HEALTH KNOWLEDGE AND ATTITUDE REGARDING BLEACHING AGENTS IN WEST SAUDI ARABIA 113 (Table V). However, it is much lower than fi gures reported from Nigeria (81.3%) (8, 24) and Senegal (92%) (9). As expected, the current study revealed that women with higher household incomes were using more bleaching creams than those with lower income (Tables I–II), although not reaching a signifi cant cut-off level. The participants in this study spent on the an average of 136.4 ± 217.3 SR (34.1 ± 54.1 USD) monthly on TPAs (Table II), which was considered relatively high keeping in mind that the household income of 45.4% of the participants was below 5,000 SR (1,250 USD) (Table I). Unexpectedly, in the present study, higher educated women (who should be more knowl- edgeable of TPAs’ side effects) used these products more signifi cantly. Similarly, the highest rate of usage unexpectedly was reported in the age group 26–40 years as it was expected to be higher in younger ages (Table I). This may be attributed to the idea that fair skin is not only a symbol of beauty but is also associated with better employment and marital pros- pects. A previous study carried out in Southern Nigeria reported that TPAs-related side effects were particularly frequent in unmarried women, literate women, and female students (24). Importantly, skin TPAs are harmful to health at a level that is comparable with or even exceeds the level of other risk behaviors (14). Despite that, the lack of knowledge of the danger of bleaching products is evident in this study, e.g. mercury is the most dangerous constituent of bleaching products as it is highly toxic. This is known by only 30.2% of Table VI Sociodemographic Factors Associated with Current Usage of Bleaching Agents Age Current use of bleaching agents χ2 p value Yes N = 230 No N = 301 Age (years) 16–25 (n = 176) 74 (42.0) 102 (58.0) 26–40 (n = 288) 144 (50.0) 144 (50.0) 40 (n = 67) 12 (17.9) 55 (82.1) 22.97 0.001 Marital status Single (n = 210) 83 (39.5) 127 (60.5) Married (n = 267) 121 (45.3) 146 (54.7) Divorced/separated (n = 39) 21 (53.8) 18 (46.2) Widowed (n = 15) 5 (33.3) 10 (66.7) 4.04 0.258 Educational level (n = 515) Illiterate (n = 25) 5 (20.0) 20 (80.0) High school or lower (n = 184) 71 (38.6) 113 (61.4) University or higher (n = 306 147 (48.0) 159 (52.0) 9.99 0.007 Occupation House wife (n = 168) 68 (40.5) 100 (59.5) Student (n = 65) 29 (44.6) 36 (55.4) Employed (n = 185) 85 (45.9) 100 (54.1) Unemployed (n = 113) 48 (42.5) 65 (57.5) 1.15 0.765 Monthly average household income in SR 2,000 ( 500 USD) (n = 88) 2,000–5,000 (500–1,250 USD) (n = 153) 26 (29.5) 62 (70.5) 5,001–10,000 (1,250–2,500 USD) (n = 151) 71 (46.4) 82 (53.6) 10,001–20,000 (2,500–5,000 USD) (n = 107) 70 (46.4 81 (53.6) 20,000 ( 5,000 USD) (n = 32) 47 (43.9) 60 (56.1) 16 (50.0) 16 (50.0) 8.56 0.073

JOURNAL OF COSMETIC SCIENCE 114 the participants as the most toxic product of TPAs whereas more than half of them (53.2%) selected corticosteroids (Figure 5). Comparable results have been reported by Alghamdi in his study (16). Regarding the duration of applying TPAs in the present study, 8.7% had used bleaching creams continuously for more than 1 year with an overall duration ranging between 1 and 72 mo (Table III). This is quite smaller than the report in a previous Saudi study (16) where the duration of the bleaching practice ranged between 1 and 150 mo (12.5 years). In Senegal, the duration ranged between 1 and 420 mo (35 years) (9). That may be related to the degree of skin darkness. Concerning the amount of TPAs used each month, it ranged between 1 and 800 g (mean 61.6 ± 98.5 g/mo) (Table II). Actually, this extremely necessitates health education. Toxicity of some components, e.g. mercury is related to the dose and duration of exposure. In an- other Saudi study, it ranged between 2 and 600 g (mean 90.09 g/mo). In African coun- tries, such as Nigeria, the amount ranged between 60 and 150 g/mo (25) whereas in Senegal the amount ranged between 15 and 350 g/mo (9). The maximum amount used in the present study (800 g) is considered too big if we recognize that 45 g of bleaching cream is quite enough to cover the whole body (16). The difference between our fi gures and those reported in African countries is attributed to the fact that skin color in African countries is of the dark black (type VI) whereas in Saudi Arabia it is lighter (skin type IV–V) (16). In the present study, 11.6% of the investigated women continued applying TPAs during pregnancy whereas 20% did that during lactation (Table II). Quite close results were observed in a previous Saudi study regarding the main city Riyadh where 10.3% of women continued applying bleaching products during pregnancy and 20.8% during lac- tation (16). These fi gures are very far from those reported in Senegal where rates of ap- plication of TPAs throughout pregnancy or lactation were 81% and 87%, respectively (9). This difference may be attributed to the lower level of awareness about the dangers of using nonprescribed medications or products during pregnancy in Senegal compared with Saudi Arabia. Hamed et al. (19) reported that women who use skin lightening agents are more likely to believe that lighter skin color has a positive role to play in self-esteem, perception of beauty and youth, marriage, and employment opportunities compared with nonusers. In the current study, self-reported complications of discontinuing the use of bleaching prac- tice were returning of the normal skin color or a darker one, skin dryness and skin rash (Figure 4). These side effects prevent the consumers from discontinuing this practice. Therefore, there is a need to make a more public awareness to ask for medical advice instead of continuing using these products. Our study had some limitations. It included a nonprobability convenient sample of women attending outpatient clinics in general hospitals in Al-Madinah city, which affect the generalizability of results. Its cross-sectional nature creates diffi culties in ascertaining causality. CONCLUSIONS By the end of this study, we can draw many conclusions. The use of skin TPAs is a common practice among Saudi women aged 16–60 years attending outpatient clinics of general hospitals in Al-Madinah city, Saudi Arabia. It is signifi cantly higher among women aged