Knowledge, attitudes, and practices regarding chronic atrophic gastritis in gastroenterology outpatient patients

Abstract

Background

This study aimed to investigate the knowledge, attitudes and practices (KAP) of gastroenterology patients regarding chronic atrophic gastritis (CAG).

Methods

A cross-sectional study was conducted between November 2023 and January 2024 in Southwest Hospital, Army Medical University, in Chongqing, China. It included patients visiting gastroenterology outpatient clinics. Their demographic characteristics and KAP scores were assessed using self-administered questionnaires.

Results

A total of 615 valid cases were enrolled. Among them, 328 (53.33%) were female. The mean knowledge, attitude, and practice scores were 10.72 ± 5.69 (possible range: 0–18), 44.91 ± 7.97 (possible range: 0–60), and 21.25 ± 5.11 (possible range: 0–36), respectively. Path analysis revealed that knowledge directly affected attitude (β = 0.628, P < 0.001) and attitude directly affected practice (β = 0.138, P < 0.001); however, the direct effect of knowledge on practice was not significant (β = -0.003, P = 0.947). Therefore, knowledge had an indirect effect on practice through attitude.

Conclusion

Gastroenterology outpatients in this study exhibited inadequate knowledge, moderate attitudes, and inactive practices regarding CAG. Enhancing patient education and awareness programs, particularly targeting those with lower education levels and non-medical occupations, could improve knowledge and foster more proactive attitudes and practices towards managing CAG within gastroenterology settings.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28466-y.

Background

Chronic gastritis (CG) is a condition characterized by persistent inflammation or thinning of the stomach lining. It manifests with symptoms such as abdominal pain, a feelings of fullness, a burning sensation, acid reflux, belching, and loss of appetite. Additionally, it can lead to emotional disturbances, including anxiety and depression [1]. CG can be classified into two primary types: chronic superficial gastritis (also referred to as chronic non-atrophic gastritis) and chronic atrophic gastritis (CAG) [2]. Of these, CAG is particularly significant due to its widespread prevalence and its status as a precancerous condition in the gastrointestinal tract. This makes it a critical public health concern, emphasizing the importance of early detection and intervention.

The incidence of CG is influenced by numerous factors; however, Helicobacter pylori (H. pylori) infection is the predominant cause, responsible for approximately 90% of cases. This infection not only leads to CG but is also a principal factor in the development of gastric cancer [3, 4]. The progression from H. pylori colonization to chronic gastritis, followed by atrophic gastritis, intestinal metaplasia, and eventually gastric cancer, underscores the pathological pathway that necessitates vigilant medical attention [5]. The prevalence of CAG varies significantly with age, affecting around 10% of the population aged 20–50 years and surging to over 50% in individuals aged 51–65 years, highlighting the increased risk associated with aging [6]. Regions with a high prevalence of gastric cancer exhibit a greater incidence of CAG compared to areas with lower rates, underscoring the correlation between CAG and gastric cancer. However, the diagnostic rate of CAG via endoscopy remains low, ranging from 17.7% to 39.8% [7]. This highlights the need for heightened public health focus and preventive measures against this condition.

The Knowledge-Attitude-Practice (KAP) theory significantly influences health behaviors, leveraging the KAP questionnaire to deeply understand the target population’s knowledge, attitudes, and practices within the healthcare sector. This approach not only assesses the demand and level of acceptance of pertinent information but also serves as a cornerstone of health literacy. Rooted in the belief that knowledge positively influences attitudes, which in turn, dictate practices [8, 9]. Patients who seek care at gastroenterology clinics, often due to gastrointestinal discomfort, are at a heightened risk for conditions such as Chronic Atrophic Gastritis (CAG). Their existing engagement with healthcare services, prompted by their symptoms, designates them as a crucial demographic for exploring their comprehension, attitudes, and management strategies regarding a condition that could lead to gastric cancer. The urgency of such exploration is underscored by the insidious nature of early gastric cancer, which typically remains asymptomatic, resulting in a significantly low early diagnosis rate [10]. Given that CAG is a precancerous stage potentially leading to gastric cancer, it is paramount to elevate awareness and understanding among patients who may be on the cusp of this disease continuum but are yet to recognize their vulnerability.

Despite existing studies on gastric cancer and its screening [11, 12], few studies have focused on KAP toward CAG among patients in gastroenterology clinics. Therefore, this study aimed to explore the KAP of gastroenterology patients regarding CAG.

Methods

Study design and participants

This cross-sectional study was conducted between November 2023 and January 2024 in Southwest Hospital, Army Medical University, located in Chongqing, China, and included patients attending the Gastroenterology Outpatient Department through convenience sampling. The study was ethically approved by the Southwest Hospital Medical Ethics Committee (approval number: KY2023134), and informed consent was obtained from all participants. The data collection was conducted via a QR code posted in the Gastroenterology Outpatient area, and thus all patients visiting the outpatient clinic during the study period were potential participants. Approximately 3,500 patients visited during the study period.

Inclusion criteria: (1) Patients who visited the gastroenterology outpatient department of the First Affiliated Hospital of the Army Medical University during the trial period; (2) Age 18 years or older; (3) Voluntary participation in research and signing of informed consent form.

Exclusion criteria: (1) Patients with benign tumors of the digestive tract; (2) Other chronic diseases that seriously affect survival, including malignant tumors, acute myocardial infarction, and severe hypertension; (3) History of mental illness, including the use of psychotropic drugs; (4) Presence of acute or severe digestive system diseases, including acute gastritis, pancreatitis, and acute hepatitis; (5) Patients deemed unsuitable by investigators.

Questionnaires were distributed to the study participants via web-based formats. The electronic questionnaire was constructed on the Wenjuanxing platform, and a QR code was generated. This QR code was posted in the Gastroenterology Outpatient area. Participants could scan the QR code and complete the questionnaire during their clinic visit.

Questionnaire

The formulation of the questionnaire was guided by pertinent literature [1, 13, 14]. Following its initial development, a pilot study was conducted with a limited sample size (n = 62), yielding a Cronbach’s alpha coefficient of 0.767, which indicated an acceptable internal consistency.

The final version of the questionnaire was administered in Chinese and comprised four distinct dimensions: demographic characteristics, knowledge, attitude, and practice. The knowledge dimension comprises 19 items. For items 1–18, correct responses were awarded 1 point and incorrect or ambiguous answers received 0 points, therefore, the possible range for knowledge scores was 0–18 points. Additionally, the final question was used to validate response effectiveness. The attitude dimension consists of 15 questions, rated on a five-point Likert scale ranging from “strongly agree” (4 points) to “strongly disagree” (0 points), with a cumulative score range of 0–60 points. Meanwhile, the practice dimension comprises 10 questions, with questions 1 and 2 scored as 4 points for “yes” responses and 0 points for “no” responses. Questions 4–10 employ a Likert scale, with a total score range of 0–36 points. According to Bloom’s cutoff, a widely utilized criterion in KAP studies, participants who achieved scores exceeding 80% of the total were categorized as possessing sufficient knowledge, positive attitudes, and proactive practices. Those who attained scores within the 60% to 80% range were deemed to have moderate levels of knowledge, attitudes, and practices. Scores falling below 60% of the total were indicative of inadequate knowledge, negative attitudes, and inactive practices [15].

Statistical analysis

Statistical analysis was conducted using SPSS 26.0 (IBM Corp., Armonk, N.Y., USA). Continuous variables were described using mean ± standard deviation (SD), and compared using t-tests or analysis of variance (ANOVA). Categorical variables were presented as n (%). The Pearson correlation analysis was employed to assess the correlations between knowledge, attitude, and practice scores. Univariate and multivariate logistic regression analyses were conducted to explore factors independently associated with sufficient knowledge, positive attitudes, and proactive practices, using 80% of the total score as the cut-off value. Variables with P < 0.05 in the univariate analysis were included in the multivariate regression. Structural equation modeling (SEM) was utilized to explore the interaction among KAP. A two-sided P < 0.05 was considered statistically significant in this study.

Results

A total of 783 questionnaires were initially collected. The screening of questionnaires resulted in the exclusion of 12 cases in which informed consent was not obtained, 135 cases with logical errors in answering item 19 of the knowledge dimensions, 6 cases with insufficient response time (< 120 s), 6 cases with participants below 18 years old, and 9 cases with logical errors in other questions. The final number of valid questionnaires was 615 cases. Of those, 328 (53.33%) were female, with a mean age of 41.96 ± 13.14 years. Additionally, 441 (71.71%) resided in urban areas, 323 (52.52%) had a college or bachelor’s degree, 152 (24.72%) were employed in medical or healthcare-related fields, while 463 (75.28%) worked in non-medical occupations, 486 (79.02%) had no underlying diseases, and 243 (39.51%) visited the clinic for routine health check-ups (Table 1).

Table 1.

Demographic characteristics and knowledge, attitude, practice scores

	N(%)	Knowledge		Attitude		Practice
		mean ± SD	P	mean ± SD	P	mean ± SD	P
Total		10.72 ± 5.69		44.91 ± 7.97		21.25 ± 5.11
Age (years)	41.96 ± 13.14
Gender			0.079		0.886		< 0.001
Male	287(46.67)	10.29 ± 5.76		44.96 ± 7.86		20.26 ± 5.08
Female	328(53.33)	11.10 ± 5.61		44.87 ± 8.08		22.11 ± 4.98
Residence			< 0.001		0.001		0.665
Rural	174(28.29)	9.23 ± 5.74		43.19 ± 8.41		21.10 ± 5.28
Urban	441(71.71)	11.31 ± 5.57		45.59 ± 7.70		21.30 ± 5.04
Ethnicity			0.237		0.010		0.046
Han	574(93.33)	10.80 ± 5.66		45.13 ± 7.92		21.36 ± 5.14
Minority ethnicity	41(6.67)	9.71 ± 6.05		41.80 ± 8.24		19.71 ± 4.37
Education			< 0.001		< 0.001		0.099
Primary school and below	49(7.97)	7.86 ± 5.92		42.37 ± 9.23		21.22 ± 5.27
Junior/high school/ technical school	191(31.06)	8.61 ± 5.45		43.51 ± 7.74		21.93 ± 5.29
Associate /bachelor’s degree	323(52.52)	11.96 ± 5.41		45.86 ± 7.69		21.01 ± 4.92
Master’s degree and above	52(8.46)	13.54 ± 4.34		46.54 ± 8.15		20.21 ± 5.30
Occupation			< 0.001		0.008		0.407
Medical and related fields	152(24.72)	14.20 ± 3.87		46.40 ± 7.62		20.95 ± 5.04
Other	463(75.28)	9.58 ± 5.73		44.42 ± 8.03		21.34 ± 5.13
Monthly Income (CNY)			< 0.001		0.017		0.082
< 5000	235(38.21)	9.18 ± 5.99		43.64 ± 8.28		21.57 ± 5.48
5000–10,000	236(38.37)	11.41 ± 5.26		45.50 ± 7.76		20.61 ± 4.95
10,000–20,000	96(15.61)	11.77 ± 5.71		45.83 ± 7.15		21.49 ± 4.51
> 20,000	48(7.80)	12.79 ± 4.31		46.35 ± 8.43		22.27 ± 4.92
Underlying diseases (Multiple choice)
Diabetes	21(3.41)	10.62 ± 4.76		44.95 ± 9.29		22.05 ± 6.69
Hypertension	52(8.46)	11.08 ± 4.60		45.96 ± 8.92		22.52 ± 4.65
Chronic kidney disease	12(1.95)	10.92 ± 5.38		43.00 ± 4.97		21.42 ± 5.47
Other diseases	60(9.76)	9.93 ± 6.15		44.40 ± 8.32		21.43 ± 5.63
No underlying diseases	486(79.02)	10.85 ± 5.74		44.92 ± 7.87		21.08 ± 5.00
Reason for current visit (Multiple choice)
Routine health check-up	243(39.51)	12.07 ± 5.35		46.07 ± 7.60		20.78 ± 4.93
Upper abdominal discomfort	138(22.44)	10.00 ± 5.63		44.64 ± 8.19		22.31 ± 5.20
Follow-up for digestive system diseases	106(17.24)	10.48 ± 5.00		45.74 ± 7.19		23.47 ± 4.97
Changes in bowel habits	45(7.32)	10.33 ± 5.26		44.44 ± 7.51		22.38 ± 5.21
Referral recommended by doctors from other departments	17(2.76)	9.06 ± 5.70		45.35 ± 8.47		20.88 ± 5.22
Other	122(19.84)	10.05 ± 6.3		43.47 ± 8.58		19.75 ± 4.73

The mean knowledge, attitude, and practice scores were 10.72 ± 5.69 (possible range: 0–18), 44.91 ± 7.97 (possible range: 0–60), and 21.25 ± 5.11 (possible range: 0–36), respectively. Gastroenterology patients who differed in residence (P < 0.001), education (P < 0.001), occupation (P < 0.001), and average monthly household income (P < 0.001) were more likely to have different knowledge scores. Those with differences in residence (P = 0.001), ethnicity (P = 0.010), education (P < 0.001), occupation (P = 0.008), and average monthly household income (P = 0.017) were more likely to have different attitude scores. In addition, differences in gender (P < 0.001) and ethnicity (P = 0.046) contributed to differences in practice scores (Table 1).

The distribution of knowledge dimensions revealed several noteworthy points. Notably, the statement “The more symptoms present, the higher the degree of progression of atrophic gastritis.” (K8) had a correctness rate of only 8.13%, indicating that a very small proportion of participants recognized this as an incorrect statement. Furthermore, the two knowledge items with the lowest correctness rates were “Chronic atrophic gastritis can be classified into open type (O-I, O-II, O-III) and closed type (C-I, C-II, C-III) based on the location and extent of atrophy observed during gastroscopy.” (K14) with 43.74% and “Intestinal metaplasia is generally distributed focally, and biopsy may not always accurately capture it.” (K11) with 47.15%. These findings suggest a significant need for improvement in the participants’ knowledge regarding these topics (Supplementary Table 1).

In general, the attitudes of gastroenterology patients tended to be positive; however, a significant proportion remained neutral on specific questions. Notably, 37.07% were neutral regarding whether chronic atrophic gastritis is more serious than other types of gastritis (A1). Similarly, 40.16% expressed neutrality on the question of whether the presence of intestinal epithelial hyperplasia indicates a greater risk of gastric cancer (A5). Furthermore, 36.75% were neutral about whether surgery is an appropriate treatment for atrophic gastritis and intestinal metaplasia. Optimistically, for all attitude items, only a small proportion of individuals were unequivocally opposed (Supplementary Table 2).

Responses to the practice dimension indicated that 54.96% and 55.77% do not undergo regular screening for HP infection (P1) and gastroscopy (P2), respectively. Conversely, 34.96% and 38.37% sometimes consume spicy and irritating foods (P6) and pickled, smoked, and fried foods (P7), respectively. When diagnosed with chronic atrophic gastritis (P10), 38.21% agreed to consider surgery as a treatment option; however, 32.68% expressed hesitation (Supplementary Table 3).

Correlation analysis showed that there were significant positive correlations between knowledge and attitude (r = 0.472, P < 0.001) as well as practice (r = 0.098, P = 0.015). Additionally, there was a correlation between attitude and practice (r = 0.213, P < 0.001) (Table 2).

Table 2.

Correlation analysis

	Knowledge	Attitude	Practice
Knowledge	1
Attitude	0.472(P < 0.001)	1
Practice	0.098(P = 0.015)	0.213(P < 0.001)	1

Multivariate logistic regression analysis indicated that education level of Master’s degree and above (OR = 2.990, 95% CI: [1.047–8.535], P = 0.041) and non-medical related occupations (OR = 0.367, 95% CI: [0.231–0.581], P < 0.001) were independently associated with knowledge (Table 3). Additionally, the knowledge score (OR = 1.224, 95% CI: [1.171–1.280], P < 0.001) was independently associated with positive attitude (Table 4). Furthermore, attitude score (OR = 1.049, 95% CI: [1.026–1.072], P < 0.001), age (OR = 1.039, 95% CI: [1.025–1.053], P < 0.001), and female gender (OR = 1.663, 95% CI: [1.188–2.326], P = 0.03) were independently associated with proactive practice (Table 5).

Table 3.

Univariate and multivariate analysis for sufficient knowledge

	Univariate analysis		Multivariate analysis
	OR (95%CI)	p	OR (95%CI)	p
Age (years)*	0.970(0.958 0.984)	< 0.001	1.000(0.983 1.017)	0.985
Gender
Male	ref.
Female	1.414(1.014 1.973)	0.041	1.106(0.753 1.623)	0.609
Residence
Rural	ref.
Urban	2.332(1.562 3.482)	< 0.001	1.357(0.845 2.179)	0.207
Ethnicity
Han	ref.
Minority ethnicity	0.919(0.472 1.792)	0.805
Education
Primary school and below	ref.
Junior/high school/ technical school	0.785(0.356 1.732)	0.549	0.728(0.319 1.661)	0.451
Associate /bachelor’s degree	3.298(1.592 6.833)	0.001	1.915(0.802 4.571)	0.143
Master’s degree and above	5.757(2.368 13.999)	< 0.001	2.990(1.047 8.535)	0.041
Occupation
Medical and related fields	ref.
Other	0.216(0.146 0.318)	< 0.001	0.367(0.231 0.581)	< 0.001
Monthly Income (CNY)
< 5000	ref.
5000–10,000	1.689(1.142 2.500)	0.009	0.975(0.619 1.538)	0.915
10,000–20,000	2.790(1.702 4.574)	< 0.001	1.203(0.678 2.134)	0.529
> 20,000	2.361(1.248 4.467)	0.008	1.198(0.584 2.455)	0.622

*Analyzed as as continuous variables in the regression analysis

Table 4.

Univariate and multivariate analysis for positive attitude

	Univariate analysis		Multivariate analysis
	OR (95%CI)	p	OR (95%CI)	p
Knowledge score*	1.213(1.166 1.262)	< 0.001	1.224(1.171 1.280)	< 0.001
Age (years)*	0.980(0.965 0.995)	0.009	0.985 (0.967 1.003)	0.100
Gender
Male	ref.
Female	1.081(0.719 1.624)	0.708
Residence
Rural	ref.		ref.
Urban	1.881(1.229 2.878)	0.004	1.430(0.870 2.351)	0.159
Ethnicity
Han	ref.
Minority ethnicity	0.796(0.369 1.718)	0.561
Education
Primary school and below	ref.
Junior/high school/ technical school	1.138(0.556 2.328)	0.723
Associate /bachelor’s degree	2.019(0.999 4.080)	0.050
Master’s degree and above	2.769(0.958 8.000)	0.060
Occupation
Medical and related fields	ref.		ref.
Other	0.475(0.274 0.825)	0.008	1.851 (0.915 3.745)	0.087
Monthly Income (CNY)
< 5000	ref.		ref.
5000–10,000	1.925(1.210 3.063)	0.006	1.192(0.691 2.057)	0.528
10,000–20,000	2.347(1.197 4.599)	0.013	1.486(0.681 3.245)	0.320
> 20,000	1.676(0.742 3.784)	0.214	0.746(0.301 1.849)	0.527

*Analyzed as as continuous variables in the regression analysis

Table 5.

Univariate and multivariate analysis for proactive practice

	Univariate analysis		Multivariate analysis
	OR (95%CI)	p	OR (95%CI)	p
Knowledge score*	1.015(0.987 1.044)	0.304
Attitude score*	1.038(1.017 1.060)	< 0.001	1.049(1.0261.072)	< 0.001
Age (years)*	1.036(1.023 1.050)	< 0.001	1.039(1.0251.053)	< 0.001
Gender
Male	ref.		ref.
Female	1.606(1.166 2.211)	0.004	1.663(1.1882.326)	0.003
Residence
Rural	ref.
Urban	1.074(0.755 1.527)	0.693
Ethnicity
Han	ref.
Minority ethnicity	0.508(0.258 1.001)	0.050
Education
Primary school and below	ref.
Junior/high school/ technical school	1.245(0.664 2.334)	0.494
Associate /bachelor’s degree	0.817(0.448 1.492)	0.511
Master’s degree and above	0.506(0.226 1.133)	0.098
Occupation
Medical and related fields	ref.
Other	1.278(0.882 1.850)	0.194
Monthly Income (CNY)
< 5000	ref.		ref.
5000–10,000	0.669(0.465 0.963)	0.031	0.757(0.513 1.118)	0.162
10,000–20,000	0.720(0.447 1.161)	0.178	0.829(0.498 1.380)	0.471
> 20,000	0.926(0.498 1.723)	0.809	0.892(0.466 1.705)	0.729

*Analyzed as as continuous variables in the regression analysis

Path analysis revealed that knowledge had a direct effect on attitude (β = 0.628, P < 0.001) and attitude directly affected practice (β = 0.138, P < 0.001). However, the direct effect of knowledge on practice was not significant (β = -0.003, P = 0.947); therefore, knowledge had an indirect effect on practice through attitude (Table 6).

Table 6.

Path analysis

			Estimate	P
Attitude	<---	Knowledge	0.662	< 0.001
Practice	<---	Attitude	0.138	< 0.001
Practice	<---	Knowledge	-0.003	0.947

Discussion

This study revealed that gastroenterology patients exhibit limited knowledge, moderate attitudes, and inactive practices regarding CAG. Enhancing patient education and awareness about CAG is critical to promoting proactive practices and improving overall management of this condition in clinical settings.

These findings offer valuable insights into the KAP concerning CAG among gastroenterology patients. Insufficient knowledge may lead to delays in early disease identification and intervention, thereby increasing the risk of serious outcomes, such as gastric cancer [16]. Moderate attitudes reflect a potentially insufficient awareness among patients about managing CAG, which may not sufficiently motivate proactive health behaviors. Additionally, inactive practices highlight the challenges in translating knowledge into behavior.

The disparities observed across demographic and socio-economic variables reflect the complexity of health education and behavior in relation to chronic diseases. For instance, gender differences in practice scores, with females exhibiting more proactive practices than males, resonates with existing literature which suggests women are generally more health-conscious and likely to engage in health-promoting behaviors [17]. This finding underscores the importance of gender-sensitive approaches in health promotion efforts. Moreover, the implications of these findings extend beyond the local context, highlighting a need for similar investigations in diverse populations to assess the universality of these trends. The influence of residence on knowledge and attitude scores emphasizes the gap in health information accessibility and health literacy between urban and rural populations. A previous study has consistently shown that urban residents have better access to health information and resources, which could explain the higher scores in urban participants [18]. Addressing this gap may involve creating tailored health education programs for rural communities, adapting these to their specific cultural contexts to increase effectiveness.

Ethnic disparities in attitude and practice toward CAG management indicate the role of cultural factors in health behaviors. These differences may stem from cultural backgrounds, ethnic variations, and dietary preferences [19, 20].

The multivariate logistic regression results highlighted that having a Master’s degree and above is independently associated with significantly higher knowledge scores. This finding is consistent with the baseline characteristics, which showed a clear trend of increasing knowledge scores with elevated educational levels, and is in line with the broader public health literature, which posits that higher educational attainment is associated with better health literacy and outcomes [21]. This underscores the need for education-based interventions in CAG management education. Moreover, individuals not working in medical and related fields showed lower knowledge levels. The baseline characteristics further corroborate this, revealing significantly higher knowledge scores among those in medical-related occupations. This suggests that targeting interventions based on occupation could be an effective strategy for health education and promotion efforts. Income-related disparities in knowledge and attitude scores further point to the social determinants of health, where higher income correlates with better access to health information and resources [22].

The correlation analysis found significant positive associations between knowledge of CAG and attitudes, as well as between attitudes and practices. These results suggest that individuals with greater knowledge of CAG tend to exhibit more positive attitudes, which in turn promotes better health practices. The indirect effect of knowledge on practice through attitude, as revealed by path analysis, underscores the critical role of attitude in mediating health behaviors. This aligns with the Health Belief Model, which posits that personal beliefs about health significantly influence health-related behaviors [23]. Therefore, interventions aimed at improving practices in CAG management should focus on enhancing both knowledge and attitudes.

The analysis of the knowledge section revealed substantial variability in patient awareness of CAG. A notable observation is the high level of awareness regarding the role of H. pylori infection and other risk factors in the development of CAG. Conversely, a significant gap in knowledge was evident regarding the progression and symptomatology of atrophic gastritis, particularly the misconception about symptom presence indicating disease progression. This gap indicates a critical area for educational efforts to inform patients about the asymptomatic nature of early-stage CAG. Recommendations to address these knowledge gaps include developing public health campaigns that leverage both traditional and digital media to disseminate accurate information about the symptomatology and progression of CAG. Healthcare providers should also emphasize the asymptomatic nature of early CAG during clinical encounters and the importance of regular screenings for high-risk populations [24, 25].

The attitudes section highlighted moderate patient concern about the potential for CAG to progress to cancer, which mirrors the concerns noted in studies, where the cancer progression fear from chronic conditions was a significant motivator for seeking medical advice [26]. However, ambivalence towards the efficacy of endoscopic examinations and treatments was evident, suggesting a lack of confidence in current diagnostic and management strategies for CAG. This ambivalence could be detrimental to patient engagement in proactive health behaviors and adherence to treatment protocols. To cultivate a more informed and proactive attitude among patients, it is recommended to enhance doctor-patient communication, providing clear, evidence-based information about the effectiveness of diagnostic and treatment options for CAG. Additionally, patient testimonies and videos could be integrated into educational materials to illustrate successful management and treatment outcomes, thereby boosting confidence in available medical interventions [27].

Regarding practices, the data indicated a reluctance towards regular HP testing and gastroscopy examinations, which is concerning given the asymptomatic nature of early-stage CAG. This reluctance may be attributed to a lack of symptomatic urgency to the perceived invasiveness and discomfort associated with such procedures. To encourage better health practices, recommendations include streamlining the process for scheduling and conducting HP tests and gastroscopy examinations to make them less daunting and more accessible. Additionally, educational interventions should underscore the importance of these procedures in early detection and management of CAG, potentially incorporating technology-based reminders and scheduling assistance to improve patient compliance. Moreover, promoting lifestyle modifications through community-based programs can address the low adherence to recommended dietary practices, emphasizing the role of diet in managing and preventing CAG [28].

This study has several limitations that should be acknowledged. First, the cross-sectional design restricts the ability to establish causality between knowledge, attitudes, and practices towards CAG. Additionally, reliance on self-reported data introduces the potential for recall bias and social desirability bias, particularly in assessing practices related to CAG management. Participants may overreport desirable practices or provide responses they perceive as socially acceptable. Consequently, the measured practices may differ from real-world behaviors, and the findings should be interpreted with caution. Moreover, as the data collection was conducted through a QR code, it was not possible to calculate an exact response rate. This may limit the precision of participant engagement and the representativeness of the sample. In addition, the use of self-administered questionnaires may have introduced response bias. Patients who were more interested in health-related topics or had higher levels of health awareness might have been more inclined to participate, whereas those with lower interest or awareness may have opted out. As a result, the KAP observed in this study could be overestimated compared to the overall gastroenterology outpatient population. Furthermore, as the patients’ responses could have been influenced by discussions with their doctors, but this factor was not evaluated in the study, which is another limitation. However, the finding of inadequate knowledge, moderate attitudes, and inactive practices still emphasizes the need for patient education. This study was conducted among a Chinese population with a high prevalence of gastric cancer. The regional focus may limit the generalizability of the findings to broader populations, considering variations in healthcare systems and cultural factors. Nevertheless, the conceptual framework underlying this study, based on the KAP model, is widely applicable across different populations and healthcare settings. The observed relationships among knowledge, attitudes, and practices regarding chronic atrophic gastritis are likely to be relevant in other regions, particularly those with a substantial burden of gastric cancer. As the association between CAG and gastric cancer has been well-established in various global populations, this underscores the necessity for enhanced public health education and early detection strategies, which are also applicable in other regions with differing prevalence rates of CAG and gastric cancer. However, caution should be exercised when extrapolating the absolute levels of KAP, as these may vary according to local disease prevalence, health literacy, and access to healthcare resources. Furthermore, no formal analysis for construct validity was conducted prior to data collection, further studies could be conducted to verify and optimize the questionnaire. Despite these limitations, the study offers significant strengths. The large sample size enhances the reliability of findings, while the use of rigorous analytical methods such as multivariate logistic regression and path analysis adds depth to the understanding of factors influencing these variables. Additionally, the identification of educational and occupational associations provides actionable insights for targeted interventions to improve patient outcomes in CAG management.

Conclusion

In conclusion, gastroenterology outpatients in this study demonstrate inadequate knowledge, moderate attitudes, and inactive practices towards CAG. It is imperative to prioritize efforts aimed at enhancing patient education programs focused on CAG to improve knowledge, attitudes, and subsequent proactive health practices. Targeting demographic groups identified as having lower levels of awareness and engagement is particularly crucial in this endeavor.

Abbreviations

KAP

Knowledge, attitudes and practices

CAG

Chronic atrophic gastritis

CG

Chronic gastritis

SD

Standard deviation

ANOVA

Analysis of variance

SEM

Structural equation modeling

Authors’ contributions

Jing Wu and Mei Yang carried out the studies, participated in collecting data, and drafted the manuscript. Hengyu Wang and Zhenyu Wu performed the statistical analysis and participated in its design. Li Liu and Lei Chen participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

The study was carried out after the protocol was approved by the Southwest hospital Medical Ethics Committee (approval number: KY2023134). I confirm that all methods were performed in accordance with the relevant guidelines. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments, and written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.