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Original Research (Original Article) 


Anwar Abdullah Alhazmi et al, 2020;4(3):660–667.

International Journal of Medicine in Developing Countries

A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah

Anwar Abdullah Alhazmi1, Basil Abdulaziz Alkhaldi1*, Rayan Abdulrahman Alhazmi2, Abdullah Mohammed Alzahrani1, Nehal Khalid Damanhouri3

Correspondence to: Basil Abdulaziz Alkhaldi

*Medical Intern, Umm Al Qura University, Makkah, Saudi Arabia.

Email: Basil.a.Alkhaldi [at] gmail.com

Full list of author information is available at the end of the article.

Received: 09 December 2019 | Accepted: 14 January 2020


ABSTRACT

Background:

Hypothyroid disorder is a major public health problem. There is a high rate of thyroid disorders within the Saudi population. This study aimed to describe and evaluate the knowledge, attitude, and practice of adult Saudi patients regarding hypothyroidism.


Methodology:

A cross-sectional, observational study was conducted over 2 months (September–October 2018) in Makkah, Saudi Arabia. Adult Saudi patients with hypothyroidism, aged 18 years or more, living in Makkah, were invited to participate in this study. Data were entered, coded, and processed using Microsoft Excel and the software Statistical Package for the Social Sciences (version 23).


Results:

The present study included 177 participants; most of the patients had low levels of knowledge (69.5%), some of them were quite concerned (51.6%), and 74.0% of the participants practiced a moderate level of a safety measure. The low level of knowledge was more significant in males (p = 0.032). In addition, the age was a significant factor, particularly the age group older than 45 associated with the low level of knowledge (p = 0.009), the extreme level of concern (p = 0.044), and a moderate level of practice (p ≤ 0.013).


Conclusions:

Most of the Saudi patients with hypothyroidism had low levels of knowledge regarding their condition and were quite concerned and practiced a moderate level of a safety measure. The low level of knowledge was more significant in males. Furthermore, health education efforts should be directed toward improving Saudi general populations’ knowledge, attitude, and practice about the hypothyroid disorder.


Keywords:

Knowledge, attitude, practice, hypothyroidism, Makkah.


Introduction

Hypothyroidism indicates a decrease in the production of thyroid hormone by the thyroid organ and can be primary (abnormality in the thyroid organ itself) or secondary (as a result of pituitary or hypothalamic illness). Primary hypothyroidism is the etiology in roughly 99% of the cases of hypothyroidism [1].

Their signs and symptoms change significantly from range to range and are dependent on the amount of iodine in the diet [2]. Nearly one-third of the world’s populace lives in the zones of iodine insufficiency [3]. Untreated hypothyroidism adversely affects the physical and mental well-being of the patients [47]. The rate and predominance of thyroid dysfunction showed that approximately half of the populace with thyroid dysfunction still undiscovered [8].

The Ministry of Health (MOH) in Saudi Arabia said that a lot of thyroid dysfunction cases are undiscovered and, therefore, are not treated because the patient does not have any symptoms, pointing out that the thyroid gland disorder is one of the common diseases, especially among women of childbearing age. The MOH posted an awareness infographic about the symptoms associated with hypothyroidism or hyperthyroidism and advised the persons who have these symptoms for a long time to visit a doctor.

There is a high rate of thyroid disorders within the Saudi female [9]. Much has been published about knowledge, attitude, and practice regarding patients with hypothyroidism. However, no studies have been reported in the Makkah Region, Saudi Arabia.


Subjects and Methods

A cross-sectional, observational study was conducted over 2 months (September–October 2018) in Makkah, Saudi Arabia. Adult Saudi patients with hypothyroidism, aged 18 years or more, living in Makkah, were invited to participate in this study.

After an extensive literature review, the questionnaire instrument used in this study was formulated based on a validated questionnaire published in India [7]. The questionnaire consisted of four sections, namely, sociodemographic characteristics, knowledge, attitudes, and practice toward hypothyroidism.

One of the authors who speak both Arabic and English has translated the questionnaire into Arabic to facilitate Saudi participants. To ensure the reliability of the questionnaire, one of the researchers reviewed the primary version, and then, the first version of the questionnaire was validating after using the standard forward and backward method.

The sample size of the pilot study consisted of four hypothyroidism patients. Minor modifications were made. These four patients were not included in the study. The data were collected using a self-administered survey that was available in paper and web-based format to suit the respondents’ preferences. A representative sample of 250 participants living in various areas of Makkah was selected randomly.

The scoring evaluation of the three knowledge, attitude, and practices (KAP) sections was conducted as follows: (1) a score will create for knowledge, each correct answer (“yes” for positive and “no” for negative statements) was given 1 point and an incorrect answer (“no” for positive and “yes” for negative statements) including responses as “do not know” was given 0 point. The level of knowledge was categorized as “low” (≤12 points), “average” (13–15 points), or “high” (≥16 points) as per the total score; (2) for attitude, the level of concern was categorized as “extremely concerned” (if agreement [point 4 or 5 on the Likert scale] was marked for all 5 statements), “quite concerned” (if agreement was shown for 3–4 statements), “little concerned” (if agreement was marked for 1–2 statements), and “not concerned” (no agreement); and (3) for practice, 1 point was given for each precautionary statement practiced by the patient (total score ranged from 0 to 8 points). A “high level” of precaution was considered for a score of ≥7 points, a “moderate level” for the score between 4 and 6 points, and a “poor level” was assigned for the score <3 points.

The data were entered, coded, and processed using Microsoft Excel and the software Statistical Package for the Social Sciences, version 23, for the Windows system. Descriptive statistics, frequencies, and percentages were used to describe all the variables. Association between dependent variables (participants’ KAP) and independent variables (participants’ sociodemographics) was tested using the Chi-square test. The p-values of <0.05 were considered to be statistically significant.


Result

The present study included 177 participants; the majority of them were females (91%), whereas the males were only 9%. The age above 45 years represents 35.6% of the study population. Most of the patients were undergraduates (61%), followed by postgraduates (39%); the healthcare workers represent 5.1% of the study population.

Table 2 summarizes the answers given to all questions on the knowledge domain. Approximately half (52.5%) of the participants had correct knowledge about the shape of the thyroid gland. Regarding the effects of hypothyroidism, weight gain was correctly answered by 90.96% of patients, followed by 80.8% of patients who answered muscle pain and 78.53% who answered dry skin as symptoms of hypothyroidism. In addition, 71.2% correctly identified cold intolerance and 66.7% identified constipation as symptoms of hypothyroidism.

Table 1. Baseline characteristics (n = 177).

Frequency Percent (%)
Gender
Male 16 9.0
Female 161 91.0
Age (years)
18–25 21 11.9
26–35 39 22.0
36–45 54 30.5
>45 63 35.6
Education
Postgraduate 69 39.0
Undergraduate 108 61.0
Do you work in the health field?
Yes 9 5.1
No 168 94.9

About 7.3%, 6.2%, and 2.3% of patients had incorrect knowledge about dry skin, weight gain, and muscle pain, respectively, as the effects of hypothyroidism. Neck swelling associated with hypothyroidism was correctly answered by 65.5% of patients. A reasonable number of patients had incorrect knowledge about the symptoms of menstrual irregularities (7.9%) and depression (14.1%) in hypothyroidism. About one-third (40.1%) did not know about the increased risk of hypothyroidism during pregnancy, and 32.2% of patients did not know that the risk for thyroid disorders may be hereditary. Approximately one-half of the patients had knowledge about hypercholesterolemia (53.7%) or medications (50.8%), causing hypothyroidism.

Table 2. Details of the responses of patients on the knowledge domain (N = 177).

Question on the knowledge domain Answered correctly (N, %) Incorrectly answered (N, %) Do not know (N, %)
The thyroid gland is a butterfly-shaped gland, located in the neck 93 (52.5) 7 (4) 77 (43.5)
Hypothyroidism is not related to increase TSH levels 22 (12.4) 55 (31.1) 100 (56.5)
Hypothyroidism may cause cold intolerance 126 (71.2) 19 (10.7) 32 (18.1)
Hypothyroidism may cause dry skin 139 (78.5) 13 (7.3) 25 (14.1)
Hypothyroidism may cause muscle aches/pain 143 (80.8) 4 (2.3) 30 (16.9)
Hypothyroidism may cause constipation 118 (66.7) 25 (14.1) 34 (19.2)
Hypothyroidism may cause weight gain 161 (91.96) 11(6.2) 5(2.8)
Iodine deficiency in the diet may lead to hypothyroidism 105 (59.3) 10(5.6) 62(35)
Patients with hypothyroidism may be at an increased risk of having depression 99 (55.9) 25 (14.1) 53 (29.9)
Patient with hypothyroidism might have more risk of having increased cholesterol levels 95 (53.7) 18 (10.2) 64 (36.2)
Thyroid disorders do not run in the family 75 (42.4) 57 (32.2) 45 (25.4)
Patients with swelling or abnormality in the neck may be suffering from hypothyroidism 116 (65.5) 36 (20.3) 25 (14.1)
Certain medications may increase the risk of developing hypothyroidism 65 (36.7) 32 (18.1) 80 (45.2)
Hypothyroidism does not occur in pregnancy 44 (24.9) 71 (40.1) 62 (35)
Hypothyroidism is diagnosed by measuring TSH levels in the blood 107 (60.5) 14 (7.9) 56(31.6)
Hypothyroidism is treatable 144 (81.4) 8 (4.5) 24 (13.6)
Alternative forms of medication, such as Ayurveda and homeopathy, may be useful to treat hypothyroidism 90 (50.8) 34 (19.2) 53 (29.9)
Hypothyroidism may cause abnormal menstruation 130 (73.4) 14 (7.9) 33 (18.6)
Hypothyroidism is a medical condition due to low thyroid hormone level 126 (71.2) 3 (1.7) 48 (27.1)

Most of the patients (69.5%) had a low level of knowledge. The low level of knowledge was more significant in males (p = 0.032) and in an age group older than 45 (p = 0.009) (Table 3).

Table 4 shows the details of the responses of patients on the attitude domain regarding hypothyroidism. The highest agreement (150, 84.7%) was found for the statement, women are at a greater risk of developing hypothyroidism and should test at regular intervals for hypothyroidism, and the treatment for hypothyroidism should be initiated after consultation with a physician only. 145 (81.9%) respondents agree that pregnant women should be tested for hypothyroidism. However, 32 (18.1%) participants disagree that people having relatives diagnosed with hypothyroidism should be tested for hypothyroidism.

In general, scores of the attitude domain showed that 51.6% of the participants were quite concerned. There was a significant association between age and the level of concern (extremely) (p = 0.044), which was more prevalent in the age group of above 45 years (Table 5).

The majority of patients (162, 91.5%) took their medications daily, whereas 15 (8.5%) participants were not taking their medication. TSH level was tested routinely by 144 (81.4%) patients. A small number of patients (33, 18.6%) took only hypothyroidism medication. However, 144 (81.7%) patients were taking their hypothyroidism medication with other drugs.

Table 3. Evaluation of the association of the levels of knowledge with gender, age groups, and educational qualification.

Different levels of the knowledge domain
Low level
n
Average
n
High level
n
Gender
Male 15 1 0
Female 108 38 15
p* 0.032 0.074 0.089
Age groups (years)
18–25 14 6 1
26–35 27 8 4
36–45 38 13 3
Older than 45 44 12 7
p* 0.009 0.073 0.090
Educational qualification
Postgraduate 45 17 7
Undergraduate 78 21 8
p* 0.078 0.090 0.06
Health care
No health care 118 36 14
Health care 5 3 1
p* 0.065 0.070 0.1

Table 4. Details of the responses of patients on attitude domain (N = 177).

Question on attitude domain Agree (N, %) Neutral (N, %) Disagree (N, %)
Treatment for hypothyroidism should be initiated after consultation with a physician only 150 (84.7) 18 (10.2) 9 (5.1)
People with relatives/family members diagnosed with hypothyroidism should be tested for hypothyroidism 101 (57.1) 44 (24.9) 32 (18.1)
Pregnant women should be tested for hypothyroidism 145 (81.9) 31 (17.5) 1 (6)
People above the age of 35 years should be tested frequently for hypothyroidism 138 (78) 19 (10.7) 20 (11.3)
Women are at a greater risk of developing  hypothyroidism and should be tested at regular intervals for hypothyroidism 150 (84.7) 20 (11.3) 7 (4)

The majority of patients (74.0%) practiced a moderate level of safety measure. There was a significant association between age groups and a moderate level of practice among the age group older than 45 (p ≤ 0.013) (Table 7).


Discussion

This study aimed to describe and evaluate the knowledge, attitude, and practice of adult Saudi patients with hypothyroidism in Makkah. The present study included 177 hypothyroidism patients; the majority of them were females (91%), whereas the males were only 9%. The age above 45 years old represents 35.6% of the study population. Most of the patients were undergraduates (61%), followed by postgraduates (39%); the healthcare workers represent 5.1% of the study population. Our results revealed that hypothyroidism was more common in females than in males, which were in agreement with many previous studies [1020].

Most of the patients in our study (69.5%) had a low level of knowledge. In 2017, Kumar et al. conducted a cross-sectional study to assess the KAP and adherence to treatment for the participants with primary hypothyroidism in Delhi. The majority constituted females (85.6%), similar to our results. In addition, the knowledge and awareness related to hypothyroidism were poor in the majority of participants [21].

Table 5. Evaluation of the association of the levels of attitude with gender, age groups, and educational qualification.

Different levels of attitude domain
Extremely Concerned n Quite concerned n Little concerned n Not concerned n
Gender
Male 2 10 1 3
Female 65 81 13 2
p* 0.2 .247 0.233 0.1
Age groups (years)
18–25 7 11 3 0
26–35 18 21 0 0
36–45 20 24 5 5
Older than 45 22 35 6 0
p* 0.044 0.120 0.094 0.70
Educational qualification
Postgraduate 28 35 6 0
Undergraduate 39 56 8 5
p* 0.20 0.09 0.14 0.13
Health care
Nonhealth care 66 84 13 5
Health care 1 7 1 0
p* 0.059 0.099 0.084 0.067

Table 6. Details of the responses of patients on practice domain (N = 177).

Question on practice domain Yes  (N, %) No  (N, %)
Did you ask your doctor for more information/counseling on how to manage hypothyroidism? 119 (67.2) 58 (32.8)
Do you look for information on hypothyroidism on the internet/smartphone? 112 (63.3) 65 (24.9)
As advised by your physician, do you get your TSH level tested regularly? 66 (37.3) 111 (62.7)
Do you take your thyroid medication with any other medication? 144 (81.4) 33 (18.6)
Do you take your medication 30–60 minutes before breakfast on an empty stomach? 150 (84.7) 27 (15.3)
Do you miss any doses of your medication for hypothyroidism? 65 (36.7) 112 (63.3)
Do you take your medication for hypothyroidism medication daily? 162 (91.5) 15 (8.5)

In this study, approximately half (52.5%) of the patients had correct knowledge about the shape of the thyroid gland. Regarding the effects of hypothyroidism, weight gain was correctly answered by 90.96% of patients, followed by 80.8% of patients who answered muscle pain and 78.53% of patients who answered dry skin as symptoms of hypothyroidism. In addition, 71.2% correctly identified cold intolerance and 66.7% identified constipation as the symptoms of hypothyroidism. Neck swelling associated with hypothyroidism was correctly answered by 65.5% of patients.

In Saudi Arabia, Almousa et al. found that among hypothyroidism patients, 17% of patients associated with thyroid disorders with disturbances in the menstrual cycle and recurrent miscarriage. In addition, 30.3% associated with psychological factors, such as depression, confusion, mood swings, lack of concentration, and anxiety; 27.4% associated with joint pain and fatigue; and 25.3% associated with constipation and/or diarrhea, voice changes, and swelling of the neck [22].

Table 7. Evaluation of the association of the levels of practice with gender, age groups, and educational qualification.

Different levels of practice domain
Poor level
n
Moderate level
n
High level
n
Gender
Male 3 11 2
Female 34 120 7
p* 0.040 0.003 0.080
Age groups (years)
18–25 5 16 0
26–35 7 30 2
36–45 12 37 5
Older than 45 13 48 2
p* 0.030 0.013 0.2
Educational qualification
Postgraduate 15 50 4
Undergraduate 21 81 5
p* 0.060 0.078 0.099
Healthcare
Nonhealth care 36 124 8
Health care 1 7 1
p* 0.089 0.075 0.079

About one-third (40.1%) of our participants did not know about the increased risk of hypothyroidism during pregnancy, and 32.2% of patients did not know that the risk for thyroid disorders may be hereditary. In agreement, Kumar et al. (2017) found that only 36.4% of hypothyroid patients knew correctly that T4 needs to be continued during pregnancy. Many participants (30.4%) believed that hypothyroidism could lead to weight gain in excess of 10 kg [21].

In this study, approximately one-half of the patients had knowledge about hypercholesterolemia (53.7%) or medications (50.8 %), causing hypothyroidism. Sethi et al. [23] found that about 18.4%, 26.2%, 27.8%, and 37.6% of hypothyroid patients lack knowledge that weight gain, fatigue, muscle pain, and dry skin were the symptoms of hypothyroidism, respectively. Patients had poor knowledge about various risks correlated to hypothyroidism, such as abnormal menstruation (41.6%), hypercholesterolemia (65.6%), depression (47%), and medications causing hypothyroidism (74.2%).

Our results revealed that most of the patients had low levels of knowledge (69.5%), some of them were quite concerned (51.6%), and most of them practiced a moderate level of a safety measure (74.0%). Similarly, Sethi et al. [23] conducted a cross-sectional study to assess the KAP in patients with hypothyroidism in India. Most of the hypothyroid patients had low levels of knowledge (66.6%), were quite concerned (46.6%), and practiced a moderate level of precaution (77.8%); these results were similar to our findings.

In the current results, the low level of knowledge was more significant in males (p = 0.032). In addition, the age was a significant factor, particularly the age group older than 45 associated with the low level of knowledge (p = 0.009), the extreme level of concern (p = value of 0.044), and a moderate level of practice (p ≤ 0.013). Although age and gender were the significant factors associated with knowledge, attitude, and practice among Saudi patients with hypothyroidism in our study, education was not significant.

On contrary to our results, Sethi et al. [23] found significant associations between education level and the scores of knowledge, concern, and precautions taken. In the present study, the highest agreement (150, 84.7%) was found for the statement: a female is at a greater risk of having hypothyroidism and should test at regular intervals for hypothyroidism, and treatment should be initiated after consultation with a physician only. Among the participants, 145 (81.9%) participants agree that pregnant women should be tested for hypothyroidism. In general, scores of the attitude domain showed that 51.6% of the participants were quite concerned.

Sethi et al. [23] found that the majority of hypothyroid patients (91.4%) affirmed the need to consult a physician for medical advice before treatment beginning. However, a small percentage did not agree on testing pregnant females (20.2%) and family members (26.2%) for hypothyroidism. The majority of hypothyroid patients (93.2% and 92.6%) practiced compliance with frequency and timings for medications, respectively; however, one-third reported missing doses].

In this study, most of the patients (162, 91.5%) were taking their medication daily, whereas 15 (8.5%) participants were not taking their medication. TSH level was tested routinely by 144 (81.4%) patients. A small number of patients (33, 18.6%) took only hypothyroidism medication. However, 144 (81.7%) were taking their hypothyroidism medication with other drugs.

Dew et al. [24] conducted a study to explore the attitudes and perceptions of patients to thyroid hormone replacement therapy. They found that patients generally had a low knowledge of their disease. In addition, patients who had experienced hypothyroid symptoms at initial diagnosis had a better knowledge of disease susceptibility, and this was reflected in excellent adherence to medication in this group of patients. In addition, Kumar et al. [21] found that 90.4% of participants were adherent to T4, 2.4% were moderately adherent, and the remaining 7.2% of participants were non-adherent to T4.


Conclusion

The present study concluded that most of the Saudi patients with hypothyroidism had low levels of knowledge regarding their condition, quite concerned, and practiced a moderate level of a safety measure. The low level of knowledge was more significant in males. In addition, age was a significant factor, particularly the age group older than 45 years associated with a low level of knowledge, the extreme level of concern, and a moderate level of practice. Health education efforts should be directed toward improving Saudi general populations’ knowledge, attitude, and practice about the hypothyroid disorder.


List of Abbreviations

KAP Knowledge, attitude, and practices
MOH Ministry of Health

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval was obtained from the Human Research Ethics Committee, King Abdulaziz Hospital, Makkah, Saudi Arabia (Reference No. (H-02-k-076-1811-066).


Author details

Anwar Abdullah Alhazmi1, Basil Abdulaziz Alkhaldi1, Rayan Abdulrahman Alhazmi2, Abdullah Mohammed Alzahrani1, Nehal Khalid Damanhouri3

  1. Medical Intern, Umm Al Qura University, Makkah, Saudi Arabia
  2. Medical Intern, King Abdulaziz University, Makkah, Saudi Arabia
  3. Family Medicine Consultant, Alnwariah Center, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alhazmi AA, Alkhaldi BA, Alhazmi RA, Alzahrani AM, Damanhouri NK. A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. IJMDC. 2020; 4(3): 660-667. doi:10.24911/IJMDC.51-1575930154


Web Style

Alhazmi AA, Alkhaldi BA, Alhazmi RA, Alzahrani AM, Damanhouri NK. A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. http://www.ijmdc.com/?mno=77351 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1575930154


AMA (American Medical Association) Style

Alhazmi AA, Alkhaldi BA, Alhazmi RA, Alzahrani AM, Damanhouri NK. A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. IJMDC. 2020; 4(3): 660-667. doi:10.24911/IJMDC.51-1575930154



Vancouver/ICMJE Style

Alhazmi AA, Alkhaldi BA, Alhazmi RA, Alzahrani AM, Damanhouri NK. A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. IJMDC. (2020), [cited March 29, 2020]; 4(3): 660-667. doi:10.24911/IJMDC.51-1575930154



Harvard Style

Alhazmi, A. A., Alkhaldi, . B. A., Alhazmi, . R. A., Alzahrani, . A. M. & Damanhouri, . N. K. (2020) A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. IJMDC, 4 (3), 660-667. doi:10.24911/IJMDC.51-1575930154



Turabian Style

Alhazmi, Anwar Abdullah, Basil Abdulaziz Alkhaldi, Rayan Abdulrahman Alhazmi, Abdullah Mohammed Alzahrani, and Nehal Khalid Damanhouri. 2020. A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. International Journal of Medicine in Developing Countries, 4 (3), 660-667. doi:10.24911/IJMDC.51-1575930154



Chicago Style

Alhazmi, Anwar Abdullah, Basil Abdulaziz Alkhaldi, Rayan Abdulrahman Alhazmi, Abdullah Mohammed Alzahrani, and Nehal Khalid Damanhouri. "A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah." International Journal of Medicine in Developing Countries 4 (2020), 660-667. doi:10.24911/IJMDC.51-1575930154



MLA (The Modern Language Association) Style

Alhazmi, Anwar Abdullah, Basil Abdulaziz Alkhaldi, Rayan Abdulrahman Alhazmi, Abdullah Mohammed Alzahrani, and Nehal Khalid Damanhouri. "A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah." International Journal of Medicine in Developing Countries 4.3 (2020), 660-667. Print. doi:10.24911/IJMDC.51-1575930154



APA (American Psychological Association) Style

Alhazmi, A. A., Alkhaldi, . B. A., Alhazmi, . R. A., Alzahrani, . A. M. & Damanhouri, . N. K. (2020) A cross-sectional study to evaluate knowledge, attitude, and practice among Saudi patients with hypothyroidism in Makkah. International Journal of Medicine in Developing Countries, 4 (3), 660-667. doi:10.24911/IJMDC.51-1575930154