Public knowledge, awareness and perception of gut microbiome and faecal microbiota transplantation in Singapore: a survey study

Abstract

Introduction:

Despite the exponential increase in microbiome research, knowledge and beliefs about the gut microbiome and faecal microbiota transplantation (FMT) remain unclear. The aim of this study was to identify the extent of knowledge, awareness and perception among the general public regarding the gut microbiome and FMT.

Methods:

An online questionnaire on knowledge and beliefs about the gut microbiome and FMT was administered to 1831 participants. Data analysis software was used to generate descriptive statistics and explore associations between knowledge and sociodemographic variables.

Results:

Even though only 33% of participants had heard of the gut microbiome, more than 92% had consumed probiotic drinks or supplements. While 85% had not heard of the FMT procedure, 72% of respondents would consider having FMT to treat Clostridioides difficile infection (CDI). Willingness to receive FMT depended mainly on recommendation from healthcare providers (77%). Knowledge and awareness regarding the gut microbiome and FMT were relatively low, despite most participants having prior gut health-related behaviours.

Conclusion:

This study identified the public’s perceptions of FMT and the potential barriers to its uptake. Insights from the study highlight the need for health education to enhance acceptance of FMT and the importance of using information supported by medical professionals to immunise the public against poorly validated science.

INTRODUCTION

The human gut microbiota refers to the combination of bacteria, archaea and other microbes that colonise and reside in the gastrointestinal tract. While microorganisms in the human body were discovered as early as the 1880s,[1] research on the gut microbiota has only started to gain significant momentum in the past decade, driven by advancements in scientific methods. Recent papers published on the science behind the gut microbiota support the notion that the microbes living in our gut are crucial to our survival. It was thus imperative to delve deep into the study of human–microbe interactions. Basic functions of the microbiota include absorbing nutrients and energy from diet, regulating metabolite bioavailability, and maintaining gut epithelial cells, among many others.[2] Researchers have gone on further to explore the role of the gut microbiota in various health conditions and diseases. Extreme imbalance in the composition of the gut microbiota is associated with chronic inflammatory diseases, such as Crohn’s disease and ulcerative colitis.[3] Moreover, the gut microbiota has also been reported to be involved in altering signals to the brain to influence host energy metabolism, thus having important implications in the treatment of obesity.[4] Finally, the gut microbiota has also been implicated in the development of cancers,[5] whereby a compromised gut epithelial barrier allows migration of bacteria and the subsequent release of carcinogenic metabolites damaging host DNA.[6] Nevertheless, research is still in its early stages. Further studies are required to test these hypotheses and determine exact causes and effects. It is pertinent to note that currently, the use of microbiota-based therapeutics is Food and Drug Administration (FDA)-approved only for recurrent Clostridioides difficile infection (CDI),[7] and should not be recommended for the treatment of other medical conditions.[8]

SUMMARY BOX

What is known?

While public knowledge of the gut microbiome and faecal microbiota transplantation (FMT) is limited abroad, it is largely unknown in Singapore..

What is new?

This study reveals that while a majority of individuals engage in gut-health-related behaviours, awareness of the gut microbiome and FMT remains low. Notably, most respondents are open to FMT to treat Clostridioides difficile infection if recommended by a healthcare provider.

What is the impact?

These findings underscore the need for targeted health education from trusted sources to counter misinformation and improve acceptance of FMT as a treatment option.

Given the crucial role the gut microbiota plays in the balance of health and diseases, there has been a great interest in applying microbiome-based therapeutics, such as FMT,[9,10,11,12,13,14] disease-specific probiotics,[15,16] bacteriophages and microbiota-mediated metabolites,[17,18,19,20] for a myriad of medical conditions. For patients with recurrent CDI, FMT has proven to be effective in both rebalancing the gut microbiome and restoring its natural functions. In one study, 90% of recurrent CDI patients who had received FMT were successfully treated as compared to 26% of patients who had undergone the vancomycin regimen, the prior standard of care medical therapy.[21] Furthermore, a long-term follow-up study revealed that 91% of patients who had received FMT for recurrent CDI had observed resolution of CD-related symptoms without recurrence within 90 days of FMT.[22]

However, the importance of this ‘forgotten organ’ (i.e., the gut microbiota) may be underestimated in the general population. A study conducted on Australian participants found that only 66 % of respondents were able to define the term ‘gut flora’ accurately.[23] In Qatar, less than 60% of participants had heard of studies on the gut microbiome and gut disease.[24] The gut microbiota and FMT are complex topics and may be subject to misconceptions and misinformation. As such, poorly informed individuals are unable to make better decisions regarding microbiota-based therapies — perhaps due to fear or scepticism — thus avoiding a potentially beneficial therapeutic option.

With the increasing attention on the gut microbiota and the expanded use of FMT for other indications beyond CDI, it is imperative to understand the general public’s knowledge, awareness and perception of the human gut microbiota and FMT. This is the first study conducted in the general public population of a multi-ethnic Asian country that identified potential barriers to accepting FMT as a treatment, thereby providing guidance on how these issues can be overcome.

METHODS

Recruitment

The study was conducted from August 2020 to July 2021. Participants were recruited from the Singapore Population Health Studies (SPHS) Online Panel, managed by the National University of Singapore (NUS), Saw Swee Hock School of Public Health. Ethics approval was obtained from the NUS Institutional Review Board for Social, Behavioural and Educational Research (Ref No.: H-18-011). The online panel consisted of adult Singaporeans and long-term residents from the three major ethnic groups, namely Chinese, Malay and Indian. Panel members were invited to participate in monthly surveys on research topics related to public health. The inclusion criteria were (a) age ≥21 years, (b) Singaporean or Singapore Permanent Resident, (c) able to read English, (d) frequent user of the Internet, and (e) owns a personal email account. Exclusion criteria were participants under the age of 21 and those who did not respond or refused to participate.

The current questionnaire was made available to all 2509 members who made up the online registry at that time, and they were notified via email and/or SMS. The notification included details of the questionnaire and a unique link to the survey, which was administered on the Research Electronic Data Capture (REDCap) platform, a secure web-based application for managing data collection for research studies. The questionnaire was available for ten days of recruitment, with a reminder email or SMS sent on the fifth day after the first notification. Consent to participate in the survey was indicated when participants clicked on the survey link, completed the survey and submitted it. They may choose to abort the survey at any time. A total of 1831 participants responded to the questionnaire and were recruited.

Questionnaire

The aim of the questionnaire survey was to characterise the general public’s knowledge, awareness and perceptions of the gut microbiome and FMT procedure, as well as their willingness to become FMT donor. The questionnaire consisted of 19 multiple-choice questions, which took approximately 10 to 15 minutes to complete. Explanations of the gut microbiota and FMT process were provided where applicable. Participants were asked questions regarding their existing knowledge, awareness and perceptions about these topics. The category of questions and the gut microbiome knowledge score for each participant are described in Table S1 [Supplementary Digital Appendix]. Each option was assigned a score, and the knowledge score was derived from the sum of scores, depending on the options selected.

Knowledge of the gut microbiome functions and attitudes towards FMT donation and treatment were measured using Cronbach’s alpha (α).[25] Briefly, knowledge of gut microbiome functions comprised seven items (α = 0.5831); knowledge of gut microbiome through the use of probiotic products two items (α = 0.4326); experience with CDI two items (α = 0.3189); perception of FMT as a treatment for CDI seven items (α = 0.7719); factors increasing likelihood to have FMT via colonoscopy eight items (α = 0.3584); factors influencing willingness to be an FMT donor seven items (α = 0.4814) and factors influencing willingness to collect stool samples five items (α = 0.5955) [Table S2, Supplementary Digital Appendix].

Statistical analyses

Only data from completed questionnaires were analysed. Completed sets of responses were anonymised, tabulated and analysed using Microsoft Excel (Microsoft Corp, Redmond, WA, USA). All statistical analyses were performed using JMP Pro version 17.0.0 (JMP Statistical Discovery LLC, Cary, NC, USA). Descriptive statistics, including frequency, mean and standard deviation, were measured to summarise the data collected. A simple linear regression was used to explore the correlation between knowledge and age. Comparison of differences in mean knowledge score was conducted using the Mann–Whitney U test for gender and the Kruskal–Wallis test for ethnicity, level of education and monthly household income. Data visualisation was performed using RStudio version 1.4.1106 (Posit PBC, Boston, MA, USA). A two-tailed P value of < 0.05 was considered to be statistically significant.

RESULTS

Demographics of participants

Out of 2509 panel members who received the invitation to participate, 1831 questionnaires were received, with a response rate of 73.0%. Of the completed responses, 1830 were used for data analysis. There were 1075 (58.7%) females and 755 (41.3%) males with a mean age of 46.2 (range 21–87) years. The participants’ demographics are summarised in Table S3 [Supplemental Digital Appendix], where the distribution of age, gender and other sociodemographic variables was similar to that in the pool of eligible participants, with the exception of ethnicity [Table S4, Supplementary Digital Appendix].

Gut microbiome

Knowledge and awareness of gut microbiome functions

Among the respondents, only one-third (598, 32.6%) had ever heard of the gut microbiome. Of these respondents, the top two known functions of the gut microbiome were influencing weight (37.7%) and contributing towards diseases (36.7%) [Figure 1a].

Figure 1.

(a) Chart shows the knowledge of gut microbiome functions amongst respondents who had heard of the gut microbiome; (b) Mosaic plot compares the highest level of education attained across various age groups.

Association of knowledge with sociodemographic variables

The mean knowledge score of participants was 0.88 ± 1.57 out of a total score of 5. A simple linear regression analysis on knowledge score and age revealed a significant negative relationship (β = −0.060, t (1828) = −2.57, P < 0.05), suggesting that younger respondents were more knowledgeable about the gut microbiome than older respondents [Table 1]. A comparison of differences in mean knowledge score was not significant across all sociodemographic variables except for education level. Results of the Kruskal–Wallis test indicated a significant difference among the education groups (χ² (6, N = 1830) = 59.59, P < 0.0001). Further analysis of the distribution of education level across age groups revealed that the proportion of university graduates was higher among respondents aged 21–49 years and conversely, lower in the older age groups (≥50 years) [Figure 1b].

Table 1.

Association of knowledge scores with sociodemographic variables.

Characteristic	n (%)	Knowledge score, Mean±SD	P
Age (yr)			0.010*
21–29	291 (15.9)	1.06±1.67
30–39	360 (19.6)	0.97±1.67
40–49	419 (22.9)	0.84±1.51
50–59	365 (20.0)	0.73±1.47
60–69	306 (16.7)	0.89±1.60
70–79	82 (4.5)	0.76±1.37
80–89	7 (0.4)	0.71±1.11
Gender			0.450
Male	755 (41.3)	0.94±1.63
Female	1075 (58.7)	0.84±1.52
Ethnicity			0.093
Chinese	1537 (84.0)	0.87±1.55
Malay	82 (4.5)	0.60±1.29
Indian	167 (9.1)	1.00±1.75
Others	44 (2.4)	1.23±1.87
Highest education			<0.0001*
Refuse to answer	12 (0.7)	0.25±0.62
No formal qualification	5 (0.3)	2.00±2.35
Primary	17 (0.9)	1.06±1.71
Secondary	313 (17.1)	0.59±1.32
Vocational training	58 (3.2)	0.24±0.96
Post-secondary	542 (29.6)	0.73±1.47
University and above	883 (48.2)	1.12±1.70
Average monthly household income (SGD)			0.127
<2000	260 (14.2)	0.85±1.53
2000–3999	329 (18.0)	0.86±1.58
4000–5999	309 (16.9)	0.90±1.59
6000–10,000	484 (26.4)	0.83±1.56
>10,000	279 (15.2)	1.11±1.69
Do not know	82 (4.5)	0.79±1.47
Refuse to answer	87 (4.8)	0.64±1.25

*Statistically significant at P < 0.05. SD: standard deviation

Gut health-related behaviours

Despite the relatively low level of awareness of the gut microbiome, the majority of respondents had engaged in behaviours related to improving gut health. Almost all (n = 1697, 92.7%) participants had consumed a probiotic drink before, with half (843, 49.7%) taking probiotic drinks for reasons other than improving the health of their gut. There was no significant association between consumption of probiotic drinks or supplements and self-reported awareness of the gut microbiome. Instead, there were more participants who had consumed a probiotic drink and/or supplement in the group that had never heard of the gut microbiome [Figure 2]. Respondents who had never heard of the gut microbiome but had consumed a probiotic drink made up more than 60% of the study population (n = 1133, 61.9%) as compared to 30.8% who were aware of the gut microbiome. Similarly, there was a higher percentage who had consumed a probiotic supplement and were not aware of the gut microbiome than those who were aware (29.8% vs. 20.5%).

Figure 2.

Graph shows (a) number of participants who had consumed a probiotic drink differentiated by awareness of gut microbiome; (b) number of participants who had consumed a probiotic supplement differentiated by awareness of gut microbiome.

Further analysis revealed that between participants who had consumed either a probiotic drink and/or supplement before and those who had never done so, there was no significant difference in their knowledge scores (P = 0.255) [Table S5, Supplementary Digital Appendix]. Knowledge score was also not significantly associated with probiotic consumption (P = 0.403) [Table S6, Supplementary Digital Appendix]. Completing education at the university level was found to be significantly associated with probiotics consumption (χ² (1, N = 1830) = 10.93, P = 0.0009), where degree holders were more likely to consume probiotics compared to those without a degree. Having a bachelor’s degree was also significantly associated with knowledge score (P < 0.0001) [Table S5, Supplementary Digital Appendix].

Faecal microbiota transplantation

Awareness and perceptions of FMT

In general, 1552 (84.8%) of the respondents had never heard of the FMT process. Additionally, 1701 (93.0%) respondents had never suffered from CDI, while only 77 (4.2%) had friends or family members who had ever contracted CDI. Among those who had heard of FMT before (278, 15.2%), 44 (15.8%) had either suffered from or knew someone who had suffered from CDI, and 61 (21.9%) respondents had undergone a colonoscopy.

The majority of participants (1440, 78.7%) had never undergone a colonoscopy. Of those who had (390, 21.3%), 61 (15.6%) participants were aware of FMT and 162 (41.5%) reported that their level of discomfort during colonoscopy was at the lowest (based on a scale of 1 to 10, with 1 being ‘No pain at all’ and 10 being ‘Worst pain imaginable’) [Figure 3]. The majority (346, 88.7%) rated their level of discomfort at 5 or less. More than half (1064, 58.1%) of the participants would prefer the FMT liquid faecal preparation to be administered via colonoscopy instead of through the nasal passage. Out of these participants, 261 (24.5%) had previously undergone a colonoscopy.

Figure 3.

Ratings of level of discomfort during colonoscopy procedure for participants who had undergone colonoscopy before.

A total of 1318 (72.0%) respondents would consider FMT if they contract a CDI. For those who would not consider FMT, the reasons for refusal included a preference for oral medication such as antibiotics (57.2%), discomfort with the concept of FMT (54.1%), and concerns about infection risks (46.3%) [Figure 4a]. More than half of the participants (n = 954, 52.1%) would be more inclined to consider the procedure if the FMT preparations were available in the form of oral capsules.

Figure 4.

(a) Graph shows the reasons for low acceptance of FMT as treatment if suffering from Clostridioides difficile infection (CDI) (512 respondents); (b) Chart shows the reasons that will increase willingness to undergo FMT via colonoscopy (1830 respondents).

Overall, the deciding factors that would increase participants’ willingness to receive FMT were recommendation from healthcare providers (77.1%), clinical studies on its effectiveness (59.7%) and personal research (30.4%) [Figure 4b], with the least influence from social factors such as peer recommendations.

Perception of stool donation and collection

The majority of respondents (57.3%) would not consider being a stool donor for FMT. The main concerns were discomfort with collecting stool samples (55.1%), perception that it would be troublesome to undergo numerous tests (48.7%), and doubts that they would be healthy enough to qualify (36.2%) [Figure 5a]. Of the remaining 782 (42.7%) respondents who indicated that they would consider stool donation, 154 (19.7%) were already aware of FMT and 697 (89.1%) were comfortable with collecting stool samples [Figure 5b].

Figure 5.

(a) Graph shows the reasons for low willingness to be an FMT stool donor (out of 1048 respondents); (b) Mosaic plot compares the distribution of participants who would consider being an FMT stool donor across their comfortability with collecting stool samples.

Some concerns regarding stool collection included hygiene and cleanliness issues, and feeling embarrassed by the process [Figure S1 ^{(75.6KB, tif)} , Supplemental Digital Appendix]. The most important consideration for the stool collection process was convenience, followed by ease and cleanliness of the process [Figure S2 ^{(76.4KB, tif)} , Supplemental Digital Appendix].

DISCUSSION

Analysis of the data revealed that only one-third (32.6%) of respondents had heard of the gut microbiome, and yet the large majority had consumed a probiotic drink and/or supplement before. The discrepancy between awareness of the gut microbiome and gut health-related behaviours can be explained by environmental and situational factors, in which individuals are often motivated not by desires to specifically enhance their gut health, but by the need to sustain overall well-being. Consistent with past studies,[23] our results showed that almost all (95.5%) of the participants who expressed awareness of the gut microbiome had consumed a probiotic drink and/or supplement before. Interestingly, our results further showed that more participants in the group that had never heard of the gut microbiome had consumed a probiotic drink or supplement than the group with prior knowledge. With the rise of probiotic products on the market and growing public interest,[26,27] health-conscious individuals may be increasingly motivated to explore the benefits of probiotics, leading them to learn more about the gut microbiome. Raising awareness of the benefits of probiotic products may pave the way for educating the public about the gut microbiome, since many are already engaging in these gut-health-related behaviours. Education may be supported by advertisement in the form of product brochures, infomercials or promotional food carts in supermarkets. Such marketing campaigns may pique the curiosity of the general public about probiotics and consequently increase awareness about the gut microbiome. Another possible reason behind the disconnect between probiotic consumption and awareness of the gut microbiome could be due to marketing perceptions. When marketing probiotic products, there may be more emphasis on potential health benefits, rather than the science behind their purported effects. Substantiating health claims poses a challenge for manufacturers due to the complexity of defining intended uses and adhering to the stringent regulatory processes that ensue.[28,29] Consequently, probiotic manufacturers may prioritise marketing strategies aimed at bolstering consumer appeal and highlighting widely acknowledged health benefits while steering clear of making new claims that would necessitate the provision of evidence. Nevertheless, increasing consumer awareness could prove to be an effective marketing strategy as well. Educating consumers on the science behind probiotics could build trust and credibility, which will in turn drive consumer appeal.

Our results show that the most recognised function of the gut microbiome is its influence on weight. There is growing literature on the involvement of the gut microbiome in metabolic regulation,[30] energy utilisation from diet,[31] and more complex mechanisms pertaining to metabolic diseases[32] such as obesity[33,34] and type 2 diabetes mellitus.[35] This has garnered interest from both medical professionals and the general public, as it suggests promising avenues for microbiome-based interventions in weight management and potentially other more severe health conditions. Moreover, given that the rising obesity rate in Singapore residents aged 18–74 years, from 10.5% in 2020 to 11.6% in 2022,[36,37] it is likely that high-risk individuals, especially young working adults,[38] are starting to pay more attention to their diet and lifestyle practices. Since weight serves as a prominent indicator of health, it is essential to consider not only dietary habits, but also the major role of the gut microbiome in digestion and metabolism.

In our study, age and education level were found to be significantly associated with participants’ knowledge of the gut microbiome. We also observed a higher proportion of university graduates among participants aged 21–49 years than among those aged ≥ 50 years. Efforts to raise awareness about the gut microbiome can be directed at these target groups — the older population who are more likely to have attained a lower education level and individuals not trained in biology-related fields.

There was no significant difference in knowledge scores between participants who had consumed probiotics and those who had not. Additionally, knowledge score was not significantly associated with probiotic consumption — indicating that understanding the function of the gut microbiome does not necessarily translate into the behaviour of consuming probiotics. This gap between knowledge and behaviour may be attributed to several factors. First, while gut microbiome science still remains a relatively new field with low public awareness, there has been extensive research on the potential of probiotics to treat other non-gastrointestinal health issues.[39] Certain probiotic products on the market have demonstrated therapeutic efficacy when formulated with specific strains, such as Lactobacillus casei DN-114001, which helps prevent paediatric diarrhoea and respiratory infections, and Bifidobacterium animalis subsp lactis (BB-12), which is effective for eczema.[40] Additionally, such probiotics products are widely available in various forms and easily accessible both online and in stores, allowing consumers to seek symptom relief for non-gut-related conditions, regardless of their understanding of gut health. Second, although probiotic products have been in the market for decades, regulatory guidelines in Singapore have shaped marketing claims to focus on overall well-being, rather than solely promoting gut health.[41] This is supported by our finding that 49.7% of participants who had consumed a probiotic drink did so for reasons unrelated to improving their gut health. Taken together, these factors suggest that many consumers choose probiotic products for reasons that extend beyond their knowledge of gut microbiome science.

Interestingly, having a bachelor’s degree was significantly associated with probiotics consumption and knowledge score. This suggests that holding a degree is associated with greater knowledge about the gut microbiome, aligning with the expectation that higher education may correlate with more exposure to health-related information, even if not related to the gut microbiome. Additionally, higher economic status associated with higher education may provide individuals with more resources to engage in health behaviours, such as probiotics consumption.

Despite evidence supporting its effectiveness, existing literature highlights barriers in the attitudes and acceptance of FMT among both medical professionals and patients. The first study conducted in an Asian country revealed that only 45.6% of physicians from across China had an understanding of FMT concepts.[42] A separate study found that although 79% of the clinicians surveyed perceived FMT to be a potential future treatment for some gastrointestinal diseases, 50% considered it as a last resort and only 23% would administer it in the context of a clinical trial.[43] Major concerns include a lack of supporting evidence, infection risks and safety issues. Patients are also relatively ill-informed about FMT. In a study conducted at a Minneapolis hospital, Goodman et al. reported that less than 15% of patients with CDI had learned of FMT from varying sources.[44] The patients’ greatest concerns centred around infection risks, uncertainly about treatment effectiveness, and the perception of stool transplantation as unpleasant or distasteful (commonly referred to as “the yuck factor”). What is worth highlighting is that these patients were more open to undergoing FMT if their physician recommended the treatment. The findings of Goodman et al.[44] align with those of our study — more than 80% of our respondents were unaware of FMT, and the main reasons for not considering FMT were a preference for oral medication, discomfort with the concept of FMT and concerns about infection. Interestingly, these factors are based on individual preference and beliefs about FMT. Not including the qualitative ‘Others’ option, the lowest ranked option was that FMT was ‘not guaranteed to be effective’, an opinion that was likely influenced when presented with more information or scientific evidence. It is not surprising then that ‘recommendation from healthcare provider’ was also the top factor that increases willingness to undergo FMT. Healthcare professionals are a reliable source of information and are generally trusted by the public. A 2018 study found that doctors and healthcare specialists were the top preferred and most useful sources of information for Singaporean cancer patients, as compared to other sources such as print material and family or friends.[45] Given the a strong foundation of trust between patients and doctors, the process of dissemination and uptake of information would generally be smoother. The significance then lies in training healthcare professionals in the fundamentals of FMT, thus ensuring that they would be fully equipped to inform and guide patient decision-making.

The current study found that almost 90% of participants who had ever undergone a colonoscopy rated their level of discomfort during colonoscopy at 5 or less, with 41.5% reporting that they felt ‘No pain at all’ during the procedure. Since FMT is predominantly administered via colonoscopy, more emphasis could be placed on describing the colonoscopy procedure in public education about FMT. Additionally, these educational materials could include excerpts from individuals sharing their experience of the colonoscopy procedure. Clarifying misconceptions that the general public may have about colonoscopy may reduce perceived risks related to the procedure, and in turn, lower barriers to accepting FMT as a treatment.

In our study, the main reason for not considering FMT as a treatment option was a preference for oral medication. This result is corroborated by the finding that more than half of the participants would be much more inclined to consider FMT if the faecal preparations were administered in the form of oral capsules. A previous study conducted on patients with no CDI described the FMT procedure as ‘floral reconstitution’ (FR) without disclosing details of the treatment to avoid influencing participant decision.[46] Overall, all aspects of FR were rated as ‘somewhat unappealing’, with the most negative ratings being ‘the need to handle stool’ and ‘receiving FR via nasogastric tube’. However, 90% of patients were willing to consider FR as a treatment for CDI if it was available as a colourless and odourless pill; this was a statistically significant increase from 81% who would accept FR in the current formulated faecal solution. These findings suggest that willingness to accept the FMT treatment may increase if current FMT formulations are presented in a much more aesthetically pleasing mode.

Despite the high proportion of participants who would consider being treated via FMT, almost 60% would not consider being a stool donor. Some concerns included the perception that it would be troublesome to undergo numerous tests and doubts that they would be healthy enough to qualify as donors. There is less flexibility in finding solutions to overcome these barriers, as stringent testing is required to ensure the safety and quality of the donated sample, given that the selection of healthy donors is compulsory. The top reason for not being a donor was discomfort with collecting stool samples. Responses to a follow-up question revealed that their discomfort stemmed from a perception that there was a lack of hygiene and the collection process was dirty or embarrassing, among others. Similarly, aesthetic factors and embarrassment were drawbacks of stool donation previously identified in another study.[47] Nevertheless, the study highlighted several factors that motivated participants to be stool donors — high acceptance of FMT, monetary compensation and altruism. Future research could explore possible motivators for stool donation in the context of the Singapore population, which may then be leveraged to overcome such barriers.

There are some limitations in this study. First, there were no appropriate validated instrument relevant to the Singapore context to assess attitudes and perceptions regarding the gut microbiome and FMT; hence, the questionnaire was developed by adapting from existing questionnaires.[44,46,48,49] Additional research is required to validate this questionnaire for future applications. Second, the distribution of survey respondents differed from the pool of eligible participants in terms of ethnicity (P < 0.017). At the time when the survey was conducted, the majority of the online panel were Chinese. Furthermore, a large majority of those who actually participated by completing the questionnaire were Chinese, thus exacerbating the differences in distribution and resulting in the underrepresentation of other races. The requirement for panellists to be anglophone, which avoided the need to translate surveys into multiple languages, also meant that the results of the study could not be applied to those unable to read English. Although the online panel was recruited from the general public, the requirement for English proficiency likely resulted in a sample that is not nationally representative and is skewed toward individuals with higher socioeconomic status and education levels. Nevertheless, it is important to highlight that the majority of Singaporeans are literate in English,[50] which reduces the impact of this limitation on generalisability. Recruitment efforts for subsequent studies could be more targeted towards ethnicities and non-English-speaking individuals, to improve the generalisability of findings in the Singapore population. Additionally, this study did not explore motivations behind donating stool samples. The degree of knowledge and perceptions of the gut microbiome and FMT of healthcare professionals such as gastroenterologists were also not analysed. Future studies could delve into these areas to supplement the findings from the present study. A multipronged approach to increase knowledge and awareness of the gut microbiome and FMT may then be designed to tackle the current barriers.

In conclusion, this study assessed the level of knowledge, awareness and perceptions regarding the gut microbiome and FMT among members of an online panel recruited from the general public of Singapore. Even though knowledge and awareness regarding the gut microbiome were relatively low in the respondent population, gut health modification practices were common — offering an opportunity to leverage these behaviours to enhance awareness and education efforts. The study also identified barriers to stool donation and acceptance of FMT as a treatment option, and highlighted misconceptions that may be resolved by providing validated facts. Motivations behind accepting FMT are also influenced by education from healthcare professionals and availability of scientifically validated information. Strategies to overcome these barriers may focus on raising awareness of the gut microbiome and its benefits to cater to an increasingly health-conscious society, as well as making information on FMT readily available and accessible for both the general public and healthcare professionals.

Acknowledgement

We thank Yeo Shumian (Saw Swee Hock School of Public Health) for the coordination of questionnaire data, Rachel Quek (AMILI Pte Ltd) for project initiation, and Dr Chia Choon Yee for guidance on data analysis

Conflicts of interest

The following authors are associated with AMILI Pte Ltd: Lim JFY is the CEO and co-founder; Lee JWJ is a co-founder; and Lim L and Toh KY are salaried employees.

Supplemental digital content

Appendix at http://links.lww.com/SGMJ/A185

Figure S1

Reasons for low acceptance for stool collection process (out of 928 respondents who would not be comfortable collecting stool samples). Main concerns include the stool collection process being unhygienic (43.0%), dirty (41.6%), and that it would be embarrassing (39.1%).

Figure S2

Rating of most important aspect in stool collection process (out of 902 respondents who would be comfortable collecting own stool sample). The top 3 aspects voted were convenience (33.4%), ease of process (25.2%) and cleanliness (20.2%).

SUPPLEMENTARY MATERIALS

Table S1.

Categorization of questions

Category	Concept*	Question	Scoring Instructions
Awareness	GM	The gut microbiome refers to the collection of trillions of microorganisms such as bacteria found in the gastrointestinal tract. Have you heard of the gut microbiome before?
Awareness	FMT procedure	A faecal microbiota transplant (FMT) is a medical process in which a faecal preparation from a screened donor is transplanted into the colon of a patient. It is used to treat Clostridium difficile (C. Diff) infections. This is usually done via colonoscopy. Have you heard of this process before?
Knowledge	GM	Based on your knowledge, what is the gut microbiome capable of doing? Select all that apply.	Assign score for each option as follows:
		1.Influencing weight	(1) - (5): 1
		2.Producing vitamins	(6):5
		3.Affecting sleep	(7):0
		4.Affecting intelligence	Knowledge score = sum of scores based on options selected
		5.Contributing to diseases like diabetes and obesity
		6.All of the above
		7.Unsure
Perception	FMT procedure	If you were suffering from a C. diff infection, would you consider having a faecal microbiota transplant (FMT) to treat it? FMT has a cure rate of 8595%.
		Why not? Select all that apply.
		1.It is not guaranteed to be effective
		2.The concept of a faecal microbiota transplant makes me uncomfortable
		3.I would prefer to take oral medication like antibiotics
		4.It might be expensive
		5.I am concerned about infections
		6.Others - Please specify other reasons why you would not consider having a faecal microbiota transplant (FMT).
Perception	FMT procedure	Which of the below, if any, would increase your likelihood of having a faecal microbiota transplant (FMT) via colonoscopy?
		1.Recommendation from close family or friends
		2.Recommendation from extended family
		3.Celebrity endorsement
		4.Personal research
		5.Clinical studies on the effectiveness of the treatment
		6.Others - Please specify what other factors would increase your likelihood of having a faecal microbiota transplant (FMT) via colonoscopy?
		7.None of the above
Perception	FMT procedure	The faecal preparation usually comes in liquid form and can also be administered through the nasal passage. If asked to choose, would you prefer administration via the nasal passage or via a colonoscopy?
Perception	FMT procedure	If the faecal preparations were available in the form of orally administered capsules instead of a colonoscopy, would this make you more or less likely to consider an FMT procedure?
Perception	FMT donor	The FMT process relies on the availability of a suitable stool donor. Donors must pass a series of screening tests before they become eligible to be donors. This includes a blood test, clinician interview, and overall health survey. Would you consider being an FMT stool donor?
		Why not? Select all that apply.
		1. I do not think I am healthy enough to qualify.
		2. It is too troublesome to go through so many tests.
		3. I do not feel comfortable collecting stool samples.
		4. I do not think my stool samples will be put to good use.
		5. I am not convinced that FMT is a viable procedure.
		6. I am concerned about my data privacy.
		7. Others - Please specify other reasons why you would not consider being an FMT stool donor.
Perception	FMT donor	The process of becoming a donor involves collecting stool samples. Would you be comfortable with this?
		Why not? Select all that apply.
		1. It is unhygienic.
		2. It is a dirty process.
		3. I would be embarrassed.
		4. I do not know how to collect a stool sample.
		5. Others - Please specify other reasons why you would not be comfortable collecting stool samples.
Perception	FMT donor	Hypothetically, if you were asked to collect a stool sample (for a general health screening, for example), what would be the most important aspect of the stool collection process for you?
		1. Availability of clear instructions
		2. Cleanliness of the process
		3. Convenience of the process
		4. Cost of the collection kit
		5. Ease of the process 6Others - Please specify what would be the most important aspect of the stool
		6. collection process for you.

*GM : gut microbiome; FMT: faecal microbiota transplantation

Table S2.

Values of Cronbach's alpha reported for each factor in the questionnaire

Factor	α value
Knowledge of functions of gut microbiome (7 items)	0.5831
Knowledge of gut microbiome through probiotic products (2 items)	0.4326
Experience with CDI (2 items)	0.3189
Perception of FMT as a treatment for CDI (7 items)	0.7719
Factors increasing likelihood to have FMT via colonoscopy (8 items)	0.3584
Factors influencing willingness to be an FMT donor (7 items)	0.4814
Factors influencing willingness to collect stool samples (5 items)	0.5955

Table S3.

Demographic profile of survey respondents (N = 1830)

Characteristic	Number	Percentage
Age (in years), mean, range	46.2	21-87
Gender
Male	755	41.3
Female	1075	58.7
Ethnicity
Chinese	1537	84.0
Malay	82	4.5
Indian	167	9.1
Others	44	2.4
Marital status
Never married	578	31.6
Currently married	1100	60.1
Separated/divorced	104	5.7
Widowed	32	1.7
Refuse to answer	16	0.9
Children
Yes	1024	56.0
No	793	43.3
Refuse to answer	13	0.7
Grandchildren
Yes	145	7.9
No	875	47.8
Refuse to answer	3	0.2
Monthly household income on average (SGD)
Less than $2000	260	14.2
$2000 - $3999	329	18.0
$4000 - $5999	309	16.9
$6000 - $10,000	484	26.4
More than $10,000	279	15.2
Do not know	82	4.5
Refuse to answer	87	4.8
Housing type
Public housing 1-3-room flat	409	22.4
Public housing 4-room flat	671	36.6
Public housing 5-room or executive flat	522	28.5
Private condominium	137	7.5
Landed property	64	3.5
Do not know	3	0.2
Refuse to answer	13	0.7
Others	11	0.6

Table S4.

Comparison of sociodemographics in survey respondents and total pool of potential participants from the SPHS Online Panel

Characteristics	Total	Percentage	Respondents	Percentage	Non-respondents	Percentage	P-value
Age							0.705
21 to 29 years	411	16.4	291	15.9	120	17.7
30 to 39 years	542	21.6	360	19.6	182	26.8
40 to 49 years	575	22.9	419	22.9	156	23.0
50 to 59 years	480	19.1	365	20.0	115	16.9
60 to 69 years	388	15.5	306	16.7	82	12.1
70 to 79 years	105	4.2	82	4.5	23	3.4
80 to 89 years	8	0.3	7	0.4	1	0.1
Gender							0.733
Male	1021	40.7	755	41.3	266	39.2
Female	1488	59.3	1075	58.7	413	60.8
Ethnicity							0.017
Chinese	2012	80.2	1537	84.0	475	70.0
Malay	141	5.6	82	4.5	59	8.7
Indian	282	11.2	167	9.1	115	16.9
Others	74	2.9	44	2.4	30	4.4
Marital status							0.986
Never married	790	31.5	578	31.6	212	31.2
Currently married	1514	60.3	1100	60.1	414	61.0
Separated/divorced	140	5.6	104	5.7	36	5.3
Widowed	40	1.6	32	1.7	8	1.2
Refuse to answer	25	1.0	16	0.9	9	1.3
Highest Level of Education							0.597
Refuse to answer	17	0.7	12	0.7	5	0.7
No formal qualification	8	0.3	5	0.3	3	0.4
Primary	35	1.4	17	0.9	18	2.7
Secondary	461	18.4	313	17.1	148	21.8
Vocational training	93	3.7	58	3.2	35	5.2
Post-secondary	720	28.7	542	29.6	178	26.2
University and above	1175	46.8	883	48.2	292	43.0
Monthly household income on average (SGD)							0.799
Less than $2000	343	13.7	260	14.2	83	12.2
$2000 - $3999	471	18.8	329	18.0	142	20.9
$4000 - $5999	431	17.2	309	16.9	122	18.0
$6000 - $10,000	627	25.0	484	26.4	143	21.1
More than $10,000	380	15.1	279	15.2	101	14.9
Do not know	116	4.6	82	4.5	34	5.0
Refuse to answer	141	5.6	87	4.8	54	8.0
Housing type							0.999
Public housing 1-3-room	560	22.3	409	22.3	151	22.2
flat
Public housing 4-room flat	928	37.0	671	36.7	257	37.8
Public housing 5-room or	722	28.8	521	28.5	201	29.6
executive flat
Private condominium	181	7.2	135	7.4	46	6.8
Landed property	78	3.1	64	3.5	14	2.1
Do not know	4	0.2	3	0.2	1	0.1
Refuse to answer	18	0.7	13	0.7	5	0.7
Others	18	0.7	14	0.8	4	0.6

Table S5.

Association between probiotics consumption, university education and mean knowledge score

Characteristic	Mean (SD) of knowledge score	P-value	Statistical Test
Probiotics Consumption
Yes	0.89 (1.57)	0.255	Wilcoxon Two-sample test
No	0.75 (1.54)
University Education
Yes	1.12 (1.70)	<0.0001	Wilcoxon Two-sample test
No	0.66 (1.40)

Table S6.

Simple logistic regression analysis of knowledge score and probiotic consumption

Independent variable	b	se	Z ratio	Prob.
Knowledge score	0.059	0.070	0.837	0.403
Constant	2.78	0.115	24.2	0.00

Funding Statement

This research was funded by AMILI Pte Ltd, Singapore.