Knowledge regarding helicobacter pylori infection among patients in hail region of Saudi Arabia

Abstract

BACKGROUND:

Helicobacter pylori (H. pylori) is a gram-negative widely prevalent bacterium that is known to cause chronic gastritis, peptic ulcer disease, gastric carcinoma, and gastric lymphoma. Considering peptic ulcer patients will experience chronic relapse, eliminating H. pylori in this population is significant to prevent further relapses. The treatment should be based on the comorbidities and patient preferences. The objective of this study was to determine the level of knowledge, attitudes, and practices among patients generally in the Hail region of Saudi Arabia.

MATERIALS AND METHODS:

A descriptive cross-sectional study was conducted in the year 2023, among 880 participants which were selected through simple random sampling method. Data were collected using a validated self-administered questionnaire. Descriptive statistics and Mann–Whitney and Kruskal–Wallis H-test analysis were conducted to determine the knowledge level among different sociodemographic characteristics. P value of 0.005 was considered significant.

RESULTS:

Among 880 respondents, more than half (55.2%) had moderate knowledge regarding H. Pylori infection. Around 85.8% respondents have heard about H. pylori, and 23.9% were diagnosed with this bacterium. Higher knowledge score was more associated with the female gender (P = 0.001), having heard of H. Pylori infection (P < 0.001), and previous diagnosis of H. Pylori infection (P < 0.001).

CONCLUSION:

Study results showed that only 23.1% had good knowledge regarding H. Pylori infection, which requires public education and campaigns, especially among those who are at high risk. Further studies are suggested to include more populations and to elicit false concepts around the subject.

Introduction

Helicobacter pylori (H. pylori) is a gram-negative bacterium that is known to cause chronic gastritis, and it contributes to the development of peptic ulcer disease, gastric carcinoma, and gastric lymphoma.[1] It is a widely prevalent organism affecting approximately 50% of all people.[2] H. pylori infection correlates with peptic ulcer disease (63%) and with gastric cancer (100%), and it has a pathogenic rule in peptic ulcer disease and gastric cancer.[3] In the developed countries with a falling prevalence of infection and with the treatment of ulcer patients, the proportion of all peptic ulcer disease due to H. pylori is decreasing. In contrast, the prevalence in developing countries remains high with fewer patients receiving treatment. Untreated patients with peptic ulcer will experience chronic relapsing and remitting disease that causes mortality and morbidity because of bleeding, pain, and perforation. Thus, eradication of H. pylori in patients with a history of ulcer disease is important to prevent subsequent relapses.[4] Furthermore, screening and eradicating H. pylori infection is of most importance for the effective prevention of gastric cancer.[5] Low socioeconomic status, consumption of meat, fish, and family history of peptic ulcers have been found to increase the risk of acquisition of H. pylori infection.[6] Patients with H. pylori infection may be asymptomatic; however, most patients with symptoms will appear after developing gastric ulcers and present with abdominal pain, anorexia and vomiting, loss of weight, and hyperacidity.[7] The diagnosis is made by noninvasive and invasive tests. Noninvasive tests include urea breath test, blood sample, saliva and urinary antibody test, and stool antigen test. Invasive tests include acquiring a biopsy for microscopy, rapid urease test, culture, and brush cytology.[8] A study was conducted in the United Arab Emirates; the results shows that healthcare providers had good knowledge compared with community people.[9] Another study was conducted in Jordan; 63% of papulation had good knowledge regarding H pylori infection.[10] This study aims to assess the public awareness of H. pylori infection in the Hail region, Saudi Arabia.

Materials and Methods

Study design, sample technique, and sample size

Study design and setting

A cross-sectional study was carried out in the Hail region, Kingdom of Saudi Arabia.

Study participants and sampling

Sample size calculation through Epi info software, with a confidence level of 95%, and margin of error of 5%, the sample size was estimated to be 384 participants. The study was conducted over a period of 6 months, from May 2023 to November 2023. All methods were performed in accordance with the relevant guidelines and regulations. Convenience sampling was used to include the study participants.

Data collection tool and technique

Inclusion criteria included adults who are residents in the Hail region. An online anonymous survey was shared through social media platforms; informed consent from all participants obtained via the online survey and agreement to complete the anonymized online questionnaire was accepted as a willingness to participate in the study. Our study used a prevalidated pretranslated questionnaire, collected from a previous study.[10] Data are provided within the manuscript.

The questionnaire was developed through previous literature and World Health Organization guide to develop the knowledge survey. Questionnaire consists of two section: first, sociodemographic information and second, awareness regarding H. Pylori infection section. The knowledge of H. Pylori infection has been assessed using a 23-item questionnaire. The correct answer for each question was identified and coded with 1, while the incorrect answer was coded with 0. Total score points were calculated by adding all 23 items. A possible score range from 0 to 23 points has been generated. The higher the score, the greater the knowledge about H. Pylori infection. By using 50% and 75% as cutoff points to determine the level of knowledge, participants were considered as poor knowledge if the score was below 50%, 50% to 75% were considered moderate, and above 75% were considered good knowledge levels.

Ethical consideration

This study was approved from the ethical approval committee of university of Hail with approval number is H-2022-251, and all participants were given the consent to participate before entering in the study.

Statistical analysis method

Data entry and data analyses were performed using Statistical Packages for Software Sciences (SPSS) version 26, Armonk, New York, IBM Corporation. Descriptive statistics were used to elaborate the proportion of responses for each respondent. Values were computed and reported as numbers and percentages for categorical variables, while mean and standard deviation were used to define continuous variables. The knowledge score was compared with the sociodemographic characteristics of participants by using Mann–Whitney Z-test and Kruskal–Wallis H-test. The normal test (statistical collinearity) was measured using the Shapiro–Wilk test and the Kolmogorov–Smirnov test. The knowledge score follows the non-normal distribution; thus, the nonparametric tests were applied. Statistical significance was determined at P < 0.05.

Results

Eight hundred and eighty participants completed the survey. As described in Table 1, 54.1% were aged between 18 and 30 years old, 66.5% being females. Respondents who were bachelor’s degree holders constitute 71%. More than half (52.6%) were earning less than 5,000 SAR monthly. The prevalence of participants who have heard about H. Pylori infection was 85.8%. Previous diagnosis of H. Pylori infection was reported by 23.9%. Of them, 89% underwent treatment [Table 1].

Table 1.

Sociodemographic characteristics of participants (n=880)

Study Data	n (%)
Age group
• 18 – 30 years	476 (54.1%)
• 31 – 40 years	171 (19.4%)
• 41 – 50 years	139 (15.8%)
• >50 years	94 (10.7%)
Gender
• Male	295 (33.5%)
• Female	585 (66.5%)
Educational level
• Elementary school	05 (0.60%)
• Middle school	15 (1.7%)
• High school	189 (21.5%)
• Bachelor’s degree	625 (71.0%)
• Master or PhD	46 (5.2%)
Occupational status
• Employed in Medical Field	38 (4.3%)
• Employed in Nonmedical Field	298 (33.9%)
• Student	393 (44.65%)
• Unemployed	151 (17.15%)
Monthly income (SAR)
• <5,000	463 (52.6%)
• 5,000 – 9,000	130 (14.8%)
• 10,000 – 20,000	234 (26.6%)
• >20,0000	53 (6.0%)
Heard of H. Pylori infection
• Yes	755 (85.8%)
• No	125 (14.2%)
Previous diagnosis of H. Pylori infection
• Yes	210 (23.9%)
• No	670 (76.1%)
Treated for H. Pylori infection (n=210)
• Yes	187 (89.0%)
• No	23 (11.0%)

In Table 2, respondents were aware that the most common risk factor for H. Pylori infection was the consumption of raw vegetables and fruits (85.7%), followed by not washing hands before meals (82.6%) and consumption of fast food (73.1%). Respondents believed that the most common symptom of H. Pylori was abdominal pain (85.3%), followed by nausea (76.7%) and loss of appetite (73.9%). According to participants, the most common method to diagnose H. Pylori was endoscopy (52%) and stool test (43.8%). Complications of H. Pylori mostly occur through gastritis (63.6%). The majority (77.2%) knew that H. Pylori should be treated with antibiotics (77.2%). Only 28.9% had the knowledge that H. Pylori is an infectious disease. The overall knowledge score was 14.4 (SD 4.08), with good, moderate, and poor knowledge levels found among 23.1%, 55.2%, and 21.7%, respectively.

Table 2.

Assessment of the participants’ knowledge of H. Pylori infection (n=880)

Knowledge statement	Correct Answer n (%)
Which of the following is a risk factor for H. Pylori infection?
1. Consumption of raw vegetables and fruits (yes)	754 (85.7%)
2. Not washing hands before a meal (yes)	727 (82.6%)
3. Consumption of outside food from an unknown source (yes)	643 (73.1%)
4. Consumption of unfiltered water (yes)	564 (64.1%)
5. Consumption of untreated water (yes)	551 (62.6%)
Which of the following is a symptom of H. Pylori infection?
6. Abdominal pain (yes)	751 (85.3%)
7. Nausea (yes)	675 (76.7%)
8. Heartburn (yes)	650 (73.9%)
9. Loss of appetite (yes)	643 (73.1%)
10. Belching (yes)	619 (70.3%)
11. Weight loss (yes)	608 (69.1%)
12. Bloating (yes)	542 (61.6%)
13. Bad breath (yes)	514 (58.4%)
Which of the following methods are used to diagnose H. Pylori infection?
14. Endoscopy (yes)	458 (52.0%)
15. Stool test (yes)	385 (43.8%)
16. Urea breath test (yes)	355 (40.3%)
17. Blood test (yes)	347 (39.4%)
Which of the following complication may occur with H. Pylori infection?
18. Gastritis (yes)	560 (63.6%)
19. Gastric/Duodenal Ulcer (yes)	531 (60.3%)
20. Gastric cancer (yes)	192 (21.8%)
21. Should H.pylori infection be treated? (yes)	845 (77.2%)
22. To the best of your knowledge, how is H. Pylori infection treated? (antibiotics)	679 (77.2%)

When measuring the differences in the score of knowledge and the sociodemographic characteristics of participants [Table 3], it was found that a higher knowledge score was more associated with the female gender (Z = 3.458; P = 0.001), having heard of H. Pylori infection (Z = 6.130; P < 0.001) and previous diagnosis of H. Pylori infection (Z = 6.190; P < 0.001) [Table 3].

Table 3.

Differences in the score of knowledge and the sociodemographic characteristics of participants (n=880)

Factor	Knowledge Score (23) Mean±SD	Z/H-test	P §
Age group
≤30 years	14.6±4.09	1.565	0.118
>30 years	14.2±4.06
Gender
Male	13.6±4.53	3.458	0.001**
Female	14.8±3.78
Educational level
High school or below	14.3±4.10	0.006	0.995
Bachelor or higher	14.4±4.08
Occupational status
Employed	14.2±4.28	4.421	0.110‡
Student	14.7±3.99
Unemployed	14.0±3.81
Monthly income (SAR)
<10,000	14.4±4.04	0.222	0.824
≥10,000	14.3±4.17
Heard of H. Pylori infection
Yes	14.8±3.86	6.130	<0.001**
No	12.0±4.58
Previous diagnosis of H. Pylori infection
Yes	15.9±3.36	6.190	<0.001**
No	13.9±4.18

^§=P-value has been calculated using Mann–Whitney Z-test. ^‡=P-value has been calculated using Kruskal–Wallis H-test. **=Significant at P<0.05 level

Among study participants, the knowledge level was good knowledge 23.1%, moderate knowledge 55.20, and poor knowledge 21.7% [Figure 1].

Figure 1.

Level of knowledge regarding H. pylori infection among study participants

Discussion

This study evaluates the general population’s knowledge regarding H. Pylori (HP) infection. The knowledge of our population regarding HP infection was adequate. More than half (55.2%) of our respondents were considered to have moderate knowledge, 23.1% were considered good, and only 21.7% were considered poor knowledge levels. The overall mean knowledge score was 14.4 (SD 4.08) out of 23 points. This is comparable with the study done in Al Ahsa,[10] 54.9% of the Al-Ahsa general population knew HP, including risk factors, diagnosis, treatment, and complications. Contradicting these reports, a study conducted in the USA[8] documented limited knowledge about HP, particularly about the transmission and its link with gastric cancer. This has been concurred by the cross-sectional study among Jordanian population,[11] with 68.7% reporting a low level of knowledge. It is necessary to raise awareness of HP among the general public as this bacterium is usually transmitted through daily commodities such as raw vegetables and fruits, outside food from unknown sources, and unfiltered water. Health education, especially about proper hand hygiene and the risk factors for HP, is important to prevent HP-related infection.

Data in this study suggest that female participants were more associated with having a better knowledge of HP compared to their male counterparts. This is consistent with a United Arab Emirates study.[12] Based on their reports, females were seen to have better knowledge scores compared with males. In addition, participants with a medical background typically demonstrated higher knowledge scores than those working in other fields. This was also seen in the reports of study conducted in the Northwest Region of Cameroon,[9] wherein gender, age, level of education, and occupation were the factors that influenced knowledge. In our study, however, age, education, occupational status, and monthly income were found to have no statistically significant association with knowledge (P > 0.05), which was consistent results with the study conducted in Al Ahsa.[10]

Basic knowledge about HP is crucial to infection prevention. In our study, a high proportion of our respondents (85.8%) have heard about HP infection, and having heard of HP infection was more associated with having better scores in knowledge. Furthermore, we noted that the prevalence of previous HP infection was 23.9%, among those who had infections had been treated. Similarly, respondents who had previous diagnoses of HP had better knowledge of HP infection. Among the Chinese population,[13] the majority (68.9%) also have heard about HP, but their attitude about it was less, as 67.5% had never done an HP test.

In the specific assessment of knowledge about HP infection, our results indicate that although the majority of respondents were aware of several risk factors for HP infection—such as the consumption of raw vegetables and fruits (85.7%), improper hand hygiene before meals (82.6%), consumption of fast food (73.1%), and drinking unfiltered (64.1%) and untreated water (62.6%)—only 28.9% recognized that HP is an infectious disease. A previous study conducted in the United Arab Emirates[12] identified additional risk factors for HP infection, including meat consumption, dining in restaurants, smoking, and drinking unfiltered or nonboiled water. Many of these risk factors are preventable, highlighting the need for increased awareness to improve prevention rates. Interestingly, a report from a study conducted in Alkharj, Riyadh, Saudi Arabia,[14] indicated that a lack of knowledge regarding HP is associated with nutritional factors, food allergies, and food intolerance. Surprisingly, a considerable proportion (71.4%) of respondents were unaware that washing hands after using the toilet is negatively associated with HP.

Likewise, our respondents were seen to have a better understanding of HP symptoms, with a more than 60% accuracy rate for identifying the right symptoms, such as abdominal pain, nausea, heartburn, loss of appetite, belching, weight loss, and bloating, only a symptom related to bad breath was rated below 60%[15]. In spite of sufficient knowledge of HP symptoms, their knowledge of how to diagnose the disease was suboptimal, as only 52% knew that it could be diagnosed by endoscopy (52%), stool test (43.8%), urea breath test (40.3%), and blood test (39.4%). In addition, even though 63.6% and 60.3% were aware that gastritis and gastric/duodenal ulcer were the main complications associated with HP infection, only 21.8% knew gastric cancer was also a complication of HP infection. This mirrored the study carried out among Jordanian population,[11] as most of the surveyed subjects knew HP’s signs and symptoms. Some of them were abdominal pain (75.5%), nausea/vomiting (68.4%), and abdominal bloating (59.8%). Regarding knowledge about HP diagnosis, endoscopy was also rated the highest (62.4%), followed by stool antigen (62.2%), while the least was the urea breath test (13.8%).

Limitations and recommendation

This study has different limitations. First, recall bias due to self-reported data which leading to low accurate information. Second, representation of target papulation may be not accurate due to small sample size. Moreover, cross-sectional studies provide lack of temporality which no association of cause and effect. The study recommends implementing community-based health education programs to raise the awareness about H pylori infection, its transmission, and prevention methods.

Conclusions

Our studied population showed that more than half (55.2%) had moderate knowledge regarding H. Pylori infection, 28.9% had the knowledge that H. Pylori is an infectious disease, females were seen to have better knowledge scores compared to males as H. Pylori infection has many preventable risk factors, and more awareness is required to achieve a better prevention rate, which requires public education and campaigns, especially among those who are at high-risk. Further studies are suggested to include more populations and to elicit false concepts around the subject.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.