Knowledge, attitudes, and practices of self-ear cleaning among medical and non-medical students at King Khalid University, Abha, Saudi Arabia

Abstract

Knowledge, attitudes, and practices of self-ear cleaning among medical and non-medical students at King ABSTRACT Background: Earwax production provides a barrier against infections and affords a defense mechanism against insects and water. Many people do not have sufficient knowledge about complications of unprofessional self-ear cleaning. This study assessed the knowledge, attitudes, and practices of self-ear cleaning among students of King Khalid University, Kingdom of Saudi Arabia.

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© IJMDC. https://www.ijmdc.com
International Journal of Medicine in Developing Countries
Knowledge, attitudes, and practices of
self-ear cleaning among medical and non-
medical students at King Khalid University,
Abha, Saudi Arabia
Abdulaziz Ahmed A. Alshehri1*, Khalid Ayed Asiri1, Moshabab Saeed
D. Alahmari1, Haifa Hisham A. Alwabel1, Yahya Dhafer Alahmari2,
Syed Esam Mahmood3
ABSTRACT
Background: Earwax production provides a barrier against infections and affords a defense mechanism against
insects and water. Many people do not have sufficient knowledge about complications of unprofessional self-
ear cleaning. This study assessed the knowledge, attitudes, and practices of self-ear cleaning among students
of King Khalid University, Kingdom of Saudi Arabia.
Methodology: This cross-sectional study was conducted among randomly selected medical and non-medical
students of King Khalid University, Abha, Saudi Arabia. A structured questionnaire was used to study the demo-
graphic characteristics, knowledge, attitudes, and practices regarding self-ear cleaning.
Results: Out of 394 respondents, the majority (57.9%) were medical students. The mean age was 22 ± 2.8
years with a male:female ratio of 1:1. A higher proportion (55.1%) thought that ear self-cleaning is beneficial
and about three-quarters of them practiced it before. Hygiene was the most common reason for practicing
ear self- cleaning (45%). About two-thirds cleaned both outside and inside of their ears. Nearly half practicing
ear self-cleaning did it for more than 5 years and nearly three quarters did it occasionally. Cotton bud was the
most common tool used (77.7%). The majority (75.6%) did not report any complications related to their habits.
About 56% had moderate knowledge, whereas 12% had poor knowledge about ear self-cleaning. Medical stu-
dents showed higher knowledge and lower ear self-cleaning practices as compared to the non-medical ones.
Conclusion: The relevant courses and awareness programs about ear self-cleaning practices aiming to reduce
their numbers and complications should be adopted. Further studies to assess the knowledge about ear
self-cleaning practices should be conducted.
Keywords: Ear cleaning, self, knowledge, practices, and students.
Introduction
Cerumen (earwax) production occurs regularly and
naturally in the ears of humans and many other mammals
[1, 2]. It provides a natural barrier against infection and
defense mechanism of the ear against water and insects
[3]. It cleans and acts as a lubricant of the ear’s skin and
the inner canal of the ear [4]. Cerumen is a mixture of
immunity particles that provide the ear with bactericidal
power, helping in maintaining the ear clean and lower
incidence of infections [5]. It has an acidic pH that
also provides extra protection being not favorable for
microorganisms [6]. Cleaning of the ear canal occurs
as the result of the “conveyor belt” process of epithelial
migration aided by jaw movement [7]. In some cases,
this mechanism of self-removing excess earwax fails to
cause cerumen obstruction, which makes earwax external
Correspondence to: Abdulaziz Ahmed A. Alshehri
*College of Medicine, King Khalid University, Abha,
Saudi Arabia.
Email: abdulazizalshehri.com@gmail.com
Full list of author informaon is available at the end of
the arcle.
Received: 19 April 2020 | Accepted: 30 April 2020
Abdulaziz Ahmed A. Alshehri et al, 2020;4(5):001–008.
https://doi.org/10.24911/IJMDC.51-1584110722
ORIGINAL ARTICLE
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cleaning necessary [8]. Cerumen obstruction is also called
cerumen impaction which causes blocking of ear canal
leading to ear discomfort, itching, and hearing loss [9].
Cerumen prevents the physician from good evaluation of
the inner ear and audiovestibular system, and this is this
reason that the physician may need to clean up earwax
[10,11]. Many people have the habit of inserting different
objects into the ear to remove earwax; this is called self-
ear cleaning. They assume that it is good for ear hygiene
and important to remove excess earwax [12,13] besides
thinking that cerumen is an infection indication or its
impaction causing nuisance and pain for them [14,15].
Unprofessional practice to remove earwax using tools
such as cotton buds or matchsticks may lead to different
complications such as otitis cerumen impaction, injuries
[16–18], or otitis externa having a high risk for hearing
loss. We can prevent or reduce injuries and symptoms
related to ear self-cleaning by educating the public about
the danger of ear self-cleaning [12]. Therefore, this study
was undertaken to assess the knowledge, attitudes, and
practices of self-ear cleaning among medical and non-
medical students of King Khalid University and to find
out any differences between medical and non-medical
students about their knowledge status.
Subjects and Methods
This descriptive cross-sectional study was conducted
at King Khalid University, a public university in Abha,
Saudi Arabia, among both medical and non-medical
students. A pre-designed questionnaire was used to
assess knowledge, attitudes, and practices of ear self-
cleaning among the students. The questionnaire had two
sections: the first section included personal information
such as age, gender, name of the college, and academic
year, followed by multiple questions to evaluate attitude
and practices of ear self-cleaning, and the second
section composed of closed-ended questions (yes and
no) measuring the knowledge about ear self-cleaning
with I do not know the option to reduce the random
selection. The major outcome variable was self-ear
cleaning. The independent variables included socio-
demographic variables, perception of benefit of self-ear
cleaning, reason(s) for practicing or not practicing self-
ear cleaning, and the tool(s) used for self-ear cleaning. A
stratified random sampling technique was used to collect
the data to ensure that the questionnaire was distributed
to the maximum level evenly between the students of
medical and non-medical colleges. The inclusion criteria
included being medical or non-medical students at the
University of King Khalid aged from 17 to 45 years
old and agreeing to participate in the questionnaire.
Teachers, other employees, and students older than
45 years were excluded from the study. The sample
size of this study was calculated to be 386, distributed
evenly between medical students (193) and non-medical
students (193). The results were evaluated statistically by
computing the proportions of their yes and no answers.
The collected data were tabularized, systematized, and
transferred to the Statistical Package for the Social
Sciences software (V. 20.0). The Chi-square analysis to
detect the participants’ knowledge, attitude, and practice
level between the two studied groups was applied. The
study was conducted after obtaining permission from
the Institutional Research and Ethics Committee of
King Khalid University. Furthermore, each participant
was informed about the aim of the study and explained
the role of the participant before obtaining the desired
information. Confidentiality was maintained, and all
collected information was used only for this study.
Results
This study was carried out among a randomly selected
sample of 394 respondents with a mean age of 22 ±
2.8 years. The male:female ratio was almost 1:1 with
males representing 49% of the sample, whereas females
represent 51% (Table 1). The population of the sample
Figure 1. Beliefs about ear self-cleaning.
Table 1. Personal data of the students.
Mean age 22.09 ± 2.894
First year 43 10.9%
Second year 64 16.2%
Third year 100 25.4%
Fourth year 65 16.5%
Fifth year 41 10.4%
Sixth year 81 20.6%
Male 193 49%
Female 201 51%
Self-ear cleaning practice Yes No
Cleaning 74% 26%
Total 394 100%
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is divided between medical college students, such as
Pharmacy and Human Medicine (57.9%), and non-
medical college students, such as Engineering and
Sciences (42.1%). Moreover, most of the students in this
sample were studying in the third year (25.4%), followed
by students studying in the sixth year (20.6%), fourth year
(16.5%), second year (16.2%), and first year (10.9%), and
the rest of them were studying in the fifth year (10.4%)
(Table 1). The majority of students (55.1%) thought that
ear self-cleaning is beneficial, whereas, on the other
hand, 7.1% of students thought that ear self-cleaning is
non-beneficial, and 11.7% of them thought that it rather
a harmful process. Furthermore, 26.1% of students were
not sure about its beneficial role (Figure 2). The majority
(74%) of them had practiced ear self-cleaning before. In
Table 2, a higher proportion of those who considered
ear self-cleaning to be harmful were males (76.10%),
whereas nearly one-third of those who thought it to be
non-beneficial were females (Figure 1). About 73.80%
of the males did not usually practice ear self-cleaning
practice, whereas 26.20% of females did not practice it.
In general, gender had no significant role in participants’
opinions about the beneficial or non-beneficial use of
self-ear cleaning. Furthermore, 47.5% of the non-medical
students thought that it was beneficial, whereas 80.40%
of medical students considered it to be harmful. Nearly
51.20% of medical college students usually practiced ear
self-cleaning, whereas 48.80% of non-medical college
students usually did practice ear self-cleaning. According
to the academic year, it was found that 8.30% of first-
year students thought that it was beneficial and 10%
of them usually practiced ear self-cleaning. Moreover,
18.90% of second-year students thought that it was
beneficial and 17.50% of them usually practice ear self-
cleaning. Nearly 24% of third-year students thought that
it was beneficial and 27.20% of them usually practiced
Figure 2. Reasons for non-self-ear cleaning.
Table 2. Relation between demographic factors and students' opinions about ear self-cleaning practices.
p-value
Usual practice for
self-ear cleaning p-value
Ear self-cleaning
Variables
No Yes Harmful Not sure Beneficial Non-Bene-
ficial
<0.001 73.10% 40.90% <0.001* 76.10% 62.10% 35.90% 64.30% Male Gender
26.20% 59.10% 23.90% 37.90% 64.10% 35.70% Female
<0.001
76.70% 51.20%
0.180
80.40% 53.40% 52.50% 78.60% Medical
College College
23.30% 48.80% 19.60% 46.60% 47.50% 21.40% Non-Medical
College
0.040*
13.60% 10.0%
0.021*
8.70% 19.40% 8.30% 3.60% First
Academic
years:
12.60% 17.50% 8.70% 17.50% 18.90% 3.60% Second
22.30% 26.50% 23.90% 27.20% 24.00% 32.10% Third
10.70% 18.60% 4.30% 12.60% 20.70% 17.90% Fourth
10.70% 10.30% 10.90% 7.80% 11.10% 14.30% Fifth
30.10% 17.20% 43.50% 15.50% 17.10% 28.60% Sixth
*Significant p value: <0.05.
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ear self-cleaning. About 20.7% of fourth-year students
thought that it was beneficial and 18.60% of them usually
practiced ear self-cleaning. Moreover, 11% of fifth-year
students thought that it was beneficial and 10.30% of
them usually practiced ear self-cleaning. About 17.10%
of sixth-year students thought that it was beneficial and
17.20% of them usually practiced ear self-cleaning.
Academic year had no significant effect on participants’
opinions about the beneficial or non-beneficial role of
self-ear cleaning (Table 2). For students who said that
they did not practice ear self-cleaning, we tried to figure
out the reasons. Figure 3 shows that most of the students
did not practice ear self-cleaning because they were afraid
of wax impaction (54%), whereas other reasons were the
presence of the foreign body (7.9%) and infection (5%).
Nearly 33% of students did practice it because of other
different reasons. Hygiene was the most popular reason
stated for practicing ear self-cleaning (45%). Other
reasons included the desire of removing ear wax (23%),
removal of dirt (16%), feeling of itchiness (14%), and
prevention of ear infection (0.7%).
Almost two-thirds of students, who practiced ear self-
cleaning, cleaned both outside and inside of the ear, and
19.9% only cleaned the outside of the ear, whereas the rest
cleaned only the inside of the ear. Furthermore, 50.5% of
these students practiced ear self-cleaning for more than
5 years, and almost one-fifth of them practiced it at least
once daily. Cotton bud was the most common tool used by
students for self-ear cleaning (77.7%), whereas 4.8% of
them used key, 2.1% matchstick, 11% feather, and 4.4%
used other objects. Most of the students who practiced
ear self-cleaning did not show to have any complications
due to their practice (75.60%). However, 17.2% of
them complained of pain (17.2%), bleeding (1.7%), and
inflammation of the ear (3.8%) (Table 3). Nearly 56%
of students had moderate knowledge, whereas 32% had
high knowledge and 12% had poor knowledge of self-
ear cleaning (Figure 3). In Table 4, the results show
that 56.20% of students with slight knowledge were
males, whereas 48.20% of female students had moderate
knowledge and 57.30% of females had higher knowledge.
In general, gender had no significant effect on participates'
knowledge about ear self-cleaning (Figure 4). Nearly,
72.60% of students with high knowledge were from
medical colleges. The majority (33.30%) of students with
low knowledge were of the third year, whereas 20.8% of
students with low knowledge were from the second and
fourth year each, respectively, followed by students of
the first year (12.5%), sixth year (8.30%), and fifth year
(4.20%). In the high knowledge group, the students of the
sixth year represented the highest proportion (33.90%),
followed by students of the third year (25%), fifth year
(14.5%), second year (11.30%), and first year (6.5%).
Discussion
The ear as an organ is responsible for the function of
hearing and balance mechanism with a lubricating and
immune system that represents in earwax. However,
many people tend to self-clean ear wax in the home
for many reasons which may lead to further problems.
In the present study, we assessed knowledge, attitude,
and practice of self-ear cleaning among medical and
non-medical students. The overall prevalence of earwax
self-cleaning was 75% in this study. This prevalence
seems to be lower than the study of Olaosun et al. who,
in their study among Nigerian youths, found that 93.4%
of the respondents practiced self-ear cleaning [12]. The
higher prevalence was also reported by Afolabi et al. [14]
in Kaduna (90%), Amutta et al. [17] in Sokoto (80%),
Olajide et al. [18] in Niger state (92.8%), and Lee et
al. [19] in Malaysia (92%). On the other hand, the lower
prevalence (53%) was reported by Hobson and Lavy
in London in their hospital-based study (20) and also
by Macknin et al. [21] who found a prevalence of 62%
in a pediatric clinic in Cleveland, Ohio, United States.
Considering that hospital-based prevalence figures
have external validity issues because they are prone to
systematic error from selection bias and may not be a
Figure 3. Reasons for self-ear cleaning.
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true estimate of the community prevalence, this study
presents stronger evidence of a high prevalence of self-
ear cleaning in the community. The majority (75%) of
the participants practiced self-ear cleaning, of whom
55.1% perceived this to be beneficial in this study.
Some participants believed that self-ear cleaning is
non-beneficial and may even be harmful (18.8%). This
percentage is very low as compared with the previous
studies which showed an increase in the percentage
between 55.1% and 74.2% [9,22,23]. Hygiene is the
most common reason why people tend to clean their
ear (45%) in this study which resembles the result of
Table 4. Relationship between demographic factors and the level of knowledge of students (N = 394).
Variables Knowledge level p-value
Slightly Knowledgeable Moderately Knowledgeable Highly Knowledgeable
Gender Male 56.20% 51.80% 42.70% 0.064
Female 43.80% 48.20% 57.30%
College
Medical college 50.00% 51.40% 72.60%
0.000*
Non-Medical
College 50.00% 48.60% 27.40%
Academic
year
First year 12.50% 13.10% 6.50%
0.000*
Second year 20.80% 18.00% 11.30%
Third year 33.30% 23.90% 25.00%
Fourth year 20.80% 19.80% 8.90%
Fifth year 4.20% 9.50% 14.50%
Sixth year 8.30% 15.80% 33.90%
*Significant at p-value ≤ 0.05.
Table 3. Practices of ear self-cleaning.
(N = 292) Number of respondents with
yes responses Percentage
Practice ear self-cleaning
Clean the outside of the ear only 58 19.90%
Clean inside of the ear only 30 10.30%
Clean both outside and inside of the ear 203 69.80%
Duration of use of cotton bud
(years)
Less than 5 years 144 49.50%
More than 5 years 147 50.50%
Frequency of using cotton bud for
ear cleansing
Occasionally 214 73.50%
Once daily 59 20.30%
Twice daily 13 4.50%
At least thrice daily 5 1.70%
Which ear frequently cleaned
Clean both the ears equally 246 84.50%
Clean the right ear more 27 9.30%
Clean the left ear more 18 6.20%
Tools used for self-ear cleaning
Cotton bud 226 77.70%
Key 14 4.80%
Matchstick 6 2.10%
Feather 32 11.00%
Other objects 13 4.40%
Which complication do you have
due to ear self-cleaning
Otitis external 11 3.80%
Pain 50 17.20%
Bleeding 5 1.70%
Other 5 1.70%
No complication 220 75.60%
Total 291 100.00%
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another study [9]. However, other studies indicated that
itching and removing dirt and wax from the common ear
canal were the most reasons [17]. Cotton bud was the
most common tool used by students for self-ear cleaning
(78%), mostly practicing it occasionally and cleaning
both ears equally form inside and outside. This finding is
similar to the observations of researchers in the previous
studies [17,20,21,24]. However, a complication of ear
self-cleaning was not found in most of the cases, and
almost one-quarter of our respondents complained of
pain, inflammation, and even bleeding.
Regarding the knowledge of students, we found that
only one-third of students had a complete or high level
of knowledge about earwax and its cleaning, of whom
12% had poor knowledge which is lower than another
study conducted in Al Majmaah University, where 55.4%
of medical students had poor knowledge about ear self-
cleaning [22]. However, this low level of knowledge was
also seen in other studies showing many wrong beliefs
concerning cerumen and self-ear cleaning. Hobson et al.,
who conducted a survey on 325 individuals, observed that
the majority of them cleaned their ears with cotton buds
regularly and were ignorant about the injurious effects
[20]. Salahuddin et al. [25] had a similar observation,
whereby 93% of the hospital patients who practiced ear
self-cleaning were ignorant of its harmful effects.
In this study, gender does not affect either attitude or
knowledge of students about ear self-cleaning; however,
gender has a great effect on practicing ear self-cleaning
as females more frequently practiced it as compared
to males (F:M = 3:2). The other studies have alluded
to gender differences in the frequency of ear cleaning,
with more females cleaning more frequently than males
[26,27]. The association between the frequency of ear
cleaning and gender did not yield a statistically significant
relationship in this study versus the study of Oladeji et
al. [1], where it was found to be highly significant (p =
0.004). On the other hand, the previous studies revealed
more male preponderance over females [20–27]. Next, in
this study, we noticed that the type of college has a great
effect on the level of knowledge, attitude, and practice of
ear self-cleaning as the students of medical colleges were
more able to identify the practice as a harmful habit, were
less frequently practicing it, and had a higher level of
knowledge than other students of non-medical students.
Moreover, students of a higher level of education had
higher knowledge and were less practicing. This can
be explained as medical students are more aware of
medical facts on the importance of earwax and its
mechanism of working and its naturally self-removing
process. However, these results indicate the need for
more programs to increase the knowledge about earwax,
its nature, and the harmful effects of self-ear cleaning,
especially among the students of non-medical colleges.
These programs should also trigger other people in the
community other than university students including
people of all ages. This survey is not without limitations;
the major limitation was that it is a self-reported behavior
of current and previous practices (i.e., ear self-cleaning)
which can be easily influenced by social desirability and
recall bias. Besides, this study was conducted in a single
university; therefore, we cannot generalize these results
all over the country. However, more studies should be
conducted to assess the knowledge and practices of ear
self-cleaning in different places over the kingdom.
Conclusion
In this study, the level of knowledge among students
was low with a high prevalence of ear self-cleaning. The
students of medical college had more knowledge with
less practicing of this habit than students of other non-
medical students. Therefore, more courses and programs
should be implemented to increase their awareness
about ear self-cleaning aiming to reduce the number of
Figure 4. Knowledge level among respondents.
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Knowledge of self-ear cleaning among students
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practicing it, which, in turn, would help in reducing its
complications.
Conict of interest
The authors declare that there is no conict of interest
regarding the publicaon of this arcle.
Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.
Consent for publicaon
Informed consent was obtained from all the parcipants.
Ethical approval
The study was conducted in accordance with the Declaraon
of Helsinki, and the Ethics and Research Commiee of the
College of Medicine of King Khalid University approved the
protocol (ECM#2020-132-HAPO-06-B-001 l, 02-1-2020).
Author details
Abdulaziz Ahmed A. Alshehri1, Khalid Ayed Asiri1, Moshabab
Saeed D. Alahmari1, Haifa Hisham A. Alwabel1, Yahya Dhafer
Alahmari2, Syed Esam Mahmood3
1. College of Medicine, King Khalid University, Abha, Saudi
Arabia
2. ENT Department, Abha Maternity and Pediatric Hospital,
Abha, Saudi Arabia
3. Professor of Community Medicine, Department of Family
and Community Medicine, King Khalid University, Abha,
Saudi Arabia
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