Assessment of Saudi Public Knowledge , Attitude and Awareness towards Oral Benefits of Probiotics : A Cross-Sectional Study

Little is known about probiotic consumption or beliefs, in spite of its enhanced availability. Therefore, the aim of this study was to assess the knowledge, awareness, and attitudes of Saudi publics towards the oral benefits of probiotics. The web-based crosssectional survey was conducted among 600 Saudi individuals through a questionnaire which was randomly distributed through online social media. Each of them was asked to complete a questionnaire including socio-demographic data and took a probiotic knowledge test.Probiotic knowledge was significantly linked with marital status, gender and those who are working in the health field, Majority of them were females (87.1%) being more knowledgeable than males (79.9%). The highest percentages of participants who heard about beneficial bacteria were those who are in the age group 36-45 years old at 87.3%, highly educated at 87.5%, postgraduates at 89.2%, married at 88.9%, and those who are working in the health field at 94.4%. Although beneficial, lack of sufficient knowledge concerning probiotics restricted its usage among few respondents. There is a need for further education and promotion of the general public in regards to the definition, oral benefits, sources and usage of probiotics.


Health and wellness
Public awareness and interest in food that is highly related to their health benefits are flourishing.Even though there is a gap between the biomedical sciences experiments and the business of marketing, the accessibility of healthpromoting channels/media leads the consumer to seek healthier food and drinks. 1,2

Lactic acid bacteria
It has been documented that the gastrointestinal tract of an adult human contains up to 500 different species of microorganisms present in interdependence with the host, providing benefits such as protection against microbial infections, stimulating immune function.Any decrease in this normal endogenous flora may lead to the microbial imbalance which might result in gastroenteritis and diarrhea. 3The term "functional food" was introduced in Japan in the 1980s describing food products fortified with special constituents that provide beneficial health effect.Lactic acid bacteria and bifidobacteria were heavily studied as normal components of the intestinal microbiota having a safe application within the food industry. 1

Probiotics
The FAO/ WHO definition of a probiotic: "Live microorganisms which when administered in adequate amounts confer a health benefit on the host", 4 however, inconsistencies between FAO/ WHO Expert Consultation Report and the FAO/ WHO Guidelines were clarified to take into account advances in science and applications. 5ecent studies have shown a high level of awareness, knowledge, and consumption of probiotics supplements in some developed countries such as Canada, Australia, and the USA which deliver an advanced health care system, 3 however, this appears in contrary to some developing countries such as Nigeria and Arabian Gulf countries. 6

study design
A web-based cross-sectional survey questionnaire was randomly distributed through online social media (WhatsApp and Twitter) to reach at least 600 Saudi individuals (minimum sample size).The survey was conducted from October to November 2017.
The questionnaire was divided into two sections: demographic information; and awareness towards probiotic benefits on the oral cavity.The number of questions was 6 for the first section and 8 for the second section; with a total of 14 questions.1115 participates completed the online survey.

statistical analysis
All statistical analyses were set at a significant level of when P-value less than 0.05 (P<0.05) using statistical program (SPSS) version 22.0 software (SPSS Inc., Chicago, IL, USA).The frequencies and percentages for all nominal variables were calculated.Chi-square and Fisher's exact tests were used to compare the demographic characteristics with different questions of the questionnaire.

resuLts demographic data
The total number of the current study respondents was 1093 and a vast majority of them were females (70.9%), aged <45 years old (almost 80%), married (62.8%) and highly educated (65%).More than half of the respondents (52.2%) are unemployed, 35.7% are the employee and working outside the health field, and 4.8% are the employee and working within the health field.Among those who are working within the health field, 18.9% is the dentist.Social media was the highest scored source of information by 39% for the current study participants followed by Self-Culture (Reading medical books and magazines) by 34.5%, friends, and family by 19%, while hospitals and doctors were the lowest scored source by only 7.5% of the study participants(table 1).awareness of Probiotics When respondents were asked if they have ever heard of beneficial bacteria, the results showed that most of the participants answered "yes".The analysis was done according to the respondent's socio-demographic characteristics and it was found that a statistically significant (P<0.01)higher percentage of females (87.1%) compared to males (79.9%) have ever heard about beneficial bacteria.The highest percentages of participants who heard about beneficial bacteria were those who are in the age group 36-45 years old at 87.3%, highly educated at 87.5%, postgraduates at 89.2%, married at 88.9%, and those who are working in the health field at 94.4%.There was a statistically significant difference between the different age groups, different educational level groups, marital status and job title groups in regards to if they hear or did not hear about beneficial bacteria since all P-values were < 0.05(table 2

). attitude towards effects of oral Probiotics
Most of the participants have a positive attitude towards the point that beneficial bacteria have a positive and beneficial effect on oral and dental health.It was positively scored by 78% of females and 65.2% of males with a highly statistically significant difference between the two genders (P<0.01).The positive score was higher among those aged 35-46 years old with a statistically significant difference between the different age groups (P<0.05).76.6% of highly educated have the positive attitude towards that point compared to 71.9% of the low educated participants, however, such difference was statistically non-significant (P0.10).Similarly, there were no statistically significant differences between the different educational level, marital status and job title groups in terms of their attitude towards that point, giving that the highest positive attitude was from young adult participants, and employee working in the health field at 85.7% and 80.8%; respectively(table 3).
Most of the participants have a negative attitude towards the question" Do you think beneficial bacteria have a negative or harmful effect on oral and dental health?"The negative attitude was non-statistically significant (P 0.41) lower in males compared to females at 74.5% and 77.1%, respectively.Participants aged>46 years old showed the highest negative attitude at 83.3%, with a statistically significant difference between the different age groups (P <0.01).There were no statistically significant differences between the different educational level, marital status, and job title groups in terms of their attitude towards that point.The negative attitude was higher among intermediate school, those who are not working in the health field and married participants at 87.5%, 79.3%, and 77.9%, respectively (table4).
As shown in (table 5), the question "What do you think is the negative effect of beneficial bacteria on oral health and general health?" was correctly answered (Cause imbalance in the balance of oral bacteria) by 62.3% and 58.7% of males and females respectively, with no significant difference.Additionally, the highest percentage of correct answers to it was seen from participants ages 36-45, high educational level, single and participants who are working in the health field.However, there were no statistically significant differences between the different groups of age group, educational level, marital status and job title (all P-value > 0.05).
The highest proportion of participants knows the beneficial effect of beneficial bacteria on oral and dental health (prevent or reduce dental carries), such knowledge was higher As shown in (table 7), the vast majority of the participants (87.5% of males and 91.6% of females) have the correct knowledge about the benefits of beneficial bacteria (good for immunity).Results showed no statistically significant differences between the groups of any of the studied socio-demographic characteristics, as all P values were >0.05.
Most of the participants (77.6% of males and 86.6% of females) heard the correct information that beneficial bacteria are found in yogurt.Such knowledge was higher in females, eldest, highly educated, married and those who are not working in the health field.The differences in-between the knowledge of genders, age groups, educational level, marital status and job title groups were statistically significant(table 8).

discussion
There has been a spiraling interest in utilizing natural remedies to treat or avert human ailments.In the developed world the growth of probiotic products has been rapidly increased. 7ur study revealed that the general population in Saudi Arabia seems to have good awareness and knowledge of probiotics.In accordance with the study of Reshma Thirunavakarasu et al, 8 the respondents of the current study showed that there is a high level of knowledge and awareness on the importance of probiotics towards one's health, and most of the respondents were females.This might be justified by females' better compliance and fulfillment to fill the online survey since they are highly active in the social media.We also noticed that in the current study, females had greater knowledge and awareness level than males.It was in concordance with the study by Al-Nabulsi et al, where 75.7% of female students correctly identified probiotics. 9The behaviors of men and women are considerably dissimilar, predominantly toward healthy foods.Men exhibit reduced eagerness to comply with dietary guidelines than women.One probable justification for this might be that since women are more knowledgeable about food and nutrition than men, they are more engrossed and interested in their physical appearance and health. 9But in contrastto Payahoo et al study, 10 reported female students had the lower level of knowledge than male students.Another study by Babajimopoulos et al supported Payahoo et al study in which 29% of men were more familiar than women (18%) with the term probiotics among urban consumers in Greece. 9dditionally, a higher knowledge level was shown in the current study compared to a previous study conducted on medical science students where they had a satisfactory level of knowledge about probiotics and their health effects this was anticipated due to the quality of education and training that the health science students usually receive.In this study, respondents had only elementary education and those in health care professions showed the highest positive attitude at 85.7% and 80.8% respectively.The high percentage of those with elementary education could be attributed to the wide exposure to different general topics in life.One more survey done on general dental practitioners revealed that around 22% of the respondents were not aware of the constituents of probiotics, and 19% of them were above 55 years of age, which implicit that the information of probiotics was highest in younger age groups. 11t was in accordance with another study by Betz et al, who found that younger patients (<45 years of age) (P = 0.011), and who had higher education level (P = 0.001) were more likely to be familiar with the probiotic perception than older patients, or with less education. 12But in disparity to this, the study conducted in Jordan exposed that college students had deprived knowledge of probiotics.Merely 11.7% of students had a little level of knowledge about probiotics and 7.0% were capable to recognize probiotics. 9Also, another study revealed insufficient knowledge and awareness regarding probiotics among the chemists. 13oreover, a higher percentage of respondents reported that they heard and aware of the term probiotics compared to a Nigerian study published in 2015, 3 putting in consideration that the Nigerian one was conducted on healthcare professionals.The current study showed that a maximum number of participants were aware of the beneficial role of probiotics in decreasing dental caries and improving the immunity.This is in contrast to what have been previously reported in the study conducted in Brazil, 14 in which only 7.86% of participants have chosen "reduction of caries" when asked the benefits arising from the ingestion of probiotic foods compared to 87.5% of males and 91.6% of females in our study who did so.This reflects the high knowledge and awareness level of the Saudi population about the benefits of probiotics in prevention of caries, putting in consideration that the current study was conducted among the general population not only dental ones.Additionally, when this question was asked to dental students in a similar study, results showed that 80.5% of participants were unaware of the role of probiotics in the prevention of any disease in the oral cavity. 8he current study clearly revealed that the participants had a basic knowledge of probiotics.Such results might be due to the fact that there is a correlation between having heard of probiotics and knowing about probiotics since the majority of the participants heard about probiotics and correctly answering it as "found in yogurt".It was in line with Reshma et al, where 44.5% of the participants have selected yogurt as the source.On the other hand, 32.5% have selected both milk and yogurts as the source of probiotics. 8Yogurt was scored as the preferred source of probiotics by almost half of Nigerian clinicians. 7A similar study exhibited results in which 38.2% have selected yogurt as the source, however, 54.6% of the respondents were unaware of the source. 15 the study of Stanczak and Heuberger published in 2009, 15 when participants were asked about the reason for consuming probiotics they have chosen the option 'increase immune function', and this is in line with the current study since vast majority have chosen the same option when asked about the benefits of probiotics.But it is in contrast with the study by Reshma et al when asked concerning the motive for consuming probiotics 83.5% of the respondents have selected the option to improve the gastrointestinal condition. 8A 2007 consumer attitudes survey revealed that 37% of respondents were consuming probiotics for immune health and 41% for digestive health and 11% for immunity. 16and 41% for digestion in the study by Betz et al. 12 Some of the respondents had some concerns in regards to the use of probiotics and they think that probiotics have a negative or harmful effect on oral and dental health, mainly imbalance in oral bacteria.In the Nigerian study, 3 healthcare professionals also raised many concerns regarding the use of probiotics including the possibility of the products being unsafe as they may lead to patients' infection.There are some studies suggest that such reported cases of fungemia and bacterial sepsis due to the use of probiotics may have been observed in compromised immune system patients or those with chronic diseases. 3But in contrast to this in a study by Betz et al, revealed that patients did not consider that probiotics were harmful, as declared by 90% of patients replied with 'not at all' or 'a little' to the statement 'probiotics are harmful'. 12To support this, another study exhibited 96.3% of the consumers found probiotic consumption as safe as they didn't found any side effects after consuming probiotics. 17he participants showed a reasonably high educational level and the replies were observed to be almost independent of this requisite, a finding which is similar to what has been previously reported in the literature. 3Similarly, is working in the health field wasn't necessary for good knowledge and attitude towards probiotics, since the current results showed no significant difference between those who are working and those who are not working in the health field in most of the assessed items.The limitation of the current study was a poor response of males when compared to females.This could be due to un-cooperation of males to fill the online survey which could have been different if the hard copy of the survey was distributed.

concLusion
The results obtained from this crosssectional survey study among the general Saudi population and health care professionals showed that they have good knowledge, awareness, and attitude towards probiotics and its significance in dentistry.Despite a plethora of information accessible on probiotics, few respondents did not hear about probiotics, unaware of its benefits and don't know its source.This signifies the enormity of the gap that subsists in the propagation of scientific information to the general community in Saudi Arabia.This also indicates that still there is a need for further education and promotion of the general public in regards to the definition, oral benefits, sources and usage of probiotics.A further clinical investigation should be carried on to confirm the beneficial influence of the oral probiotics on dental and oral health.

table 1 .
Demographic data of the study participants

table 3 .
Positive attitude towards the effects of oral probiotics among participants

table 4 .
Negative attitude towards the effects of oral probiotics among participants

table 5 .
Study participants' background of probiotics negative effect

table 6 .
Study participants' background of probiotics beneficial effect

table 7 .
Study participants' knowledge of probiotics benefits

table 8 .
Study participants' knowledge of probiotics