Knowledge, Attitudes, and Practices of Cardiac Healthcare Workers Toward Thoracoscopic Surgery in Xinjiang: A Cross-Sectional Study

Introduction

The recent decade has seen numerous improvements in cardiac surgery, leading to higher safety, reduced trauma, faster rehabilitation, and better cosmetic outcomes.¹ Those improvements translated into the development of cardiac thoracoscopic surgery, including partial sternotomies, small incisions, video-assisted procedures, total thoracoscopy, and robot-assisted procedures.² Many studies showed that compared with median sternotomy, these minimally invasive procedures are safe, feasible, and effective, decrease the need for blood transfusion, and improve rehabilitation.^3–7 Still, the learning curve is steep, the technical requirements are high, specialized equipment is needed, and the costs are higher.¹

Of course, thoracoscopic cardiac surgery will require knowledge of the procedures and the willingness to use them. Since there are advantages to using thoracoscopic cardiac surgery, examining the knowledge, attitude, and practice (KAP) of the cardiac healthcare workers toward the procedure could provide the barriers that affect its application. Continuing education activities could then be implemented to correct knowledge gaps and improve attitudes. A KAP study is a structured survey method that provides quantitative and qualitative data about the gaps, misunderstandings, and misconceptions regarding a given subject in a specific population.^8,9 There are currently no studies on the KAP of cardiac healthcare workers toward thoracoscopic cardiac surgery. One study reported that most European thoracic surgeons were unaware of ergonomics and related physical discomfort during thoracoscopic surgery.¹⁰ Still, it has been highlighted that knowledge must be sufficient before performing thoracotomy and thoracoscopy and that proper attitudes must be cultivated by demystifying the apparent complexity of thoracoscopy.¹¹

Therefore, this study aimed to investigate the KAP of cardiac healthcare workers in Xinjiang regarding thoracoscopic cardiac surgery. The results could help identify the gaps and barriers to deploying thoracoscopic cardiac surgery in Xinjiang and develop continuing education activities and policies.

Methods

Study Design and Participants

This cross-sectional study was conducted from September 2023 to May 2024 at the Department of Cardiac Surgery, First Affiliated Hospital of Xinjiang Medical University, and enrolled healthcare workers working in cardiac surgery (convenience sampling). The study was approved by the ethics committee of (K202309-02). Informed consent was provided by all participants before completing the questionnaire.

The inclusion criterion was healthcare workers involved in cardiac surgery (ie, cardiac surgeons, cardiologists, anesthetists, critical care physicians, and operating room medical staff) from the Xinjiang region. The exclusion criteria were individuals not related to the field of cardiovascular diseases.

Questionnaire

The questionnaire was designed by the investigators based on the literature.^3,5,10,11 The questionnaire was revised according to the comments from three experts in cardiac surgery. A pilot test was conducted with 46 respondents, and the reliability coefficient was 0.918.

The final questionnaire was in Chinese and encompassed four domains: demographic information (age, gender, marital status, highest education level, hospital grade, professional title, position, years of work experience, history of training in thoracoscopic cardiac surgery, and history of applying thoracoscopic cardiac surgery treatments), knowledge dimension, attitude dimension, and practice dimension.

The knowledge dimension comprised 13 questions, including 12 proper knowledge questions and one trap question. “No understanding at all” was scored 0 points, “some understanding” was scored 1 point, and “thorough understanding” was scored 2 points, for a total score range of 0–24 points. The trap question was a question that was obviously false. It was set up to make sure the participants were actually reading the questions. Hence, questionnaires with “true” to the trap question were excluded. In the present study, the trap question was 3×7+6=26, true or false.

The attitude dimension included seven questions scored using a 5-point Likert scale. For questions A1, A2, A3, A6, and A7, the scoring ranged from strongly agree (5 points) to strongly disagree (1 point), indicating a positive to negative attitude. For questions A4 and A5, the scoring was reversed, ranging from strongly agree (1 point) to strongly disagree (5 points), indicating a negative to positive attitude. The total score range was 7–35 points.

The practice dimension comprised nine questions, also using a 5-point Likert scale, with a maximum of 45. The responses were scored based on the frequency of proactive behavior, ranging from always (5 points) to never (1 point), with a total score range of 7–35 points.

For all three dimensions, a scoring threshold of >70% for each dimension was established to define adequate knowledge, positive attitudes, and proactive practices.^12,13

Study Course

This multicenter study enrolled participants at several hospitals, including the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region People’s Hospital, Huanghe Road Central Hospital of Xinjiang Uygur Autonomous Region, the Third People’s Hospital of Xinjiang Uygur Autonomous Region, Wuhan Asia Heart Hospital of Xinjiang Uygur Autonomous Region, the First People’s Hospital of Kashgar, the Second People’s Hospital of Kashgar, the First People’s Hospital of Hotan, and the People’s Hospital of Ayush. The director of the cardiac surgery department of each hospital was contacted. He was responsible for contacting the participants at his hospital and distributing the QR codes. The questionnaires were distributed to the study participants via a WeChat QR code using the Questionnaire Star platform. All questionnaire items were mandatory for submission. A given IP address could be used only once to submit a questionnaire. Questionnaires with an incorrect answer to the trap question, questionnaires with response time <50 s or >1800 s (determined by the online survey system), or questionnaires filled with an obvious pattern (eg, all first choices) were considered invalid and were excluded from the analysis.

Sample Size Calculation

The number of questionnaires required should be 5–20 times the number of KAP items in the questionnaire.^14,15 Given that there were 12, 7, and 9 knowledge, attitude, and practice items, respectively, for a total of 26 KAP items, at least 130 (26×5) questionnaires were needed.

Statistical Analysis

Descriptive analyses were performed on the demographic data and KAP scores of the participants, using means ± standard deviations to present the data. For group comparisons, Student’s t-test (two groups) and analysis of variance (ANOVA) (more than two groups) were used for normally distributed data, while non-parametric tests were used for data that did not conform to normal distribution. Categorical data were presented as n (%). Multivariable regression was conducted with the KAP scores as dependent variables to analyze the relationship between demographic data and KAP scores. The KAP scores were categorized based on the 70th percentile of their distributions. Variables with P<0.05 in the univariable analyses were included in the multivariable analyses. Spearman correlation analysis was used to examine the correlations between knowledge, attitude, and practice scores. A structural equation modeling (SEM) analysis was performed to examine the relationships among KAP dimensions based on the hypotheses that H1) knowledge influences attitude, H2) knowledge influences practice, and H3) attitude influences practice. A mediation analysis was performed to examine the direct and indirect influences. P-values were reported to three decimals, with P<0.05 considered statistically significant. The analyses were performed using SPSS 22 for all analyses except SEM (IBM, Armonk, NY, USA) and AMOS 22 for SEM (IBM, Armonk, NY, USA).

Results

Characteristics of the Participants

A total of 221 questionnaires were returned. After excluding 27 questionnaires with incorrect responses to the trap question, 194 valid questionnaires were included in the analysis. Among the 194 participants, 102 (52.58%) were male, and the largest age subgroup was 31–40 years (49.48%). The majority of the participants were married (74.23%), had a bachelor’s degree (55.15%), were working in tertiary hospitals (97.94%), had a junior title (41.75%), were physicians (48.97%), were working in the cardiothoracic surgery department (49.48%), had >10 years of experience (49.48%), had no training in thoracoscopic cardiac surgery (60.31%), and had experience in applying thoracoscopic cardiac surgery (60.31%) (Table 1).

Table 1 Characteristics of the Participants and KAP Scores

Knowledge

The mean knowledge score was 12.97±5.74, on a theoretical maximum of 24 (54.04%), indicating poor knowledge. In addition, 40 participants (20.62%) had a knowledge score >70%. The knowledge scores were associated with gender (P=0.001), job (P=0.001), departments (P<0.001), attended training related to thoracoscopic cardiac surgery (P<0.001), and experience in applying thoracoscopic cardiac surgery for patient treatment (P<0.001) (Table 1). The scores were poor for all knowledge items, with the majority of participants responding that they had some knowledge of all items and with <23% having good knowledge. The item with the highest “good knowledge” rate was K8 (22.68%). The item with the lowest “good knowledge” rate was K1 (17.53%) (Table 2).

Table 2 Distribution of the KAP Scores in the Knowledge Dimension

Attitudes

The mean attitude score was 26.11±2.57, on a theoretical maximum of 35 (74.60%), indicating a positive attitude; 133 participants (68.56%) had an attitude score >70%. The attitude scores were associated with the participant’s job (P=0.033) (Table 1). The item with the most positive attitude was A2 (91.23%), while the item with the lowest score was A3 (18.56%) (Table 3).

Table 3 Distribution of the KAP Scores in the Attitude Dimension

Practices

The mean practice score was 30.70±9.34, on a theoretical maximum of 45 (68.22%), indicating poor practice; 106 participants (54.64%) had practice scores >70%). The practice scores were associated with hospital level (P=0.034), job (P=0.011), departments (P<0.001), attended training related to thoracoscopic cardiac surgery (P<0.001), and experience in applying thoracoscopic cardiac surgery for patient treatment (P<0.001) (Table 1). The practice item with the highest score was P7 (62.37%), while the lowest score was observed for P3 (29.38%) (Table 4).

Table 4 Distribution of the KAP Scores in the Practice Dimension

Correlations

The knowledge scores were correlated to the attitude (r=0.186, P=0.009) and practice (r=0.560, P<0.001) scores. The attitude scores were correlated to the practice (r=0.367, P<0.001) scores (Table 5).

Table 5 Correlation Analysis

Multivariable Analysis

Having a doctoral degree (OR=25.7, 95% CI: 1.59–416, P=0.022) and no experience in applying thoracoscopic cardiac surgery for patient treatment (OR=0.05, 95% CI: 0.01–0.31, P=0.001) were independently associated with the knowledge scores (Table 6). Being a nurse (OR=0.48, 95% CI: 0.24–0.94, P=0.034) was independently associated with the attitude scores (Table 7). The knowledge scores (OR=1.17, 95% CI: 1.05–1.30, P=0.003), the attitude scores (OR=1.45, 95% CI: 1.22–1.73, P<0.001), and working in the cardiology (OR=0.17, 95% CI: 0.03–0.95, P=0.044), anesthesiology (OR=0.20, 95% CI: 0.05–0.77, P=0.019), and the operating room (OR=0.04, 95% CI: 0.00–0.32, P=0.002) departments were independently associated with the practice scores (Table 8).

Table 6 Univariable and Multivariable Analyses of the Knowledge Dimension

Table 7 Univariable and Multivariable Analyses of the Attitude Dimension

Table 8 Univariable and Multivariable Analyses of the Practice Dimension

SEM and Mediation Analyses

The fit indexes of the SEM model were good (Table 9). In the SEM (total effects) (Figure 1), knowledge influenced attitude (β=0.08, P=0.010), attitude influenced practice (β=0.98, P<0.001), and knowledge influenced practice (β=0.90, P<0.001) (Table 10). In the mediation analysis, knowledge directly influenced attitudes (β=0.08, P=0.010), attitude directly influenced practice (β=0.97, P<0.001), and knowledge influenced practice directly (β=0.89, P<0.001) and indirectly (β=0.07, P=0.023) (Table 11).

Table 9 Fit Indexes of the SEM Analysis

Table 10 SEM Analysis Parameters

Table 11 Mediation Analysis

Figure 1 Structural equation modeling.

Discussion

Thoracoscopic cardiac surgery can achieve better patient outcomes than median sternotomy, but it is a complex procedure with pros and cons. This multicenter cross-sectional study investigated the KAP of cardiac healthcare workers in Xinjiang regarding thoracoscopic cardiac surgery. The results showed that cardiac healthcare workers in Xinjiang had poor knowledge, positive attitudes, and poor practice regarding thoracoscopic cardiac surgery. Improving knowledge should improve both attitudes and practices. This study identified important knowledge gaps that could be improved.

Thoracoscopy is a complex intervention with a steep learning curve. Molnar et al¹¹ advocated that knowledge must be sufficient before performing thoracoscopy procedures; in addition, proper attitudes must be cultivated by demystifying the apparent complexity of thoracoscopy. The present study showed that the knowledge scores toward thoracoscopy were poor among cardiac healthcare workers in Xinjiang. All knowledge items had poor scores, indicating that continuing education about thoracoscopy, in general, should be designed and implemented in the cardiac healthcare community. On the other hand, the attitudes were favorable, indicating that the participants could be tempted to suggest and/or perform thoracoscopy given the opportunity. Still, the present study did not investigate whether the participants had access to the equipment and whether their hospital had policies for or against thoracoscopy for cardiac surgery. Of course, material and/or institutional barriers would hinder the performance of thoracoscopy and the participants’ interest in the procedure. Thoracoscopy can be performed robotically, which requires expensive equipment, but it can also be performed by video, which is less expensive.^1,11 Only one study reported about the KAP toward an aspect of thoracoscopic surgery, and not about the KAP of thoracoscopy cardiac surgery, ie, that most European thoracic surgeons were unaware of the ergonomics and physical comfort during thoracoscopic surgery.¹⁰

Higher education and experience in thoracoscopic cardiac surgery were independently associated with better knowledge scores. Nurses had lower attitude scores, possibly because they were not making decisions about treatments and surgical methods. Working in the cardiothoracic surgery department was associated with higher practice scores, which is consistent with the fact that it is the department where thoracoscopic procedures would actually be performed.

The multivariable, SEM, and mediation analyses support the idea that knowledge influences attitude and practice and that attitude influences practice. It is consistent with the KAP theory, which stipulates that knowledge is the basis for practice, while attitude is the force driving practice.^8,9 Hence, improving the knowledge of thoracoscopic cardiac surgery should translate into better attitude and practice.

Limitations

This study had limitations. Although the number of participants met the sample size requirements, the participants represented only a small proportion of the cardiac healthcare workers in Xinjiang and an even smaller proportion of the Chinese ones, limiting generalizability. The questionnaire was designed by the investigators according to local practice and policies, limiting generalizability and exportability. The design was cross-sectional, and the data represent a single point in time. Nevertheless, the present study could be used as a historical baseline for future intervention studies. Cross-sectional studies cannot be used to evaluate causality. SEM analyses allow some surrogate of causality, but the results must be interpreted cautiously as the causality is statistically inferred rather than observed.^16–18 Finally, all KAP studies are at risk of the social desirability bias,^19,20 ie, the participants can respond to what they know they should do instead of what they are doing.

Future Directions

In future studies, a KAP educational intervention should be designed and investigated to improve the KAP of cardiac healthcare workers regarding thoracoscopic cardiac surgery.

Conclusion

In conclusion, cardiac healthcare workers in Xinjiang had poor knowledge, positive attitudes, and poor practice regarding thoracoscopic cardiac surgery. Improving knowledge should improve both attitudes and practices. This study identified important knowledge gaps that could be improved.