HEALTH KNOWLEDGE AND ATTITUDE REGARDING BLEACHING AGENTS IN WEST SAUDI ARABIA 103 The harms caused by using skin beaching products result from acute or chronic long-term exposure to some hazardous chemical agents that may be present in these products (14). With this globally growing phenomenon studies from Saudi Arabia are still very few (15, 16) to assess the magnitude of the problem and to explore the knowledge, attitudes, and patients’ practices toward using TPAs among Saudi women. There may be a high use of skin-lightening products (containing mercury) in Saudi Arabia (15). Alghamdi confi rmed the importance of evaluating skin bleaching practice in Riyadh (central Saudi Arabia) to protect women’s health (16). Our study is the fi rst report from west Saudi Arabia to investigate the patients’ need toward education and counseling regarding the use of TPAs. The main objectives of this study were to estimate the prevalence of the use of TPAs, potential health effects, and to explore the knowledge of women attending governmental hospitals clinics at Al-Madinah Al-Munawwarah city (west Saudi Arabia). PATIENTS AND METHODS This is a cross-sectional study aiming at investigating the patients’ attitudes and needs toward health education and counseling regarding the use of TPAs. The study was carried out at Al-Madinah Al-Munawwarah city. It is located at the northwestern region of the Kingdom of Saudi Arabia (KSA) and is considered to be the second holiest Islamic city after Makkah. Al-Madinah is the city of peace and tranquility and is a place of numerous historical and archaeological sites. In Al-Madinah Al-Munawwarah city, there are three general hospitals belonging to the Ministry of Health King Fahad, Ohud, and Al-Ansar hospitals where the study was carried out. POPULATION AND SAMPLING The study was conducted in three hospitals King Fahad tertiary care hospital, 680 beds Ohud Secondary care, 250 beds and Al-Ansar secondary care with 100 beds. All women aged between 16 and 60 years, attending outpatient clinics at the three general hospitals, were involved in this study throughout the period of study conduction (March–April 2016) and constituted the study population. The minimum sample size for this study has been decided according to Swinscow (17) as follows: n = Z2 × P × QD2 (1) where: n: Calculated sample size Z: The z-value for the selected level of confi dence (1-- ) = 1.96. P: The estimated prevalence of using TPAs in the population = 38.9%, i.e., 0.389 (16). Q: (1 - P) = 61.1%, i.e., 0.611 D: The maximum acceptable error = 0.04. So, the calculated minimum sample size was: n = (1.96)2 × 0.389 × 0.611 = 571. (0.04) (2)

JOURNAL OF COSMETIC SCIENCE 104 Aft er a non-probability convenient sampling technique, approximately 600 women at- tending outpatient clinics of the three general hospitals were recruited by the authors proportionally to beds (250 from King Fahad hospital, 200 from Ohud hospital, and 150 from Al-Ansar hospital). DATA COLLECTION Self-administered valid Arabic questionnaire has been used to collect data from the partici- pants as previously reported (16). Used questionnaire included 27 questions personal infor- mation (age, marital status, educational level, occupation, and monthly average household income), detailed information regarding the use of TPAs, such as the age at which the par- ticipants started using them, the duration and frequency of usage, source of obtaining these agents, reason(s) for usage during pregnancy and lactation, money spent monthly on TPAs, parts of bodies they applied these products to, and the amounts (grams) applied. To help the participants to identify the amount used per month, four empty jars/tubes of different ca- pacities were shown to them. The women were also asked about the safety of the bleaching agents, whether or not they believed that bleaching creams obtained at herbal stores were safe, whether they thought bleaching creams might harm their skin or general health, and whether they were willing to use bleaching creams even if the components of the cream were unknown. From the given components such as corticosteroids, hydroquinone, and mercury, they were asked to choose the most dangerous component to human health. The study passed by many phases. The authors visited King Fahad, Ohud, and Al-Ansar hospitals’ outpatient clinics where women of different age groups, marital status, level of education, and economic status. The authors gave a self-administered questionnaire to women attending different hospital clinics in Al-Madinah city during the waiting time (before meeting relevant physicians in outpatient clinics). The authors explained to them that the research interest beyond the questionnaire focuses on TPAs, not regular cosmetics. The authors collected the ques- tionnaire after being fi lled in. ETHICAL CONSIDERATION The following approvals were obtained before and during study conduction: -App roval from the local training committee. -Appr oval from local ethical committee. -Perm ission from the health authorities responsible for King Fahad hospital. -Perm ission from the health authorities responsible for Ohud hospital. -Perm ission from the health authorities responsible for Al-Ansar hospital. -Part icipants’ permission. In addition, confi dentiality of data was assured. A pilot study was done on 50 women to test the wording and clarity of the questions as well as the average time required to complete the questionnaire. As a feedback, the ques- tionnaire was clear and an average of 9 minutes was required to complete it. The collected data within the pilot study were not included into the main study. The authors fulfi lled all the required offi cial approvals. All participants were reassured by the authors about the objectives of this study. They were assured that participation in this study is optional.