Knowledge and attitudes towards vitiligo in egyptian and palestinian communities: a cross-sectional study

Abstract

Background

Vitiligo is an acquired dermatological condition characterized by localized skin depigmentation. It affects 0.5% to 2% of the population, impacting individuals across various ages, races, and genders. The psychosocial effects of Vitiligo can significantly influence quality of life, particularly in people with darker skin tones, where the contrast of lesions is more pronounced.

Objectives

This study evaluated public knowledge, attitudes, and misconceptions regarding Vitiligo in Egypt and Palestine, focusing on specific demographic Variations and the potential need for improved community engagement and education.

Method

A multicenter cross-sectional study was conducted involving 1,045 participants from Egypt and 450 participants from the West Bank. An online self-administered questionnaire was developed using Google Forms. The eligibility criteria for participation included Egyptian and Palestinian citizens residing in the West Bank. Individuals under 18 years or outside the designated study settings were excluded from participation. This study was conducted from April 2024 to August 2024.

Results

The analysis indicated that 62.8% of participants demonstrated adequate knowledge of Vitiligo; however, only 87.6% exhibited favorable attitudes toward the condition. The study revealed significant variations in knowledge and attitudes based on gender, occupation, previous health professional experience, and social status.

Economic level and geographic location. Educational level was found to have a considerable impact on attitudes.

Multiple linear regression analysis identified several significant predictors of.

Knowledge and attitude scores included male gender, age categories of 18 to 25 and over 50, marital status, occupation in a health profession, personal experience with Vitiligo, prior awareness of the condition, and the attitude score itself. This explained 30.2% of the variance in knowledge scores and 28.1% in attitude ratings.fig.

Conclusion

This study provides valuable insights into public awareness and perceptions of Vitiligo in Egypt and Palestine. A significant proportion of the participants demonstrated adequate awareness of the condition; however, favorable opinions appeared less prevalent. Notable discrepancies were observed among the various demographic characteristics, highlighting the need for targeted initiatives, such as media campaigns and school-based education, aimed at addressing information gaps and improving public perception.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-22663-x.

Introduction

Vitiligo is a chronic skin condition characterized by depigmented lesions resulting from the autoimmune destruction of melanocytes, the cells responsible for producing melanin [1]. This disorder affects individuals of all ages, races, and sexes, with a global prevalence of 0.5% to 2% [2].

While Vitiligo is non-contagious and non-life-threatening, it can significantly affect individuals'psychological well-being and quality of life, particularly in children, adolescents, and young adults [3]. This condition is more noticeable in individuals with darker skin tones, often leading to heightened visibility and associated psychosocial challenges [4].

Vitiligo is broadly classified into two types: non-segmental and segmental. Non-segmental Vitiligo, the more common variant, includes generalized and acrofacial subtypes, whereas segmental Vitiligo typically presents before the age of 20 years and has a more favorable prognosis [5]. Although the exact etiology remains unclear, a combination of genetic, immunological, and environmental factors is believed to contribute to its development [6]. Potential triggers such as sunburn, stress, trauma, and hormonal changes may exacerbate the condition, but these factors likely interact with the underlying predispositions [7].

The psychosocial impact of Vitiligo is profound, particularly in regions where cultural stigma and misconceptions persist. In some societies, individuals with Vitiligo may face social exclusion or be perceived as"outsiders,"leading to anxiety, shame, and reduced self-confidence [8, 9]. Despite its prevalence, public understanding of Vitiligo remains limited, with misconceptions about its contagiousness or causes often prevailing [10].

Addressing these knowledge gaps through public education is critical for improving societal attitudes and the well-being of affected individuals.

Studies on Vitiligo have been conducted in various regions, focusing on different aspects of the condition. In Western countries, Bibeau et al. investigated the prevalence of Vitiligo and its impact on the quality of life among adults in Europe, Japan, and the USA [11]. In India and Thailand, Asati et al. and Juntongjin et al. conducted cross-sectional surveys to assess public knowledge and attitudes toward Vitiligo [12, 13]. Similarly, in China, research has explored awareness and treatment preferences among patients with Vitiligo [14], while in Turkey, studies have evaluated patients'knowledge, opinions, and attitudes regarding the condition [15].

In the Middle East, studies on public knowledge of and attitudes toward Vitiligo are limited. Research in Jordan, Saudi Arabia, and Northern Ethiopia has revealed varying levels of awareness and persistent misconceptions despite generally supportive attitudes [16–19]. For instance, studies in Saudi Arabia found that while attitudes toward individuals with Vitiligo were positive, understanding the nature of the condition was often deficient [18, 20]. Similarly, research in Northern Ethiopia highlighted that higher levels of knowledge were associated with older age, urban residence, and higher education [19].

These findings underscore the need for targeted public education initiatives to dispel myths and foster inclusivity.

Due to limited research on Vitiligo in the Middle East, this study represents one of the first efforts to examine public knowledge and attitudes toward Vitiligo in Egypt and Palestine. By assessing perceptions and addressing misconceptions, this research aims to challenge stereotypes, improve societal understanding, and ultimately enhance the quality of life of individuals living with Vitiligo.

Methods

Study design

We conducted a cross-sectional study to assess public knowledge and attitudes toward Vitiligo among individuals in Egypt and Palestine. Utilizing a

In a self-administered online questionnaire, we collected data to gain insights into respondents'demographic characteristics, knowledge levels, and attitudes concerning Vitiligo.

Study setting

We conducted the study across two primary regions, Egypt and Palestine. Egypt, with a population of approximately 100 million, and Palestine, specifically the West Bank, with an estimated population of 5 million, provide diverse cultural contexts for investigating public perceptions of Vitiligo. The online nature of the study allowed participants from various urban, suburban, and rural areas to contribute, ensuring a broad representation of vitiligo perspectives.

Study population

This study targeted Egyptians and Palestinians over 18 as the primary population for the survey. A total of 1,102 Egyptian and 527 Palestinian participants were included. The sampling was conducted through social media platforms like Facebook and WhatsApp to reach a broad audience.

Eligibility criteria

The eligibility criteria for this study included participants 18 years or older residing in Egypt or Palestine, with the requirement that they have access to the Internet and the capability to complete the online questionnaire. Individuals under 18 years of age and those who did not disclose their country of origin were excluded from this study. This selection process ensured that the study focused exclusively on the adult population, thereby facilitating the collection of pertinent data regarding their understanding and attitudes toward Vitiligo. Although Vitiligo affects all age groups, minors were excluded from this study because the Ethics Committees in Egypt and Palestine required informed consent from parents before enrollment in the study, which was inapplicable owing to the online nature of the questionnaire.

Sample size

The minimum required sample size was 385 from the East Bank and 770 from Egypt, calculated using the OpenEpi online calculator, assuming that the population size of Egypt was 100,000,000, the population size of Palestinians in the West Bank was 5,000,000, a 5% margin of error, a 95% confidence interval, and 50% as the response distribution.

Data collection

We collected data between April 15, 2024, and August 20, 2024, using a self-administered questionnaire distributed via Google Forms. The questionnaire was adapted from a study conducted by Al-Shobaili et al. (2015). It was created by the researchers and validated by two dermatologists [21]. The questionnaire included four sections. The first section addressed the participants'sociodemographic characteristics, including age group, gender, educational level, paternal educational level, maternal educational level, marital status, family income, employment status, location distribution, and whether they had a health-related profession. The second section was designed to capture participants'previous exposure to Vitiligo using four questions: whether they had heard of Vitiligo, had been diagnosed with Vitiligo, had a partner diagnosed with Vitiligo, or lived with someone diagnosed with Vitiligo. The third section included 18 questions to assess the participant's knowledge of the disease, with"Yes,""Maybe,"and"No"answers. These included questions about the nature of the disease, including whether it was contagious, hereditary, autoimmune, hygiene-related, systemic, food-related, lethal, triggered by psychological distress, the probability of leading to death, whether there is a treatment for Vitiligo, and whether it is magic or witchery. Finally, the fourth section assessed participants'attitudes toward Vitiligo and constituted nine statements to evaluate their agreement with them. These included participants'attitudes toward vitiligo patients in situations such as sharing food, becoming friends, shaking hands, hiring decisions, the probability of divorce occurring if the partner was diagnosed with Vitiligo, and their intimate relationships with others.

Knowledge score

In the"knowledge"section, one point was given for a correct response to a question, whereas an incorrect answer and a"Maybe"answer were given zero points. The aggregate of the individual scores was used to calculate the total score, which ranged from 0 to 18. Statistical comparisons were conducted using the percentage of each participant's total knowledge score. According to Tsadik et al. (2020 [19],"sufficient knowledge"was defined as scores greater than or equal to the median score; conversely,"insufficient knowledge"was defined as scores below the median level. The knowledge score, consisting of 18 items, demonstrated good internal consistency with a Cronbach's alpha of 0.783.

Attitude score

For every participant, the percentage of the total attitude score was calculated and used for statistical comparison. People were classified as having a"positive"or a"negative attitude."The sum of the participants'answers in the attitude score varied from − 8 to 8. Participants who scored above zero had a positive attitude, whereas those who scored below zero had a negative attitude. The attitude score, comprising eight items, showed strong reliability with a Cronbach's alpha of 0.808.

Data analysis

An Excel spreadsheet was used to extract data from the electronic questionnaire. Subsequently, Jamovi (version 2.5) [Computer Software] was used for data analysis. Frequent distributions and percentages were employed for categorical variables, whereas central tendency and dispersion measures were used for continuous variables.

Independent t-test for two-group comparisons and one-way ANOVA for

Nonparametric data (Kruskal-Wallis test) for more than two comparison groups were utilized to examine any potential associations between the variables under comparison and calculate the effect size. Differences were considered statistically significant at a p-value of 0.05. All data have been pre-checked, and none followed a normal distribution. The test results, including normality assessments, are provided in the supplementary file.

Ethical approval and consent

Ethical approval was obtained from the Ethics Committee of the Faculty of Medicine at the University of Mansoura, Egypt (IRB No.: R.24.03.2549), and the Faculty of Medicine at Al-Quds University, Jerusalem (IRB No.: 383/REC/2024). All participants signed an informed consent form before participating in this study.

Results

Sociodemographic characteristics of the respondents

The study on knowledge of and attitudes toward Vitiligo among Egyptian and Palestinian communities involved 1,535 respondents, primarily female (72.11%) and younger than 35 (89.83%). Most participants resided in urban areas (58.95%) and held at least a bachelor's degree (79.86%), with similar educational attainment among their parents (54.13% paternal and 53% maternal education levels at the bachelor's or diploma level). Singles accounted for 75.96% of the population, and students comprised the largest occupational group (52.76%), followed by employed individuals (27.29%) and unemployed participants (19.95%). About 58.5% had a health-related professional background, while only 14.9% belonged to higher-income groups (above L.E. 6,000) (Table 1).

Table 1.

Study participants'background characteristics and knowledge and attitude scores based on some selected characteristics (n = 1535)

	Knowledge							Attitude Scores
	N	Mean	Median	SD	IQR	P-value	Effect size	N	Mean	Median	SD	IQR	P-value	Effect size
Age group (years)
< 35	1379	11.55	12	3.56	4	0.126	0.0027	1379	4.93	6	3.27	4	0.095	0.00307
35–50	119	12.03	13	3.16	3			119	4.86	5	2.71	3
> 50	37	12.41	13	3.05	4			37	4.49	5	2.66	3
Sex
female	1107	11.97	13	3.12	3	<.001	0.0155	1107	5.18	6	3.09	4	<.001	0.0174
male	428	10.66	12	4.26	5			428	4.23	5	3.44	5
Status
single	1166	11.67	12	3.48	4	0.173	0.00121	1166	5.15	6	3.11	4	<.001	0.01983
not-single	369	11.39	12	3.65	4			369	4.16	5	3.43	5
Income level
L.E 6000–12000	760	11.7	12	3.37	4	0.012	0.00578	760	4.79	6	3.32	5	<.001	0.01043
Less than L.E 6000	545	11.25	12	3.83	4			545	4.75	6	3.2	5
More than L.E. 6000	230	12.14	13	3.13	3			230	5.69	6	2.78	3
Location
Rural	630	11.45	12	3.63	4	0.177	0.00119	630	4.53	5	3.31	4	<.001	0.01245
Urban	905	11.72	13	3.44	4			905	5.18	6	3.13	4
Occupation
Unemployed	306	11.13	12	3.39	4	<.001	0.0111	306	4.03	5	3.7	5	<.001	0.0179
Employed	419	11.85	13	3.74	3			419	4.89	6	3.07	4
Student	810	11.66	12	3.44	4			810	5.26	6	3.03	4
Health Professional
Yes	898	12.22	13	3.21	3	<.001	0.0481	898	5.19	6	3.04	4	<.001	0.00953
No	637	10.74	12	3.75	4			637	4.52	5	3.42	5

The influence of sociodemographic characteristics on knowledge and attitude scores

A total of 1535 individuals filled out the self-administered online questionnaire: 1045 (68%) Egyptian and 490(32%) Palestinian. The average and standard deviation of knowledge and attitude scores of the total sample were 11.61± 3.52 and 4.91± 3.22, respectively. Nine hundred sixty-four, or about two-thirds of the population (62.8%), showed sufficient knowledge about Vitiligo. Only 12% of participants had negative attitude scores (Fig. 1). Females represented 72.11% of our sample and reported significantly higher knowledge and attitude scores (p < 0.001). Most participants were younger than 35 years of age (89.83%). According to the Kruskal-Wallis test, age did not significantly affect the attitude or knowledge scores. More than half of the population (58.95%) lived in urban areas. The geographic area did not significantly affect knowledge scores but was significantly associated with higher attitude scores (p < 0.001). Previous health professions represented 58.5% of the study population and had significantly higher attitudes and knowledge scores (p < 0.001). The proportion of singles was 75.96% of the total population and was significantly associated with higher attitude scores (p < 0.001), whereas it had no impact on knowledge (p = 0.173). Regarding occupation, employed (27.29%) had significantly higher knowledge scores (p < 0.001), whereas students (52.76%) had significantly higher attitude scores. Higher income levels represented only 14.9% of the participants and were associated with significantly higher knowledge and attitude scores (p < 0.001) (Table 1).

Fig. 1.

The average of knowledge and attitude divided by the status group

The majority had a bachelor's degree (79.86%), and paternal and maternal education had a bachelor's degree or diploma (54.13% and 53%, respectively). Our results showed significant differences between the different groups of personal, paternal, and maternal education levels (P-value < 0.001) (Table 2).

Table 2.

Health study of participants'personal, paternal, and maternal education levels and their influence on their knowledge and attitude scores (n = 1535)

	Knowledge							Attitude Scores
	N	Mean	Median	SD	IQR	P-value	Effect size	N	Mean	Median	SD	IQR	P-value	Effect size
Education level
High school	170	10.05	11	3.79	5	<.001	0.0281	170	3.28	4	3.81	6	<.001	0.0281
Bachelor's degree/diploma	1226	11.77	12.5	3.42	3			1226	5.18	6	3.01	4
Higher education	139	12.08	13	3.56	5			139	4.57	6	3.58	5
Paternal education level
High school	516	11.06	12	3.76	5	<.001	0.0122	516	4.28	5	3.34	4.25	<.001	0.0285
Bachelor's degree/diploma	831	11.92	13	3.38	3			831	5.15	6	3.12	4
Higher education	188	11.73	12	3.26	4			188	5.6	6	3.03	4
Maternal education level
High school	606	11.05	12	3.74	4.75	<.001	0.0166	606	11.05	12	3.74	4.75	<.001	0.0298
Bachelor's degree/diploma	814	11.95	13	3.38	3			814	11.95	13	3.38	3
Higher education	115	12.04	13	2.96	4			115	12.04	13	2.96	4

The influence of previous exposure to vitiligo on knowledge and attitude scores

Almost 94% of the study population had heard of Vitiligo, and only 4.4% had the disease. Table 3 shows a significant association between having Vitiligo, being married to a partner with Vitiligo, having heard of Vitiligo, and having higher knowledge and attitude scores (p < 0.001).

Table 3.

Health study of participants'personal, paternal, and maternal education levels and their influence on their knowledge and attitude scores (n = 1535)

	Knowledge							Attitude Scores
	N	Mean	Median	SD	IQR	P-value	Effect size	N	Mean	Median	SD	IQR	P-value	Effect size
The participant lives with a patient with Vitiligo
No	1425	11.59	12	3.54	4	0.492	3.07E- 04	1425	4.96	6	3.14	4	0.525	2.64E- 04
Yes	110	11.85	13	3.25	4			110	4.35	6	4.04	6
The participant's partner has Vitiligo
With no partner	780	11.67	12	3.41	4	<.001	0.0115	780	5.3	6	2.87	4	<.001	0.0219
Yes	47	9.6	10	3.7	6			47	1.85	2	4.47	6.5
No	708	11.67	13	3.59	4			708	4.69	6	3.36	5
Participant has Vitiligo
No	1466	11.72	13	3.5	4	<.001	0.0263	1466	5.09	6	3.06	4	<.001	0.0396
Yes	69	9.26	9	3.23	5			69	1.14	0	4.11	6
The participant has heard of Vitiligo
Yes	1444	11.89	13	3.17	3	<.001	0.0491	1444	5.13	6	3.06	4	<.001	0.0504
No	91	7.12	8	5.33	11			91	1.53	1	3.79	5.5

Regression analysis estimated independent predictors of knowledge and attitude scores

The results of the multiple linear regression analysis with the knowledge score as the criterion variable revealed the following significant predictors: (1) Male sex (estimate = − 0.81, p < 0.001); (2) age between 18 and 15 years and older than 50 years (estimate = 1.8, p = 0.001); (3) health profession (estimate = 1.35, p < 0.001); (4) participant having vitiligo (estimate = − 1.19, p = 0.006); (5) having heard of vitiligo (estimate = 3.17, p < 0.001); (6) family member with vitiligo (estimate = 0.8837, p = 0.006); (7) bachelor’s degree or diploma holders (estimate = − 1.8142, p = 0.018); (8) high school education (estimate = − 2.2885, p = 0.003); and (9) attitude score (estimate = 0.36, p < 0.001). The model explained 30.2% of the variance in the knowledge scores, and the F-test validated the fitness (F-statistic: 23.2, 28, and 1502 degrees of freedom, p < 0.001) (Supplementary material).

The results of the multiple linear regression analysis with attitude score as the criterion variable revealed the following significant predictors: (1) ages between 26–35 years and 18–25 years (estimate = − 0.7035, p = 0.005), (2) living in urban areas (estimate = 0.3344, p = 0.023), (3) bachelor's degree or diploma holders (estimate = 1.4157, p = 0.046), (4) participant having Vitiligo (estimate = − 2.24, p < 0.001), (5) having heard of vitiligo (estimate = 1.71, p < 0.001), (5) partner with Vitiligo (estimate = − 0.9863, p = 0.029), and (6) knowledge score (estimate = 0.31, p < 0.001). The model explained 28.1% of the variance in the attitude scores, and the F-test validated the fitness (F-statistic: 21 on 28 and 1506 degrees of freedom, p < 0.001) (Figs 2, 3, 4, 5 and 6) (supplementary material).

Fig. 2.

QQ plot assessing the normality of residuals in the multiple linear regression model with knowledge score as the criterion variable

Fig. 3.

QQ plot assessing the normality of residuals in the multiple linear regression model with attitude score as the criterion variable

Fig. 4.

Scatter plot depicting the relationship between knowledge and attitude towards Vitiligo, grouped by sex (0 = Female) (1 = Male)

Fig. 5.

Scatter plot depicting the relationship between knowledge and attitude towards Vitiligo, grouped by type of work (0 = Other), (1 = Student), and (2 = Worker)

Fig. 6.

Scatter plot depicting the relationship between knowledge and attitude towards Vitiligo, grouped by previous medical experience (0 = No) and (1 = Yes)

Participants’ responses to the questions that build up the knowledge and attitude scores

According to our results, 85% of patients denied the disease, and only 5.9% reported that Vitiligo is contagious. Twenty-eight percent (20.8%) of the patients had an autoimmune etiology. Over one-third (35,6%) denied that Vitiligo affects patients'social lives, and about one-fourth (25.3%) refused to believe that Vitiligo was exaggerated by exposure to psychological stress. Moreover, when asked about the roles of magic and witchery, only 4.6% thought these could be triggering factors.

For more details regarding the participants'answers to questions assessing the knowledge score, refer to the Supplementary material.

Regarding participants'attitudes toward Vitiligo, 87.5% disagreed with the statement,"I would divorce my partner if they were diagnosed with vitiligo,"and 83.8% agreed with the statement,"I would hire a vitiligo patient". When asked about intimate relationships, only 9.9% agreed that Vitiligo affected them.

Additionally, 24.3% disagreed with the statement,"I would marry a vitiligo patient,"and only 5.7% and 7.5% refused to shake hands and eat food prepared by vitiligo patients, respectively. For more details regarding participants'extent of agreement with statements assessing attitude scores, refer to Table 4.

Table 4.

Response of the participants to attitude questions about Vitiligo

I would hire a vitiligo patient (%)
No	91 (5.9)
Yes	1286 (83.8)
I would shake hands with a vitiligo patient (%)
No	88 (5.7)
Yes	1339 (87.2)
I would become a friend with a vitiligo patient (%)
No	68 (4.4)
Yes	1348 (87.8)
I would eat food prepared by a vitiligo patient (%)
No	115 (7.5)
Yes	1243 (81.0)
I would marry a vitiligo patient (%)
No	373 (24.3)
Yes	598 (39.0)
I would marry a family member who has Vitiligo (%)
No	354 (23.1)
Yes	645 (42.0)
My intimate relationship would be affected by my partner's vitiligo diagnosis (%)
No	1049 (68.3)
Yes	152 (9.9)
I would want to divorce if my partner got diagnosed with Vitiligo (%)
No	1343 (87.5)
Yes	70 (4.6)

Sociocultural influences on knowledge and attitude toward vitiligo

Sociocultural factors, including educational systems, healthcare accessibility, and prevalent cultural beliefs in Egypt and Palestine, may influence regional differences in public knowledge and attitudes toward Vitiligo. Our sample's high proportion of urban, educated respondents suggests a generally favorable awareness of Vitiligo. However, misconceptions about its etiology and impact on social interactions may reflect deeper cultural and historical perceptions of skin diseases. Traditional beliefs about skin conditions, stigma, and access to dermatological care may shape public attitudes in some communities. Additionally, variations in public health initiatives and media representation of Vitiligo could contribute to the differences in awareness levels between the two populations. Future research should explore how these sociocultural aspects influence perceptions and whether targeted awareness campaigns can effectively address specific misconceptions.

Discussion

Vitiligo is a chronic depigmenting autoimmune skin disorder with an overall prevalence of 3% in the Middle East and Africa [22]. Its visible nature often carries a high stigma towards patients. In his book (1963), Erving Goffman primarily introduced stigma as a deeply discredited trait. Stigma manifests in various forms. Self-stigma, known as felt stigma, is the fear of discrimination and shame that keeps people from seeking help [23]. Enacted stigma refers to the experience of discrimination or unfair behavior by others [23]. Courtesy stigma or associative stigma affects people in close relationships with stigmatized persons, such as the family [24]. Stigma theory explains how public knowledge, common misconceptions, and general attitudes contribute to the affected individuals'psychological burden and quality of life.

Although our regression models accounted for 30.2% of the variance in knowledge and 28.1% in attitude, additional unmeasured sociocultural factors likely contributed to these outcomes. Religious beliefs, media exposure, personal experiences with Vitiligo, and prevailing cultural narratives were not explicitly analyzed but may significantly influence public knowledge and attitudes. Future research should consider incorporating these variables to provide a more comprehensive understanding of the determinants of vitiligo-related awareness and perceptions.

The findings of this study revealed that 62.8% of the participants had sufficient knowledge about Vitiligo, consistent with findings from Jordan [17] and Northern Ethiopia [19]. Similarly, a multi-ethnic study in Thailand reported 66% overall knowledge, with significant variations among ethnic groups in which Arabians had the highest knowledge score [13]. Contrary to previous results, data from a Chinese study showed that half of the studied population (44.7%), particularly those from rural areas or with low education levels, had insufficient knowledge of Vitiligo [14].

As shown in our results, almost half of the population in Egypt and Palestine (49.5%) believed that the disease was autoimmune. This is consistent with the Saudi study conducted by Fatani et al. (2016) [18]. In contrast, as reported by Murshidi et al. (2023), over half of Jordanians denied that Vitiligo is an autoimmune disorder [17], and a minority of Northern Ethiopians and Saudis, as reported by Algarni et al. (2021), shared this belief [19, 20]. These findings reflect the higher levels of knowledge about the nature of the disease among Egyptians and Palestinians.

In their studies, Algarni et al. (2021) and Fatani et al. (2016) showed that the majority of the respondents denied that the disease is infectious [20, 18], which is consistent with our results, where 86.5% of the respondents agreed with this. Moreover, all three studies (Algarni et al., 2021; Fatani et al., 2016; and our study) agreed that the disease was not dangerous and did not lead to skin cancer [18, 20].

This present study is in keeping with two other studies in which most participants either did not know or agreed that the disease is hereditary, and only a few chose"NO"as the correct answer [18, 20]. In contrast, 65.3% of respondents in a study in Northern Ethiopia believed that the disease was not hereditary [17].

Psychological stress does not appear to be a significant triggering factor in disease progression, as reported by Murshidi et al., 2023, Algarni et al., 2021, and our study, in which less than half of the participants agreed that the disease was exaggerated by psychological stress [17, 20]. In contrast, most respondents from Northern Ethiopia and Turkey recognized the role of psychological stress in exaggerating the disease [19, 20], emphasizing the need to increase awareness among Arab societies regarding the role of mental and psychological health in the disease course. Similarly, in Jordan [17], Northern Ethiopia [19], and our study, a minority of the respondents believed that magic and witchery might have a role in disease etiology. These results are reassuring and reflect better insights into myths and misconceptions related to the disease.

Sixty-two and eight percent (62.8% and 78.5%) of the Saudi participants agreed that the disease significantly affects social status (Algarni et al., 2021, and Fatani et al., 2016 studies, respectively), which is approximately double the number of our results [18, 20]. Additionally, almost half of the respondents of the Saudi population believed that the disease was treatable, compared to only 26.4% in our study.

Regarding attitudes, only 12% of the participants showed negative attitudes towards vitiligo patients. Similarly, in Jordan, a minority of respondents act negatively toward vitiligo patients [17]. The public attitude of our population was significantly greater than that of Indians. According to Asati et al., 2016, only 16.9% of respondents had a good attitude, which was comparatively low [12]. In our study, the most commonly reported negative attitude was the willingness to marry vitiligo patients, with only 39% of respondents declaring that they would marry someone with Vitiligo. This result is quite close to the results of Murshidi et al. (2023), Algarni et al. (2021), and Fatani et al. (2016), in which a minority of respondents agreed [17, 18, 20]. In Middle Eastern communities, the stigma surrounding Vitiligo is greatly influenced by cultural norms and beauty standards. Clear and flawless skin is overvalued, especially for women. In traditional societies, women with skin diseases suffer from a lack of marriage opportunities and social isolation [25]. However, the results of the Arab countries are still much higher than those reported in the Northern Ethiopian study, where only 6.7% have the will to marry a vitiligo patient [19]. Despite having a more positive attitude towards marriage in the Middle East, engagement in a healthy, stable relationship is still challenging for vitiligo patients.

Interestingly, the highest attitudes in this study were towards the employment of vitiligo patients, where 83.8% of respondents agreed that they would hire vitiligo patients. These results are similar to those reported for Jordan and Saudi Arabia [17, 18]. In contrast, less than half of the study population in Northern Ethiopia agreed to hire vitiligo patients [19]. Additionally, our study found attitudes such as eating food prepared by a vitiligo patient and shaking hands with vitiligo patients were highly positive, with most respondents agreeing. In contrast, fewer respondents showed a positive attitude in such situations in Tsadik et al. (2020) and Fatani et al. (2016) [18–20]. In general, Arab societies are highly influenced by Islamic teachings, which play an essential role in shaping public attitudes and behaviors. Islam counteracts stigma by encouraging compassion, promoting acceptance, and prohibiting discrimination based on physical appearance. Cultural and religious factors foster supportive societal attitudes and alleviate the psychological burden.

When asked whether there is a lack of public awareness regarding Vitiligo and its treatment, 82.8% of Egyptians and Palestinians and most Saudi respondents, as reported by Fatani et al. (2016), answered"yes"[18]. This highlights the need for public awareness campaigns and stresses its vital role in improving vitiligo patients'quality of life and potentially decreasing the prevalence of depression and anxiety.

In this study, people aged over 35 years, those who had heard about the disease, health care professionals, females, individuals from urban areas, those living with a vitiligo patient, and families with a monthly income of more than 12000 LE (equal to more than 6000 NIS in Palestine) showed higher overall knowledge scores. These results are consistent with the findings of Tsadik et al. (2020) and Murshidi et al. (2023) [17, 19]. The lowest overall knowledge and attitude scores were found among those who had not heard of the disease before and, surprisingly, participants with Vitiligo and whose partners had Vitiligo. This was unexpected because the latter two results are quite the opposite of what has been shown in previous studies, where participants with Vitiligo and participants who lived with partners with Vitiligo had the highest knowledge and attitude levels. This result may be influenced by the small sample size relative to the large geographic area included.

One of the highest attitude scores was among younger participants aged less than 35 years and students. This result is promising because the new generation is more influenced by and attached to social media platforms, which could be used as an easily accessible awareness tool. Females, singles, health care professionals, individuals who previously heard about the disease, those who live in urban areas, families with higher monthly income, and bachelor's degree holders or higher educational levels were found to have significantly higher attitude scores.

The present study found a significant relationship between higher knowledge and attitude scores among the study population. As a result, participants who were educated about the disease tended to show more positive attitudes toward the patients. This is consistent with previous studies by Murshidi et al. (2023), Fatani et al. (2016), and Tsadik et al. (2020) [17–19]. Thus, raising public awareness is the cornerstone of changing the public's attitude towards the disease.

The lack of public awareness and community support for patients with Vitiligo seems to be a global issue. As the stigma theory proposes, public health interventions should focus on clarifying myths and increasing community exposure [26]. This could be achieved via community workshops to inform people about the disease, awareness-raising programs in colleges and schools, and social media campaigns using social media platforms such as YouTube and Instagram. In 2023, a comparative quasi-experimental study by Khalil et al. found that an educational program effectively improved knowledge and attitudes toward Vitiligo among Saudi and Egyptian professionals and non-professionals, emphasizing the importance of health awareness programs for affected individuals [27]. Our study primarily focused on the Middle Eastern population; however, the results could be applied to broader regions in Asia, Africa, and Latin America with comparable cultural and

Socioeconomic circumstances. Although direct applicability to other populations with different cultural norms and socioeconomic factors could be limited, this study adds to the literature by addressing comparative perspectives with non-Middle Eastern countries. This could help determine the global and regional factors influencing public perception of Vitiligo.

Limitation of study

This study has some limitations that should be considered. First, our sample size was relatively small due to the large geographic areas included, which adversely affected our results. Additionally, online questionnaires may contribute to sampling bias, where older participants and those not used to or not having access to modern technology are potentially excluded from the study. However, using online questionnaires was appropriate to ensure a higher response rate, larger sample size, participants'privacy, and cost-effectiveness. In particular, the current political situation in Palestine has limited access to the entire population.

Accordingly, incorporating offline or in-person surveys was challenging.

Unlike other observational studies, cross-sectional studies do not include individuals over time. This fact may contribute to temporal bias, where it may be challenging to ascertain the temporal order of exposure and outcome, and may have consequences for causal inferences. Because the data were gathered over four months, seasonal or cultural variations might have impacted participant responses. Social events, national holidays, weather changes, and political situations may have affected public perception and response rates [28]. Furthermore, this study did not examine the actual behavior of the participants. It depends only on self-reported responses to attitude-related questions, which could be subjective to a large extent. Unlike other studies that focused on a specific country or region, we conducted this study in two different countries to provide a bigger picture of the perception of the disease in Middle Eastern countries. Our recommendations for future researchers are to validate our findings in diverse geographic areas to assess generalizability, focus on a broadly representative sample, and attempt to use more reliable, objective tools to investigate the public's behaviors. Future researchers should incorporate offline data collection for greater inclusivity, validate findings across diverse regions to assess generalizability, focus on a representative sample, and use more reliable and objective tools to investigate the public's behaviors.

Authors’ contributions

Concept and design: AMS, SRME, SHS. Survey design: SRME. Data collection: AMS, SRME, SHS, ZRA, MAEF, EAO, AR, AYAMI, and YSH. IRB approval: SHS, MAE, SHF. Data analysis: KM, IS, and SRME. Writing: AMS, SRME, IS, SHS, ZRA, MAEF, EAO, AR, AYAMI, BMAZ, and YSH. Revising manuscript: AMS, IS, KM, SHS. Supervision: AMS.

Funding

This research received no external funding.

Data availability

All raw and analyzed data generated during this study are provided as supplementary materials.

Declarations

Ethics approval and consent to participate

The study was conducted following the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Faculty of Medicine Ethics Committee at the University of Mansoura, Egypt (IRB No.: R.24.03.2549) and the Faculty of Medicine et al.-Quds University, Jerusalem (IRB No.: 383/REC/2024). All the participants signed a consent form before participating in the study.

Consent for publication

Not applicable; this paper does not include any personal data.

Competing interests

The authors declare no competing interests.