70.4 %)	54 (55.1 %)
Type of caregiver
Family member	89 (90.8 %)	–
Housemaid	7 (7.1 %)	–
Home nurse	2 (2.1 %)	–
Family member caregiver relationship with the patient
Son/Daughter	48 (53.9 %)	–
Parent	18 (20.2 %)	–
Spouse	7 (7.9 %)	–
Sibling	5 (5.6 %)	–
Distant relative	5 (5.6 %)	–
Cousin	3 (3.4 %)	–
Grandson/Granddaughter	2 (2.2 %)	–
Grandparent	1 (1.1 %)	–
Educational level
Less than High School	26 (26.5 %)	–
Highschool	36 (36.7 %	–
Bachelors	33 (33.7 %)	–
Masters	3 (3.1 %)	–
Do you work in the medical field?
Yes	9 (9.2 %)	–
No	89 (90.8 %)	–
Years of caregiving
Less than one year	30 (30.6 %)	–
1–3 years	44 (44.9 %)	–
4–6 years	11 (11.2 %)	–
7–9 years	4 (4.1 %)	–
Ten years and above	9 (9.2 %)	–
Have you ever heard about bedsores?
Yes	73 (74.5 %)	–
No	63 (25.5 %)	–
Have you ever received any education on bedsores?
Yes	35 (35.7 %)	–
No	63 (64.3 %)	–
Source of info
Internet/social media	13 (37.1 %)	–
Homecare	12 (34.3 %)	–
School/university	5 (14.3 %)	–
Doctor	3 (8.6 %)	–
Work	2 (5.7 %)	–
Does the patient have any bedsores now?
Yes	–	29 (29.6 %)
No	–	67 (68.4 %)
I don't know	–	2 (2.0 %)
Did the patient have any bedsores at any time during their life?
Yes	–	38 (38.9 %)
No	–	60 (61.2 %)
Does the patient have any medical condition causing limited mobility?
Yes	–	88 (89.8 %)
No	–	10 (10.2 %)
Does the patient have any medical condition causing fecal incontinence?
Yes	–	25 (25.5 %)
No	–	73 (74.5 %)
Does the patient have any medical condition causing urine incontinence?
Yes	–	30 (30.6 %)
No	–	68 (69.4 %)
Does the patient have diabetes mellitus?
Yes	–	42 (42.9 %)
No	–	56 (57.1 %)
Does the patient have cerebral palsy?
Yes	–	8 (8.2 %)
No	–	90 (91.8 %)

Notes: Age data are expressed as mean ± standard deviation, and others are expressed as numbers (N) & percentages (%).

Abbreviations: N: number, SD: standard deviation.

3.2. Knowledge regarding pressure ulcer prevention

The mean total score of caregiver's knowledge for all 21 questions before educating them was 11.06 ± 3.71. After education, the total mean score reached 16.96 ± 2.73 (p < 0.001). Questions 1, 2, and 19 received the most correct answers before education. On the other hand, questions 6, 17, and 21 received the least correct answers. Table 3 demonstrates the mean scores for all the questionnaire knowledge items before and after education.

Table 3.

Caregivers' response to the questionnaire knowledge items.

	Score before education Mean ± SD	Score after education Mean ± SD	P-value
1. If a seated person does not change his position, pressure injury may occur.	0.88 ± 0.32	1.00 ± 0.00	<0.001*
2. The skin should be moisturized after cleansing.	0.80 ± 0.40	0.97 ± 0.17	<0.001*
3. It is appropriate not to change the position of areas with reddened skin.	0.57 ± 0.49	0.71 ± 0.45	0.038*
4. Dry skin prevents the occurrence of pressure injury.	0.44 ± 0.49	0.80 ± 0.40	<0.001*
5. The use of any type of alcohol-containing product, such as rosemary oil, can help prevent the occurrence of pressure injury.	0.38 ± 0.48	0.92 ± 0.27	<0.001*
6. The use of Talcum powder on the skin prevents the occurrence of pressure injury.	0.19 ± 0.39	0.76 ± 0.43	<0.001*
7. In people with delicate and fragile skin, it is easier for pressure injury to appear.	0.76 ± 0.43	0.89 ± 0.31	0.006*
8. Moisture from urine and sweat may lead to the occurrence of pressure injury.	0.74 ± 0.43	0.96 ± 0.19	<0.001*
9. If we see a reddened area in the skin of the patient that does not bleach when touched, we must inform the nurse as it may be a pressure injury.	0.71 ± 0.45	0.96 ± 0.19	<0.001*
10. Massage of reddened areas helps prevent the occurrence of pressure injury.	0.31 ± 0.46	0.80 ± 0.40	<0.001*
11. The application of soap and very strong detergents to wash a bedridden patient who has bladder and bowel incontinence, is helpful in the prevention of pressure injury.	0.60 ± 0.49	0.84 ± 0.37	<0.001*
12. The use of any kind of soap, gel, or detergent is good for cleaning a bedridden person.	0.38 ± 0.48	0.67 ± 0.47	<0.001*
13. The use of dressing on areas susceptible to pressure injuries can reduce the risk of the occurrence of pressure injuries.	0.58 ± 0.49	0.80 ± 0.40	<0.001*
14. A diet rich in fats (oils, meats, eggs) helps prevent the occurrence of pressure injury.	0.34 ± 0.47	0.59 ± 0.49	<0.001*
15. A diet rich in protein (meat, fish, and eggs) and vitamins (fruits and vegetables) helps prevent the occurrence of pressure injury.	0.49 ± 0.50	0.89 ± 0.31	<0.001*
16. Poor nutrition increases the risk of the occurrence of pressure injury.	0.64 ± 0.48	0.98 ± 0.14	<0.001*
17. The use of soft cushions under the patient's feet while sitting can help prevent the occurrence of pressure injury.	0.04 ± 0.19	0.23 ± 0.42	<0.001*
18. Placing the patient's feet on a small chair or footstool, if they do not reach the ground, can be helpful in the prevention of pressure injury.	0.63 ± 0.48	0.93 ± 0.25	<0.001*
19. It is better to use the pillow or blanket that is under the bedridden patient in order to move them in bed.	0.68 ± 0.46	0.94 ± 0.24	<0.001*
20. For complete bed rest, it is better to raise the head of the bed up to 30 degrees to prevent the occurrence of pressure injury.	0.62 ± 0.48	0.88 ± 0.32	<0.001*
21. Putting enough blankets and sheets under the bedridden patient can help prevent the occurrence of pressure injury.	0.28 ± 0.44	0.47 ± 0.50	0.003
The combined score of all questions	11.06 ± 3.71	16.96 ± 2.73	<0.001*

Notes: data are expressed as mean ± standard deviation.

Abbreviations: N: number, SD: standard deviation, *: statistical significance at <0.05.

Before getting educated, 60.2 % of caregivers agreed or strongly agreed that they were confident in preventing bedsores. However, after being educated, the percentage reached 95.9 %. Furthermore, 44.9 % of caregivers agreed or strongly agreed that preventing bedsores is hard and believed that other people are more qualified for the job. After educating them, only 28.6 % still believed so, while the rest believed that they were qualified to do it. Based on self-reported feedback, 98 % of caregivers reported that the education provided regarding the prevention of bedsores was beneficial for them.

Despite the previous results, some factors influenced the total pre-education score. Caregivers who had heard about bedsores before scored significantly higher than others (11.83 ± 3.07 vs. 8.80 ± 4.50, p = 0.004). Moreover, caregivers who received any education regarding bedsores prior to filling out the questionnaire scored significantly higher (12.20 ± 10.42 vs. 10.42 ± 3.90, p = 0.023). However, other factors, such as the number of years of caregiving and the caregivers' educational level, did not have any significant effect on the score. Table 4 demonstrates the different factors influencing the total score recorded before receiving education.

Table 4.

The effect of different sociodemographic and personal details of caregivers on the total score before receiving the education.

	Total score of caregivers' pre-education Mean ± SD	p-value
Sex
Male	11.10 ± 3.79	0.942
Female	11.04 ± 3.71
Educational level
Less than Highschool	11.80 ± 3.58	0.161
Highschool	11.52 ± 3.06
Bachelors	9.87 ± 4.31
Masters	12.00 ± 3.46
Do you work in the medical field?
Yes	11.11 ± 4.56	0.967
No	11.05 ± 3.65
Years of caregiving
Less than one year	12.26 ± 2.86	0.084
1–3 years	10.31 ± 4.34
4–6 years	12.18 ± 2.13
7–9 years	11.25 ± 4.99
Ten years and above	9.22 ± 2.72
Have you ever heard about bedsores?
Yes	11.83 ± 3.07	0.004*
No	8.80 ± 4.50
Have you ever received any education on bedsores?
Yes	12.20 ± 10.42	0.023*
No	10.42 ± 3.90
Did the patient have any bedsores at any time during their life?
Yes	11.65 ± 3.28	0.208
No	10.68 ± 3.95

Notes: expressed as data are expressed as mean ± standard deviation.

Abbreviations: N: number, SD: standard deviation, *: Significant at <0.05.

4. Discussion and conclusion

4.1. Discussion

In this study, we aimed to evaluate the knowledge and awareness of PU preventive methods among caregivers before and after educating them. We found that the majority of caregivers were not properly educated on the prevention of PUs. This is comparable to previous studies and further stresses that caregivers who lack education about bedsore prevention during their patients' hospitalization must be taken into consideration for proper interventions [7,8].

Furthermore, we found that education level did not significantly influence the level of PU knowledge among caregivers. When comparing these results with existing literature, some studies reported a correlation between educational level and PU prevention knowledge [12,13], while others found results similar to ours, showing no significant relationship [[14], [15], [16]]. Upon reviewing the methodologies of these studies, we noted important differences. For example, one study that showed a correlation had a limited sample size (30 participants) [12], while another categorized education levels into only two groups: “Illiterate” and “Literate” [13]. In contrast, our study employed broader categorization, dividing education levels into “Less than High School,” “High School,” “Bachelor,” and “Master.” Interestingly, studies that also found no significant influence of education level similarly employed more detailed categorization of education levels.

These variations in categorization and sample size could account for the discrepancies in findings across studies. In our study, the lack of a significant relationship between education level and PU knowledge is likely due to an overall deficiency in structured caregiver training. This was evidenced by the finding that most caregivers cited the internet and social media as their primary sources of information on PU prevention. While the reliance on these sources was not unexpected, it highlights a critical gap in hospital-based caregiver education programs. The absence of standardized, accessible educational interventions leaves caregivers dependent on informal sources that may not always provide accurate guidance. For example, a recent study found that more than one-third of videos on social media regarding emergent general surgery procedures contained misinformation. Videos from healthcare professionals and institutions had less misinformation, while those from patients and non-medical groups had significantly more misinformation [17]. This underscores the urgent need for hospitals and healthcare institutions to develop and implement comprehensive caregiver training programs, ensuring that caregivers have access to accurate and practical information about PU prevention.

After providing education for the caregivers in our study, the knowledge levels and confidence levels both significantly increased. Similarly, previous research supports that teaching and involving family members and caregivers other than healthcare workers in preventing PUs is effective [18,19]. This is evident in our study, as those who received prior education regarding PUs initially had higher knowledge scores than those who never did. A Turkish study employed brochures to educate patients and caregivers on pressure ulcers, and most found it satisfactory [20]. Another study found that when caregivers received special “pressure ulcer prevention training” it was associated with increased knowledge compared to the routing ward training [21]. Likewise, our study found that it was beneficial to the caregivers regarding PU prevention knowledge.

Given that pressure ulcers can be easily prevented by frequent turning and prophylactic measures, this makes providing education to caregivers is crucial [22]. A previous study revised the different guidelines for PU prevention and highlighted that no clear guidelines exist for the role of family and caregivers on the prevention of PUs, making it crucial to establish future guidelines and education for them [5].

4.2. Innovation

This study is one of the first to specifically target home caregivers, rather than healthcare professionals, in assessing the impact of educational interventions on pressure ulcer prevention knowledge. We adopted an innovative, multi-faceted approach by developing original educational materials tailored to a non-professional audience, including videos, booklets, and brochures available in both Arabic and English.

A key challenge in creating these materials was ensuring they were both medically accurate and accessible to individuals without medical backgrounds; striking the right balance between simplicity and accuracy was crucial. Additionally, delivering this content in both Arabic and English required careful consideration of cultural nuances and language barriers to ensure that the material was relevant and easily understood by caregivers from diverse backgrounds. To address these challenges, the materials were reviewed by specialists from various fields, including internal medicine, general surgery, anesthesia, and intensive care, to ensure medical clarity and accuracy. Additionally, we conducted a pilot test with a select group of caregivers to assess the comprehensibility and appropriateness of the content. These strategies ensured accessibility and comprehension, regardless of caregivers' medical backgrounds, promoting inclusivity and enhancing the potential for widespread application in diverse home settings.

4.3. Conclusion

In conclusion, our study found that implementing educational material such as videos, booklets, and brochures could increase both awareness and confidence about PU knowledge and prevention. Further recommendations on establishing a PU education program and implementing a risk assessment scale to enhance the quality of life of bedsore patients and their caregivers would help decrease PU incidence, complications, and associated morbidities. Furthermore, future studies should evaluate whether the observed increase in confidence translates into measurable behavioral changes. Such research would provide valuable insights into the long-term impact and effectiveness of educational interventions.

The following are the supplementary data related to this article.

Supplementary video 1

Pressure ulcer educational video (English)

Supplementary video 2

Pressure ulcer educational video (Arabic)

Supplementary material 1

Pressure ulcer prevention booklet (English)

Supplementary material 2

Pressure ulcer prevention booklet (Arabic)

Presentation at a meeting

Not applicable.

Fundings and support

All authors have declared that no financial support was received from any organization for the submitted work.

CRediT authorship contribution statement

Maram T. Alkhatieb: Writing – review & editing, Supervision, Methodology, Conceptualization. Rahaf W. Shigdar: Writing – review & editing, Writing – original draft, Visualization, Methodology, Investigation. Zainab A. Alkhalifah: Writing – review & editing, Writing – original draft, Methodology, Investigation. Hussain A. Alkhalifah: Writing – review & editing, Writing – original draft, Formal analysis, Data curation. Hanan F. Alsabri: Writing – review & editing, Writing – original draft, Investigation. Lama W. Attar: Writing – review & editing, Writing – original draft, Methodology, Investigation. Hana Z. Fatani: Writing – review & editing, Writing – original draft, Methodology, Investigation. Haifa M. Alnahdi: Writing – review & editing, Supervision, Conceptualization.

Ethical considerations

Privacy and confidentiality were maintained throughout the study and the data was only accessed by the authors. Privacy and confidentiality were maintained throughout the study, and the data were only accessed by the authors. This study was conducted in accordance with the ethical principles mentioned in the Declaration of Helsinki (2013). Ethical approval was obtained from our center's Research Biomedical Ethics Committee (reference number 125–24).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

All data collected for this study are included in the tables and results.