Knowledge and Awareness About the Risk Factors of Urolithiasis Among the General Population in Makkah, Saudi Arabia

Introduction

Urolithiasis, commonly known as kidney stones or nephrolithiasis, is a prevalent and complex medical condition characterized by the formation of calculi within the urinary tract. It primarily affects the kidneys and ureters but can also involve the bladder and urethra. The global incidence of kidney stones has seen a marked increase over the past few decades, raising significant public health concerns. In Saudi Arabia, studies have indicated a lifetime risk of developing kidney stones as high as 20% with a pronounced male predominance, where the incidence ratio stands at approximately 3.2:1 compared to women.^1,2 This condition not only causes acute pain and discomfort but can also lead to severe complications including chronic kidney disease, urinary tract infections, and the need for surgical interventions.

The etiology of nephrolithiasis is multifactorial and encompasses a complex interplay of dietary, environmental, and genetic factors. In Saudi Arabia, lifestyle choices significantly influence the risk of stone formation. For instance, low fluid intake is a critical risk factor, particularly in the context of the region’s hot and arid climate. This can lead to dehydration and concentrated urine—conditions that promote crystallization.^3,4 Additionally, high consumption of animal proteins, excessive sodium intake, and insufficient dietary calcium are prevalent among this population and have been linked to the formation of calcium oxalate stones, which account for approximately 80% of all kidney stones.

Public awareness regarding the risk factors for urolithiasis remains alarmingly low, particularly among individuals who are not part of the medical community. A study in Jeddah indicated widespread ignorance about the causes and preventative measures related to urolithiasis.⁴ Similarly, research in Jazan found that a significant portion of the population lacked awareness about the risk factors associated with urinary stones. This underscores the need for educational initiatives.⁵ Furthermore, a cross-sectional observational study highlighted the necessity of enhancing public knowledge to foster healthier lifestyle choices that could mitigate the risk of stone formation.⁶

The implications of untreated urolithiasis extend beyond individual health, significantly impacting healthcare systems. In the United States, kidney stones account for approximately 1 million emergency room visits annually resulting in healthcare costs that exceed $5 billion.⁷ In Saudi Arabia, the rising prevalence of nephrolithiasis presents parallel challenges including strained healthcare resources and a need for more effective management strategies.

In light of this context, this study assessed the knowledge and awareness of the general population in Makkah regarding the risk factors associated with urolithiasis. By evaluating the level of understanding about dietary and lifestyle factors contributing to kidney stone formation, this research aims to identify critical gaps in knowledge that can be addressed through targeted educational initiatives. Furthermore, understanding public perceptions of urolithiasis will be instrumental in developing community-based prevention programs aimed at promoting healthier lifestyles. Ultimately, enhancing public awareness regarding kidney stones is not just vital for improving individual health outcomes but is also essential for reducing the overall burden of this condition on society. By fostering a comprehensive understanding of the risk factors associated with urolithiasis, this study aspires to contribute to future prevention efforts that can enhance public health in Saudi Arabia and beyond.

Subjects and Methods

This descriptive cross-sectional study was conducted from February 18, 2025, to April 20, 2025, involving 452 adult participants residing in Makkah.

Study Respondents

Inclusionary Criteria

Adults residing in Makkah, Saudi Arabia, aged 18 years and older, of both genders, who spoke Arabic and provided informed consent after being briefed about the study’s purpose and objectives.

Exclusionary Criteria

Individuals younger than 18, individuals who provided incomplete data, and non-Arabic speakers.

Sample Size Determination

The minimum sample size required for this study was calculated using OpenEpi version 3.0. Based on the population of Makkah, which is 2,427,924 according to the General Authority of Statistics (2022), a 95% confidence interval (CI) was used with an anticipated frequency of 50% and a design effect of 1. The calculated sample size was thus 385 participants.

Data Collection

An online Arabic questionnaire was designed using Google Forms. We utilized a modified version of a previously validated questionnaire originally developed for similar research conducted in the United Arab Emirates.⁸ The original questionnaire was modified to focus solely on the risk factors associated with urolithiasis. To suit the context of Makkah, Saudi Arabia, the questions were adjusted to reflect the local population’s demographics, lifestyle, and health behaviors, ensuring relevance to the region. The modified questionnaire underwent expert review by three professionals in the field to assess content validity and clarity. Additionally, a pilot study was conducted on a small sample of 15 participants from the target population to evaluate the questionnaire’s reliability and comprehensibility. This process helped identify any issues, and necessary adjustments were made before the final distribution. The questionnaire was distributed electronically through social media, ensuring broad coverage of the target population in Makkah. To protect against response bias, the survey was anonymous, and all participants were informed that their responses would be kept confidential. Additionally, we ensured that participants were fully briefed about the purpose of the study to minimize social desirability bias. The respondents received electronic links accompanied by the survey objectives, the target population, and a request to participate voluntarily. The questionnaire consisted of the following sections:

1. Consent form
2. Demographic characteristics
3. History of urolithiasis among participants or their family members
4. Previous knowledge of urolithiasis prevention
5. Knowledge about risk factors of urolithiasis
6. Knowledge about recommendations of the amount of certain consumed foods to prevent urolithiasis

A score of “1” was given for every correct answer, and a score of “0” was given for every wrong or “I don’t know” answer in parts 5 and 6 of the questionnaire. The total possible score was 29. If a participant’s score was less than 60% of the total, then the overall awareness score was classified as poor. If the participant’s score was 60% or higher, then the overall awareness score was considered good.^7,8 The 60% threshold for categorizing “good awareness” was chosen based on previous studies in similar contexts, where this cut-off effectively distinguished between those with adequate versus inadequate knowledge of the risk factors for urolithiasis.

Data Analysis

Data was statistically analyzed using the (SPSS) application version 26. The Chi-squared test (χ2) was applied to qualitative data that was expressed as numbers and percentages to investigate the association between the variables. Quantitative data were expressed as mean and standard deviation (mean ± SD), and a p-value <0.05 was considered statistically significant.

Results

Of the 452 participants, 40.3% were 20–29 years old, 66.2% were males, 49.1% had a bachelor’s degree in education, and 87.6% had a moderate living standard. About 10% (10.6%) of the participants had kidney stones before, and 47.3% reported that their family members had kidney stones. Most participants (64.8%) had received information about kidney stone disease prevention, mostly from physicians (36.1%). Of those who received information about kidney stone disease prevention, 60.5% thought that the information received helped them to make changes in their diet and lifestyle (Table 1).

Table 1 Distribution of Studied Participants According to Their Demographic Characteristics, Having Kidney Stones Among Participants or Their Family Members, and Receiving Information About Kidney Stones Prevention

Participants’ responses to knowledge items related to risk factors of kidney stones are illustrated in (Table 2). We found that 44.5% of participants knew that hypertensive patients are more likely to form kidney stones, 37.6% knew that stones can recur after some years, and 45.1% knew that climate has an effect on kidney stone formation. Awareness that bariatric surgery increases the risk of developing specific types of kidney stones was at 29.9%.

Table 2 Participants’ Responses to Knowledge Questions About Kidney Stone Risk Factors

Most participants (77.2%) correctly denied the misconception that increased fluid intake causes stone formation. About 67.5% were aware that urinary tract infections (UTIs) can elevate the risk, whereas 37.4% recognized that certain bowel conditions associated with chronic diarrhea may contribute to stone formation.

More than half of the participants (57.5%) knew that obesity, prolonged sitting, and physical inactivity are risk factors, and 60.2% were aware that elevated blood levels of calcium and uric acid increase the likelihood of developing stones. Furthermore, 61.9% correctly recognized the importance of dietary modifications in preventing kidney stones.

Regarding medication-related risks, 13.9% and 28.8% denied the role of antacids and diuretics, respectively, in stone formation. Only 6.9% believed that exercise of all types increases the risk. Meanwhile, 43.8% and 37.6% correctly identified hormonal imbalances or gout, and a family history of kidney stones, respectively, as contributing factors.

Participants demonstrated varying levels of knowledge regarding dietary practices recommended for the prevention of kidney stone formation. A majority reported that increasing the intake of vegetables (71%), citrus fruits (41.2%), and fluids such as water or juice (74.6%) could contribute to reducing the risk of kidney stones. Similarly, 58.8%, 36.5%, and 69.2% of participants recognized that limiting the consumption of meat, nuts, and salty foods, respectively, may help lower the risk.

In terms of beverages, 58.6%, 56%, and 67.6% of respondents believed that reducing the intake of coffee, tea, and soft drinks, respectively, could decrease the likelihood of stone formation. Additionally, 59.5% acknowledged that a reduction in fatty food consumption may be beneficial in preventing kidney stones.

However, knowledge was considerably lower regarding the role of other specific foods. Only 29.2%, 18.8%, and 25.7% of participants identified dark chocolate, spinach, and eggs, respectively, as items that should be limited to reduce the risk (Table 3).

Table 3 Participants’ Responses to Knowledge Questions Regarding Health Experts’ Recommendations on the Recommended Amounts of Food Consumption for Kidney Stone Prevention

The mean knowledge score among participants was 14.21 ± 5.5. Based on the predefined classification of knowledge levels, only 24.1% of participants demonstrated a good level of knowledge regarding the risk factors of kidney stones, while the majority (75.9%) exhibited poor knowledge (Figure 1).

Figure 1 Percentage distribution of knowledge level about risk factors of kidney stones.

The prevalence of good knowledge level about risk factors of kidney stones was significantly higher among participants aged 20–29 years (59.6%) (p=<0.05). Of note, a non-significant relationship was found between knowledge level and other participants’ demographics or having kidney stones among participants or their family members (p≤0.05) (Table 4 and Figure 2).

Table 4 Relationship Between Knowledge Level About Risk Factors of Kidney Stones and Participants’ Demographics, as Well as Having Kidney Stones Among Participants or Their Family Members

Figure 2 Relationship between knowledge level about risk factors of kidney stones and participants’ age (n=452). Note: (χ2 = 26.91, p-value = <0.001).

Discussion

Urolithiasis is a multifactorial condition influenced by various factors such as age, gender, nutrition, climate, and body mass index (BMI).⁹ This study assessed the knowledge and awareness of the general population in Makkah, Saudi Arabia, regarding the risk factors of urolithiasis. Of the 452 participants, 299 (66.2%) were male and 153 (33.8%) were female. Nearly half (49.1%) held a bachelor’s degree, and most (87.6%) reported a moderate living standard. The mean knowledge score was 14.21 ± 5.5 with only 24.1% of participants demonstrating good knowledge about kidney stone risk factors, while 75.9% had poor knowledge. These findings align with a study conducted in Hail, where 59.4% of participants had low awareness, 39% had moderate awareness, and only 1.7% demonstrated high awareness of urolithiasis.¹⁰

Our study showed that good knowledge was significantly more prevalent among participants aged 20–29 years (59.6%), which may reflect increased access to health information through digital platforms in younger populations. In contrast, a study in the United Arab Emirates reported that individuals aged 40–49 had the highest knowledge levels.⁸ There was no significant association between knowledge and other demographic variables such as gender, education level, or personal or family history of kidney stones. This contrasts with findings from previous studies where higher education levels and a family history of kidney stones were significantly associated with increased awareness.^5,11 However, the uniformly low awareness across most demographic groups is itself an important finding, underscoring the need for broader public health interventions. While these differences were not statistically significant, the consistent lack of awareness across various groups highlights a critical gap in understanding that should be addressed.

This study explored multiple non-dietary risk factors for urolithiasis, including hypertension, obesity, sedentary lifestyle, bariatric surgery, and family history. While many participants recognized common risk factors like hypertension and obesity, awareness of other factors, such as bariatric surgery and the hereditary nature of the condition, remained limited. The low levels of awareness can be attributed to factors such as limited public health campaigns, lack of education on these lesser-known risk factors, and cultural influences that may downplay the importance of preventive healthcare. Misconceptions about kidney stones and inadequate communication of scientific information may also contribute to the knowledge gap. These findings are consistent with prior research, which similarly identified low awareness of multifactorial risk factors for urolithiasis.⁵ To address these issues, targeted health education programs, incorporating culturally appropriate messaging and focusing on both common and lesser-known risk factors, could improve public understanding and awareness.

Awareness of environmental contributors was moderate, with many participants acknowledging the role of hot climates in kidney stone formation. Despite the well-documented link between dehydration in hot weather and increased stone risk, this finding mirrors the knowledge gap reported in previous studies.^5,8 Given Makkah’s hot and arid climate, this represents an important area for targeted public health education.

Understanding of stone recurrence was limited, with many participants unaware that kidney stones can recur. This contrasts with higher awareness in similar populations,⁸ suggesting a need to emphasize the chronic nature of the disease in public health messaging. The low awareness may stem from insufficient education on the long-term aspects of urolithiasis. To address this, health campaigns should focus on the recurring nature of kidney stones and preventive measures.

Participants demonstrated selective knowledge of dietary factors. While many recognized the benefits of increased water intake and vegetable consumption, fewer identified the protective role of citrus fruits and juices. Awareness of the risks associated with salty food and meat intake was higher, but knowledge of oxalate-rich foods was limited. These findings are consistent with prior research, such as a study in Malaysia,¹² which also found general awareness but poor detailed knowledge of dietary contributors to urolithiasis. To improve understanding, public health campaigns should provide more detailed information on specific dietary factors that contribute to kidney stone formation.

Moreover, while many participants rejected the misconception that dietary modifications are unnecessary, a significant portion still failed to recognize the importance of diet in preventing kidney stones. Similar misconceptions have been reported in other studies, highlighting the need for more effective nutrition-focused education as part of urolithiasis prevention strategies.⁸

Despite the observed knowledge gaps, this study provides valuable insight into the public’s understanding of urolithiasis risk factors in Makkah. A key strength lies in the use of a culturally adapted, pilot-tested, and expert-reviewed questionnaire, thus confirming clarity, validity, and relevance of the resulting data. The use of a diverse sample that exceeded the minimum required size further enhanced the generalizability of the findings. The findings have important public health implications because they identify specific areas of misunderstanding—particularly regarding lesser-known risk factors and dietary contributors—that can be addressed through targeted educational initiatives. By informing health authorities and policymakers, this research supports the development of focused awareness campaigns and preventive strategies aimed at reducing the burden of kidney stones in the community.

Limitations

This study does have several limitations. Being a cross-sectional design, it captures knowledge and awareness at a single point in time and cannot establish causality. The use of an online self-administered questionnaire may have introduced selection bias, potentially excluding individuals without internet access or those less digitally literate such as older adults or those in lower socioeconomic groups. Additionally, there may have been bias due to varying educational levels among participants, as individuals with lower education levels might have faced challenges in fully understanding the questionnaire. Furthermore, the reliance on self-reported data is subject to response bias including social desirability and recall bias. The study also focused exclusively on Arabic-speaking residents of Makkah, which may limit the applicability of findings to non-Arabic speakers or populations in other regions of Saudi Arabia. Finally, while the questionnaire assessed knowledge, it did not evaluate actual behaviors or preventive practices related to urolithiasis, which are equally important in addressing disease burden.

Conclusion

This study aimed to assess the knowledge and awareness of the general population in Makkah, Saudi Arabia, regarding the risk factors of urolithiasis. The findings revealed a generally low level of understanding, with only 24.1% of participants demonstrating good knowledge. Notably, while younger adults showed higher knowledge scores, many participants were unaware of important risk factors such as bariatric surgery, hormonal imbalance, and specific dietary contributors. These results underscore the need to close knowledge gaps through community education, which may help reduce the incidence and health burden of kidney stones. To improve generalizability, future research could use a larger, more diverse sample from different regions and with varying educational backgrounds. Including behavioural assessments would also help understand how knowledge translates into preventive actions.