Gaps in knowledge and prevention of kidney stone disease among Palestinian adults: findings from an online cross-sectional survey

Abstract

Background

Kidney stone disease (KSD) is a common and largely preventable urological condition with rising incidence worldwide. Public knowledge, awareness, and everyday preventive practices are critical for early prevention, particularly in settings with constrained healthcare resources. This study assessed knowledge, awareness, and selected lifestyle practices related to KSD among adults in Palestine and examined sociodemographic factors associated with preventive understanding.

Methods

A cross-sectional online survey was conducted among 510 adults residing in Palestine between January and October 2025 using snowball sampling via social media platforms. Data were collected with a structured questionnaire adapted from a validated Malaysian tool and culturally tailored to the Palestinian context. The survey assessed sociodemographic characteristics, KSD knowledge, awareness of prevention, and dietary and lifestyle practices. Descriptive statistics, χ² tests, t-tests/ANOVA, Pearson correlation, and multivariable linear and logistic regression were used.Methods

Results

Participants were predominantly young (median 19 years) and female (81.2%). The mean knowledge score was 3.16 ± 1.74 out of six, indicating moderate understanding. While 94.1% had heard of kidney stones, only 56.3% had heard about ways to prevent them, and detailed knowledge of risk factors such as dehydration, high dietary salt, and animal protein intake was limited. Educational attainment independently predicted higher knowledge (p < 0.001), whereas gender, income, and family history were not significant predictors. A weak but statistically significant positive correlation was observed between knowledge score and a composite healthy-lifestyle index (r = 0.21, p < 0.01), suggesting that greater knowledge is associated with, but does not fully determine, healthier behaviors.

Conclusion

Among this predominantly young, educated online sample, general awareness of kidney stones was high but comprehensive preventive knowledge and some lifestyle practices remained suboptimal. Given the modest link between knowledge and behavior, public health strategies in Palestine should combine clear educational messages on hydration and diet with practical, culturally appropriate support to address behavioral and structural barriers. Integrating KSD prevention into primary care counseling, school health programs, and community campaigns may help reduce the future burden of kidney stone disease.

Introduction

Urolithiasis is a common urinary tract condition characterized by the formation of calculi within the kidneys and ureters [1]. It arises through physicochemical processes that promote crystal nucleation, growth, and retention within the urinary system [2]. Globally, the burden of urolithiasis varies considerably, with prevalence estimates ranging from 7 to 13% in North America, 5–9% in Europe, and 1–13% across Asia [3, 4]. Several Middle Eastern countries have also reported rising trends in recent decades, partly attributed to climatic and lifestyle factors [5].

The development of urolithiasis is influenced by a combination of genetic, metabolic, dietary, and environmental determinants. Modifiable risk factors such as low fluid intake, high sodium and animal protein consumption, elevated body mass index (BMI), and exposure to high ambient temperature play significant roles in increasing urinary supersaturation and promoting stone formation [6–8]. Hydration patterns and diet, in particular, represent central contributors to both risk and prevention [7, 8].

Although many risk factors for urolithiasis are modifiable, studies from Asia and the Middle East consistently show limited public understanding of hydration, diet, and lifestyle contributors to stone formation [8, 9]. These persistent gaps highlight the need for population-specific assessments to guide effective prevention strategies.

In Palestine, however, there is a noticeable lack of published research addressing public knowledge and awareness of urolithiasis. Given the country’s hot climate and evolving lifestyle patterns, assessing community understanding of this condition remains essential. Therefore, this study aims to evaluate the knowledge and awareness of adults attending healthcare centers in Palestine regarding urolithiasis, with the goal of identifying existing gaps and informing future public health strategies.

Methodology

Study design and setting

We conducted a descriptive cross-sectional study between January and October 2025 to assess knowledge, awareness, and selected preventive practices related to kidney stone disease among adults residing in Palestine. An online, structured, self-administered questionnaire (Google Forms) was distributed using a snowball sampling approach via major social media platforms (Facebook, WhatsApp, and Instagram). Participants were recruited from across the West Bank, including East Jerusalem, and the Gaza Strip where internet access allowed. Although the use of social-media distribution enabled broad geographical reach, it yielded a non-probabilistic convenience sample consisting primarily of younger, highly educated individuals with reliable internet access. Recruitment depended on voluntary participation and peer-sharing rather than random selection, which introduces self-selection bias and limits external validity. Therefore, findings should be interpreted as reflective of digitally connected Palestinian adults rather than the general population.

Participants

Eligible participants were Palestinian residents aged 18 years or older who could read and respond to the survey in Arabic or English. Individuals working or studying in health-related fields (e.g. medicine, nursing, pharmacy, laboratory sciences) were excluded to minimize inflation of knowledge scores due to professional training.

The minimum sample size was estimated using Epi Info™ version 7.2, assuming a 50% prevalence of adequate awareness of kidney stone prevention, a 95% confidence level, and a 5% margin of error. In the absence of prior data on KSD awareness in Palestine, we used 50% as a conservative estimate that maximizes required sample size, as commonly recommended for cross-sectional studies when true prevalence is unknown. Allowing for potential non-response and incomplete questionnaires, we aimed to recruit at least 385 participants. Ultimately, 510 complete questionnaires were obtained, exceeding the minimum required sample size.

Questionnaire development

The questionnaire was adapted from a previously validated instrument assessing knowledge, awareness, and dietary practices related to urolithiasis in Malaysia [10], with additional items on lifestyle factors tailored to the Palestinian context. It comprised five sections: (1) sociodemographic characteristics (age, gender, marital status, education, income, and occupation); (2) medical history and lifestyle behaviors (presence of chronic illnesses, family history of kidney stones, smoking, alcohol intake, and physical activity); (3) factual knowledge about KSD etiology, symptoms, treatment, and prevention; (4) awareness of preventive measures; and (5) dietary and lifestyle practices (frequency of water, fruit, vegetable, meat, caffeine, and dairy intake).

The original English version was translated into Arabic by a bilingual medical researcher and independently back-translated into English by another bilingual researcher. Discrepancies were resolved by consensus to ensure conceptual and linguistic equivalence. Content validity was assessed by a panel of three experts in public health and nephrology, who independently rated each item for relevance, clarity, and cultural appropriateness using a four-point scale. Items judged as ambiguous or less relevant were revised or, in a few cases, removed. The pre-final Arabic questionnaire was piloted among 30 adults from the target population to evaluate comprehension, wording, and completion time. Feedback from the pilot led to minor modifications in phrasing but no structural changes. Data from the pilot were not included in the final analysis.

To ensure measurement reliability, internal consistency was assessed for key subscales. The six-item knowledge scale demonstrated acceptable reliability (Cronbach’s α = 0.72), and the attitude-related Likert items showed strong reliability (α = 0.81). Cultural adaptation followed a standardized process that included forward translation, back-translation, expert review, and cognitive testing during the pilot to confirm conceptual equivalence and relevance for Palestinian adults. These steps support the content validity and contextual appropriateness of the final questionnaire.

Scoring and variable definition

Six key multiple-choice questions assessed participants’ factual understanding of kidney stone formation, dietary risk factors, symptoms, treatment, and prevention. Each correct response received 1 point, yielding a total knowledge score from 0 to 6. Awareness was evaluated through binary questions (e.g. “Have you heard about ways to prevent kidney stones?”). Dietary frequency responses (“never,” “monthly,” “weekly,” “daily”) were numerically coded from 0 to 3 to allow quantitative analysis. A composite lifestyle index was constructed by summing normalized scores for physical activity, water consumption, fruit intake, and moderation of animal protein, where higher values indicated healthier practices.

Reliability testing showed acceptable internal consistency for the six-item knowledge scale (Cronbach’s α = 0.72) and for the attitude-related Likert items (α = 0.81), which captured agreement with general preventive health statements (e.g. recommended water intake, exercise, and regular health check-ups). Awareness was treated as a dichotomous variable due to its binary nature.

Data management and statistical analysis

Data were automatically captured from Google Forms and exported into Microsoft Excel, then analyzed using Python (pandas, matplotlib, scipy) and IBM SPSS Statistics version 25. Descriptive statistics (means ± SD, medians, interquartile ranges, frequencies, and percentages) were used to summarize demographic characteristics, knowledge levels, and dietary and lifestyle behaviors.

Inferential analyses included χ² tests to examine associations between categorical variables (e.g. gender, education, and prevention awareness); independent t-tests or one-way ANOVA to compare mean knowledge scores across demographic subgroups; and Pearson correlation coefficients (r) to evaluate linear associations between continuous variables (e.g. age, knowledge score, and lifestyle index). Multivariable linear regression was used to identify independent predictors of knowledge score, and logistic regression was used to examine predictors of prevention awareness. For key associations, effect sizes (e.g., Cohen’s d, η², odds ratios) and 95% confidence intervals were calculated and reported alongside p-values in accordance with recommended statistical-reporting guidelines.

Ethical considerations

Ethical approval for this study was obtained from the Institutional Review Board Committee of Al-Quds University, Jerusalem, Palestine (471/REC/2025). At the beginning of the online survey, potential participants were presented with an information page describing the study objectives, procedures, potential risks and benefits, and the voluntary nature of participation. Only individuals who provided electronic informed consent by clicking an “agree” button could access the questionnaire. No names, ID numbers, contact information, or IP addresses were collected, and all responses were stored on password-protected servers accessible only to the research team. Participants could exit the survey at any time before submitting their responses. The study complied with the principles of the Declaration of Helsinki (2013 revision).

Results

Participant characteristics

A total of 510 individuals participated. The mean age was 21.95 ± 8.24 years (range 18–85), with a predominantly young cohort (median 19 years; 75% ≤ 20 years old). Females comprised the majority (81.2%, n = 414) of respondents. Most participants were single (84.3%), consistent with the youthful sample. Socioeconomic status varied: about two-thirds reported an average monthly income sufficient for basic needs (65.1%), 15.3% reported low income, and 19.6% reported high income. Educational attainment was relatively high; 60.6% held a bachelor’s degree or higher and only 1.0% had primary-level education (Table 1). Regarding health background, 27.1% had a family history of kidney stones (first-degree relative or grandparent), while 88.0% reported no chronic illnesses. Alcohol consumption was rare (1.8% reported drinking), and about half of the participants (50.2%) engaged in regular exercise or physical activity. This profile reflects the online, snowball sampling strategy, which reached mainly young, university-educated women.

Table 1.

Participant demographics and baseline characteristics (N = 510) values are presented as n (%) for categorical variables and mean ± SD for continuous variables

Characteristic	Category	n	%
Age (years)	Mean ± SD / Range	21.95 ± 8.24 (18–85)	—
Sex	Male	96	18.8
	Female	414	81.2
Marital status	Single	430	84.3
	Married	66	12.9
	Divorced/Widowed	14	2.7
Educational level	Primary	5	1
	Secondary	125	24.5
	Diploma	71	13.9
	Bachelor’s or higher	309	60.6
Monthly income	Low	78	15.3
	Average	332	65.1
	High	100	19.6
Family history of kidney stones	Yes	138	27.1
	No	372	72.9
Any chronic illness	Yes	61	12
	No	449	88
Alcohol use	Yes	9	1.8
	No	501	98.2
Regular exercise	Yes	256	50.2
	No	254	49.8

SD Standard deviation. Categorical variables are presented as counts and percentages, and continuous variables are reported as mean ± SD. Percentages may not sum to 100% due to rounding. This table provides an overview of participants’ demographic and baseline health characteristics, including age, sex, marital status, education level, income, family history of kidney stones, chronic illness, alcohol use, and engagement in regular exercise

Knowledge and awareness of urolithiasis

Knowledge about kidney stones varied widely among participants. Nearly all respondents (94.1%) had heard of kidney stones, indicating a high basic awareness of the condition. However, only 56.3% reported having heard about ways to prevent kidney stones. On objective knowledge questions, participants demonstrated mixed results. For example, when asked “Where do kidney stones form?” 43.1% correctly recognized that stones can form throughout the urinary tract (“all of the above”), whereas 40.8% believed they form only in the kidney (likely reflecting the literal term “kidney” stones). Knowledge of dietary causes of stones was particularly limited only 18.8% correctly identified the causative role of various foods (selecting “all of the above”), while the majority (57.8%) answered “I don’t know” (with smaller fractions incorrectly singling out items like meat or white rice). In contrast, knowledge of common symptoms of kidney stones was higher, with 65.1% correctly identifying all major symptoms (flank pain, painful urination, etc.) and only 11.4% responding that they did not know the symptoms as shown in Fig. 1.

Fig. 1.

Correct knowledge responses on key urolithiasis questions. Bars show the percentage of participants who answered each knowledge question correctly (by selecting “All of the above” when it was the correct response)

Overall, the composite knowledge score (count of 6 knowledge questions answered correctly) was modest. The mean knowledge score was 3.16 ± 1.74 out of 6 (median 3, interquartile range 2–5), indicating that on average about half of the knowledge questions were answered correctly by each participant. Only 40 individuals (7.8%) answered all 6 questions correctly, whereas 45 individuals (8.8%) did not answer any correctly. The majority had intermediate knowledge (scores of 2–5). Participants fared best on questions about treatment and prevention: 66.9% knew that multiple treatment options exist (extracorporeal shock wave lithotripsy, surgery, and medications), and 72.7% recognized the full range of effective prevention methods (e.g. high fluid intake, healthy diet, and maintaining normal body weight). In terms of risk factors, 49.0% correctly marked all key risk factors (such as dehydration, heredity, and certain metabolic conditions), while 26.3% admitted not knowing risk factors.

Participants’ self-assessed knowledge and attitudes reflected similar patterns. On a 0–10 agreement scale (0 = strongly disagree, 10 = strongly agree), respondents strongly endorsed general preventive health measures: the mean agreement that “one should drink 8 glasses of water daily for prevention” was 7.98 ± 2.56, and that “regular exercise is recommended” was 8.0 ± 2.59 out of 10. There was also high agreement that information should be sought from healthcare providers (mean 7.96) and that “everyone should have an annual health check-up” (7.65 ± 2.89). In line with knowledge results, fewer respondents were confident about specific dietary recommendations the importance of eating 3–5 servings of fruits/vegetables daily had moderate support (mean 5.83 ± 2.96), and understanding of the need to reduce high protein intake unless fluid intake is increased was relatively low (mean agreement only 4.02 ± 2.97). Many were uncertain about recognizing stone symptoms: self-reported awareness of kidney stone symptoms scored a mean of 4.9 ± 2.7, consistent with the fact that one-third did not correctly identify all symptoms in the objective quiz. Interestingly, most disagreed that “preventing stones requires a lot of effort” (mean 4.87, suggesting many feel prevention is feasible). Finally, there was broad recognition that “drinking alcohol may cause urinary stones” (mean agreement 7.69 ± 2.83).

Factors associated with knowledge and awareness

As shown in Table 2, educational level was the main factor associated with knowledge about kidney stones. Participants with a bachelor’s degree or higher had significantly higher mean knowledge scores (3.40 ± 1.68) than those with only secondary education (2.68 ± 1.58; p < 0.001 by ANOVA). In post-hoc comparisons, the difference between college-educated and secondary-educated respondents remained significant (mean difference ≈ 0.72 questions; p < 0.001), whereas participants with diploma-level education scored in between these groups. Gender was not significantly associated with knowledge (females = 3.21 ± 1.70 vs. males = 2.93 ± 1.81; p = 0.17), and no significant differences were observed by income level (p = 0.39). Participants with a family history of kidney stones had slightly higher mean scores (3.29 ± 1.80) than those without (3.10 ± 1.72; p = 0.28). A weak but statistically significant positive correlation was observed between age and knowledge score (r = 0.093, p = 0.037), indicating that older participants tended to achieve marginally higher knowledge scores.

Table 2.

Knowledge score and prevention awareness by participant subgroups knowledge score values are mean ± SD. awareness is the percentage answering “Yes” to having heard about kidney stone prevention

Factor	Knowledge Score (Mean ± SD)	Heard of Prevention (% Yes)	P (Knowledge)	P (Awareness)
Gender	Male: 2.93 ± 1.81 Female: 3.21 ± 1.70	Male: 58.3% Female: 55.8%	0.17	0.67
Education level	Primary: 2.20 ± 1.92 Secondary: 2.68 ± 1.58 Diploma: 3.00 ± 1.93 Bachelor +: 3.40 ± 1.68	Bachelor +: 59.2% Secondary: 52.0%	< 0.001	0.24
Income level	Low: 2.97 ± 1.88 Average: 3.23 ± 1.66 High: 3.05 ± 1.79	Low: 52.6% Average: 57.5% High: 56.0%	0.39	0.78
Family history	Yes: 3.29 ± 1.80 No: 3.10 ± 1.72	Yes: 63.0% No: 54.3%	0.28	0.1

SD Standard deviation. Knowledge scores represent the mean number of correct responses (range 0–6). Prevention awareness indicates the percentage of participants reporting that they have heard about kidney stone prevention. Comparisons of mean knowledge scores were conducted using independent t-tests or one-way ANOVA, as appropriate. Associations between categorical variables and awareness were analyzed using chi-square (χ²) tests. These comparisons illustrate subgroup differences in knowledge and preventive awareness across demographic and socioeconomic categories

Overall, 56.3% of participants reported having heard of kidney stone prevention. Awareness did not differ significantly by gender (females = 55.8% vs. males = 58.3%; p = 0.67), education level (p = 0.24), income (p = 0.78*), or family history (p = 0.10). However, participants with higher knowledge scores were markedly more likely to report awareness of preventive measures, showing a strong positive association between knowledge and prevention awareness (χ² = 64.9, p < 0.001) as Fig. 2. Logistic regression analysis confirmed this relationship, indicating that each one-point increase in knowledge score was associated with 1.35-fold higher odds of having heard of prevention (95% CI: 1.18–1.51; p < 0.001).

Fig. 2.

Relationship between knowledge score and awareness of kidney stone prevention. The percentage of participants aware of prevention increased steadily with higher knowledge scores, ranging from 22.2% among those scoring 0 to 77.5% among those answering all six questions correctly. The shaded area represents the 95% confidence interval

Dietary and lifestyle practices

As shown in Table 3, nearly all participants (94.9%) reported drinking water at least once daily, 3.1% weekly, and 2.0% monthly, while none reported never drinking water. daily fruit and vegetable intake was frequently reported (61–62%), with most others consuming them weekly (~ 30%) and fewer than 10% monthly or less. Daily dairy consumption was reported by 68% of participants (data not shown). Regarding animal protein, 43.9% consumed meat daily, ~ 35% weekly, ~ 15% monthly, and 5% never. Fish consumption was less frequent, with only ~ 5% daily, ~ 30% weekly, ~ 50% monthly, and ~ 15% never. Beverages such as tea, coffee, or soft drinks were consumed daily by ~ 64%, weekly by ~ 25%, and rarely or never by ~ 1%. Overall, most participants reported high water intake and frequent consumption of fruits, vegetables, and meat, whereas fish intake was relatively low.

Table 3.

Frequency of consumption of selected foods and beverages among participants (N = 510) values represent percentage of participants reporting each frequency

Item	Daily (%)	Weekly (%)	Monthly (%)	Never (%)
Water	94.9	3.1	2.0	0
Fruits	61.0	30.0	8.0	1.0
Vegetables	60.0	32.0	7.0	1.0
Meat (red/white)	43.9	35.0	15.0	5.0
Fish/Seafood	5.0	30.0	50.0	15.0
Tea/Coffee/Soft drinks	64.0	25.0	10.0	1.0

Daily: consumption at least once per day. Weekly: consumption at least once per week. Monthly: consumption once per month or less. Never: no consumption of the listed item. Percentages reflect participants’ self-reported intake frequency for water, fruits, vegetables, meat, fish, and caffeinated or sweetened beverages, offering insight into common dietary and hydration behaviors in the study population

As shown in Tables 3 and 64% of participants reported daily consumption of tea, coffee, or soft drinks, and approximately 25% consumed these beverages several times per week. Around 10% drank them rarely or not at all. Pork consumption was almost nonexistent, with 97% reporting never eating pork (data not shown). Alcohol use was minimal, with only 1.8% reporting any alcohol consumption, typically on an infrequent or monthly basis. Overall, most participants reported frequent intake of caffeinated or sweetened beverages, while alcohol and pork consumption were extremely uncommon.

Dietary practices differed significantly by gender for several items (Table 3). Men were more likely to consume meat daily (57.3% of males vs. 40.8% of females; χ², p = 0.005). Daily consumption of tea, coffee, or soft drinks was also higher among men (76.0%) compared with women (61.1%; p = 0.006). In contrast, fruit and vegetable intake did not differ significantly between sexes, with both groups reporting similar daily consumption rates of approximately 60% (p > 0.5). Water intake was nearly universal among both genders, with no significant difference observed. No significant associations were identified between dietary habits and education or income level. For instance, daily meat consumption was reported by ~ 50% of higher-income participants and 41% of those with lower income (p = 0.15, n.s.). Similarly, no correlation was found between participants’ knowledge scores and their dietary practices, as those with higher knowledge were equally likely to consume meat or other foods frequently (all p > 0.05).

Regarding other lifestyle factors, 95% of participants reported drinking water daily, although the actual volume of intake was not assessed. About half (50.2%) engaged in regular exercise. There was no significant association between exercise habits and knowledge or awareness of kidney stones (all p > 0.3). A modest but statistically significant positive correlation was observed between the overall lifestyle index and knowledge score (r = 0.21, p < 0.01; Fig. 3), indicating that participants with healthier hydration and dietary patterns tended to have slightly higher knowledge levels. However, frequent daily consumption of meat and caffeinated or sweetened beverages both recognized risk factors for KSD when not balanced by adequate fluid intake [3, 11] remained common, underscoring that knowledge alone did not consistently translate into optimal preventive practices in this sample.

Fig. 3.

Relationship between healthy lifestyle index and knowledge score. Each point represents an individual participant’s composite lifestyle index and corresponding knowledge score. The solid line shows the linear regression trend with a 95% confidence interval (shaded). A weak but positive correlation was observed (r = 0.21, p < 0.01), indicating that higher lifestyle scores were modestly associated with greater knowledge of kidney stone prevention

Discussion

This cross-sectional online survey of 510 Palestinian adults found that although almost all participants had heard of kidney stones, objective knowledge of KSD etiology, risk factors, and prevention was only moderate. On average, respondents answered about half of the factual questions correctly. Educational attainment was the only consistent sociodemographic predictor of higher knowledge, while gender, income, and family history were not significantly associated. A weak but statistically significant correlation between the knowledge score and the composite healthy-lifestyle index (r = 0.21) indicates an association between higher knowledge and some healthier practices. However, because of the cross-sectional design, these findings do not imply a causal relationship; individuals with healthier behaviors may also be more inclined to acquire health-related knowledge. Thus, the observed associations should be interpreted as descriptive rather than indicative of directional effects.

Preventive practices in this sample showed a heterogeneous pattern of behaviors with potential public-health relevance. Despite frequent daily water intake, high consumption of caffeinated or sweetened beverages and animal protein behaviors consistently linked to increased urinary supersaturation in regional and global literature [3, 10–14] remained widespread. These findings align with studies from Saudi Arabia and Malaysia reporting similar discordance between general awareness and adherence to recommended dietary practices. In combination, such behaviors may sustain or exacerbate the rising KSD burden in Middle Eastern populations, where climatic heat stress already elevates dehydration risk. The absence of strong associations between knowledge and healthier lifestyle patterns suggests structural, cultural, and environmental factors may moderate behavioral change, underscoring the need for interventions that extend beyond education alone.

Our results are broadly consistent with studies from other regions. In Malaysia, Sowtali et al. reported a mean KSD knowledge score of 2.70 ± 1.15 out of six and concluded that awareness of modifiable risk factors was limited despite general familiarity with kidney stones [10]. The Saudi study by Baatiah et al. found that 64.1% of participants had low awareness and fewer than 1% had high awareness, even though disease prevalence was substantial [12]. A more recent survey from Chengdu, China, likewise showed insufficient knowledge and only moderate attitudes and preventive practices, with structural equation modeling indicating that knowledge had both direct and indirect effects on behavior [13]. In a particularly vulnerable group, Syrian refugees in northern Jordan exhibited very low awareness and limited understanding of symptoms and management [15]. Compared with these studies, the Palestinian sample in our study showed slightly higher mean knowledge scores but a similar pattern of partial awareness, modest knowledge–behavior linkage, and a strong educational gradient. This convergence across diverse settings supports the validity of the adapted questionnaire and highlights the global challenge of improving KSD prevention.

The implications for public health in Palestine are substantial. KSD is one of the few non-communicable conditions for which prevention through relatively simple lifestyle measures adequate hydration, dietary modification, weight control is both feasible and cost-effective [16]. The moderate knowledge levels and common high-risk dietary practices observed here indicate a missed opportunity for prevention, particularly among young adults who formed the majority of our sample. Educational attainment emerged as a key determinant of knowledge, echoing broader evidence that health literacy mediates the relationship between education and preventive behavior [17]. However, the modest correlation between knowledge and lifestyle index in our data, as well as in other populations [10], underscores that increasing knowledge is necessary but not sufficient; interventions must also address behavioral, cultural, and structural barriers.

Evidence from broader health promotion research suggests that both hydration and health literacy are amenable to targeted intervention. A recent systematic review of hydration care found that multi-component programs combining educational input, reminders, and environmental or organizational changes can meaningfully improve fluid intake and reduce dehydration risk among adults in community and clinical settings [18]. Similarly, a quasi-experimental study in Iranian health centers showed that an education-based intervention substantially increased health literacy scores and was accompanied by improvements in multiple health-promoting behaviors [19]. These findings indicate that KSD prevention strategies in Palestine are likely to be more effective if kidney-stone specific messages are embedded within broader hydration promotion and health-literacy initiatives, rather than relying on isolated, one-off informational campaigns.

Several barriers are particularly relevant in the Palestinian context. Intermittent water supply and concerns about water safety may discourage high fluid consumption, especially in low-income or rural households. Cultural norms around frequent consumption of tea, coffee, and sugar-sweetened beverages, as well as traditional high-salt and animal-fat dishes, may be difficult to modify without supportive environments and practical alternatives [3, 14]. Periods of fasting and long working hours in hot environments can further exacerbate dehydration risk. At the health-system level, preventive counseling about KSD is rarely incorporated into routine primary-care visits, and few public campaigns focus specifically on stone prevention [20, 21]. Addressing these challenges will require multi-level strategies that combine individual education with supportive policies and community-based interventions.

Based on our findings and existing evidence, several intervention priorities emerge. First, structured health education on KSD should be integrated into primary-care consultations, particularly for patients with known risk factors such as obesity, hypertension, or a family history of stones. Standardized educational materials and brief counseling protocols for physicians, nurses, and community health workers could ensure consistent communication of key messages on hydration, diet, and early symptom recognition [11, 22]. Second, school and university health programs could incorporate topics on kidney health and hydration, targeting adolescents and young adults who, in our study, formed the majority of the online sample. Third, community-level campaigns using social media, local radio, and community organizations could increase reach and tailor messages to cultural beliefs and language preferences [23, 24]. Such interventions should emphasize practical strategies (e.g. carrying water bottles, substituting sugar-sweetened drinks with water, moderating animal protein intake) rather than relying solely on abstract information.

Strengths and limitations

This study has several strengths. It represents one of the first large-scale assessments of public knowledge, awareness, and preventive practices related to KSD in Palestine. The use of a structured questionnaire adapted from a validated Malaysian instrument, followed by expert review, translation/back-translation, and pilot testing, enhances content validity and facilitates international comparison [10]. The sample size was adequate for multivariable analysis, and internal consistency of the knowledge and attitude scales was acceptable.

Several unmeasured or partially measured confounders may have influenced the observed associations. Socioeconomic status, although captured broadly through income self-report, may not adequately reflect access to safe water, dietary quality, or healthcare utilization factors known to affect KSD risk. Hydration habits were assessed as frequency rather than fluid volume, which may have obscured important variation in actual intake. Additionally, comorbidities, medication use, and occupational exposure to heat were not examined in detail, limiting the ability to account for physiologic or environmental contributors. These unmeasured confounders may have attenuated or inflated observed associations between knowledge, awareness, and lifestyle practices.

Nonetheless, important limitations must be acknowledged. The cross-sectional design precludes causal inferences about the relationships between knowledge, awareness, and behavior. The online, snowball sampling strategy introduced selection bias, yielding a predominantly young, female, and highly educated sample that does not represent older adults, men, residents of rural areas, or individuals with lower educational attainment. As such, the findings should be interpreted as reflecting an online, digitally connected segment of the population rather than the Palestinian population as a whole. In addition, all data were self-reported and are therefore subject to recall bias and social desirability bias, particularly for dietary intake, fluid consumption, and physical activity. We did not measure actual fluid volumes or biochemical markers, and we did not assess attitudes toward healthcare utilization or qualitative aspects of health beliefs, which may further influence preventive practices. These limitations may partly explain the modest observed associations between knowledge and lifestyle behaviors.

Future research

Future studies should aim to recruit more representative samples, including older adults, rural residents, and individuals with lower educational attainment, ideally using mixed recruitment strategies that combine online and community-based sampling. Longitudinal and interventional research is needed to determine whether improvements in knowledge and health literacy lead to sustained changes in hydration and dietary practices and to reductions in KSD incidence. Qualitative work, such as focus groups and in-depth interviews, could provide deeper insight into cultural beliefs, perceived barriers, and facilitators of preventive behavior in the Palestinian context. Finally, intervention trials evaluating school-based education, community campaigns, and primary-care–based counseling would generate evidence to guide scalable, cost-effective KSD prevention strategies tailored to similar low-resource settings.

Conclusion

This study provides one of the first assessments of public knowledge, awareness, and preventive practices related to kidney stone disease among adults recruited through an online survey in Palestine. While general awareness of kidney stones was high, detailed understanding of risk factors and effective preventive measures remained limited, and some common lifestyle behaviors such as frequent consumption of animal protein and sweetened or caffeinated beverages were not consistently aligned with recommendations. Educational attainment was the strongest correlate of knowledge, and although the association between knowledge and the healthy-lifestyle index was statistically significant, the cross-sectional design prevents drawing conclusions about directionality. Awareness alone may not fully explain lifestyle behavior, and further longitudinal or interventional studies are required to determine whether improvements in knowledge translate into sustained preventive practices. These findings highlight the need for structured, evidence-based public health interventions that combine clear educational messages with practical support to overcome behavioral and structural barriers, particularly for groups with lower education or limited access to health information. Integrating KSD prevention into primary-care services, school and university health programs, and community outreach initiatives may help reduce the future burden of kidney stone disease in Palestine and similar settings.

Authors’ contributions

Salahaldeen Deeb and Alhareth M. Amro were responsible for the conceptualization, writing, and completion of the manuscript, as well as performing the data analysis, including statistical interpretation and drawing conclusions from the findings. Ayshe M. Zoabi was responsible for writing of the introduction section. Tasneem Z. Deeb, Ayshe M. Zoabi, Sadeen F. amer, Deema N. Al-muhtaseb, Taima Z. Al Haddad, Mayar Z. Deeb, Dareen A. Al Qasrawi, Ahmad H. Khanfar contributed to the study by overseeing the data collection process, ensuring the accuracy and reliability of the gathered information. Each author participated in reviewing and revising the manuscript, providing essential input throughout the research. Their combined efforts in data collection, analysis, and manuscript development were crucial to the successful completion of the study.

Funding

The authors received no specific funding for this work.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All procedures involving human participants complied with the ethical standards of the Institutional Review Board Committee of Al-Quds University, Jerusalem, Palestine (471/REC/2025), and with the 1964 Helsinki declaration and its later amendments. Ethical approval was obtained from the Institutional Review Board Committee of Al-Quds University prior to data collection. Electronic informed consent was obtained from all participants before they accessed the questionnaire. No identifying information was collected, and participation was voluntary.

Consent for publication

Not applicable; the manuscript contains no individual person’s data.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.