Bad posture is a significant risk factor for musculoskeletal pain among medical professionals. Prolonged shoulder flexion and improper spinal alignment can lead to discomfort and potential injuries. Poor workstation setup and prolonged standing or sitting can further contribute to the development of musculoskeletal pain. Healthcare practitioners should prioritize good posture and ergonomics to mitigate these risks and maintain their well-being throughout their careers [1]. As confirmed by multiple reports, sedentary lifestyles and poor sitting posture are on the rise, leading to musculoskeletal pain and significant health implications [2]. The global impact of the COVID-19 pandemic has been profound, particularly on teaching and learning practices. This mode of education is expected to continue until early 2021, potentially posing health and physiological challenges for university students [3]. Having a physiotherapist in the school setting promotes the development of healthy postural habits. Following the program, all adolescents reported reduced back pain [4].   The relationship between knowledge and attitude toward ergonomic sitting position, sitting duration, and posture among medical students was examined. The results showed that 23.3% of participants had good knowledge, 40% had adequate knowledge, and 56.7% had a positive attitude towards ergonomic sitting positions. Furthermore, 60% of participants spent more than 8 hours a day sitting, and 43.3% maintained a straight sitting posture [5]. Tavakkol et al. conducted a study to assess the prevalence of low back pain among operating room personnel and its association with their awareness of risk factors. The findings revealed that the prevalence of low back pain was 74% among the personnel. However, no significant relationship was found between the prevalence of low back pain and the personnel’s awareness of risk factors. This highlights the significance of addressing low back pain in the operating room setting [6]. Furthermore, it is advisable to implement early diagnostic survey programs as a preventive measure against long-lasting pain in adulthood. It is recommended that future research focus on evaluating the impact of school ergonomics and furniture designed to provide comprehensive support for the body, aiming to prevent musculoskeletal pain. To assist adolescents in managing musculoskeletal pain and promoting a healthy lifestyle, school nurses should develop and execute structured health education programs. These programs should address various aspects, such as proper coping strategies for musculoskeletal pain and the adoption of healthy habits [7].   Relevant studies show that medical students experience stress and perceive knowledge gaps during their academic journey [8,9]. These studies suggest a potential lack of emphasis on correct posture during medical education. Further research is needed in Saudi Arabia to identify strategies to assess awareness of proper posture among medical students.   Objectives Primary Objective: To assess the knowledge and awareness of the correct posture while studying among students in KSA.   Secondary Objective   To identify the relationship between knowledge of practices regarding correct posture during studying among medical students and sociodemographic characteristics To establish awareness of practices regarding correct posture during studying among medical students in association with sociodemographic characteristics   Materials and Methods This cross-sectional study was conducted in the Kingdom of Saudi Arabia. The target population for this study is medical students. The research was shared and advertised through online posters, online study groups, social media, and any common areas frequented by medical students. Interested students can then voluntarily participate in the study. The research team use a combination of convenience sampling to ensure a representative sample.   Inclusion and Exclusion Criteria Participants must be currently enrolled in medical colleges as medical students, encompassing all years of medical school, including both pre-clinical and clinical years. The study aims to include both male and female participants, allowing for a diverse representation of genders. It is imperative that participants willingly provide informed consent to participate in the study, ensuring their autonomy and understanding of the research objectives. The study specifically targets full-time medical students who are not employed, as this criterion helps to focus on individuals whose primary commitment is their medical education. Finally, the study is limited to Saudi Arabian nationals, aiming to gather data from this specific demographic group.   Individuals who are unwilling or unable to provide informed consent, graduated medical professionals, such as doctors, residents, or fellows, participants with physical impairments or medical conditions that may affect their posture or ability to adhere to proper posture guidelines, Non-Saudi Arabian nationals, part-time or distance-learning medical students and individuals who are not enrolled in medical programs, including students from other healthcare disciplines was excluded from the study. These exclusion criteria are put in place to ensure the homogeneity and relevance of the participant population for the specific objectives of the study.   Method For Data Collection and Instrument (Data Collection Technique and Tools) A structured questionnaire was utilized as the study tool. This tool has been developed based on relevant studies conducted in Saudi Arabia. The final version of the questionnaire consists of 12 questions, categorized into two main sections. The first section includes questions about participants' knowledge and background characteristics. The second section focuses on the importance of correct posture in ergonomics and the need to include related courses in the medical curriculum. The survey instrument was a self-administered, anonymous questionnaire in English. It was comprised of questions aimed at assessing participants' knowledge and awareness of the correct sitting position, duration of sitting, health disorders associated with prolonged sitting, and the importance of posture for medical students. This instrument has been previously used among health students in Saudi Arabia. Data collection was conducted through participants' responses to the questionnaire. The questionnaire gathered information on demographic factors such as age, gender, and specialty. Participants were asked about their average daily sitting duration, preferred sitting location, and usual sitting position.   Scoring System Knowledge Score: Promoted responses of general knowledge about good posture were considered for calculating the knowledge score. Each respondent was asked 6 questions that could be answered with a yes or no, and a score of 1 was given for a 'yes' answer. There was no negative marking for 'no. The maximum possible score for the knowledge part was 6x1 = 6.   Awareness Score Each respondent was asked a 6-item questionnaire related to their awareness of the right posture. Responses were recorded as strongly agree, disagree, somewhat agree, somewhat disagree, don't know, or can't say. Depending on the level of awareness, scores ranging from 0 to 5 were allotted. A score of '0' was given for don't know or can't say responses. Similarly, the maximum possible score for the awareness section was 6x5 = 30.   The participants were classified based on their scores in the knowledge section, resulting in the formation of three distinct groups. Those who achieved a score of 6 were categorized as possessing a commendable level of knowledge, while those who scored 4–5were classified as having a moderate level of knowledge. Lastly, individuals who scored 3 or lower were designated as having a comparatively limited level of knowledge. The participants were categorized into three distinct groups during the awareness phase, as determined by their scores. Those who achieved a score between 26 and 30 were recognized as having excellent awareness. Participants scoring between 21 and 25 were acknowledged as having moderate knowledge, while individuals scoring 20 or below were identified as having limited awareness.   Analysis and Entry Method The data was initially entered into a computer using Microsoft Office Excel Software, specifically the 2016 version for Windows. Subsequently, the data was transferred to the Statistical Package for the Social Sciences (SPSS) software. The specific version used for analysis was IBM SPSS Statistics for Windows, Version 20.0, developed by IBM Corp. This software was utilized to conduct the statistical analysis of the data. In this study, both descriptive statistics and the chi-square test were used.

Table 1 displays various demographic parameters of the participants with a total number of 288. The participant sample consists of participants with a mean age of 22.7 years, and 46.2% of the participants are under the age of 22. A statistical analysis reveals that women (65.6%) make up most of the research participants because of an apparent gender disparity that could impact the study results. The Southern Region dominates participant enrollment, but both the Northern and Eastern Regions exhibit insufficient participation, because of which the findings may lack wider geographical applicability. Most participants reside in families that earn more than 15000 SR per month because 68.8% of respondents fall within this category, demonstrating an upper-class family background. This group demonstrates excellent academic performance because 43.4% of students maintain a Very Good GPA rating.   Figure 1 shows important findings regarding the study time habits of the entire 288 participant group. Among the entire 288-person sample, only 14 individuals studied for less than an hour daily, constituting 4.9% of the group. The research data indicates that 152 participants, composing 52.8% of the study body, spend longer than five hours daily in academic studying activities. The study duration of four to five hours per day was indicated by 81 participants, which represented a total of 28.1% of the respondents. Fifty-two percent of the participants engaged in their studies for more than five hours a day, whereas 14.2% distributed their study time across one to three hours daily.   Table 2 in the research article presents detailed findings regarding medical students' understanding and behavior patterns for proper studying posture, together with critical patterns and challenges. The study duration of more than five hours per day was reported by a significant number of respondents (52.8%), thus prompting concerns about long-term effects on musculoskeletal health. The study demonstrates a key problem in this demographic since 74.3% of students suffered pain after their academic work. This research shows that back pain stands out as the most prevalent condition since it affects 84.7% of respondents, with neck and shoulder pain ranking second, indicating potential poor alignment of existing study postures to ergonomic standards. Almost all (96.9%) participants from the study observed musculoskeletal disorders, yet 92.7% understood that proper posture serves as a protective measure against such health problems.   As shown in Figure 2, The demographic figure illustrates how 288 study participants detected the connection between bad posture and musculoskeletal issues. 144 individuals who make up 50% of the sample showed strong agreement toward the statement positioning them as particularly aware of this matter. A substantial 41.7% of participants joined 120 others to accept the link between posture and musculoskeletal health based on their responses. A minority portion of survey participants displayed ambiguity regarding this statement since 21 individuals (7.3%) were undecided, but 3 respondents (1.0%) disagreed with it.   Table 3 in the research article reveals powerful information about medical students' recognition and opinion levels regarding posture and ergonomics in their studies. Study participants demonstrated strong agreement about their familiarity with risky musculoskeletal injuries from improper posture because 50.0% strongly agreed while 58.3% stated correct posture was essential. The results demonstrate that medical students possess a well-developed understanding of posture impacts on health since their academic workload represents a high level of challenge. The medical curriculum should include ergonomics courses according to 49.3% of students who participated in the study.   Table 1: Sociodemographic Characteristics of Participants (N=288) Parameter No. Percentage Age (Mean: 22.7, STD:1.6) 22 or less 133 46.2 23 years old 93 32.3 24 or more 62 21.5 Gender Female 189 65.6 Male 99 34.4 Region of residence Northern Region 14 4.9 Southern Region 131 45.5 Central Region 77 26.7 Eastern Region 13 4.5 Western Region 53 18.4 Monthly family income Less than 5000 12 4.2 5000 – 10000 18 6.3 10001 – 15000 60 20.8 More than 15000 198 68.8 Academic year 2 6 2.1 3 23 8.0 4 63 21.9 5 102 35.4 6 59 20.5 Intern 35 12.2 Current GPA Excellent (at least 3.50 out of 4.00 or (at least 4.50 out of 5.00) 92 31.9 Very good (2.75 to 3.49 out of 4.00) or (3.75 to 4.49 out of 5.00) 125 43.4 Good (1.75 to 2.74 out of 4.00) or (2,75 to 3.74 out of 5.00) 64 22.2 Satisfactory (1.00 to 1.74 out of 4.00) or (2.00 to 2.74 out of 5.00) 7 2.4     Figure 1: Time of Daily Studying Among Participants   Table 4 shows medical students’ understanding about proper study postures. Survey results show that students who hold an acceptable level of knowledge about ergonomics take up 60.8% of the sample which represents a substantial portion of the total participants. A large number of students (78.5% and 7.3%) show moderate to low levels of awareness about correct posture, according to the results released by the research article.   Table 5 shows that medical students display mainly positive understanding about correct posture practices during their studies, according to the presented data. A substantial number of 61.5% respondents had expert knowledge about proper posture advantages thus showing their understanding of how correct posture prevents musculoskeletal problems during study hours. Additionally, a large proportion of 32.3% of participants showed moderate understanding of postural health although they still had room to develop their knowledge base. Educational strategies should focus on the 6.3% population segment, which demonstrates minimal understanding because it represents an essential educational need.   Table 6 shows that knowledge of practices regarding correct posture during studying has statistically significant relation to gender (p value = 0.010), age (p value = 0.0001), monthly family income (p value = 0.0001), academic year (P value=0.0001), time spent studying daily (p value = 0.003), and usual posture during studying (p value = 0.001). It also shows statistically insignificant relation to region of residence, and current GPA. Participants of female gender, aged 23 years old, with a monthly income of more than 15000 SAR, in the fifth academic year, and studying more than 5 hours daily were found to have higher knowledge level than others.   Table 7 shows that awareness of practices regarding correct posture during studying has a statistically significant relation to academic year (p value = 0.027), current GPA (p value = 0.001), and time of daily studying (p value = 0.026). It also shows a statistically insignificant relation to gender, age, region of residence, monthly family income, and usual posture during studying. Participants who are in the fifth academic year, have excellent GPAs, and spend more than 5 hours studying daily had better awareness levels than others.   Table 2: Parameters Related to Knowledge of Practices Regarding Correct Posture During Studying Among Medical Students (N = 288).   Parameter No. Percentage How much time did you spend studying daily? Less than an hour 14 4.9 1-3 hours 41 14.2 4-5 hours 81 28.1 More than 5 hours 152 52.8 What is your usual posture while studying? Sitting at a desk 222 77.1 Sitting on bed 27 9.4 Lying down 31 10.8 Other 8 2.8 Do you experience any pain or physical discomfort after studying? Yes 214 74.3 No 11 3.8 Sometimes 63 21.9 If you experience pain after studying, where do you usually feel it?* Neck 202 70.1 Back 244 84.7 Shoulders 107 37.2 Arms/hands 127 44.1 Other 35 12.2 How much pain do you feel in the neck after studying? 0 67 23.3 1 78 27.1 2 143 49.7 How much pain do you feel in the back after studying? 0 29 10.1 1 71 24.7 2 188 65.3 How much pain do you feel in the shoulders after studying? 0 157 54.5 1 74 25.7 2 57 19.8 How much pain do you feel in the arms after studying? 0 178 61.8 1 74 25.7 2 36 12.5 How much pain do you feel in the hands after studying? 0 151 52.4 1 74 25.7 2 63 21.9 Musculoskeletal disorders/problems include disorders of the muscles, bones, tendons, ligaments, and joints No 9 3.1 Yes 279 96.9 Sitting too long with the correct posture can prevent musculoskeletal disorders No 21 7.3 Yes 267 92.7 The correct sitting position when the forearm lies on the table or is supported No 15 5.2 Yes 273 94.8 Sitting too much can cause musculoskeletal disorders No 12 4.2 Yes 276 95.8 Upright posture while sitting is the only correct posture No 48 16.7 Yes 240 83.3 *Results may overlap

The problems related to medical students' knowledge and understanding of posture have progressively gained importance over the last few years. A cross-sectional study investigated medical students' knowledge and perception of proper studying postures in educational institutions throughout the Kingdom of Saudi Arabia. This research showed that the relationship between study time length and self-reported ergonomics familiarity leads to an increased incidence of academic-related musculoskeletal discomfort in students. Previous research supports this study by demonstrating a high incidence of musculoskeletal disorders, which affects students who spend numerous hours studying from multiple postures.   The research shows that medical students demonstrate good comprehension of ergonomic postural practices since 60.8% of them exhibit this capability. Although awareness about posture stands high at 60.8%, 74.3% of respondents admit to experiencing discomfort and lower back pains activate as the leading discomfort reported among 84.7% of respondents. The reported statistics that show pain prevalence match previously published research such as Hasan et al. [11], who documented 88.5% of undergraduate students experiencing musculoskeletal pain problems across different educational settings. Similar to Alnaimat et al. [12], the obtained comparative data showed that medical students commonly experience persistent bodily pain, so early intervention and ergonomics-focused healthcare curricula need to be developed.   Table 3: Participants’ Awareness of Practices Regarding Correct Posture During Studying Among Medical Students (N = 288). Parameter No. Percent (%) I’m familiar with the potential musculoskeletal risks associated with poor posture Strongly agree 144 50.0 Agree 120 41.7 Undecided 21 7.3 Disagree 3 1.0 Ergonomics (Efficient design to sit) and maintaining correct posture are crucial to me during studying Strongly agree 168 58.3 Agree 93 32.3 Undecided 27 9.4 Ergonomics (Efficient design to sit) courses should be included in the medical curriculum Strongly agree 142 49.3 Agree 116 40.3 Undecided 24 8.3 Disagree 3 1.0 Strongly disagree 3 1.0 I am interested in learning about ergonomics (Efficient design to sit) Strongly agree 161 55.9 Agree 97 33.7 Undecided 27 9.4 Disagree 3 1.0 I am confident in my ability to identify poor posture habits Strongly agree 140 48.6 Agree 121 42.0 Undecided 15 5.2 Disagree 6 2.1 Strongly disagree 6 2.1 Correct posture positively impacts overall well-being Strongly agree 155 53.8 Agree 103 35.8 Undecided 27 9.4 Strongly disagree 3 1.0   Table 4: Shows Knowledge of Practices Regarding Correct Posture During Studying Among Medical Students, Score Results. Parameters Frequency Percent Commendable level of knowledge 175 60.8 Moderate knowledge level 92 31.9 Low knowledge level 21 7.3 Total 288 100.0   Table 5: Shows Awareness of Practices Regarding Correct Posture During Studying Among Medical Students Score Results. Parameters Frequency Percent Excellent awareness 177 61.5 Moderate awareness 93 32.3 Limited awareness 18 6.3 Total 288 100.0   Students who dedicated more than five hours to daily studying experienced higher rates of back and neck pain, as confirmed by results from Abumohssin et al. [13] and other studies. The prolonged study duration intensified their discomfort due to improper sitting positions. Research shows that musculoskeletal complaints affect a large number of students who study intensively [14] while confirming the widespread occurrence of these complaints during this period. The collected data shows that students who have better posture understanding tend to report more discomfort even though their enhanced knowledge does not fully lead to positive changes in their workspace behavior.   Females exhibited better scores in ergonomic knowledge than males among university students, according to the statistical data (p≤0.05). According to Wijnhoven et al. [15], studies demonstrate that females suffer from musculoskeletal disorders at a higher rate than males. The review conducted by Alshagga et al. [16] demonstrated higher incidence rates of pain in medical students, with special attention to academic pressure along with study-related behaviors as contributing risk factors. Medical education needs to explicitly address the way women report pain differently because it remains important for current and future curricula and ergonomic consultations directed at students.   The study data shows Southern Region respondents make up most of the participants at a time when economic disparities show through family income levels, thus affecting access to ergonomic resources. The literature supports that socioeconomic status shapes health outcomes, especially regarding school bag-induced musculoskeletal pain, according to Kanjilal et al. [17]. The educational and ergonomic resources for students in Saudi Arabia appear more accessible to those students who have a monthly family income exceeding 15,000 SAR. The importance of ergonomics education stands clear, according to Khan and Chew [18], while this essential medical field remains poorly established.   Table 6: Relation Between Knowledge of Practices Regarding Correct Posture During Studying Among Medical Students and Sociodemographic Characteristics   Parameters Knowledge level Total (N = 288) p-value* Commendable level of knowledge Moderate or low knowledge level Gender Female 125 64 189 0.010 71.4% 56.6% 65.6% Male 50 49 99 28.6% 43.4% 34.4% Age 22 or less 69 64 133 0.0001 39.4% 56.6% 46.2% 23 years old 72 21 93 41.1% 18.6% 32.3% 24 or more 34 28 62 19.4% 24.8% 21.5% Region of residence North Region 5 9 14 0.068 2.9% 8.0% 4.9% Southern Region 86 45 131 49.1% 39.8% 45.5% Central Region 44 33 77 25.1% 29.2% 26.7% Eastern Region 5 8 13 2.9% 7.1% 4.5% Western Region 35 18 53 20.0% 15.9% 18.4% Monthly family income in SAR Less than 5000 3 9 12 0.0001 1.7% 8.0% 4.2% 5000 - 10000 0 18 18 0.0% 15.9% 6.3% 10001 - 15000 36 24 60 20.6% 21.2% 20.8% More than 15000 136 62 198 77.7% 54.9% 68.8% Academic year 2 0 6 6 0.0001 0.0% 5.3% 2.1% 3 5 18 23 2.9% 15.9% 8.0% 4 32 31 63 18.3% 27.4% 21.9% 5 73 29 102 41.7% 25.7% 35.4% 6 45 14 59 25.7% 12.4% 20.5% Intern 20 15 35 11.4% 13.3% 12.2% Current GPA Excellent 62 30 92 0.067 35.4% 26.5% 31.9% Very good 65 60 125 37.1% 53.1% 43.4% Good 43 21 64 24.6% 18.6% 22.2% Satisfactory 5 2 7 2.9% 1.8% 2.4% How much time do you spend studying daily? Less than an hour 3 11 14 0.003 1.7% 9.7% 4.9% 1-3 hours 20 21 41 11.4% 18.6% 14.2% 4-5 hours 55 26 81 31.4% 23.0% 28.1% More than 5 hours 97 55 152 55.4% 48.7% 52.8% What is your usual posture while studying? Lying down 10 21 31 0.001 5.7% 18.6% 10.8% Sitting at a desk 141 81 222 80.6% 71.7% 77.1% Sitting on the bed 21 6 27 12.0% 5.3% 9.4% Other 3 5 8 1.7% 4.4% 2.8% *P value was considered significant if ≤ 0.05.   Table 7: Awareness of Practices Regarding Correct Posture During Studying Among Medical Students in Association with Sociodemographic Characteristics Parameters Awareness level Total (N = 288) p-value* Excellent awareness Moderate or limited awareness Gender Female 120 69 189 0.327 67.8% 62.2% 65.6% Male 57 42 99 32.2% 37.8% 34.4% Age 22 or less 78 55 133 0.573 44.1% 49.5% 46.2% 23 years old 61 32 93 34.5% 28.8% 32.3% 24 or more 38 24 62 21.5% 21.6% 21.5% Region of residence North Region 8 6 14 0.245 4.5% 5.4% 4.9% Southern Region 88 43 131 49.7% 38.7% 45.5% Central Region 46 31 77 26.0% 27.9% 26.7% Eastern Region 5 8 13 2.8% 7.2% 4.5% Western Region 30 23 53 16.9% 20.7% 18.4% Monthly family income Less than 5000 3 9 12 0.060 1.7% 8.1% 4.2% 5000 - 10000 12 6 18 6.8% 5.4% 6.3% 10001 - 15000 36 24 60 20.3% 21.6% 20.8% More than 15000 126 72 198 71.2% 64.9% 68.8% Academic year 2 0 6 6 0.027 0.0% 5.4% 2.1% 3 11 12 23 6.2% 10.8% 8.0% 4 38 25 63 21.5% 22.5% 21.9% 5 67 35 102 37.9% 31.5% 35.4% 6 38 21 59 21.5% 18.9% 20.5% Intern 23 12 35 13.0% 10.8% 12.2% Current GPA Excellent 68 24 92 0.001 38.4% 21.6% 31.9% Very good 65 60 125 36.7% 54.1% 43.4% Good 37 27 64 20.9% 24.3% 22.2% Satisfactory 7 0 7 4.0% 0.0% 2.4% How much time do you spend studying daily? Less than an hour 5 9 14 0.026 2.8% 8.1% 4.9% 1-3 hours 20 21 41 11.3% 18.9% 14.2% 4-5 hours 49 32 81 27.7% 28.8% 28.1% More than 5 hours 103 49 152 58.2% 44.1% 52.8% What is your usual posture while studying? Lying down 13 18 31 0.127 7.3% 16.2% 10.8% Sitting at a desk 141 81 222 79.7% 73.0% 77.1% Sitting on the bed 18 9 27 10.2% 8.1% 9.4% Other 5 3 8 2.8% 2.7% 2.8% *P value was considered significant if ≤ 0.05.   Our study data demonstrates a considerable interest among medical students to incorporate ergonomics into curriculum education because 49.3% of respondents supported such integration. The requirement to improve medical education about musculoskeletal health matches previous recommendations from Gomes et al. [19] regarding student ergonomic learning requirements during remote education. The findings presented in Malmborg et al. [20] confirm that curriculum changes should focus on creating musculoskeletal pain prevention strategies because they affect academic performance and students' overall health status. Student awareness about the usefulness of this knowledge stands strong, yet academic establishments show minimal incorporation of such knowledge into their frameworks.   Limitations The current study has notable restrictions that require special attention. This study uses 288 medical students as participants who create a strong analytical base, yet their geographic grouping reduces the potential for a universal conclusion. Self-reported data collection methods could introduce subjective interpretation errors that affect participants' ratings of discomfort and their sense of being aware of their posture. Future investigations should augment the research by combining long-term examination with standardized measurements for posture analysis as well as injury measurement methods. The obtained research data serves as base of knowledge, yet researchers must handle results with caution because further investigation about this matter should build upon this initial information.

The findings demonstrate that Saudi medical students show a promising understanding of postural correctness and exhibit high rates of musculoskeletal pain because of their extended study activities. These results show that educational reforms alongside personalized ergonomic solutions must be implemented as soon as possible because they would reduce health risks. Future research must bridge the gap between academic student knowledge about ergonomics and their actual implementation by studying appropriate medical education interventions and ergonomic integration effects on student health.   Acknowledgement We acknowledge all of the volunteers who provided samples for this research.   Ethical approval After fully explaining the study and emphasizing that participation was optional, each participant gave informed consent. The information gathered was safely stored and utilized exclusively for the study. Funding This study was not supported by any outside sources.   Conflict of interests The authors declare no conflict of interest.   Informed consent Written informed consent was acquired from each study participant.