The study assessed parental knowledge and satisfaction regarding the NHS program among the parents of children aged three years or younger across all regions of Saudi Arabia. Data collection took place between November 2023 and February 2024. The study focused on the age group because the NHS program, initially implemented in Saudi Arabia's 30 hospitals in 2016, saw significant expansion and improvement across nearly all hospitals after 2021 (9).

Data were gathered using an electronic questionnaire. Given the absence of standardized tools for assessing parental knowledge of the NHS program, questions related to knowledge were developed by a focus group. The satisfaction section utilized questions adapted from the Parent Satisfaction Questionnaire with Neonatal Hearing Screening Program, a validated instrument widely used in various countries, including Malaysia (11), Australia (18), Iran (19), Spain (23), and the United Kingdom (28). The Arabic version, validated in Jordan (24), was used with permission. The questionnaire underwent reviews by external experts to ensure content appropriateness and underwent pilot testing with five parents to confirm clarity and comprehension.

The final questionnaire comprised 23 Arabic-language closed-ended questions organized into three sections: parental demographics, knowledge, and satisfaction. The demographic section included 10 questions about parental and child details, such as age, education, hospital of birth, and presence of risk factors. The knowledge section included six questions about the child's NHS participation, screening outcomes, reasons for non-participation if applicable, whether there was a follow-up screening, what were the follow-up screening results, and reasons for not following up if applicable. The satisfaction section contained seven questions about the receipt and clarity of pre-screening information and post-screening results, communication with NHS personnel, and overall satisfaction with the program.

The electronic questionnaire link was distributed via social media platforms (e.g., Twitter, Facebook, and WhatsApp) and personal networks, including family and acquaintances. Participants were presented with a study information sheet and consent form on the first page of the questionnaire, allowing them to opt in or decline participation before proceeding with the questions.

Awareness of the NHS was assessed among participants (n = 796; 749 women; 47 men) with prior NHS experience. The majority were Saudi nationals (98%) aged 31–40 years, with fathers being slightly older than mothers. Most parents held a bachelor's degree (60.75%), with a small proportion of them having education levels lower than high schools (2.25%). Families typically had 1–3 children (57.8%), with a significant representation from the central region (68.5%), followed by the northern (10%), eastern (7.4%), and southern (7.3%) regions. NHS screenings occurred predominantly in private (56.7%) and government (43.3%) hospitals. Notably, 295 participants (37.1%) reported that their newborns had risk factors for hearing loss (Table 1).

Figure 1 summarizes the findings from participants whose newborns underwent the NHS (n = 796). Screening results indicated that 676 newborns (84.9%) initially passed, 83 newborns (10.4%) initially failed, and the parents of 37 newborns (4.6%) were unaware of their results. Among those who failed, 78 returned for follow-up; 63 (75.9%) passed, 13 (15.7%) failed, and the parents of 2 newborns (2.4%) were unaware of their results. Five (6.0%) did not attend follow-up due to unawareness of appointment availability. Overall, at the end of the screening, 92.8% of parents reported that their newborns passed, 1.6% reported that their newborns failed, 5% were unaware of their newborns' results, and 0.6% were lost to follow-up.

Participants with prior experience (n = 796) reported satisfaction levels, shown in Table 2. Only 236 (29.6%) received pre-screening information; 519 (65.2%) did not. Information was mainly delivered verbally to examiners (71.6%), through relatives (16.5%), printed materials (8.9%), and social media (3%). Of those informed, 193 (81.8%) participants found the information adequate, whereas 20 (8.5%) found it challenging.

Regarding post-screening results, 356 (44.7%) felt inadequately informed, and 558 (70.1%) found communication with examiners straightforward. Overall, 638 (80.2%) participants expressed satisfaction with the NHS program.

In this study, 73.3% of parents reported that their newborns had undergone the NHS, whereas 7.5% had not, and 19.2% were uncertain. The primary reason cited for not participating in the NHS was the coronavirus disease pandemic (36.6%), underscoring its impact on healthcare delivery (29). Additionally, 23.2% of parents mentioned a lack of knowledge about the NHS as a deterrent, possibly influenced by recall bias or insufficient information dissemination. The uncertainty rate (19.2%) was notably higher than that reported in similar programs, such as that in Malaysia (0%) (11).

Among parents whose newborns underwent the NHS, 92.8% reported their newborns passing the screening, 1.6% reported their newborns failing, and 5% were unaware of the results. The latter could be attributed to recall bias or inadequate result communication, contributing to uncertainty. The uncertainty rate in this study from Saudi Arabia was lower compared with those in studies from Malaysia (7.5%) (11), Iran (8.7%) (19), and Jordan (49%) (24). Notably, 0.6% of parents did not attend follow-up appointments due to unawareness, a common issue reported previously (26). In Saudi Arabia, there are a few awareness campaigns regarding the significance of hearing screening and the negative impacts of hearing loss (25).

Overall, addressing parental awareness gaps is crucial for successful NHS implementation (30). The Ministry of Health should consider supporting more public awareness campaigns in Saudi Arabia. The Joint Committee on Infant Hearing advised providing clear, written information to parents about the significance of NHS, screening outcomes, and follow-up steps to reduce LTF rates (8).

The study reported that 80.2% of parents were generally satisfied with the NHS program, similar to the rate in Malaysia (80.6%) (11). However, satisfaction levels were lower than those in Australia, Iran, and Jordan, where over 90% of parents expressed satisfaction (18, 19, 24).

The lower satisfaction in our study could be due to the inadequate pre- and post-NHS information. Only 29.6% received NHS information before screening, verbally or in writing, compared with higher rates in Malaysia (95%) (11) and Jordan (69.5%) (24). Conversely, 8.5% found the information difficult to understand, which is higher than those in other studies (0%–2.9%) (11, 24). Providing written, easily understandable NHS information alongside verbal explanations enhances parental understanding and adherence (14, 31). Timing of information delivery is crucial; most parents receive information post-birth (31, 32).

Regarding satisfaction with post-NHS information adequacy, over half of parents were dissatisfied with test result information availability, akin to Jordan (57.2%) (24) but higher than the proportion in Malaysia (26%) (11). Communication ease with examiners was challenging for 29.9% of parents, emphasizing the need for simple, jargon-free communication and comprehensive written materials.

Overall, parents were generally aware of and satisfied with the NHS program, and issues with program recognition and comprehension persist. Addressing these can enhance NHS program effectiveness in Saudi Arabia.

This study has some limitations. Despite this study encompassing all regions of Saudi Arabia, most respondents (68.5%) were from the central region, warranting further regional studies. Moreover, integrating open-ended could unearth unconsidered issues. Future research could explore relationships between awareness, satisfaction, and parental demographics. The questionnaire included questions designed to answer the aim of the study; however, a detailed questionnaire is advised to be developed for obtaining comprehensive information about the parents' knowledge and satisfaction with the NHS program in Saudi Arabia.