Knowledge, Attitude and Practice of Skin Whitening Products, Among Sudanese Undergraduate Females, 2021.

Objectives: The knowledge, attitude and practice of skin-whitening products among female undergraduates in the medical campus, University of Khartoum. Methods: A cross-sectional study was conducted at the medical campus of University of Khartoum. All consenting female undergraduates were included in the study population. 417 women were chosen through proportional stratied random sampling, and were asked to complete a questionnaire.365 completed the questionnaire with a response rate of 87%. Result: 365 women completed the questionnaire, of whom 52% had average knowledge, 32% had poor knowledge and 16% had excellent knowledge,.32% had a positive attitude, and 38% reported using skin-whitening products. Knowledge, attitude and practice were associated with several factors. Conclusion : Although The overall knowledge about skin-whitening products is average. The knowledge about skin-whitening agents is rather poor. The majority of Sudanese University students have a negative attitude towards skin-whitening, but still the use of skin-whiteners is common amongst them .. Women who feel pressured by society to whiten their skin, are more likely to use skin-whiteners, as well as those who have a family history of skin-whitening. Media and social media play an important role in this matter, being the most important source of information and the most common factor pressuring women to lighten their skin as well. We recommend media and social to be used to promote the acceptance of dark skin and raise awareness about the safe practice of skin whitening. We also recommend that the Ministry of Health and Standards and Metrology Authority mandate the labeling of all products sold in Sudan detailing ingredients and concentrations of ingredients.


Background
Skin whitening, or skin bleaching, is a cosmetic procedure that aims to lighten dark areas of skin or achieve a generally paler skin tone. Skin-lightening procedures work by reducing the concentration or production of melanin within the skin. (1) Melanin is a natural skin pigment. Hair, skin, and eye color mostly depends on the sort and amount of melanin. Special skin cells called melanocytes make melanin. (1) Everyone has an equivalent number of melanocytes, but some people make more melanin than others, all which depends on the genetic composition (2) Examples of skin whitening agents are: Hydroquinone and derivatives thereof, ascorbic acid , kojic acid (3) topical steroids, mercury and clobetasol propionate, which belongs to the class of corticosteroids (4) . All which interfere with the production of melanin.
Skin whitening, is currently a widespread global phenomenon, it is estimated that 15% of the world population invest in skin whitening agents. (4) . The users of skin whitening products usually are of the younger population for example 72 percent of the women who practice skin whitening in Lahore, India fall between (20-30) years (5) The history of skin bleaching is often traced to the Elizabethan age of powder and paint, nowadays skin bleaching is practiced disproportionately within communities "of color." Especially among people of African descent. (6) The majority of scholars who studied skin bleaching acknowledge the institutions of colonialism and enslavement historically, and global White supremacy modernly, as important causes of the practice for skin bleaching. (6) Among communities of color skin bleaching represents an attempt to approximate the White ideal which is:-pale skin, long, straight hair, and aquiline features. And consequently gain access to both the humanity and social status historically reserved for Whites. (6) In Africa skin bleaching became popular as a cosmetic practice as early as the late 1950s. Coinciding with the rst wave of the African independence movements. (6) Skin-whitening is highly prevalent in university female students of Sudan, a study conducted recently in University of Algezira stated that (74.4%) of them practiced skin-whitening. (7) Skin-whitening products have several side effects both dermatological and systemic including cutaneous malignancies. (8) The complications of skin-whitening can be so severe, to the extent of hospitalization. Not to mention the nancial and medical resources that are lost to treat these complications.
A serious problem arising globally is the illegal trade of products with concentrations higher than recommended. In Sudan most of the creams analyzed for hydroquinone had concentrations of 5.7%. While the US Food and Drug Administration's acceptable limit is 2.0%. (9) The ndings of this research will help in identifying gaps in knowledge and practice and hence inform policy makers to make effective interventions regarding health promotion and drugs regulations. In order to increase safety and reduce complications. Also exploring the motives behind usage will help in properly addressing them. Furthermore compared to the wide use of whitening products in Sudan researches regarding this matter is rather lacking.

Methods
An Institutional based descriptive cross-sectional study was conducted in The Medical campus of Khartoum University, which is located in the center of Khartoum State, Sudan. It is adjacent to Al-Arabi Market and surrounded by several pharmacies, which makes the accessibility to skin-whitening products easy. Data was collected by the investigator using an online self-administered modi ed pre-tested standardized questionnaire from Ahmed A, Hamid et al (7) On Google form format, which was distributed through Whatsapp and telegram applications. Data was collected over a period of 1 month (18 th of December 2020 to 15 th of January 2021).No information leading to identi cation of a speci c subject was taken. The questionnaire focused on socio-demographic characteristics (Faculty attended, Academic year, Marital status, tribe, monthly income, Residency), skin characteristics (Type and color), Questions regarding knowledge, attitude and practice of skin-whitening and factors related to the use of skin-whitening products.
Data Analysis: Data was analyzed by SPSS Version 26. Descriptive analysis was used to summarize data in the form of counts and percentages, and then shown in a form of tables and graphs. There was no missing data. The knowledge score was grouped into poor, average and excellent. The total score was 9. 0-3 was categorized as poor knowledge, 4-6 was categorized as average knowledge and7-9 was categorized as excellent knowledge. Attitude was categorized into positive and negative as follows: More than or equal 12.5= positive attitude, Less than 12.5 = negative attitude.
Multivariate logistic regression was used to identify predictors of knowledge, attitude and practice) with a 95% con dence intervals.

Results
In this study data was collected from a total of 417, the response rate was 87%. 365 answered questions about knowledge and attitude. 140 participants used skin-whiteners therefor answered questions inquiring about habits of practice.
Socio-demographics of the study participants: More than half of the participants attended The Faculty of medicine and the rest were almost equally divided between Faculties of pharmacy and dentistry. The majority of them lived with their families and 91.2% were single. Above half of them reported that they have a light skin tone, the rest described their color as dark and the most common skin type was combination skin type. (Table 1 below) Knowledge about skin-whitening products amongst Female Undergraduates: The majority of the participants had overall average knowledge (52%) and (32%) had poor knowledge. The majority of participants had poor knowledge about skin whitening agents (81.1%) and (88%) of the participants knew that skinwhitening products can cause complications, only (60.5%) had good knowledge about the nature of these complications ( Table 2 above) The most important source of information about the side-effects was media/social media (77.2%) followed by witnessing them on others (34.9%). Only (27.5%) stated that the faculty's curriculum was a source of knowledge.
Attitude towards Skin-Whitening Products amongst Female Undergraduates: The majority of the participants had a negative attitude towards skin whitening (68%). (21.9%) believed that skinwhitening increases the opportunity for marriage, (18.6%) of participants thought that skin-whitening helps in job attainment. Only( 27.7 %), (22.2%) believed that skin whitening increases social acceptance and attractiveness, respectively. (Figure 1) Skin-Whitening Practices among Female Undergraduates: (37.8%) of the participants practiced skin-whitening. Treatment of acne scars was the main reason of usage, (77.9%) followed by lightening the skin complexion (36.4%). (Table 3) Pharmacies were the main source of skin-whitening products among respondents (63.5%), followed by through a doctor's prescription (38.6 %) and Nearly a half used the products for 1 to 6 months. (Table 3 below) (32.6%) didn't know the names and concentrations of ingredients present in their products. (Nearly a half used the products for 1 to 6 months. (Table 3 below) The majority of the participants were satis ed by the results given by skin whitening products (79.3%). The most common form of products used were creams/lotions followed by soaps (97.1%),( 45.7%) respectively.     times likely to practice skin-whitening than normal and dry skin.(P=0.001)( Table 5 above) Societal pressure was associated with attitude and practice. Participants who felt pressured by society to whiten their skin were 3.6 times more likely to have a positive attitude (P<0.001)( Table 4 above) and are 2.7 times more likely to practice skin whitening compared to those who don't feel pressured.(P=0.007)( Table 6 above) Family history of skin-whitening was associated with practice. Participants with a family history of skin-whitening are 4.5 times more likely to whiten their skin compared to those who don't.(P<0.001) ( Table 6 above) Participants, who did not obtain products through doctor's prescription and pharmacies, were 3.6 and 3.2 times more likely to be ignorant towards the ingredients present in their skin-whitening products. Compared to those who obtained products through doctors prescriptions and pharmacies. (P =0.016,P=.019) . (Table 7 below) Participants who obtained products from their friends/family members are 11 times more likely to experience side-effects than those who obtained from other sources. (P=0.012) ( Table 8 below)

Discussion
Regarding the overall knowledge about skin whitening products was, 52% had average knowledge, 32% had poor knowledge and 16% had excellent knowledge. The majority of participants in this study had negative attitude towards skin-whitening. And 38% of the participants had practiced skin-whitening in a point of their lives.
Socio-demographic factors, skin-characteristics and societal factors were signi cantly associated with knowledge, attitude and practice of skin-whitening.
Most of the participants knew that skin-whitening products can cause adverse side-effects (88%). In alignment with study conducted in University of Al-gezira (7) in Sudan, and another one in Nigeria (10) . That indicates that people generally know that skin-whitening can cause adverse side-effects.
Regarding the source of knowledge about the health risks (77.2%) reported that media/social media was their source of information.
In alignment with what was found in University of Al-Gezira. (7) This highlights the role of social media in educating about skin-whitening.
Although all of the participants attended medical and health allied faculties only (27%) mentioned the faculty's curriculum as a source of knowledge which points out the poor role of universities in educating about this matter.
(81.8%) of the participants had poor knowledge regarding skin-whitening agents .Which is even a higher percentage than what was found in university students in Nigeria (56.1%). (10) This might be due to the fact that Nigeria is a leading country in manufacturing skin-whitening products, unlike Sudan, therefor knowledge about this matter is higher.
In this study only (32%) reported a favorable attitude, much lower than what was found in University of Al-gezira, 2015 where (87.9%) reported a favorable attitude . (7) This huge difference indicates that the Sudanese population has developed a less favorable attitude towards skin-whitening in the past 5 years or might be attributed to the different study areas.
(38%) of the participants used skin whitening products. Much lower than results found in the Locality of Omdurman (89.5%). (11) This might be due to the study area, Omdurman locality has one of the largest markets in Sudan ,which is rich with shops and boutiques that sell skin-whitening products.
In this study the majority obtained products from pharmacies, (63.6%), respectively. Similar to results found in high school students in Central Sudan (52.6%) obtained from pharmacies. (12) This highlights the important role of pharmacists in regulating the purchase and use of skin whitening products in Sudan.
It is worth noting that participants who didn't obtain products through doctor's prescription and pharmacies, were 3.6 and 3.2 times more likely to be ignorant towards the ingredients present in their skin-whitening products . Which shows that products obtained under doctors and pharmacists supervision are more likely to be labeled with ingredients, thus much safer.
Only (18.6%) experienced complications in this study. Which is much lower than what was found in Ibn-Sena University, where (86%) experienced complications (5) . This difference might be because the majority in this study practiced skinwhitening for a short duration. Nearly a half used for 1 to 6 months in this study.
It is worth mentioning that those who obtained products from friends/family members are 11 times more likely to experience side-effects than those who didn't. Those participants may have used products that aren't suitable for their skin condition/type.
The main reason for using skin-whitening products, was to treat acne scars (77.9%). Substantially higher than what was found in University of Al-Gezira where, only (26.9%),reported acne and acne scars to be reason of usage (7) . This is because; the majority of consumers in this study had combination skin followed by oily skin, which are both prone to acne.
(79.3%) of users in this study were satis ed by the e cacy of the products they've used. Similar to results found in Jordan and Omdurman locality in Sudan. Where (70.9%),(75%) were satis ed ,respectively. (13), (11) Which indicates that skin whitening products are indeed e cient in delivering the expected results.
Knowledge about skin-whitening products in this study was associated with, academic year, skin color and skin type. Females with light skin were 1.5 times more likely to have poor knowledge than those with lighter skin. Similar to University of Al-Gezira. (7) This indicates that dark skinned females are more interested in skin-whitening and therefor have more knowledge. Females with combination skin 5 times more likely to have excellent knowledge than dry and normal skin-types, which could be explained by that combination skin is more challenging due to it having oily areas and dry areas, so those who possess it are more educated about skin-products, in order to nd what suits them.
It is worth noting that those who had knowledge about the side-effects and those who didn't, had similar favorable attitudes (32.7% Vs. 24.4%) towards skin-whitening (7) Which indicates that the motives behind skin-whitening are rather strong and not moved by the fear from side-effects.
The use of skin-whiteners was associated with knowledge, skin-type, societal pressure and family history. Generally, Participants with excellent knowledge tended to practice skin-whitening the most compared to those with average and poor knowledge.(58.3% Vs. 39.9%, Vs. 25.6%) This indicates that participants who don't practice skinwhitening are not interested in the matter therefor have poor knowledge. Females with oily and combination skin were more likely to use skin-whiteners than females with normal and dry skin. This can be explained by the fact that combination and oily skin are more prone to acne therefor acne scars. Which is the main reason for usage in this study.
Societal pressure showed a great impact on the matter of skin-whitening. Where Females who felt pressured by society to whiten their skin were 3.6 times more likely to have a positive attitude and are 2.7 times more likely to practice skin whitening compared to those who don't feel pressured.
The major source of pressure was media/social media. Similar to what was found in High schools of Central Sudan, where the majority admitted the in uence of media in promoting skin whitening. (12).
Participants with a family history of skin-whitening are 4.5 times more likely to whiten their skin compared to those who don't. Which points out that family usage has a strong in uence on whether a person whitens their skin or not.
The study has some limitations, it was limited to female university students, which is not representative of all Sudanese women .It also didn't include males whom nowadays practice skin-whitening as well. Nonetheless this study gives a general picture about the knowledge attitude and practice of female university students, whom lie in the age group most likely to use skin-whiteners.

Declarations
Ethics approval and Consent to participate: Figure 1 Attitude of respondents towards skin whitening products among female undergraduates of the Medical Campus of University of Khartoum, 2020-2021.