The prevalence and severity of burnout syndrome among school teachers in Makkah city, Saudi Arabia: A cross sectional study

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MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, ms466e2522 (2022) 1 of 9
The prevalence and severity of
burnout syndrome among
school teachers in Makkah city,
Saudi Arabia: A cross sectional
study
Mohammad Almatrafi1, Ethar Alsulami1*, Raghad Saleh1,
Ghadeer Sadaqa1, Renad Alamoudi1, Jumanah Althagafi1,
Faisal Alghamdi1, Reda Goweda2
ABSTRACT
Background and aim: Burnout syndrome (BS) is described by emotional
exhaustion, depersonalization and a lack of personal accomplishment. It is
now recognized as a syndrome affecting a broader range of professions.
Teaching is a profession with numerous job related stressors. In this study, we
aimed to determine the prevalence of BS among primary and secondary
school teachers In Makkah, Saudi Arabia. Methodology: Using a standardized
questionnaire, a cross sectional study of Makkah city population in Saudi
Arabia was carried out. Any primary, secondary and high school teachers in
Makkah, male and female, Saudi or not, met the inclusion criteria. In this
study, burnout was measured using The Maslach Burnout Scale (MBS). Data
were extracted, reviewed, coded, and then entered in to statistical software
IBM SPSS version 22. (SPSS, Inc Chicago, IL) P value less than 0.05 was
considered statistically significant. Result: The study survey was completed by
354 teachers in total. The exact 228 (64.4%) teachers were females (36.7%) of
the teachers who experienced high BS levels. BS was significantly higher
among young aged teachers (42.2% vs. 23.7%) and female teachers (42.1% vs.
27%). Also, there’s a significant association between the number of classes per
week and BS, additional factors included social issues, chronic diseases and
the fear of being forced to work. Conclusion: BS is wide spread among
teachers, as evidenced by the fact that 36% of respondents scored highly for
(BS). These results demonstrate the requirement for programs to support
teachers' mental health in order to improve the educational process.
Keywords: Burnout, School Teachers, Saudi Arabia.
1. INTRODUCTION
On the basis of the Cognitive Activation Theory of Stress (Ursin and Eriksen,
2004), Individuals' health is determined by how efficiently they adapt to
Medical Science
pISSN 2321–7359; eISSN 2321–7367
To Cite:
Almatrafi M, Alsulami E, Saleh R, Sadaqa G, Alamoudi R, Althagafi J,
Alghamdi F, Goweda R. The prevalence and severity of burnout
syndrome among school teachers in Makkah city, Saudi Arabia: A cross
sectional study. Medical Science 2022; 26:ms466e2522.
doi:
Authors’ Affiliation:
1College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
2Department of Community Medicine, Umm Al-Qura University,
Makkah, Saudi Arabia
3Department of family Medicine, Faculty of Medicine, Suez canal
University, Egypt
*Corresponding author
College of Medicine, Umm Al-Qura University, Makkah,
Saudi Arabia
Email: Ettr.135@gmail.com
Peer-Review History
Received: 16 October 2022
Reviewed & Revised: 17/October/2022 to 08/November/2022
Accepted: 11 November 2022
Published: 14 November 2022
Peer-review Method
External peer-review was done through double-blind method.
URL: https://www.discoveryjournals.org/medicalscience
This work is licensed under a Creative Commons Attribution 4.0
International License.
Copyright © 2022 Discovery Scientific Society.
DISCOVERY
SCIENTIFIC SOCIETY

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Medical Science, 26, ms466e2522 (2022) 2 of 9
psychosocial, environmental and physical difficulties. The response to such threats to an individual's psychological or physiological
integrity is known as stress, and it seeks to preserve physiological balance and, as a result, improve survival and reproductive
success. From this view point, teaching profession stands out as one of the most exhausted jobs with the ability to induce poor
health (Johnson et al., 2005). Burnout can literally be defined as "to be consumed or burned up." Feelings of tiredness or depletion
are also included in the word. Burnout is a term used in the work place to describe work related stress, which provides for feelings
of physical and mental tiredness, impatience, loss of interest in work and low self worth (Ribeiro et al., 2021). Burnout syndrome
(BS), which is an undesirable psychological state marked by weariness, cynicism and feelings of lost professional efficacy, is one
stress related consequence teachers may face (Arvidsson et al., 2016). Although BS is still mainly studied in the medical industry, it
is now acknowledged as a syndrome impacting a far wider variety of professions, including teaching, which has multiple job
related stressors, most of which occur on a daily basis (Ptáček et al., 2019).
Concerning several causes and contributing variables, there has been a considerable increase in mental disorders among
workers, notably teachers, in recent years. These reasons include a rise in work pace, a decrease in the number of teachers, an
increase in tasks and the assumption of new responsibilities. Additional stressors teachers must deal with include parental pressure
and often unreasonable societal expectations (Brown et al., 2002). Every one of these factors could lead to emotional stress. At the
same time, teachers are expected to control their own emotions, i.e., demands of hiding emotions (Johnson et al., 2005). Therefore,
the study of this syndrome arose primarily because of the consequences that can affect the worker's health (Marić et al., 2020).
A survey statistic showed that 10–40 percent of teachers in Western and some Eastern European nations suffer burnout, while
50–70 percent of teachers in Asian countries suffer burnout (Al-Asadi et al., 2018). According to a recent systematic study and meta-
analysis, many school teachers suffer from burnout. In particular, 28.1 % experience severe emotional tiredness, 37.9 % experience
extreme levels of depersonalization and 40.3 % low experience levels of personal achievement (García-Carmona et al., 2019).
Understanding the prevalence of BS among teachers is essential to identify risk factors for poor mental outcomes that can aid in
better assessment, targeted prevention and intervention programs, potentially minimizing the risk for adverse health outcomes
among teachers and their students (Ozoemena et al., 2021). However, little is known about the prevalence of burnout and associated
factors among school teachers in Saudi Arabia. Accordingly, this study’s goal is to find out the prevalence of BS among school
teachers in Makkah, Saudi Arabia.
2. MATERIALS AND METHODS
This cross sectional study was performed using a structured questionnaire in Makkah city population, Saudi Arabia. The study was
concluded over three months, starting in February to May 2022, after obtaining ethical approval from UQU's research ethics
committee (HAPO -02-K-012-2022-03-1005). The inclusion criteria were any primary, secondary and high school teachers in
Makkah, male and female, either Saudi or non Saudi. Exclusion criteria included any teacher participants who did not complete the
survey and were diagnosed with psychiatric disorders such as depression, general anxiety, bipolar and schizophrenia. A
quantitative study of school teachers was started in February 2022 in Makkah, Saudi Arabia. The study population is expected to be
20000 teachers. The sample size required to detect a significant effect with a 95% confidence interval in a finite population would be
377 teachers. After three months of data collection, 354 teachers participated. Data were collected from Makkah city school teachers
through an online questionnaire. The questionnaire included the following socio-demographic data: Gender, age, marital status,
children number, nationality, chronic diseases, psychiatric diseases, social problems, income, school type (elementary, secondary or
high school), governmental or private school, specialty, number of classes per week, years of service and the teachers were asked to
indicate if they are forced to do this job or not. This study measured burnout using The Maslach Burnout Scale (MBS), modifie d and
adopted from reviewed literature; an English version was translated in to Arabic. To ensure consistency, one independent bilingual
reviewer checked the Arabic translation. There are 22 Likert type items in this scale, separated into three subscales: Emotional
exhaustion (burnout) (nine items), depersonalization (five items), and professional accomplishment (eight items), formed in
multiple choice patterns ranging from 0 to 6 choices; indicate how frequently the statement applied to them (0=never, 6=everyday).
All participants in our study were given detailed information about the study's goals and all participants who were inclined to
participate in the study provided informed consent before completing the questionnaires.
Data analysis
Data were revised, coded and entered into statistical software IBM SPSS version 22 after being extracted (SPSS, Inc Chicago, IL).
Two tailed tests were used for all statistical analysis P value lower than 0.05 was statistically significant. As for burnout, Maslach
Burnout Inventory Student Survey (MBI-SS) discrete scores for different domains were calculated and categorized in to low,

MEDICAL SCIENCE l ANALYSIS ARTICLE
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moderate and high levels according to documented scale cutoff points (1, 2). Descriptive analysis using frequency distribution with
percent was done for participants' personal data, work data, experience years, medical history, social problems and degree of
burnout. Cross tabulation was done in order to evaluate the distribution of study participants' degree of burnout for the three
domains (EE, DP and PA) by their different bio-demographic and work related data. The significance of relations was tested using
Pearson's Chi square test and the exact probability test for small frequency distributions.
3. RESULTS
A total of 354 school teachers completed the study survey. Teachers' ages ranged from 24 to 60 years, with a mean age of 45.5 ± 6.6.
The exact 228 (64.4%) teachers were females, 297 (83.9%) were married and 34 (9.6%) were divorced / widows. A total of 171 (48.3%)
had four children or more, 127 (35.9%) had 1-3 children and 56 (15.8%) had no children. The income was insufficient among 303
(85.6%) teachers. A total of 45 (12.7%) were diagnosed with hypertension, 42 (11.9%) were diabetic and 257 (72.8%) had no chronic
health problems. Also, 10 (2.8%) teachers had social problems related to family, while one teacher had debts and 1 had introversion
(Table 1).
Table 1 Bio-demographic data of study school teachers in Makkah city, Saudi Arabia
Bio-demographic
data
No
%
Age in years
< 40
64
18.1%
40-49
176
49.7%
50+
114
32.2%
Gender
Male
126
35.6%
Female
228
64.4%
Marital status
Single
23
6.5%
Married
297
83.9%
Divorced / widow
34
9.6%
Number of children
None
56
15.8%
1-3
127
35.9%
4+
171
48.3%
Income level
Sufficient
51
14.4%
Insufficient
303
85.6%
Chronic diseases
None
257
72.8%
Diabetes mellitus
42
11.9%
Hypertension
45
12.7%
Hypothyroidism
9
2.5%
Others
20
5.7%
Social problems
None
342
96.6%
Family issues
10
2.8%
introversion
1
.3%
Debts
1
.3%
Table 2 Work related data of study school teachers in Makkah city, Saudi Arabia. A total of 345 (97.5%) teachers worked at
governmental schools, 136 (38.4%) were teaching in the elementary phase, 125 (35.3%) were teaching in the middle phase and 93

MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, ms466e2522 (2022) 4 of 9
(26.3%) were teaching in the high phases. Regarding teaching experience, 199 (56.2%) teachers work for more than 20 years, 127
(35.9%) teach for 10-19 years and 28 (7.9%) teach for less than ten years. As for the number of classes per week, 106 (29.9%) teachers
had more than 20 classes per week, 155 (43.8%) had 16-20 classes per week, and 71 (20.1%) had 8-15 classes per week. 119 (33.6%)
teachers thought that they were forced to do this job.
Table 2 work related data of study school teachers in Makkah city, Saudi Arabia
Work data
No
%
School type
Governmental
345
97.5%
Private
9
2.5%
Teaching phase
Elementary
136
38.4%
Middle
125
35.3%
High
93
26.3%
How long have you been
teaching?
< 10 years
28
7.9%
10-19 years
127
35.9%
20 years or more
199
56.2%
Number of classes per week
< 7
22
6.2%
8-15
71
20.1%
16-20
155
43.8%
> 20
106
29.9%
Are you forced to do this job?
Yes
119
33.6%
No
235
66.4%
Table 3 Burnout among study school teachers in Makkah city, Saudi Arabia regarding BS it was low among 31.1% of the study
teachers, moderate among 32.2%, while 36.7% of the teachers experienced high BS levels. Depersonalization/loss of empathy (DP )
was low among 51.1% of the study teachers and moderate among 29.4%, while 19.5% complained of high DP and loss of empathy.
Regarding Personal accomplishment (PA), 63.8% of the teachers had a low level of PA, 20.6% experienced moderate PA and 15.5%
experienced a high PA level (Figure 1).
Table 3 Burnout among study school teachers in Makkah city, Saudi Arabia
Burnout domains
Low degree
Moderate degree
High degree
No
%
No
%
No
%
Occupational exhaustion
110
31.1%
114
32.2%
130
36.7%
Depersonalisation / loss of
empathy
181
51.1%
104
29.4%
69
19.5%
Personal accomplishment
226
63.8%
73
20.6%
55
15.5%

MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, ms466e2522 (2022) 5 of 9
Figure 1 Burnout among study school teachers in Makkah city, Saudi Arabia
Table 4 Factors associated with BS among study teachers in Makkah, Saudi Arabia. BS was significantly higher among young
aged teachers (42.2% vs. 23.7%), female teachers (42.1% vs. 27%), teachers with sufficient income (64.7% vs. 32%), teachers with
chronic diseases (45.8% vs. 33.3%), teachers with social problems (75% vs. 35.4%), teachers with a higher rate of classes per week
(51.9% vs. 22.7%) and teachers who were forced for that job (61.3% vs. 24.3%).
Table 4 Factors associated with occupation exhaustion among study teachers in Makkah, Saudi Arabia
Factors
Occupational exhaustion
p-value
Low degree
Moderate
degree
High degree
No
%
No
%
No
%
Age in years
< 40
14
21.9%
23
35.9%
27
42.2%
.001*
40-49
43
24.4%
57
32.4%
76
43.2%
50+
53
46.5%
34
29.8%
27
23.7%
Gender
Male
48
38.1%
44
34.9%
34
27.0%
.014*
Female
62
27.2%
70
30.7%
96
42.1%
Marital status
Single
4
17.4%
5
21.7%
14
60.9%
.102
Married
92
31.0%
99
33.3%
106
35.7%
Divorced / widow
14
41.2%
10
29.4%
10
29.4%
Number of
children
None
19
33.9%
13
23.2%
24
42.9%
.438
1-3
39
30.7%
39
30.7%
49
38.6%
4+
52
30.4%
62
36.3%
57
33.3%
Income level
Sufficient
7
13.7%
11
21.6%
33
64.7%
.001*
Insufficient
103
34.0%
103
34.0%
97
32.0%
Chronic
diseases
Yes
31
32.3%
21
21.9%
44
45.8%
.025*
No
79
30.6%
93
36.0%
86
33.3%
Social
problems
Yes
1
8.3%
2
16.7%
9
75.0%
.019*$
No
109
31.9%
112
32.7%
121
35.4%
School type
governmental
108
31.3%
111
32.2%
126
36.5%
.824
private
2
22.2%
3
33.3%
4
44.4%
Teaching
phase
Elementary
38
27.9%
40
29.4%
58
42.6%
.344
Middle
40
32.0%
40
32.0%
45
36.0%
High
32
34.4%
34
36.6%
27
29.0%
31.1%
51.1%
63.8%
32.2% 29.4%
20.6%
36.7%
19.5% 15.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Occupational exhaustion Depersonalisation / loss of empathy Personal accomplishment
Low Moderate High

MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, ms466e2522 (2022) 6 of 9
How long
have you
been
teaching?
< 10 years
5
17.9%
6
21.4%
17
60.7%
.057
10-19 years
36
28.3%
43
33.9%
48
37.8%
20 years or more
69
34.7%
65
32.7%
65
32.7%
Number of
classes per
week
< 7
10
45.5%
7
31.8%
5
22.7%
.002*
8-15
29
40.8%
24
33.8%
18
25.4%
16-20
43
27.7%
60
38.7%
52
33.5%
> 20
28
26.4%
23
21.7%
55
51.9%
Are you
forced to do
this job?
Yes
13
10.9%
33
27.7%
73
61.3%
.001*
No
97
41.3%
81
34.5%
57
24.3%
P: Pearson X2 test $: Exact probability test * P < 0.05 (significant)
Table 5 Factors associated with depersonalization among study teachers in Makkah, Saudi Arabia. DP was significantly higher
among young aged teachers (29.7% vs. 13.2%), teachers with sufficient income (41.2% vs. 15.8%), teachers with a higher rate of
classes per week (29.2% vs. 22.7%) and teachers who were forced for that job (37% vs. 10.6%).
Table 5 Factors associated with depersonalization among study teachers in Makkah, Saudi Arabia
Factors
Depersonalisation / loss of empathy
p-
value
Low degree
Moderate
degree
High degree
No
%
No
%
No
%
Age in years
< 40
28
43.8%
17
26.6%
19
29.7%
.001*
40-49
77
43.8%
64
36.4%
35
19.9%
50+
76
66.7%
23
20.2%
15
13.2%
Gender
Male
70
55.6%
36
28.6%
20
15.9%
.349
Female
111
48.7%
68
29.8%
49
21.5%
Marital status
Single
9
39.1%
8
34.8%
6
26.1%
.411
Married
150
50.5%
89
30.0%
58
19.5%
Divorced / widow
22
64.7%
7
20.6%
5
14.7%
Number of
children
None
30
53.6%
18
32.1%
8
14.3%
.773
1-3
65
51.2%
34
26.8%
28
22.0%
4+
86
50.3%
52
30.4%
33
19.3%
Income level
Sufficient
16
31.4%
14
27.5%
21
41.2%
.001*
Insufficient
165
54.5%
90
29.7%
48
15.8%
Chronic diseases
Yes
46
47.9%
24
25.0%
26
27.1%
.081
No
135
52.3%
80
31.0%
43
16.7%
Social problems
Yes
3
25.0%
5
41.7%
4
33.3%
.172$
No
178
52.0%
99
28.9%
65
19.0%
School type
governmental
176
51.0%
102
29.6%
67
19.4%
.891
private
5
55.6%
2
22.2%
2
22.2%
Teaching phase
Elementary
70
51.5%
34
25.0%
32
23.5%
.361
Middle
63
50.4%
38
30.4%
24
19.2%
High
48
51.6%
32
34.4%
13
14.0%
How long have
you been
teaching?
< 10 years
10
35.7%
9
32.1%
9
32.1%
.323
10-19 years
63
49.6%
39
30.7%
25
19.7%
20 years or more
108
54.3%
56
28.1%
35
17.6%
Number of
classes per week
< 7
15
68.2%
2
9.1%
5
22.7%
.012*
8-15
42
59.2%
21
29.6%
8
11.3%

MEDICAL SCIENCE l ANALYSIS ARTICLE
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16-20
77
49.7%
53
34.2%
25
16.1%
> 20
47
44.3%
28
26.4%
31
29.2%
Are you forced to
do this job?
Yes
38
31.9%
37
31.1%
44
37.0%
.001*
No
143
60.9%
67
28.5%
25
10.6%
P: Pearson X2 test $: Exact probability test * P < 0.05 (significant)
Table 6 Factors associated with Personal accomplishment among study teachers in Makkah, Saudi Arabia. DP was significantly
higher among divorced teachers than others (32.4% vs. 4.3%). Other factors were insignificantly associated with burnout among
study teachers.
Table 6 Factors associated with Personal accomplishment among study teachers in Makkah, Saudi Arabia
Factors
Personal accomplishment
p-value
Low degree
Moderate degree
High degree
No
%
No
%
No
%
Age in years
< 40
43
67.2%
10
15.6%
11
17.2%
.138
40-49
120
68.2%
31
17.6%
25
14.2%
50+
63
55.3%
32
28.1%
19
16.7%
Gender
Male
82
65.1%
24
19.0%
20
15.9%
.862
Female
144
63.2%
49
21.5%
35
15.4%
Marital status
Single
18
78.3%
4
17.4%
1
4.3%
.033*$
Married
190
64.0%
64
21.5%
43
14.5%
Divorced / widow
18
52.9%
5
14.7%
11
32.4%
Number of
children
None
38
67.9%
13
23.2%
5
8.9%
.505
1-3
83
65.4%
22
17.3%
22
17.3%
4+
105
61.4%
38
22.2%
28
16.4%
Income level
Sufficient
32
62.7%
8
15.7%
11
21.6%
.348
Insufficient
194
64.0%
65
21.5%
44
14.5%
Chronic
diseases
Yes
59
61.5%
19
19.8%
18
18.8%
.596
No
167
64.7%
54
20.9%
37
14.3%
Social
problems
Yes
6
50.0%
2
16.7%
4
33.3%
.223$
No
220
64.3%
71
20.8%
51
14.9%
School type
governmental
221
64.1%
69
20.0%
55
15.9%
.130
private
5
55.6%
4
44.4%
0
0.0%
Teaching phase
Elementary
82
60.3%
31
22.8%
23
16.9%
.089
Middle
91
72.8%
17
13.6%
17
13.6%
High
53
57.0%
25
26.9%
15
16.1%
How long have
you been
teaching?
< 10 years
20
71.4%
5
17.9%
3
10.7%
.596
10-19 years
86
67.7%
24
18.9%
17
13.4%
20 years or more
120
60.3%
44
22.1%
35
17.6%
Number of
classes per
week
< 7
15
68.2%
5
22.7%
2
9.1%
.962
8-15
43
60.6%
17
23.9%
11
15.5%
16-20
99
63.9%
31
20.0%
25
16.1%
> 20
69
65.1%
20
18.9%
17
16.0%
Are you forced
to do this job?
Yes
79
66.4%
20
16.8%
20
16.8%
.442
No
147
62.6%
53
22.6%
35
14.9%
P: Pearson X2 test $: Exact probability test * P < 0.05 (significant)

MEDICAL SCIENCE l ANALYSIS ARTICLE
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4. DISCUSSION
The study concluded that the prevalence of BS is 36.7% among school teachers in Makkah, Saudi Arabia. In addition, the result
showed significantly higher scores among participants with the following socio-demographic characteristic, being young, female,
having chronic diseases, having higher classes per week, being forced to work and having sufficient income.
The present study showed significantly higher in young aged teachers, which is consistence with Alsadi's; contrary to his study,
ours showed more BS in females than males, while Alsadi's, Unterbrink's, and Correa-Correa's studies BS was reported more in
males (Correa-Correa et al., 2010; Unterbrink et al., 2007; Al-Asadi et al., 2018), on the other hand, other studies showed higher BS in
females than males as in (Lau et al., 2005; Zhang et al., 2014). However, some studies showed no statistical significance difference
between males and females (Luk et al., 2010; Jamshidirad et al., 2012). This inconsistency in the literature might result from the
difference in the work environment, income and financial compensation.
The existing literature showed no clear cut-off in marital status and burnout. The present study showed no statistical
significance difference between married and single teachers in relation to BS, which is in accordance with Sonnentag's, and
Mukundan's (Mukundan et al., 2010; Sonnentag et al., 2010). On the other hand, Alsadi's study showed lower BS in married
teachers, while others showed the opposite (Luk et al., 2010; Al-Asadi et al., 2018). Interestingly, teachers who thought their income
was sufficient had significantly higher BS scores than those with insufficient, while Luk's study stated that (Luk et al., 2010) come
satisfaction has an insignificant association with BS.
Regarding work overload, we found a significant association between the number of weekly classes and BS. This finding is in
line with Alsadi's, Sonnentag's and Mukundan's (Mukundan et al., 2010; Sonnentag et al., 2010; Al-Asadi et al., 2018). Our results
suggested that years of service were not associated with BS. In the present study, there was no statistically significant association
between BS and years of service, which disagrees with Alsadi's study (Al-Asadi et al., 2018). Other factors, such as chronic diseases,
social problems and the thought of being forced to work, were also significantly associated with BS. The current study did not
evaluate student related factors such as misbehaviour and high student numbers per class. And BS in relation to depression and
anxiety disorder may impact the quality of student education.
5. CONCLUSION
In conclusion, BS is high among school teachers, as 36% of respondents reported high emotional exhaustion scores (BS). Such
findings suggest implementing teacher mental well being programs to improve the education process. Future prospective national
studies are required to measure the extent of BS.
Limitations
The current study's limitations are its retrospective nature, convenient sample technique and self administered questionnaire; the
result may change with a larger population.
Acknowledgement
We thank the participants who were all contributed samples to the study.
Ethical approval
The study was approved by the Medical Ethics Committee of Umm Al-Qura University (Ethical approval code: HAPO -02-K-012-
2022-03-1005).
Informed consent
Informed consent was obtained from all individual participants included in the study.
Authors’ contributions
The authors confirm contribution to the paper as follows: Study conception and design: Ethar Alsulami, Raghad saleh, Faisal
Alghamdi; data collection: Ethar Alsulami, Raghad saleh, Faisal Alghamdi, Mohammad Almatrafi, Renad Alamoudi, Ghadeer
Sadaqa; analysis and interpretation of results: Jumanah Althagafi, Mohammad Almatrafi; draft manuscript preparation: Ethar
Alsulami, Raghad saleh, Faisal Alghamdi, Mohammad Almatrafi, Renad Alamoudi, Ghadeer Sadaqa, jumanah Althagafi; revisions
to scientific content of manuscript: Reda Goweda. All authors reviewed the results and approved the final version of the
manuscript.

MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, ms466e2522 (2022) 9 of 9
Funding
This study has not received any external funding.
Conflict of interest
The authors declare that there is no conflict of interests.
Data materials availability
All data associated with this study will be available based on the reasonable request to corresponding author.
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