Evaluation of Pediatricians’ Knowledge of Autism in Saudi Arabia

Abstract

Background:

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition, and early detection is essential for improving outcomes. Pediatricians are often the first point of contact; however, their knowledge of ASD in Saudi Arabia remains unclear.

Objective:

The aim of this sudy was to evaluate the knowledge of pediatricians in Saudi Arabia regarding childhood autism using the validated Knowledge about Childhood Autism among Health Workers (KCAHW) questionnaire.

Methods:

A cross-sectional study was conducted among 357 pediatricians practicing in Saudi Arabia from September 2021 to August 2022. Participants completed the 19-item KCAHW questionnaire, which covered four knowledge domains: social interaction impairments, communication impairments, repetitive behaviors, and classification/comorbidities. Descriptive statistics and inferential analyses (t-tests, analysis of variance, and regression models) assessed associations between participant characteristics and knowledge scores.

Results:

The mean overall knowledge score was 15.24 ± 2.23 out of 19. While most participants performed well in the communication domain (90.5% scored above average), only 49.6% scored above average in social interaction knowledge. Pediatricians trained abroad scored significantly higher in domains 1 and 2. Subspecialists, particularly those in developmental/behavioral pediatrics and neurology, scored the highest. Pediatricians with 4–6 years of experience showed a positive association with overall knowledge.

Conclusion:

Pediatricians in Saudi Arabia demonstrated above-average knowledge of ASD, significant gaps remain - particularly in social interaction and comorbidities. These findings highlight the need for enhanced ASD-focused training, particularly for locally trained and early-career pediatricians

1. BACKGROUND

Autism spectrum disorder (ASD) is a childhood-onset neurodevelopmental disorder characterized by impairments in social communication, language development, and behavior (1). Children with ASD often exhibit a strong preference for routines and may engage in repetitive behaviors. They can become distressed when faced with unexpected changes in their daily environments (2). The severity of ASD varies significantly, with some individuals requiring continuous support due to moderate to severe symptoms (1).

Early diagnosis of ASD is essential for timely intervention; however, many children are diagnosed late - often between the ages of three and ten. Delayed diagnosis reduces the effectiveness of early intervention during a critical period of brain development. Early diagnosis has gradually improved - particularly among children from high-income households or those whose parents recognize symptoms early - however, many still miss this critical window. Increasing awareness among parents and healthcare professionals about early signs is essential to improve early identification (3).

Multiple factors contribute to the development of ASD, including genetic, environmental, and possibly immunological elements that influence neurodevelopmental processes. Prenatal exposure to medications, environmental toxins, metabolic or dietary disruptions, and genetic susceptibility have been linked to an increased risk of autism. These factors interact in complex ways, often leading to heterogeneous presentations of ASD, which frequently include comorbid conditions. This complexity has made it difficult to identify consistent genetic markers and environmental exposure profiles, although ongoing research continues to advance understanding in this area (4).

According to the World Health Organization, approximately one in 160 children worldwide are diagnosed with ASD (5). The condition affects children across all ethnicities and is among the most prevalent developmental disabilities globally (1). In Saudi Arabia, reported prevalence rates include 2.618 per 1,000 children in Jeddah, 3.68 per 1,000 in Makkah, and 2.81 per 1,000 for both cities combined. These statistics underscore the urgency of early identification and appropriate resource allocation (6).

Pediatricians, often the first healthcare professionals to encounter children with ASD, play a critical role in early detection and parental guidance. Pediatricians are expected to be well-informed about ASD diagnosis and management; however, their actual level of knowledge in Saudi Arabia remains largely undocumented. Misconceptions and outdated beliefs about ASD persist among the public and may also influence healthcare professionals, hindering accurate diagnosis and timely intervention. Therefore, evaluating pediatricians’ knowledge of the etiology, clinical features, and management of ASD is essential to guide future training and educational efforts (7).

Previous international studies have identified knowledge gaps among pediatricians and pediatric residents regarding ASD. For example, a 2019 study at Dr. Sami Ulus Children’s Hospital in Turkey reported that despite psychiatry rotations, many pediatricians lacked sufficient knowledge of ASD diagnostic criteria and held misconceptions about its etiology and prognosis (7). Similarly, a 2021 cross-sectional study found that although many pediatricians had a solid understanding of core ASD symptoms, they lacked adequate knowledge of neurodevelopmental conditions and comorbidities associated with autism (8).

2. OBJECTIVE

In this study, we aimed to evaluate the knowledge of pediatricians in Saudi Arabia regarding childhood autism using a validated questionnaire. The findings will help identify knowledge gaps and guide medical education program directors in addressing areas that require improvement.

3. PATIENTS AND METHODS

Study Design and Setting

In this study, we used a cross-sectional design with a structured, validated questionnaire. Data were collected from pediatricians across Saudi Arabia between September 2021 and August 2022. The primary tool was the Knowledge about Childhood Autism among Health Workers (KCAHW) questionnaire, which consists of 19 items grouped into four domains (9). The tool provides a total score out of 19, assessing knowledge in key domains of autism-related understanding.

Study Participants

Pediatric residents, specialists, fellows, and consultants practicing in pediatric settings in Saudi Arabia were eligible. Incomplete responses were excluded. Participation was voluntary and anonymous.

Data Collection Tool and Process

The KCAHW questionnaire, used in this study, assessed knowledge across four domains:

• Domain 1: Impairments in social interaction (8 questions);

• Domain 2: Communication impairments (1 question);

• Domain 3: Repetitive and stereotyped behaviors (4 questions);

• Domain 4: Autism classification and associated comorbidities (6 questions).

Each correct response received 1 point, while incorrect or “Don’t know” responses were scored as 0. The maximum possible score was 19. The questionnaire was distributed electronically through the Research and Development Unit of the Saudi Commission of Health Specialties to all registered pediatricians in Saudi Arabia from October to December 2021. It was self-administered using Google Forms. Scoring criteria and the full questionnaire are provided in Appendices 1 and 2.

Statistical Analysis

Data were analyzed using SPSS (version 26.0). The Shapiro–Wilk test assessed data normality. Descriptive statistics summarized continuous variables (mean ± standard deviation) and categorical variables (frequencies and percentages). Group comparisons were conducted using independent t-tests and one-way analysis of variance, with statistical significance set at p < 0.05.

Ethical Considerations

The study was approved by the Institutional Review Board (IRB) of Imam Abdulrahman Bin Faisal University (Approval No. 2021-01-386; October 25, 2021). Informed consent was implied through voluntary questionnaire completion. Participants were assured of data confidentiality, and all responses were anonymized.

4. results

A total of 357 pediatricians participated in the study. The sample had a male predominance (59.4%), and most participants were between 30 and 49 years. More than half were senior registrars, specialists, or fellows (54.6%), and nearly two-thirds (63.9%) had over 10 years of pediatric experience.

Most respondents were non-Saudi nationals (64.1%), with a similar proportion having graduated (62.2%) and completed residency training (61.6%) abroad. Most participants practiced general pediatrics (67.9%), while a smaller proportion represented various pediatric subspecialties. Detailed demographic characteristics are provided in Table 1.

Table 1. Baseline characteristics among participants involved in the study .

Study Variables	Total Participants
Sex
Male	212 (59.4%)
Female	145 (40.6%)
Age group (years)
20 – 29	46 (12.9%)
30 – 39	120 (33.6%)
40 – 49	96 (26.9%)
50 and above	95 (26.6%)
Professional level
Trainee/Resident	77 (21.6%)
Senior registrar/Specialist/Fellow	195 (54.6%)
Consultant	85 (23.8%)
Experience years in the field of Pediatrics
1 – 3 years	48 (13.4%)
4 – 6 years	37 (10.4%)
7 – 9 years	44 (12.3%)
10 years or more	228 (63.9%)
Nationality
Non-Saudi	229 (64.1%)
Saudi	128 (35.9%)
Country of medical school graduated from
Abroad	222 (62.2%)
Saudi Arabia	135 (37.8%)
Country of pediatric residency training
Abroad	220 (61.6%)
Saudi Arabia	137 (38.4%)
Current specialty/subspeciality
General Pediatrics	242 (67.9%)
Pediatric Neurology	9 (2.5%)
Pediatric Pulmonology	3 (0.8%)
Pediatric Cardiology	5 (1.4%)
Pediatric Endocrinology	10 (2.8%)
Pediatric Infectious Disease	4 (1.1%)
Pediatric critical care	14 (3.9%)
Neonatology	38 (10.6%)
Developmental/Behavioral Pediatrics	2 (0.6%)
Metabolic/Genetics	2 (0.6%)
Pediatric Emergency care	13 (3.6%)
Pediatric Nephrology	2 (0.6%)
Pediatric Hematology/Oncology	5 (1.4%)
Pediatric Allergy/Immunology	4 (1.1%)
Pediatric Gastroenterology	4 (1.1%)

The pediatricians’ knowledge of autism was assessed across four domains using the KCAHW tool. The overall mean total score was 15.24 ± 2.23 out of 19, with 51.8% of participants scoring above the average.

• Domain 1 (Social Interaction Impairments):

The mean score was 7.12 ± 1.13 out of 8; 49.6% scored above the average. No participants scored zero.

• Domain 2 (Communication Impairments):

This domain had the highest proportion of above-average performers (90.5%), with a mean score of 0.91 ± 0.29 out of 1. However, 9.5% scored zero.

• Domain 3 (Repetitive Behaviors):

Mean score was 3.26 ± 0.96 out of 4; 53.5% scored above average. A small portion (0.8%) scored zero.

• Domain 4 (Classification and Comorbidities):

Mean score was 3.95 ± 1.31 out of 6; 65.8% scored above the average. Only 0.6% scored zero.

A detailed breakdown of domain-specific scores and distributions is provided in Table 2.

Table 2. The pattern of distribution of scores in the different domains of KCAHW questionnaire among the included pediatricians .

Domains	Area of knowledge/symptoms questions addressed	Total score possible	Mean scores	Number of participants with scores above the average	Number of participants scoring zero
Domain 1	Impairments in social interaction	8	7.12 ± 1.13	177 (49.6%)	0
Domain 2	Impairment in communication	1	0.91 ± 0.29	323 (90.5%)	34 (9.5%)
Domain 3	Obsessive and repetitive behavioral pattern	4	3.26 ± 0.96	191 (53.5%)	3 (0.8%)
Domain 4	Type of disorder Autism is and possible associated co-morbidity	6	3.95 ± 1.31	235 (65.8%)	2 (0.6%)
Total Domains	Summation of scores in the four domains	19	15.24 ± 2.23	185 (51.8%)	0

Comparative analysis of KCAHW scores across demographic and professional characteristics is summarized in Table 3. Key findings include:

Table 3. Comparison of mean scores of KCAHW questionnaire and its domains in relation to the participants' baseline characteristics.

Study Variables	Total KCAHW Score	Test statistics p-value	Domain 1	Test statistics p-value	Domain 2	Test statistics p-value	Domain 3	Test statistics p-value	Domain 4	Test statistics p-value
Sex
Male	15.25 ± 2.06	T = 0.17	7.22 ± 1.06	T = 1.89	0.92 ± 0.26	T = 1.54	3.22 ± 0.95	T = -0.97	3.9 ± 1.25	T = 0.17
Female	15.21 ± 2.45	0.86	6.99 ± 1.22	0.058	0.88 ± 0.33	0.12	3.32 ± 0.97	0.33	4.03 ± 1.4	0.86
Age group (years)
20 – 29	14.91 ± 2.35	F = 0.76	6.76 ± 1.32	F = 4.32	0.85 ± 0.36	F = 2.36	3.43 ± 0.78	F = 1.18	3.87 ± 1.44	F = 0.11
30 – 39	15.13 ± 2.41	0.51	6.98 ± 1.11	0.005	0.91 ± 0.28	0.07	3.24 ± 1.05	0.32	3.99 ± 1.34	0.95
40 – 49	15.45 ± 1.87		7.39 ± 0.88		0.96 ± 0.2		3.14 ± 0.98		3.97 ± 1.16
50 and above	15.33 ± 2.27		7.22 ± 1.23		0.86 ± 0.35		3.32 ± 0.89		3.93 ± 1.37
Professional level
Trainee/Resident	15.08 ± 2.21	F = 1.15	6.97 ± 1.19	F = 1.09	0.92 ± 0.27	F = 0.78	3.3 ± 0.86	F = 0.84	3.88 ± 1.4	F = 0.67
Specialist/Fellow	15.16 ± 2.25	0.32	7.13 ± 1.13	0.33	0.91 ± 0.28	0.46	3.2 ± 1.02	0.43	3.92 ± 1.26	0.51
Consultant	15.55 ± 2.18		7.24 ± 1.07		0.87 ± 0.34		3.35 ± 0.9		4.09 ± 1.37
Experience years in the field of Pediatrics
1 – 3 years	14.94 ± 2.31	F = 2.73	6.85 ± 1.24	F = 2.64	0.89 ± 0.31	F = 1.53	3.35 ± 0.84	F = 0.95	3.83 ± 1.45	F = 0.61
4 – 6 years	14.51 ± 2.57	0.044	6.86 ± 1.16	0.049	0.81 ± 0.39	0.21	3.05 ± 1.2	0.41	3.78 ± 1.08	0.61
7 – 9 years	14.95 ± 2.21		7 ± 1.12		0.93 ± 0.26		3.2 ± 1.1		3.86 ± 1.49
10 years or more	15.47 ± 2.13		7.25 ± 1.1		0.92 ± 0.28		3.29 ± 0.91		4.02 ± 1.29
Nationality
Non-Saudi	15.37 ± 2.08	T = 1.46	7.26 ± 1.04	T = 3.13	0.95 ± 0.22	T = 3.75	3.22 ± 0.96	T = -1.04	3.94 ± 1.27	T = -0.26
Saudi	15.01 ± 2.46	0.14	6.88 ± 1.24	0.001	0.83 ± 0.38	<0.001	3.33 ± 0.95	0.3	3.98 ± 1.39	0.79
Country of medical school graduated from
Abroad	15.37 ± 2.06	T = 1.48	7.27 ± 1.03	T = 3.09	0.95 ± 0.22	T = 3.84	3.23 ± 0.95	T = -0.59	3.92 ± 1.29	T = -0.53
Saudi Arabia	15.01 ± 2.46	0.14	6.89 ± 1.26	0.002	0.83 ± 0.37	<0.001	3.3 ± 0.97	0.55	4 ± 1.37	0.59
Country of pediatric residency training
Abroad	15.32 ± 2.08	T = 0.9	7.21 ± 1.09	T = 1.82	0.95 ± 0.23	T = 3.36	3.23 ± 0.96	T = -0.65	3.94 ± 1.3	T = -0.29
Saudi Arabia	15.1 ± 2.44	0.36	6.99 ± 1.18	0.069	0.84 ± 0.37	<0.001	3.3 ± 0.96	0.52	3.98 ± 1.34	0.77
Current specialty
General Pediatrics	15.2 ± 2.28	T = -0.44	7.12 ± 1.16	T = 0.02	0.93 ± 0.26	T = 1.95	3.29 ± 0.95	T = 1.02	3.86 ± 1.29	T = -1.95
Pediatric subspecialties	15.31 ± 2.12	0.66	7.12 ± 1.08	0.99	0.86 ± 0.35	0.025	3.18 ± 0.97	0.31	4.15 ± 1.35	0.026

• Sex: No statistically significant differences were observed in overall or domain-specific scores.

* Age group: Pediatricians aged 30–39 had significantly lower scores in Domain 1 (p = 0.005). No other domains showed significant differences across age groups.

* Professional level: Consultants scored higher than other groups; however, the differences were not statistically significant.

* Years of experience: Participants with more than 10 years of experience scored highest overall. Those with 4–6 years of experience had significantly lower scores in Domain 1 (p = 0.049).

Nationality and training location:

o Non-Saudis and those trained abroad scored significantly higher in Domains 1 and 2 (p < 0.01).

o Saudi-trained pediatricians scored lower in social interaction and communication domains.

Subspecialty: Pediatric subspecialists scored significantly higher in Domain 4 (p = 0.026), particularly those in developmental/behavioral pediatrics (mean = 18.5) and neurology (mean = 16.6). Domain score distributions by subspecialty are shown in Figure 1.

A multiple linear regression model was used to identify predictors of the total KCAHW score (Table 4). Most demographic and educational variables were not statistically significant.

Table 4. Multiple linear regression of the factors associated with total KCAHW score.

Variables	Adjusted Linear Regression
	p-value	Standard error	t-value	Coeff	95% CI (Lower - Upper)
Female	0.864	0.24	-0.17	-0.041	(-0.513 - 0.431)
Age group (reference = 30 - 39)
20 – 29	0.61	0.414	0.511	0.211	(-0.606 - 1.031)
40 – 49	0.281	0.299	1.078	0.322	(-0.267 - 0.913)
50 and above	0.532	0.161	0.624	0.101	(-0.216 - 0.418)
Professional level (reference = Senior registrar/Specialist/Fellow)
Trainee/Resident	0.775	0.301	0.286	0.086	(-0.506 - 0.679)
Consultant	0.181	0.289	1.341	0.388	(-0.181 - 0.959)
Experience years in the field of Pediatrics (reference = 10 years or more)
1 – 3 years	0.119	0.114	1.563	0.178	(-0.046 - 0.403)
4 – 6 years	0.014	0.194	2.471	0.48	(0.097 - 0.862)
7 – 9 years	0.142	0.352	1.473	0.519	(-0.174 - 1.212)
Saudi Nationality	0.144	0.245	-1.463	-0.359	(-0.841 - 0.123)
Medical school in Saudi Arabia	0.139	0.242	-1.48	-0.359	(-0.836 - 0.118)
Residency training in Saudi Arabia	0.363	0.242	-0.909	-0.221	(-0.836 - 0.118)
Pediatric subspecialty	0.661	0.252	0.437	0.111	(-0.385 - 0.607)

However: Pediatricians with 4–6 years of experience showed a significant positive association with higher total knowledge scores (β = 0.48, p = 0.014).

Other factors such as sex, age, nationality, training location, and subspecialty were not significant predictors in the adjusted model.

5. Discussion

In this study, we aimed to assess the knowledge of pediatricians in Saudi Arabia regarding ASD using the validated KCAHW questionnaire. A total of 357 pediatricians participated, with data collected over 12 months from September 2021 to August 2022. The mean overall knowledge score was 15.24 out of 19, indicating a generally good understanding of ASD. However, score distribution across domains and participant demographics showed significant variability, highlighting specific gaps in knowledge and the need for targeted educational interventions.

When analyzing performance across the four domains, Domain 2 (communication impairments) had the highest proportion of above-average scores (90.5%), while Domain 1 (social interaction impairments) had the lowest, with only 49.6% of participants scoring above average. Domain 1 still had a high mean score (7.12 out of 8); however, the lower percentage of high performers indicates uneven knowledge in identifying core social deficits in ASD. This is particularly concerning because impairments in social interaction are central to ASD diagnosis. Domain 4 (classification and comorbidities) also showed the greatest score variation, reflecting inconsistent understanding of ASD as a neurodevelopmental disorder and its commonly associated conditions.

These findings align with prior international research. For example, Gellert et al. (2025) in Poland and Çitil et al. (2021) in Turkey also reported strong knowledge of communication and core symptoms but weaker understanding of comorbidities (10, 11). In our study, despite a high average score in Domain 3 (repetitive behaviors), only 53.5% of participants scored above average, and a small proportion scored zero. This suggests knowledge gaps in recognizing less overt behavioral symptoms. These domain-specific differences highlight the need for balanced ASD training that addresses all diagnostic features, not just the more widely recognized ones.

Regarding demographic and professional variables, sex was not significantly associated with knowledge levels, unlike findings from some previous studies (eg., Domarecki et al., 2025), who reported higher ASD knowledge among female physicians (12). In contrast, we found that pediatricians aged 30–39 scored significantly lower in Domain 1 than those in other age groups (p = 0.005). This may reflect a knowledge decline following initial training, underscoring the need for continuous education throughout early and mid-career stages.

Training background significantly influenced knowledge scores. Pediatricians who graduated or completed residency abroad scored higher than those trained locally in Domains 1 and 2 (p = 0.002 and p < 0.001, respectively), suggesting that international programs may provide more comprehensive or structured autism education. These findings align with those of Hayat et al. (2019), who reported better autism knowledge among non-Saudi-trained physicians in Makkah (13).

Years of experience also played a nuanced role. Pediatricians with ≥10 years of experience had the highest mean scores in most domains; however, a notable finding from the multiple regression analysis was that those with 4–6 years of experience were significantly associated with higher total KCAHW scores (p = 0.014). This may reflect a cohort that is more recently trained and actively engaged in learning while still benefiting from structured education. However, this group performed poorly in Domain 1, suggesting that despite broader awareness, key diagnostic social features may be underrecognized.

Subspecialty training, particularly in developmental-behavioral pediatrics and pediatric neurology, was associated with higher knowledge—particularly in Domain 4 (p = 0.026). Pediatricians with developmental-behavioral training achieved the highest mean total score (18.5), supporting the value of targeted specialization in strengthening ASD knowledge. However, regression analysis showed that subspecialty alone was not a statistically significant predictor of the total KCAHW score (p = 0.661), suggesting that domain-specific expertise may not translate into comprehensive understanding without broader clinical exposure.

These results align with studies from Ghana (14) and Nigeria (15), where healthcare providers with greater exposure to autism cases, particularly in psychiatric or tertiary settings, demonstrated superior knowledge (14, 15). Similarly, Unigwe et al. (2017) reported that general practitioners with personal contact or clinical exposure to autistic individuals showed greater confidence and knowledge in ASD care (16).

Together, these findings highlight the multifactorial nature of autism knowledge acquisition, shaped by training quality, years of experience, clinical exposure, and subspecialty focus. They underscore the need for continuous, standardized autism education within pediatric training - particularly in Saudi Arabia, where locally trained physicians scored significantly lower in key diagnostic domains. Furthermore, the variability in performance across domains supports the refining educational tools such as the KCAHW questionnaire to ensure balanced evaluation and targeted learning.

Limitations of the study

This study has some limitations that should be acknowledged:

* Cross-sectional design: As the study captured data at a single point in time, it cannot establish causality or assess changes in knowledge over time.

* Sample representation bias: A significant proportion of participants were non-Saudi (64.1%) and had completed medical education or residency abroad (over 60%). This may limit the generalizability of the findings to Saudi-trained pediatricians.

* Self-reported and voluntary participation: Reliance on a self-administered online questionnaire may have introduced selection bias, as participants more confident or interested in ASD may have been more likely to respond. Reporting bias is also possible.

6. conclusion

This study identified important knowledge gaps among pediatricians in Saudi Arabia regarding ASD, particularly in recognizing social interaction impairments and understanding autism classification and comorbidities. Overall knowledge levels were above average; however, significant disparities were observed based on training background, experience, and subspecialty.

Pediatricians who trained or graduated abroad demonstrated stronger knowledge, particularly in core symptom domains. Those with 4–6 years of experience showed the most significant positive association with overall knowledge scores. Subspecialists, particularly in developmental-behavioral pediatrics and neurology, scored highest in understanding autism classification and comorbidities.

These findings underscore the urgent need for targeted educational interventions focused on ASD recognition, diagnosis, and management - particularly for Saudi-trained and early-career pediatricians. Enhancing ASD education during residency, integrating structured diagnostic training, and offering continuous professional development programs may help bridge current knowledge gaps and support earlier, more accurate identification of ASD in clinical practice. These results also offer valuable insights for policymakers, educators, and healthcare administrators seeking to improve autism care pathways across Saudi Arabia.

Recommendations

Based on the study findings, several recommendations are proposed to enhance pediatricians’ preparedness in ASD care. First, curricular enhancements should be made by integrating structured ASD training into undergraduate medical curricula and pediatric residency programs, with emphasis on early identification, symptom recognition, and understanding of comorbidities. Second, targeted Continuing Medical Education (CME) programs should be developed, particularly for Saudi-trained pediatricians and those with fewer than 10 years of experience, focusing on core symptom domains where knowledge gaps were identified, such as social interaction impairments and diagnostic classification. Third, there is a need for tool refinement and validation by adapting and validating the KCAHW questionnaire or alternative tools, to ensure cultural and contextual relevance within the Saudi healthcare system and considering the use of multi-domain or scenario-based assessments to enhance depth and reliability. Fourth, future studies should adopt longitudinal research designs to assess changes in pediatricians’ knowledge over time and in response to training, while incorporating qualitative methods to explore perceptions, confidence levels, and barriers to ASD diagnosis. Lastly, policy-level integration is essential, encouraging collaboration between healthcare authorities and academic institutions to develop national ASD education frameworks and clinical pathways for early diagnosis and management. By addressing these areas, pediatricians’ competence in ASD care can be significantly improved, ultimately enhancing early detection and outcomes for children with autism across Saudi Arabia.

Patient Consent Form:

All participants were informed about subject of the study.

Authors contribution:

F.O.A., B.A., and I.A. gave substantial contributions to the conception or design of the work and to the acquisition, analysis, or interpretation of data for the work. B.A., I.A., B.Al., R.T.A., H.A., H.N.A., H.A.A., B.E.A., and F.A.A.contributed to data acquisition and interpretation. F.O.A., B.A., I.A., B.Al., and R.F.A. had a part in preparing the article by drafting it or revising it critically for important intellectual content. All authors (F.O.A., B.A., I.A., B.Al., R.T.A., H.A., H.N.A., H.A.A., B.E.A., F.A.A., and R.F.A.) gave final approval of the version to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of interest:

There are no conflicts of interest.

Financial support and sponsorship:

None.