Population Knowledge, Attitude, and Practice Regarding Helicobacter pylori Transmission and Outcomes: A Literature Review

Background Helicobacter pylori infection is associated with the development of chronic gastritis, peptic ulcer disease, and gastric cancer. Current clinical recommendations are that H. pylori test-and-treat should be individualized based on comorbidities and patient preferences among populations at increased risk for certain morbidities. However, knowledge, attitudes and practices regarding H. pylori among potential patient populations are largely unknown. Materials We conducted a literature review to assess knowledge, attitudes, and practices of patients or community populations around H. pylori transmission, prevention, and associated morbidity. Results Nine studies met the inclusion criteria, all published between 1997 and 2014. Eight studies evaluated perception of H. pylori among at-risk populations, while one study evaluated perception among a general population. The studies suggest inconsistencies between the perceptions of these populations and the established understanding of knowledge, attitude, and preventive practices for H. pylori among even at-risk populations. Conclusion To adequately respond to current test-and-treat recommendations for treatment of H. pylori, general population education must be implemented, especially among at-risk populations. Further work is needed within at-risk populations in the United States to determine prevalence of H. pylori and their current knowledge if adequate prevention strategies are to be designed.

H. pylori, which involves a multistep process from chronic gastritis to atrophic gastritis to intestinal metaplasia to dysplasia to gastric cancer, can take decades to develop (3). This slow progression provides an opportunity for early detection and treatment of H. pylori, leading to the prevention of gastric cancer.
Helicobacter pylori screening and prevention among at-risk groups may reduce certain diseases and "test-and-treat" should be individualized based on comorbid illness and patient preferences (4). These at-risk populations include individuals with a number of potential indications, including a confirmed history of peptic ulcer disease and gastric MALT lymphoma (4). In the United States, higher prevalence of H. pylori has been reported among individuals living close the US/Mexico border, as well as among American Indians and Alaska natives (5)(6)(7). However, among at-risk populations, the current level of knowledge and behaviors and risk perception are unknown. This information is needed if "test-and-treat" strategies are to be successfully employed for specific populations. The aim of this review is to examine the current literature with respect to public perceptions of the impact of H. pylori.

MATeRiALS AnD MeTHODS
A framework to assess knowledge, attitudes, and practices (KAPs) was defined based on the World Health Organization Guide to Developing Knowledge, Attitude, and Practice Surveys (8). In the context of this review, "Knowledge" referred to general knowledge about H. pylori including transmission, course of infection, disease sequelae, risk/protective factors, diagnosis, treatment, and prevention. "Attitudes" referred to individual, peer, and community risk perception of getting H. pylori or its disease sequelae. "Practices" corresponded to actions people might take to prevent H. pylori infection, including hand washing, safe food preparation, and source of drinking water. These latter practices were sought because evidence suggests fecal-oral transmission may play a role in H. pylori transmission (9), and these practices were outlined by the National Institutes of Health as ways to reduce chances of H. pylori infection (10).
A literature search was conducted in April 2017 in PubMed using ("Helicobacter" OR "H. pylori") AND ("survey" OR "questionnaire") AND ("knowledge" OR "attitudes" OR "practices") as search terms. Inclusion criteria were that the study collected primary data from at-risk or members of the general population and that the study incorporated a survey to assess participants own knowledge, attitudes, or practices regarding H. pylori. There were no other exclusion terms (e.g., language or date of publication).

ReSULTS
The initial search terms yielded 133 results, with two additional studies identified through follow-up of references. After title and abstract screening to exclude articles not focused on potential patient KAP, 15 articles remained. After reviewing full text, an additional six studies were rejected because the survey included only demographic and/or clinical history without any assessment of KAP (n = 5), or H. pylori was not the primary focus of study (n = 1).
Of the nine studies included in this review, two were conducted in eastern China (11,12), two in South Korea (13,14), two in North America (15,16), and one each in Ethiopia (17), India (18), and Malaysia (19). All studies focused on populations at increased risk for gastric cancer, except the US population-based survey to assess and promote awareness (15). Within this search, no publications were found which specifically addressed gaps in KAP among the general population regarding risks associated with acquiring H. pylori infection. All studies were published between 1997 and 2014. For each study, the type of questions used in the survey tool were classified into demographic, clinical history, knowledge, attitude, or practice related questions. A summary of the questions (along with results) is presented in Table 1.

Knowledge
Six studies reported on H. pylori knowledge (11)(12)(13)(14)(15)(16). General knowledge about H. pylori was poor across all studies. Of the two studies that asked whether participants had heard of H. pylori, only 22-35% of respondents answered "yes" (11,12). Interestingly, one study found that those who tested negative for H. pylori had heard of H. pylori more often than those who tested positive (12).
Knowledge about H. pylori transmission was also generally poor. When asked how people can acquire the infection, only 26% of participants mentioned water (16). When asked whether oral transmission was usual among family members, 31.1% of participants responded "yes, " 12.6% responded "no, " and 49.5% responded "do not know" (14). When asked about transmission, people who tested positive for H. pylori showed less understanding than those who tested negative (12). One study, asking about transmission found only 23.8% of respondents correctly answered that H. pylori can be transmitted by unsafe food preparation and water sources (11).
The two studies from South Korea evaluated knowledge of H. pylori as it relates to gastric cancer. Among healthy Korean adults undergoing screening via upper endoscopy 58.3% of respondents answered "yes, " that H. pylori is known to cause gastric cancer, while 4.8% answered "no, " and 32.9% responded "do not know" (14). Randomly selected respondents in the South Korean population-based survey were asked to what degree individual factors were associated with developing and preventing gastric cancer (13). Respondents believed stress was the highest risk factor for developing gastric cancer, followed by gastric lesions (including chronic gastritis, gastric ulcer, and previous gastrectomy) and eating charred foods. Respondents believed that removing stress would have the greatest impact on preventing gastric cancer, followed by eating vegetables and fruits, and removing gastric lesions.