Knowledge, Attitudes, and Practices Related to Helicobacter pylori and Gastric Disease in Jordan: Implications for Early Detection and Eradication

Key Messages

• Main findings: This study has revealed a moderate level of knowledge regarding H. pylori infection among the Jordanian population. Although 40–60% of participants showed a high level of awareness of H. pylori and its connection to stomach ulcers and cancer, there were notable gaps in their understanding of the relationship between H. pylori infection and lifestyle factors.
• Added knowledge: This study adds new knowledge by identifying gaps in awareness of H. pylori infection within the Jordanian population, especially among individuals with different employment statuses, highlighting the need to educate vulnerable groups, such as young adults and non-medical professionals, regarding H. pylori infection risk and prevention.
• Global health impact in terms of policy and action: The study findings highlight the necessity of enhanced public health strategies to control H. pylori infection, particularly in areas with restricted healthcare resources. Integrating awareness programs into public health policies could significantly reduce the incidence of serious gastrointestinal diseases associated with chronic H. pylori infection.

Introduction

Globally, gastric cancer and ulcers are responsible for 1 million deaths annually, particularly among low- and middle-income individuals. Gastric cancer is the third leading cause of cancer-related deaths and the fifth most commonly diagnosed malignancy,¹ ranking seventh among Jordanian males and tenth among Jordanian females.² Helicobacter pylori (H. pylori) infection, a Gram-negative, flagellated, microaerophilic bacterial pathogen that selectively colonizes the stomach epithelium, causes long-lasting chronic inflammation and significantly increases the risk of developing gastric cancer, particularly with CagA-positive strains.^3,4 The majority of H. pylori infections are asymptomatic, with only a subset progressing to gastric cancer. Clinical outcomes are influenced by a complex interplay of host susceptibility, environmental factors, and bacterial strain characteristics. Genetic diversity among H. pylori isolates contributes to variations in pathogenicity, with key virulence factors such as the cag pathogenicity island (cag PAI) and VacA playing significant roles. Strains possessing a functional cag PAI and the CagA protein are associated with a higher risk of gastric cancer compared to cag-negative strains due to the oncogenic effects of CagA.³ Epidemiological studies suggest that 2–3% of individuals with H. pylori infection develop gastric cancer, while around 10% develop peptic ulcer disease.⁵

The prevalence of H. pylori infection varies significantly across regions, with higher rates observed in developing nations than in developed nations, reaching more than 70% in developing countries.^6–8 For example, in Jordan it has been estimated that approximately 88% of the Jordanian population tests positive for H. pylori.⁹ The primary mode of transmission is believed to be through oral–oral or fecal–oral contact during childhood, and the infection persists throughout life in the absence of antibiotic treatment. Therefore, risk factors for H. pylori infection are closely associated with food and personal hygiene.^5,10

The connection between H. pylori infection and an increased risk of developing stomach cancer is well-established, leading the World Health Organization to classify it as a class I carcinogen.¹¹ Notably, a study by Uemura et al found that none of the H. pylori-uninfected patients developed gastric cancer, whereas 3% of the H. pylori-infected patients did. Eradicating H. pylori, especially in individuals infected with cagA-positive strains, has been shown to significantly lower the risk of developing precancerous lesions and gastric cancer.¹²

The development of gastric cancer is a complex and gradual process that can take decades to progress from H. pylori infection, starting with the transition from normal mucosa to non-atrophic gastritis, followed by atrophic gastritis, intestinal dysplasia, and, eventually, adenocarcinoma.^13,14 This latency period offers an opportunity for early detection and elimination of H. pylori before complications occur.

Prospective studies by Mera et al have shown that successful antibiotic-mediated eradication of H. pylori significantly reduces the incidence of precancerous lesions, emphasizing the role of H. pylori in initiating a multistep cascade that leads to these lesions.¹⁵ Currently, H. pylori infection is considered the most significant and controllable risk factor for preventing gastric cancer.⁸

Despite the importance of knowledge and awareness regarding H. pylori infection and its potential complications, there is general consensus that the public lacks understanding in this regard. However, a previous study indicated that knowledge of the association between H. pylori infection and gastric cancer is likely to prompt individuals to undergo screening and receive treatment for H. pylori infection,^16,17 as knowledge correlates with positive attitudes and good practices.¹⁸ For instance, a survey conducted in the United Arab Emirates to assess the knowledge, attitudes, and practices (KAP) of the adult population regarding H. pylori-induced stomach ulcers and gastric cancer revealed that only 24.6% of adults had heard of H. pylori, with 33% willing to seek medical help if they experienced H. pylori infection symptoms. The majority of participants (approximately 61%) were unaware of the connection between H. pylori and gastric cancer.¹⁷

The purpose of this study was to evaluate current KAP levels among the Jordanian population regarding H. pylori-induced stomach ulcers. It aimed to promote early identification and eradication of H. pylori infection and raise awareness about the consequences of untreated H. pylori infection.

Materials and Methods

Development of the Survey

The survey used in this study was created by Malek et al¹⁷ and adapted for the general population in Jordan. Initially, a group of gastroenterologists and microbiologists reviewed and validated each item in the original survey and selected relevant items for this study. To ensure clarity and suitability for the general population, a pilot study was conducted using a random sample of 20 individuals. Following pilot testing, linguistic and grammatical modifications were made to enhance question comprehensibility. The internal consistency of the survey was evaluated and Cronbach’s alpha coefficient for knowledge was calculated to be 0.83. The data collected during the pilot phase were not included in the final results of this study. The well-designed and comprehensive survey was then distributed to the study population. Data collection took place from December 2023 to April 2024.

The survey of the Jordanian population regarding H. pylori infection encompassed four sections: demographics (eight items), knowledge (six items), attitudes (two items), and practices (two items). The demographic section gathered information on participants’ gender, age, nationality, educational level, and occupation. Participants were also asked about their current symptoms and previous health conditions. Knowledge was assessed through multiple-choice questions that aimed to gauge the participants’ understanding of gastric ulcers in general and H. pylori specifically. Attitudes toward the prevention of gastric ulcers and avoidance of H. pylori infection were also evaluated using multiple-choice questions. The practice section consisted of multiple-choice questions about the participants’ regular habits.

Calculation of Sample Size

The sample size was determined using the Kish formula for sample size estimation, considering a 95% significance level and a 5% margin of error. The estimated sample size was 384. A total of 408 undergraduate students were recruited for the current study.

Ethical Approval

This study was approved by the Ethics Committee of Zarqa University (approval #2023/7/5259/36).

Outcome Measures

This study was designed to evaluate the knowledge, attitudes, and practices (KAP) of the Jordanian population concerning the relationship between H. pylori infection, gastric ulcers, and cancer.

Data Analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS, version 26). Descriptive statistics (mean, standard deviation, and frequency) were used to describe the sample and knowledge, attitudes, and practice levels. A series of independent-sample t-tests and analysis of variance (ANOVA) were then used to identify differences in knowledge scores based on demographics. Results were considered statistically significant at a significance level of less than 0.05.

Results

Participant Characteristics

Table 1 presents the sociodemographic characteristics of the 398 participants. The majority (70.4%) were aged between 18 and 29 years and most were female (n=289, 72.6%). Additionally, 71.6% held a bachelor’s degree and 54.8% were employed in non-medical fields.

Table 1 Sociodemographic Characteristics of Participants (N=398)

Table 2 presents the clinical characteristics of the participants; most of the sample (n=350, 87.9%) did not currently have H. pylori infection. The participants’ most frequent health issues were acid reflux disease (heartburn) and constipation or diarrhea (47.7 and 34.4%, respectively). Loss of appetite and heartburn were the most frequent symptoms participants were currently experiencing or had previously experienced. Participants with a H. pylori infection most commonly reported experiencing constipation or diarrhea (66.7%), recurring pain or burning in the upper abdominal area (60%), and peptic ulcer disease (60%). The most prevalent symptoms reported were heartburn (53.3%) and a dull, aching pain similar to hunger (46.7%), as shown in Table 3.

Table 2 Clinical Characteristics of Participants

Table 3 Clinical Characteristics of Participants with a H. pylori Infection

Knowledge Regarding H. pylori

In terms of knowledge of H. pylori, Table 4 shows that more than half of the participants (n=256, 64.3%) had heard of it previously. For approximately one-third of participants (39.1%), the source of information was their place of study, followed by family members or friends (20.3%). The most commonly recognized causes of stomach ulcers were bacterial infections (58.5%), stress and depression (55.3%), and smoking, alcohol consumption, and drug abuse (55.0%). Additionally, 75.9% of patients reported that H. pylori infection was frequently associated with gastric ulcers. Regarding remedies, 45.7% indicated that they would use or recommend antacids to relieve ulcer symptoms, followed by drinking milk (40.2%). Regarding transmission, 60.6% of participants frequently mentioned that H. pylori was transmitted through contaminated food and water. Regarding knowledge of foods that are allowed or prohibited for individuals with stomach ulcers, Figure 1 illustrates that the majority of participants identified allowed foods such as meat (eg, beef, chicken, and fish) and dairy products (58.3 and 68.8%, respectively). On the other hand, prohibited foods included citrus fruits (eg, orange and pineapple), beverages (eg, coffee, including decaffeinated coffee, soft drinks, and black tea), and certain fruit and vegetables (eg, lemons and spicy peppers) (56.8, 75.4, and 68.6%, respectively).

Table 4 Knowledge of H. pylori-Induced Gastric Ulcers and Cancers

Figure 1 Knowledge that certain foods should be allowed or prohibited in cases of stomach ulcer.

Attitudes Toward H. pylori

Figure 2 highlights the participants’ general attitudes toward the prevention of H. pylori infection. The most commonly recommended preventive measure was the consumption of clean water and food, with 73.6% of participants advocating for it. Over half of the participants (59.3%) recognized the importance of regular medical checkups for early detection and management of H. pylori infection. Additionally, 56.5% of respondents acknowledged the significance of improving self-hygiene practices, such as maintaining personal sanitation and proper handwashing, to reduce the risk of infection. A portion of participants (54.8%) also emphasized the role of avoiding the sharing of utensils as a preventive measure, recognizing the potential for oral–oral transmission Notably, a small percentage of participants (6.0%) reported not following any of the preventive measures mentioned.

Figure 2 General attitudes of participants regarding prevention of H. pylori infection.

Practices and Daily Habits

The most frequent practices that the participants engaged in regularly were drinking coffee (36.4%), eating spicy food (32.2%), drinking soft drinks (20.9%), other forms of smoking (hookah/electronic cigarettes, etc) (17.1%), smoking cigarettes (16.3%), and use of anti-inflammatory drugs (15.1%), as presented in Table 5.

Table 5 Practices in which the Population Engages on a Regular Basis

Differences Between Knowledge Regarding H. pylori and Demographic Characteristics

As presented in Table 6, an independent-sample t-test and ANOVA were conducted to compare knowledge regarding H. pylori and demographic characteristics (gender, employment status, age, and educational level). The results showed significant differences in knowledge regarding H. pylori infection (t [396]=2.725, p ˂0.01) based on employment status.

Table 6 Differences in Knowledge Regarding H. pylori Based on Participants’ Demographic Characteristics

Discussion

Helicobacter pylori infection can lead to chronic gastritis, gastro-duodenal diseases such as gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and peptic ulcers. Usually acquired during childhood, H. pylori can last for a lifetime if left untreated. Approximately 50% of people worldwide are infected by H. pylori, and its prevalence varies according to geography and sanitary conditions. On the other hand, chronic H. pylori carriage dramatically increases the chance of acquiring site-specific illnesses. Approximately 10% of infected individuals develop peptic ulcer disease, 1–3% develop gastric adenocarcinoma, and fewer than 0.1% develop mucosa-associated lymphoid tissue (MALT) lymphoma.¹⁹

In most individuals, H. pylori colonization does not cause symptoms. Furthermore, because of its unique abilities, H. pylori can colonize the stomach epithelium in an acidic environment. The intricate virulence mechanisms of H. pylori bacteria, along with its interactions with the host immune system and environmental factors, govern the pathophysiology of the infection.²⁰ This leads to varied gastritis phenotypes, which in turn dictate the possibility of progression to a range of gastroduodenal diseases.

Research on H. pylori awareness among the general population in Jordan remains limited. This study aimed to evaluate Jordanians’ knowledge, attitudes, and practices regarding H. pylori infection, highlighting the crucial role of public awareness in infection control. The level of knowledge within a population directly influences preventive behaviors, such as adopting healthier lifestyles and seeking timely medical care.¹⁸ A well-informed community is more likely to take proactive measures to reduce H. pylori transmission, ultimately lowering infection rates and the risk of associated conditions like peptic ulcers and stomach cancer. Since increased awareness is strongly linked to positive attitudes and improved health behaviors, targeted education and awareness programs can serve as effective strategies to curb the spread of the infection.

Participants who met the inclusion criteria were asked to complete a questionnaire through interview. The questionnaire was divided into three sections: sociodemographic data (including gender, age, educational level, and occupation), information about any current symptoms or previous health conditions, and an evaluation of participants’ attitudes toward preventing gastric ulcers and avoiding H. pylori infection using multiple-choice questions. Additionally, daily practices that could affect H. pylori transmission were assessed.

Regarding H. pylori and gastrointestinal disorders, the sociodemographic details of the 398 participants provided crucial information on their knowledge, attitudes, and practices (KAP). The majority (70.4%) of participants were between the ages of 18 and 29 and likely to use contemporary health information platforms; however, they potentially lacked practical awareness of chronic gastric conditions. The predominance of female participants (72.6%) reflects common patterns in health-related research, that is, women are more likely to engage in health-seeking behaviors,²¹ albeit this disparity may restrict the applicability of the findings to men. Furthermore, a reasonably educated sample with possibly higher baseline knowledge and receptiveness to health education was suggested by the fact that 71.6% of participants had a bachelor’s degree. However, a substantial percentage of people (54.8%) work in non-medical sectors, which contrasts with findings from research in the UAE and Jordan^2,17 and suggests that there may be potential gaps in certain health-related knowledge, highlighting the need for easily accessible, focused educational activities. Notably, differences in knowledge about H. pylori infection were significant only in respect to employment status (p=0.007).

Overall, 87.9% of participants did not have a current H. pylori infection. Many patients reported experiencing acid reflux, constipation, or diarrhea (46.5 and 34.0%, respectively). Other symptoms included loss of appetite (30.7%) and heartburn (30.4%). Only 0.5% of the patients experienced recurrent episodes of stomach bleeding. This finding contrasts with other studies that suggest hemorrhage is the most common complication of ulcer disease, affecting an estimated 15–20% of ulcers.²² Additionally, Popa et al reported that approximately 40% of patients with upper gastrointestinal bleeding had a hemorrhagic ulcer,²³ which was not reflected in our study (0.5%).

Regarding general knowledge about H. pylori, gastric ulcers and their link to cancer, 40–60% of participants demonstrated good knowledge on this subject, consistent with the results of another study.²⁴ In terms of stress, depression, smoking, alcohol consumption, and drug use, the study found that approximately 55% of contributors associated these factors with gastric ulcers. In particular, smoking has been linked in many studies to the presence of approximately 69 carcinogenic chemicals, and is known to increase the rate of treatment failure in H. pylori infection.²⁵

Additionally, nearly 50% believed that poor diet and lifestyle contributed to this illness. Other factors cited by participants included medications, such as acetylsalicylic acid and diclofenac sodium (42%), malabsorption and food allergies (26%), viral or fungal infections, and autoimmune diseases (16.6 and 16.1%, respectively). These findings align with published data indicating that non-steroidal anti-inflammatory drug (NSAID) users infected with H. pylori face almost double the risk of developing bleeding peptic ulcers compared to uninfected NSAID users, and low-dose aspirin tends to cause more gastric injury in H. pylori-infected individuals than in uninfected individuals.²⁴ Furthermore, approximately 5% of participants mentioned umbilical hernias, skin burns, or bleeding as associated factors.

Conclusions

This study provides valuable insights into the knowledge, attitudes, and practices (KAP) of Jordanians regarding H. pylori infection, emphasizing the crucial role of public awareness in infection prevention and management. While participants demonstrated a moderate understanding of H. pylori, significant gaps remain in understanding the transmission, prevention, and long-term health risks of H. pylori and highlight the need for targeted educational interventions. Sociodemographic factors, particularly employment status, significantly influenced knowledge levels, suggesting that specific groups may require tailored awareness efforts.

The relatively low reported prevalence of current H. pylori infection and inconsistencies in perceived complications underscore the importance of further epidemiological studies to validate and expand upon these findings. Strengthening public health strategies, including broader access to screening programs and education campaigns focusing on hygiene, is essential to improving awareness, encouraging preventive behaviors, and reducing infection rates.

By addressing misconceptions and promoting proactive health measures, targeted interventions can contribute to better disease control and lower complication risks, and ultimately improve gastric health outcomes in Jordan. Future research should explore the long-term impact of educational initiatives and assess the effectiveness of public health strategies in reducing H. pylori transmission and related complications.