1. Introduction
Helicobacter pylori (
H. pylori) has been established as the most prevalent chronic infection globally, that, according to the previous studies, has affected more than a half of the world population [
1]. Furthermore, this infection causes chronic gastritis in all of the infected patients, and could be a major cause of other diseases, such as a peptic ulcer disease, atrophic gastritis and gastric cancer. Moreover, there are data on the association between the
H. pylori infection and irritable bowel syndrome [
1,
2,
3,
4,
5]. It was also associated with certain non-gastrointestinal diseases, such as chronic kidney disease [
6,
7]. The high costs of this infection to health systems commands constant evaluation of
H. pylori treatment and diagnosis [
1,
2,
3]. Despite the fact that the prevalence of
H. pylori has been decreasing in large countries such as the United States, Japan and Germany, the prevalence has remained high in the population which has a high incidence of gastric cancer. Moreover,
H. pylori infection has been recognized as the most common infection-related cause of death by cancer. Basic and clinical knowledge on the matter of
H. pylori has raised in the past, but the translation of this knowledge into public health intervention, such as population-wide screening and eradication, has remained poor [
8,
9].
Previous studies showed that it should be recommended that susceptibility tests of
H. pylori are performed routinely in clinical practice [
10,
11,
12]. Therefore, there is a need to improve
H. pylori testing practice, which should be adapted to patients’ age, symptoms and drug utilization, provide adequate reliability and availability, and ensure low costs for health systems. Moreover, the majority of
H. pylori therapies are utilized without an investigation of the prevalence of antibiotic resistance. One of the main reasons for this type of infection management is that susceptibility testing of
H. pylori is still not commonly available [
10,
11,
12]. Another problem of
H. pylori management is a high rate of infection recurrence. Interestingly, a study by Zhao et al. [
13] showed that European countries had the highest recurrence rate. Moreover, an increasing trend of recurrence in the past 10 years was observed, which made it a great public health problem worldwide [
13].
Despite the numerous problems addressed to the
H. pylori infection, public awareness on this matter remains low. The results of the study by Teng et al. revealed that awareness of
H. pylori infection is lacking [
14]. However, the results of the same study showed a high acceptance rate of the screening tests. Similar results of insufficient
H. pylori awareness were found in the study conducted by Hafiz et al. [
15]. Moreover, the authors concluded that educational programs are recommended for improving patients’ awareness and knowledge about
H. pylori infection [
14,
15]. A study conducted on patients with the peptic ulcer disease showed that health education contributed to the improvement of patients’ self-care ability and resulted in the reduction of
H. pylori infection rates [
16]. Based on these positive results, it seems reasonable that numerous health education studies conducted on patients would be feasible in the future.
Early detection of H. pylori decreases the risk of disease complications in patients. Moreover, the appropriate pharmacotherapy intervention leads to the eradication of this infection. In order to detect and eradicate this infection, the general population should be knowledgeable about basic information on H. pylori infection. Therefore, the aim of this study was to assess the knowledge, attitudes, habits and other factors regarding the H. pylori infection in the general population in Croatia.
4. Discussion
Overall, the knowledge of
H. pylori of the included participants could be classified as very good. However, scores were significantly lower among the older population, above the age of 60, and among participants from rural areas. Both of those factors were previously recognized as
H. pylori infection risk factors [
18,
19]. The physical health of the rural elderly was previously found to be strongly affected by their education and living conditions [
20]. Educational interventions to improve the knowledge on the matter, as well as to promote general health literacy, is therefore necessary [
14,
21,
22]. Nonetheless, health education of the elderly as well as those living in the rural areas has proven challenging, mostly owing to the lack of educational opportunities, remoteness, unfamiliarity with modern technologies and age-related cognitive decline [
23,
24]. Another interesting finding was that a lower level of knowledge resulted in almost no screening amongst participants, while those screened had higher levels of knowledge. This indicates that knowledge might be directly linked to participants’ willingness to participate in screening which is another argument in favor of the necessity of educational programs aimed towards the general population.
Most of the participants included in the present study did not undergo
H. pylori screening mainly due to the lack of symptoms, which is problematic as the infection is usually asymptomatic. Hence, despite the high knowledge score, a number of participants thought they did not need to be tested because they lacked any symptoms. On the plus side, large proportions of both untested and tested participants supported
H. pylori screening. This discrepancy between the number screened and support for screening was apparent. Other studies also showed high support for screening regardless of the number of participants actually screened [
14,
17]. Another positive was high support for eradication therapy for both their family members and for themselves, in cases where they were infected. This is further supported by the fact that almost every participant that was positive for
H. pylori infection received the treatment. Only 13.8% of participants claimed to be infected with
H. pylori, which was significantly lower than the estimated prevalence of infection in Croatia which was 52.7% [
3].
Almost a third of all treated participants claimed their therapy lasted for more than 14 days, which could mean their original therapy failed and they had to take a re-treatment. A large study on the European Registry on
H. pylori management (Hp-EuReg), conducted until 2018, found that physicians in the southeastern region, which included Croatia, predominantly prescribed the seven-day treatment regimens [
25]. However, the same study found that recently there was a shift towards a longer duration of the treatment, in concordance with the new guidelines, with the goal of improving eradication rates [
25,
26]. In our study, an equal proportion of participants received the 7–10 days’ and 11–14 days’ therapies. Our results could reflect those changes in treatment, as the number of participants receiving longer treatment increased during the three-year gap between the two studies [
25,
26]. About 15% of those treated claimed to have had a recurrence of infection. It was unclear if it had been caused by reinfection after a successful eradication or by treatment failure [
27]. Furthermore, 15% of participants strongly considered the alternative treatment options due to the unsatisfactory results of the original therapy. These numbers, combined with the number of participants who had treatment longer than 14 days, could be indicative of unfavorable treatment outcomes for certain participants.
One of the reasons could be antimicrobial resistance, as Croatia had a high rate of resistance to the antibiotics used in
H. pylori treatment, especially clarithromycin [
26]. This could limit the effectiveness of the triple therapy regimens, which used to be the predominant regimens in this region of Europe, even though quadruple regimens became the treatment of choice lately as these regimens had more success in the event of clarithromycin resistance [
25,
26].
Another obstacle for the successful eradication of
H. pylori infection in Croatia was poor knowledge and the implementation of the Maastricht V/Florence consensus report guidelines among Croatian family physicians and medical students [
28]. Furthermore, there was a poor correlation of the drug packs available on the Croatian market with treatment guidelines for
H. pylori, which would lead to more leftover antibiotics and influence patient adherence [
29]. These factors could have a deleterious effect on the development of antimicrobial resistance and need to be addressed in the future.
Among the participants in this study, risk factors for development of H. pylori infection were age over sixty years, male sex, being employed in certain professions and alcohol consumption. As no H. pylori screening was conducted as a part of this study, given the usually asymptomatic nature of the infection and an average Croatian infection rate that is higher than the one in this study, it is possible that many more participants were infected. Moreover, it is likely that those who tested positive were ones that had symptoms and that was the reason they were screened in the first place, especially since the most of untested participants declined screening because they lacked any symptoms. Based on those assumptions, we could argue that our risk factors were not actually risks of the infection’s development but risks of worsening of the infection and symptoms’ development.
Socio-economic factors, occupational risk factors and lifestyle factors, such as diet and smoking, were previously associated with the incidence of
H. pylori infection. The same factors also presented as risk factors for the development of gastritis, stomach cancer and other complications [
30,
31]. In this study, we tried to investigate whether some of those factors could influence the recovery after treatment, defined as an improvement of the symptoms. The most interesting, albeit unsurprising, finding was that smoking and coffee consumption had a detrimental effect on recovery after treatment. Less clear effects were seen with tea consumption and participants’ sex, as these results were either conflicting or based on an extremely small sample. A study by Kang et al. [
32] also found that certain dietary habits were related to improvements after eradication therapy. Spicy and salty food were found to be related to improvements of gastric atrophy and metaplasia, even though the authors of the study were not sure if those results were a consequence of their reduced intake or the fact that eradication of bacteria reduced their harmful effects [
32].
As H. pylori infection presents a significant threat to global health, it is imperative to mitigate its burden with prevention and early detection, for which a broader participation in screening programs is necessary. This study showed that people who knew more about the disease and its complications were more likely to participate. Moreover, results showed that most participants used the Internet and social media as sources of information. Therefore, a nationwide educational campaign, with more presence on those media platforms, might be beneficial. So far, no such campaign has been conducted in Croatia.
The present study has several limitations. Firstly, the survey was conducted online which could limit the representativity of the sample as only those with sufficient digital literacy and with Internet access could participate in the study. Secondly, it was a cross-sectional study which provided only an observation and limited determination of causality. Next, the study relied on participants to accurately recollect the information, thus increasing the chance of recall bias. Furthermore, there was a difference in male and female population and unequal sample sizes could influence the results of the statistical analysis and introduce bias. However, a significant effect on the results is not expected due to the statistical tests that were used, that took the sample size into account and the data were compared as frequencies instead of absolute numbers. Another possible sample bias was the discrepancy between the number of highly educated people between our sample and the general population in Croatia. As the sample contained more people with university degrees, the results might be biased towards the higher knowledge score and more favorable attitudes towards screening and other healthcare interventions, which limits the generalizability of the findings.