Knowledge and awareness level of risk factors, symptoms, and complications about MASLD among the population in Al-Baha city, Saudi Arabia

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the most common liver diseases in the world, and it affects a significant percentage of the population globally 1. MASLD is characterized by increased amounts of fat accumulation in the liver cells 2. MASLD is considered to be distinct from alcoholic fatty liver disease in that there is no history of alcohol intake in MASLD 2. The main causes of MASLD are linked to metabolic syndrome, which is a cluster of disorders that include obesity, type 2 diabetes, insulin resistance, dyslipidemia, and hypertension 3,4. MASLD is a continuum of simple hepatic steatosis and non-alcoholic steatohepatitis (NASH) 1,3.

If not properly managed, steatohepatitis can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma, thus posing a significant threat to human health 1–4. MASLD is considered to be the most common chronic liver disease in the world and is responsible for causing disease in 30.05% of the population 5. MASLD is a significant problem in Saudi Arabia, especially due to a high prevalence of obesity and type 2 diabetes 5,6. Studies indicate that MASLD is present in 16.8% of the population in Saudi Arabia 5,6. Regions such as Al-Baha City and many other areas in Saudi Arabia are facing a problem of epidemiological transition, thus increasing the risk of MASLD in their population 6.

Previous studies have highlighted MASLD as a significant problem in Saudi Arabia and worldwide 6,7. Studies indicate a significant knowledge gap in MASLD in the general population despite a high prevalence of MASLD in Saudi Arabia 7. For instance, a study conducted in Riyadh City showed that a significant percentage of the population had a poor level of knowledge about MASLD 8.

Several studies have been carried out to evaluate the awareness and knowledge of MASLD, formerly known as NAFLD, at both the international and regional levels. A study carried out in South Korea to evaluate the awareness of NAFLD among the population found that 72.8% of the people were aware of the existence of NAFLD, and 85.7% of the people surveyed were aware that the disease could affect people who do not drink alcohol. However, only 42.9% of the people surveyed were aware of the progression of the disease, such as the risk of developing cirrhosis or hepatocellular carcinoma, while only 25.7% of the people surveyed were aware of the association of the disease with cardiovascular diseases 9. A study carried out in the USA found that only 4.4-6.3% of adults diagnosed with NAFLD were aware of their condition 3. A study carried out to evaluate the policies of NAFLD awareness in Europe found that 24% of the countries in Europe had publicly funded campaigns to improve awareness of the disease 10.

A study carried out at the regional level in Egypt to evaluate the awareness of people of the risk factors of NAFLD, such as hyperlipidemia and obesity, found moderate awareness of the risk factors of the disease, although there were misconceptions about the disease 4. A recent meta-analysis carried out to evaluate the prevalence of NAFLD in the Middle East and North Africa found that the prevalence of the disease in the general population of these countries was 39.4%, with the highest prevalence found in Kuwait, Egypt, and Saudi Arabia 11.

In Al-Baha, there is a notable lack of studies specifically focused on MASLD awareness and knowledge within this region. The rationale for conducting this research is based on the need to address these knowledge gaps and provide targeted insights into the awareness levels in Al- Baha, which have been underexplored in previous research. Therefore, the aim of the current study is to assess the knowledge and awareness levels regarding the risk factors, symptoms, and complications of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) among the residents of Al-Baha City.

Methodology

a cross-sectional approach was adopted to evaluate the level of knowledge and awareness regarding MASLD among the population of Al-Baha region, KSA. The participants were selected using the convenience sampling technique through an online questionnaire administered via social media sites during July-August, 2025.

For this purpose, using the Raosoft sample size calculator was used assuming a 50% prevalence of low-level knowledge. Assuming a 95% confidence interval (CI), and with a 5% margin of error, the minimum required sample size was 384 individuals to ensure that the sample would be representative of the population of Al-Baha City. A total of 444 responses were collected, exceeding the minimum required sample size, and all were included in the final analysis.

Individuals were chosen according to particular inclusion and exclusion criteria. Residents of Al-Baha area who were 18 years of age and older were included. Respondents aged less than 18 years old and those who were not residents of Al-Baha were not allowed to participate.

Developed from the body of existing literature 8 and translated into Arabic for the target audience, a structured questionnaire was used for data gathering. There were three primary sections to the survey. Demographic data—such as age, sex, nationality, job status, and educational attainment—was gathered in the first part. The second part looked at how much the subjects knew about MASLD, including whether they had a family history of liver disease. The third part gauged participants’ grasp of MASLD, covering risk factors, symptoms, and possible consequences.

A systematic scoring method was used to measure how well individuals knew about MASLD. Participants earned 2 points for each right answer, 0 points for each wrong answer, and 1 point for neutral responses. With higher values suggesting more knowledge, the overall knowledge score varied from 0 to 42 points.

In the awareness section, which had six statements, the maximum possible score was twelve. The awareness level scoring was broken down as follows: a score of 10–12 points denotes a high level of awareness, a middle level, low as 0–6 points, and high as 7–9 points. The highest possible score in the knowledge section (15 statements) was 30 points. Knowledge was classified as High (24–30 points), moderate (18–23 points), and low (0–17 points). Combining awareness and knowledge, the overall score ran from 0 to 42 points. A score between 34 and 42 points was considered as high-level knowledge; 25–33 points as medium-level knowledge; and 0–24 points as low-level knowledge.

Before the main data collection (July–August, 2025), a small group pilot tested the questionnaire to guarantee clarity and consistency. Cronbach's alpha coefficient was used to assess the internal consistency of the questionnaire items. The scale had an alpha of 0.620 which was acceptable given the exploratory nature of knowledge-based surveys since the predominance of "don't know" responses reflects a true lack of knowledge rather than measurement inconsistency.

The Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA) was used for all statistical analyses. Description of categorical variables was made using frequency and percent; the chi-squared test assessed the relationship between knowledge and demographic elements. Hypothesis testing was performed at 5% level of significance.

Participants were informed of the research objectives, assured of confidentiality, and provided with individual consent forms prior to participating. The study was approved by the Institutional Research Board at the College of Medicine, Al-Baha University, Saudi Arabia (IRB/COM/BU-FM/2024/168), and was conducted in accordance with the ethical principles of the 1975 Declaration of Helsinki.

Results

More than half of the participants were female (55.9%). The age group with the highest representation was 18-24 years (30.9%), followed by 35-44 years (24.5%). Most of the respondents completed a bachelor’s degree (68.2%), and approximately half were employees (42.1%). A small proportion of participants were either unemployed, self-employed, retired, or engaged in other occupations (Table 1).

Table 1

Regarding awareness, half of the respondents (50.9%) had never heard of the disease, and 38.1% mentioned hearing of the disease. More than half of the respondents (56.3%) knew that fatty liver disease with the involvement of the metabolism process was dangerous, and a similar number (51.6%) were unsure if the disease could be life-threatening. The majority (60.6%) of the participants knew the disease involved fat accumulation and inflammation in the liver. In terms of the participants' information on the disease, 16.7% obtained their information on the disease from social media while 15.8% mentioned family and friends. More than two-thirds (74.5%) of the participants had not been diagnosed with the disease themselves, and did not know anyone who had been diagnosed with the disease (Table 2).

Table 2

Knowledge assessment showed variable understanding of MAFLD (Figure 1, Table 3). Although 67.6% correctly identified that healthy eating can prevent MAFLD, substantial knowledge gaps were evident in other areas.

Figure 1

More than half of the participants (57.4%) were uncertain whether family history was required for disease development (Table 3). The distribution of correct, incorrect, and “I do not know” responses across yes/no questions is illustrated in Figure 1, demonstrating that uncertainty was the most common response pattern for several items.

Table 3

The majority of participants had a low level of awareness (44.6%) about metabolic fatty liver disease, with 32.0% having a moderate level and only 23.4% demonstrating a high level of awareness. In terms of knowledge, nearly half of the participants had a low level of knowledge (46.4%), while 46.6% had a moderate level, and just 7.0% had a high level of knowledge. When combining both awareness and knowledge scores, 49.8% of participants had a low level, 44.4% had a moderate level, and only 5.9% demonstrated a high level of awareness and knowledge combined (Figure 2).

Figure 2

There was a significant association between gender and knowledge levels, with more males (57.1%) having a low level of knowledge compared to females (44.0%), and a higher percentage of females (8.5%) achieving a high level of knowledge compared to males (2.6%) (P-value = 0.003).

Age (P = 0.189), nationality (P = 0.057), and educational level (P = 0.230) were not significantly associated with knowledge. With regard to occupation, The prevalence of low-level of knowledge was higher in individuals who owned businesses, while students and employees had higher prevalence of moderate-level of knowledge. However, this was not statistically significant (P = 0.066) (Table 4).

Table 4

Discussion

The results of the current study showed gaps regarding knowledge and awareness of MASLD among the population of the Al-Baha region in Saudi Arabia. Results showed that a significant percentage of participants lacked knowledge and understanding of MASLD.

A significant percentage of participants (50.9%) in the current study were unaware of MASLD, and 44.4% lacked knowledge of the disease and its relationship with inflammation and fat accumulation in the liver. This lack of knowledge is concerning due to the health risks associated with MASLD. It has been observed in previous studies that knowledge of NAFLD and its consequences is limited in different regions of the world, especially in regions where public health education is minimal 5,9,10. In a study conducted by Wieland et al., it has been observed that only 18% of participants in the study were aware of NAFLD and its consequences 12. In another study conducted by Zhang et al., it has been observed that 31.2% of office workers lacked knowledge of NAFLD 13.

A significant percentage of participants (56.3%) were aware of the health risks associated with MASLD, which aligns with the worldwide increased recognition of MASLD 14. Nonetheless, a significant percentage (51.6%) lacked knowledge of the life-threatening risks of MASLD, which might be attribured to misconceptions and lack of understanding regarding disease severity. Indeed, previous studies have showed that participants with limited knowledge of MASLD are less likely to take preventive health measures, which can adversely affect health outcomes in the region 15,16.

Knowledge regarding the causes and symptoms of MASLD also revelealed existing knowledge gaps. Although the majority of the respondents (60.4%) identified the main cause of MASLD as the accumulation of fat in the liver, a significant number of the respondents (37.2%) lacked knowledge about the association that exists between MASLD and diabetes. Various studies have proven the close association that exists between diabetes mellitus and the incidence of MASLD 17,18. In addition, the majority of the respondents (77.7%) lacked knowledge about the number of stages of MASLD which highlights the need for educational resources that are accessibale and reliable to increase awareness regarding disease progression.

Less than three-quarters of the respondents (68.7%) lacked knowledge about the management of MASLD. This indicates and existing knowledge gaps within the public domain about the management of MASLD and the available treatment modalities. Knowledge regarding the stages of MASLD is essential in order to seek timely care to prevent the progression towards advanced stages such as cirrhosis and liver failure 19,20 and the lack of awareness might lead to delay in diagnosis and seeking timely medical care.

Overall, the results from the current study showed that 44.6% and 46.4% had low awareness and knowledge regarding MASLS, respectively. These findings are inline with several studies which showed that significant knowledge gaps were present in various populations including mid-sized cities with limited specialized hepatology services despite the increased awareness of liver diseases^21–23 .

More than half of the participants lacked knowledge about MASLD risk factors. Only 26.1% identified obesity, 19.8% identified metabolic disorders, and 10.4% identified diabetes mellitus as a risk factor. This is consistent with Alsubaie et al., who assessed the level of awareness of NAFLD among adults in Riyadh, Saudi Arabia, and found that 60% of 400 participants were aware of NAFLD. The study also showed that awareness was significantly associated with gender, age, education, and occupation 8. In contrast, the current study found a low rate of awareness (38.1%), which might be related to the difference in the population of Riyadh, which is a large city, and Al-Baha, which is a mid-sized city.

With regard to demographic aspects, gender was a factor, showing that males tend to manifest a lack of knowledge more than females. A study showed that women are more proactive in seeking information regarding health issues than men, which might explain this trend based on differences in health-seeking behaviors or health-related media engagement 24,25. The other demographic aspects, namely age, nationality, and educational level, did not show any associations with knowledge level. This suggests that awareness campaigns regarding MASLD might need to be more comprehensive and multifaceted to cover a wider demographic spectrum..

The level of knowledge regarding MASLD, as found in the Al-Baha population, was similar to findings in various international settings, showing a lack of knowledge regarding the disease, as found in different parts of the world. Morrill et al. found that Mexican-origin women in the US lacked of knowledge regarding risk factors of NAFLD, showing a dominant misconception that liver disease occurs only as a result of alcohol consumption. 26. In a study carried out in Turkey, only 33.7% of high-risk patients visiting internal medicine clinics were found to have comprehensive knowledge of steatotic liver disease, with educational level being a predictor of knowledge 27. These findings emphasize the global nature of the problem of a lack of knowledge regarding MASLD, highlighting the need for educational campaigns regarding this disease in various populations, including those in the Al-Baha region.

Based on the findings of this study, public health authorities in the Al-Baha region should implement public awareness campaigns regarding MASLD, utilizing both social media and health centers as dissemination tools, with special emphasis on males, who showed significantly low levels of knowledge regarding MASLD. In addition, people at risk of various metabolic syndromes, including obesity, diabetes, and dyslipidemia should be screened for MASLD during routine primary health care. Health care provider should also receive education regarding MASLD and candidates for screening for efficient implementation. Furthermore, MASLD should be seen as a public health problem by the general health authorities, focusing on public education to clear misconceptions regarding MASLD. Future studies should be conducted on a larger scale, at different regions of the country, utilizing a probability sampling technique to measure the level of awareness regarding MASLD in the Saudi population.

This study has several limitations. First, the cross-sectional design limits causal inferences. Second, the convenience sampling method may introduce selection bias. Third, self-reported data may be subject to recall bias. Future longitudinal studies employing random sampling are needed to confirm these findings.

Conclusion

In conclusion, the results from the current study indicate an essential need for improved public awareness and education regarding MASLD, especially in regions like Al-Baha. Public health initiatives should address these gaps by raising knowledge regarding the health consequences of the MASLD and the role of lifestyle modifications in prevention. Future research should evaluate the role of tailored educational programs in reducing the burden of MASLD in the Saudi population and improving overall knowledge.

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