Physicians’ Knowledge, Attitudes, and Practices on the Management of Helicobacter pylori–Induced Gastric Ulcers in Pakistan: A Questionnaire-Based, Cross-Sectional Survey

Abstract

Background/Objectives: In South Asia, the prevalence of Helicobacter pylori (H. pylori) infections may be as high as 60–80%, constituting a notable public health issue, with eradication strategies critical in reducing the H. pylori-associated disease burden. The aim of our study was to assess the knowledge, attitude, and practices (KAP) regarding the screening, treatment, and follow-up of H. pylori-induced gastric ulcers among physicians in Lahore, Pakistan. Methods: A self-administered, questionnaire-based cross-sectional study—including the development and validity assessment of a 24-item questionnaire—was carried out in two tertiary-care hospitals between January and May 2024. Statistical analyses (descriptive statistics, χ²-tests, binary logistic regression, and 95% confidence interval [95% CI]) were carried out using IBM SPSS 27.0. The study adheres to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. Results: Among N = 385 participants, 57.9% were male, 60.0% were aged between 25 and 34 years, 59.5% worked in a public hospital, and 55.3% had <5 years of working experience. Of them, 32.9% had noted medical journals, while 27.0% reported online educational materials as their key sources of evidence-based information. Although 91.2% and 87.3% of physicians had good knowledge and attitude levels (≥50% score) pertaining to H. pylori-associated gastric ulcers, respectively. Participants aged 25–34 years (aOR: 0.217 [95% CI: 0.08–0.589]), who have <5 years of working experience (aOR: 0.328 [95% CI: 0.136–0.790]) and those working in public hospitals (aOR: 0.130 [95% CI: 0.048–0.352]) were less likely to show poor attitudes. Furthermore, 76.5% made it a routine to discuss the risk factors of H. pylori-induced ulcers with their patients, while 67.4% highlighted the importance of follow-up testing to confirm the eradication of H. pylori. Conclusions: Inconsistent and empirical treatment approaches, lack of routine screening, and inadequate follow-up practices may further compromise eradication efforts and contribute to antimicrobial resistance. Our findings emphasize the importance of targeted educational programs to address knowledge gaps, standardize practices, and enhance the appropriate management of H. pylori-induced gastric ulcers in Pakistan.

1. Introduction

Helicobacter pylori (H. pylori) is a Gram-negative helical bacterium, recognized as a global health concern, constituting a notable disease burden to the global population, leading to chronic infections, which may have severe complications if left unmanaged [1]. Global prevalence of H. pylori is estimated at ~44.3%, with higher rates of infections observed in low- and middle-income countries (LMICs) due to numerous factors, such as health inequities, overcrowding, poor availability of WaSH (water, sanitation, and hygiene) facilities, and limited access to healthcare services, including resources for diagnostics and treatment [2]. In South Asian countries, such as Pakistan, the prevalence of H. pylori infections may be as high as 60–80% [3,4]. H. pylori infections constitute a notable public health issue, with eradication strategies being critical to reducing the burden of H. pylori-associated illnesses.

H. pylori is most commonly transmitted via direct contact with the saliva, vomit, or feces of a person carrying the bacteria, or contaminated water or foodstuffs [1]. Infection is most commonly asymptomatic; however, through its potent virulence factors (such as the cytotoxin-associated gene A [CagA], vacuolating cytotoxin A [VacA], outer membrane proteins, adhesins, and various enzymes), H. pylori can survive in the gastric mucosa, and may play pivotal roles in the development of chronic inflammation, contributing to the pathogenesis of gastritis, peptic ulcers, mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric cancer (of which, gastric ulcers represent a critical early-stage manifestation) [5,6]. The timely diagnosis of infection, and subsequent early-stage eradication of H. pylori are essential to prevent more severe complications, such as gastric cancer, associated with substantial morbidity and mortality worldwide [7,8]. Despite the accumulation of evidence and the advances in understanding of the microorganism’s biology, management of H. pylori still poses a considerable challenge, which is based on routine screening and evidence-based treatment regimens. On one hand, a prerequisite of this process is the availability of appropriate diagnostic facilities for routine screening services to detect H. pylori infections and a sufficient number of qualified healthcare professionals; following this administration of pharmacotherapy and practicing diligent follow-up is crucial for eradication efforts [9]. Several modifiable risk factors have been described, which increase the risk of developing H. pylori-induced gastric ulcers, such as the low awareness of the transmission routes of the bacteria, in addition to tobacco and alcohol consumption, and dietary habits (i.e., diet low in fruits, vegetables, and fiber; high levels of salty, spicy, fried, and/or processed foods), which may damage the mucosal lining of the stomach, promoting the persistence of bacteria [10].

Screening and diagnostic tests for H. pylori include non-invasive modalities (preferred for screening and initial diagnoses), such as the urea breath test, stool antigen test and serology, while invasive methods include endoscopy, histological examination, bacterial culture and molecular biological methods, such as polymerase chain reaction (PCR) [11,12]. Internationally accepted treatment guidelines, including the one published by the American College of Gastroenterology (ACG), and the Maastricht VI/Florence Consensus Report, underscore a “test-and-treat” approach, i.e., the use of standard eradication protocols, which is followed by confirmation of bacterial clearance [13]. Eradication regimens for H. pylori include the so-called “triple therapy,” consisting of proton pump inhibitors (PPIs), amoxicillin, and clarithromycin, and “quadruple therapy,” consisting of PPIs, bismuth, tetracyclines, and metronidazole, respectively [14,15,16]. Within ACG recommendations, quadruple therapy is now recommended as the first-choice for H. pylori eradication, particularly in areas with high resistance to clarithromycin and levofloxacin; on the other hand, the guideline discourages the use of clarithromycin or levofloxacin-based regimens unless susceptibility testing has been conducted [13]. Furthermore, all patients are advised to undergo non-invasive screening tests—such as the urea breath test or stool antigen test—to confirm eradication after completion of the therapeutic regimen [17]. These guidelines also acknowledge the novel therapeutic alternatives, such as the first-in-class potassium-competitive acid inhibitors (e.g., vonoprazan), depending on their availability in the region [18]. Based on the recommendations of the World Health Organization/International Agency for Research on Cancer (WHO/IARC), population-based H. pylori screening is now encouraged in high-risk areas to reduce the burden of gastric cancer [19,20].

Both general practitioners (GPs) and gastroenterologists have crucial roles in the detection and management of H. pylori infections [21]: on one hand, GPs are often the first to notice symptoms of dyspepsia or early-stage ulcers, and they will be the ones who implement the “test-and-treat” strategies for young patients without alarm features, usually through non-invasive H. pylori screening [22,23]. GPs are responsible for the initial identification and general management of H. pylori-induced gastric ulcers, while specialist care and invasive diagnostics are within the domain of gastroenterologists [24]. However, clinicians’ practices and adherence to the diagnostic and therapeutic recommendations is influenced by their knowledge and attitudes in the specific domain; thus, evaluating their knowledge attitude and practices (KAP) related to H. pylori-induced gastric ulcers and their eradication may lead to the identification of knowledge-practice gaps, and may bring forth direct benefits to the healthcare system [25]. Moreover, inconsistent and empirical treatment approaches, lack of routine screening, and inadequate follow-up practices may further compromise eradication efforts and contribute to antibiotic resistance in H. pylori. KAP studies published in other developing countries have highlighted considerable variability in practices and substantial knowledge gaps among clinicians, underscoring the need for context-specific assessments [25,26,27]. Despite the high prevalence of H. pylori infection in South Asia, there is a substantial lack of data assessing physicians’ knowledge, attitudes, and clinical practices regarding the screening, treatment, and follow-up of H. pylori-associated gastric ulcers in Pakistan. Previous studies have largely focused on the microbiological characteristics of H. pylori, peptic ulcer disease in general, or patient-centered outcomes, with limited emphasis on physicians’ KAP concerning H. pylori infections and their management in Pakistan; therefore, the aims of our study were the following: (i) to assess the KAP regarding screening, treatment, and follow-up of H. pylori-induced gastric ulcer among physicians practicing in Lahore, Pakistan; (ii) to determine relevant socio-demographic and professional attributes associated with participants’ KAP.

2. Materials and Methods

2.1. Study Design, Setting and Duration

A cross-sectional, observational, questionnaire-based study was performed between January and May 2024 in two tertiary-care hospitals in Pakistan. A purposive sampling approach was employed, whereby physicians fulfilling the eligibility criteria were approached directly during their clinical duties in outpatient departments, wards, and physicians’ offices within the participating hospitals. The study objectives were explained to potential participants, and questionnaires were distributed only to physicians willing to participate voluntarily. To minimize selection bias, data collection was conducted across different departments, working shifts, and weekdays during the study period to improve participant diversity. The study was conducted in Lahore, the second-largest city in Pakistan, and the 26th largest city worldwide [28]. According to the Pakistan Bureau of Statistics, 36 public and 102 private hospitals operate in the city [29]. The study was carried out between January and May 2024.

2.2. Study Population, Inclusion and Exclusion Criteria

Data collection was performed among physicians across two tertiary care hospitals, a major governmental and a private hospital in Lahore, Pakistan. The inclusion criteria of the study were as follows: (i) individuals holding MBBS (Bachelor of Medicine, Bachelor of Surgery), MBBS-FCPS (Fellowship of the College of Physicians and Surgeons), MD (Doctor of General Medicine) or MD-FCPS degrees, irrespective of board certification, (ii) being actively involved in patient-care in primary, ambulatory or hospital settings, (iii) able to read and comprehend English, allowing for the filling-out of the data collection instrument, (iv) willing to take part in the study voluntarily, and provided written informed consent. In addition, exclusion criteria of the study were: (i) healthcare and allied health staff (e.g., pharmacists, nurses, and technicians), (ii) those who were unable to comprehend English to a sufficient degree to fill out the questionnaire, and (iii) incomplete questionnaire responses.

The available data on the accurate number of physicians in Lahore, Pakistan is limited; however, using previously published sources and WHO Statistics, there is an estimated rate of 1 physicians/1000 population in Pakistan [30,31]. The minimum required sample size for the study was determined using the Raosoft Sample Size Calculator (https://raosoftcalculator.com/; accessed on: 15 December 2023), using the formula described below (1):

$$\mathit{n}=\mathit{N}{\displaystyle \frac{\mathit{x}}{\left(\mathit{N}-\mathbf{1}\right)\mathit{E}\mathbf{2}+\mathit{x}}}$$

(1)

where “x” is the expected response rate, “E” is the acceptable margin of error (5%, i.e., the required level of confidence was 95%), the population (N) was set at 13,000 (based on the proportion described above), and the expected response rate was set at 50% [32]. As a result, the required sample size of n = 374 was set for the completion of this study, to ensure appropriate statistical power for subsequent analyses [31]. A total of 420 physicians filled out the questionnaire; however, only N = 385 fully completed questionnaires were included in the final analysis, yielding a response completion rate of 91.7%.

2.3. Data Collection Tool, Pilot Testing, Validity Testing

The instrument for data collection was a self-administered, 24-item paper-based questionnaire, which was developed for the purposes of the study by the researchers, based on a thorough literature review (with studies published up until 2022), and having identified key papers relevant to the study’s context [26,27,33,34,35]. The questionnaire consisted of five main sections, as follows: (i) socio-demographic and professional characteristics (including gender, age, educational level/type of qualification, years of experience in healthcare, type of healthcare facility currently working in, and number of patients seen weekly; close-ended questions), (ii) knowledge-assessment domain (assessing participants’ understanding of the contagiousness, symptoms, risk factors, modes of transmission, and possible preventive measures of H. pylori-induced gastric ulcers; close-ended questions), (iii) attitude-assessment domain towards H. pylori-induced gastric ulcers and health-seeking behaviors (close-ended questions with “Yes”/”No” options), (iv) practice-assessment domain (questions corresponding to participants’ behaviors concerning diagnostics, treatment, and patient counseling related to H. pylori-induced gastric ulcers; participants were able to provide their responses on a five-point Likert-scale), in addition to the questions on information sources and public health educational campaigns.

The first version of the survey tool was subjected to a pilot study, during which n = 20 subjects—recommended by earlier studies [36]—were asked to fill out the questionnaire; based on their feedback, the final version of the questionnaire was prepared, which was subjected to a validity and reliability analysis [37]. The face validity of the questionnaire was assessed by a panel of 10 GPs, while content validity was assessed with the aid of 10 gastroenterologists; face and content validity were expressed as the face validity index (FVI) and content validity index (CVI), respectively [38]. FVI for the instrument was 0.916, while CVI was found to be 0.900, respectively, both within desirable ranges. The internal consistency (reliability) of the instrument’s subdomains were determined using the Cronbach α measure, which yielded the following results: (i) knowledge-assessment domain α: 0.711, (ii) attitude-assessment domain: 0.607, and (iii) practice-assessment and information-source domain: 0.645; in all subdomains, internal consistency was deemed acceptable (α > 0.600) [39].

2.4. Statistical Analysis, Analysis of Answers

Following data collection, questionnaire data were entered into spreadsheets (Microsoft Excel; Microsoft Corp. Redmond, WA, USA), and then transferred to the Statistical Package for Social Sciences v.27.0 (SPSS; IBM Corp., Endicott, NY, USA) for analysis. During descriptive analysis, categorical data were described as frequencies and percentages (n, %). During the evaluation of the participants’ answers, each correct answer was valued for one point, while incorrect answers were scored zero:; thus, in the knowledge-assessment and attitude-assessment domains it was 0–5, respectively. Results of the knowledge and attitude domains were later categorized as “poor” and “good” levels of knowledge, based on pre-defined cut-off values (<50% vs. ≥50%). The ≥50% cut-off used for categorizing knowledge and attitude levels was adopted from previously published KAP studies utilizing comparable scoring methodologies, thereby allowing consistency and comparability across studies [26,35,40,41,42]. Associations between categorical variables (poor/good results vs. socio-demographic variables) were assessed using χ²-tests and Fisher’s exact tests. Furthermore, binary logistic regression analyses were also employed to examine the association between socio-demographic variables and their knowledge and attitudes toward H. pylori-induced gastric ulcers. Results were expressed as crude (cOR) and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Prior to logistic regression analyses, assumptions relevant to binary logistic regression were evaluated. Multicollinearity among independent variables was assessed using variance inflation factor (VIF) values and tolerance statistics, with no significant multicollinearity observed among the included variables. Model fitness was evaluated using the Hosmer–Lemeshow goodness-of-fit test. Due to the fact that only completely filled-out questionnaires were included in the analysis, handling of missing data was not relevant during statistical assessments. During analyses, p-values < 0.05 were considered statistically significant.

2.5. Ethical Considerations, Informed Consent

The study was conducted in accordance with the Declaration of Helsinki (1975, last revised in 2024 [43]), and national and institutional ethical standards. The ethical approval for this study was obtained from the Ethical Committee of the Private Hospital (approval ID: DPH/24/FOP; date of approval: 30 January 2024) and the Ethical Committee of the Public Hospital (approval ID: IRB/2023/1239/SIMS; date of approval: 15 January 2024).

Before participation in our study, physicians were approached and were provided with detailed information regarding the study’s purpose, procedures, potential risks, and benefits. Written informed consent was obtained from each participant, ensuring that they understood their right to participate voluntarily and their right to withdraw at any time without any negative consequences. Confidentiality and anonymity were maintained throughout the study. The participants did not receive any incentives (monetary or otherwise) to take part in the study.

2.6. Reporting Guidelines

This manuscript adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies to ensure methodological rigor, transparency, and reproducibility [44]; the STROBE checklist is provided in Supplementary Material S1.

3. Results

3.1. Socio-Demographic and Professional Characteristics of the Participants

Overall, N = 385 (100.0%) fully completed questionnaires were included; socio-demographic and professional characteristics of physicians were summarized in

Table 1. Socio-demographic and professional characteristics of the participants (N = 385).

Variables	n, %
Gender
Male	223 (57.9%)
Female	162 (42.1%)
Age (Years)
≤24 years	76 (19.7%)
25–34 years	231 (60.0%)
35–44 years	38 (9.9%)
45–54 years	17 (4.4%)
55≤ years	23 (6.0%)
Type of professional qualification
MBBS	194 (50.4%)
MBBS-FCPS	65 (16.9%)
MD	24 (6.2%)
MD-FCPS	52 (13.5%)
Other	50 (13.0%)
Experience (Years)
˂5 years	213 (55.3%)
5–10 years	94 (24.4%)
11–20 years	42 (10.9%)
>20 years	36 (9.4%)
Type of healthcare facility
Public hospital	229 (59.5%)
Private hospital—inpatient setting	110 (28.6%)
Private hospital—outpatient setting	46 (11.9%)
Patients seen/week
˂10 patients	79 (20.5%)
10–30 patients	66 (17.2%)
31–50 patients	67 (17.4%)
>50 patients	173 (44.9%)

MBBS: Bachelor of Medicine, Bachelor of Surgery; MBBS-FCPS: MBBS-Fellowship of the College of Physicians and Surgeons; MD: Doctor of General Medicine; MD-FCPS: MD-Fellowship of the College of Physicians and Surgeons.

. Majority of respondents were males (57.9%; n = 223), employed in the public hospital (59.5%; n = 229), within the 25–34 year-old age bracket (60.0%; n = 231), with an MBBS (50.4%; n = 194) degree alone, or with a MBBS-FCPS (16.9%; n = 65) qualifications, respectively. Experience-wise, the majority (55.3%; n = 213) had less than 5 years of professional experience, while 9.4% (n = 36) had over 20 years of experience. Reflecting on the workload of respondents, the majority (44.9%; n = 173) were seeing more than 50 patients weekly, reflecting the workload faced by physicians (Table 1).

3.2. Knowledge-Level and Correlates Related to H. pylori-Associated Gastric Ulcers Among Physicians

The summary of responses associated with the knowledge on H. pylori-associated gastric ulcers among physicians is shown in

Table 2. Participants’ responses in the H. pylori-related knowledge-assessment domain of the questionnaire (N = 385).

Questions	n, %
Is H. pylori contagious?
Yes	191 (49.6%)
No	194 (50.4%)
What are the symptoms of H. pylori-induced gastric ulcers?
Abdominal pain	176 (45.7%)
Nausea and vomiting	75 (19.5%)
Indigestion	106 (27.5%)
I do not know/Unsure	28 (7.3%)
What is the primary route of transmission for H. pylori infections?
Contaminated food and water	186 (48.3%)
Person-to-person contact	39 (10.1%)
Poor hygiene practices	117 (30.4%)
I do not know/Unsure	43 (11.2%)
What are the risk factors of H. pylori-induced gastric ulcers?
Eating contaminated food	207 (53.8%)
Smoking	47 (12.2%)
Alcohol consumption	42 (10.9%)
Regular use of Non-steroidal anti-Inflammatory drugs	68 (17.7%)
I do not know/Unsure	21 (5.4%)
What are effective preventive measures to reduce the risk of H. pylori-induced gastric ulcers?
Regular hand washing	65 (16.9%)
Appropriate food hygiene practices	175 (45.5%)
Avoidance of contaminated water	38 (9.9%)
Smoking cessation	25 (6.5%)
Reduction in alcohol consumption	23 (6.0%)
None are valid	12 (3.1%)
I do not know/Unsure	47 (12.1%)

. Less than half (49.6%) of respondents correctly identified that H. pylori is contagious, while 48.3% noted correctly that contaminated food and water is viable route of transmission for H. pylori. In terms of risk factors, 53.8% identified consuming contaminated food as a relevant exposure, while for preventive measure, 45.5% mentioned appropriate food hygiene practices and 16.9% highlighted regular handwashing, respectively (Table 2). Based on the participant’s responses, the large majority, 91.2% (n = 351) of physicians had good levels of knowledge pertaining to H. pylori-associated gastric ulcers.

The distributions of respondents with good levels of knowledge showed significant differences based on age groups (p = 0.015; highest among individuals aged 25–34), type of professional qualification (p < 0.001; highest among MBBS holders), workplace (p < 0.001; higher among physicians working in public hospitals) and number of patients managed/week (p = 0.007; highest among physicians seeing >50 patients/week), respectively (

Table 3. Relevant socio-demographic correlates of H. pylori-related knowledge-assessment domain of the questionnaire (N = 385).

Variables	Knowledge-Level Categories		p-Value
	Good (n, %)	Poor (n, %)
Gender
Male	198 (51.4%)	25 (6.5%)	0.054
Female	153 (39.7%)	9 (2.4%)
Age (Years)
≤24 years	63 (16.3%)	13 (3.4%)	0.015 *
25–34 years	216 (56.1%)	15 (3.9%)
35–44 years	36 (9.3%)	2 (0.5%)
45–54 years	17 (4.4%)	0 (0%)
55≤ years	19 (4.9%)	4 (1.2%)
Type of professional qualification
MBBS	193 (50.1%)	1 (0.3%)	<0.001 ***
MBBS-FCPS	63 (16.4%)	2 (0.5%)
MD	22 (5.7%)	2 (0.5%)
MD-FCPS	49 (12.7%)	3 (0.7%)
Other	24 (6.3%)	26 (6.8%)
Experience (Years)
˂5 years	196 (50.9%)	17 (4.4%)	0.133
5–10 years	87 (22.6%)	7 (1.8%)
11–20 years	39 (10.2%)	3 (0.8%)
>20 years	29 (7.5%)	7 (1.8%)
Type of healthcare facility
Public hospital	226 (58.7%)	3 (0.8%)	<0.001 ***
Private hospital—inpatient setting	86 (22.3%)	24 (6.2%)
Private hospital—outpatient setting	39 (10.1%)	7 (1.9%)
Patients seen/week
˂10 patients	65 (16.8%)	14 (3.6%)	0.007 **
10–30 patients	64 (16.6%)	2 (0.5%)
31–50 patients	64 (16.6%)	3 (0.8%)
>50 patients	158 (41.2%)	15 (3.9%)

MBBS: Bachelor of Medicine, Bachelor of Surgery; MBBS-FCPS: MBBS-Fellowship of the College of Physicians and Surgeons; MD: Doctor of General Medicine; MD-FCPS: MD-Fellowship of the College of Physicians and Surgeons; * p < 0.05; ** p < 0.01; *** p < 0.001; p-values < 0.05 are denoted in boldface.

).

3.3. Attitudes and Correlates Related to H. pylori-Associated Gastric Ulcers Among Physicians

The summary of responses associated with the attitudes on H. pylori-associated gastric ulcers among physicians is shown in

Table 4. Participants’ responses in the H. pylori-related attitude-assessment domain of the questionnaire (N = 385).

Variables	n, %
Do you consider H. pylori-induced gastric ulcers a serious health issue?
Yes	322 (83.6%)
No	63 (16.4%)
Are you concerned about the potential risks of H. pylori infections, such as gastric ulcers?
Yes	326 (84.7%)
No	59 (15.3%)
Do you believe that anyone may be infected with H. pylori?
Yes	327 (84.9%)
No	58 (15.1%)
Do you consider early screening and diagnosis important in the prevention and management of H. pylori-induced gastric ulcers?
Yes	339 (88.1%)
No	46 (11.9%)
Do you refer patients with H. pylori-induced gastric ulcer to specialists for further evaluation and management?
Yes	301 (78.2%)
No	84 (21.8%)

. The majority of physicians (84.7%) considered H. pylori-induced gastric ulcers a serious health issue, and 84.7% believed that anyone may contract an H. pylori infection. Additionally, 88.1% considered early screening and diagnosis important in the prevention and management of H. pylori-induced gastric ulcers, and 78.2% of physicians referred patients with H. pylori-induced gastric ulcers to specialists for further evaluation and management (Table 4). Based on the participant’s responses, the large majority, 87.3% (n = 336) of physicians had their attitude levels classified as “good” pertaining to H. pylori-associated gastric ulcers.

Distributions of respondents with good attitudes showed significant differences based on age groups (p = 0.014; highest among individuals aged 25–34), type of professional qualification (p < 0.001; highest among MBBS holders), years of work experience (p = 0.045; with physicians having <5 years of work experience being the most likely with good attitudes), and type of workplace (p < 0.001; higher among physicians working in public hospitals), respectively (

Table 5. Relevant socio-demographic correlates of H. pylori-related attitude-assessment domain of the questionnaire (N = 385).

Variables	Attitude-Level Categories		p-Value
	Good (n, %)	Poor (n, %)
Gender
Male	189 (49.1%)	34 (8.8%)	0.082
Female	147 (38.2%)	15 (3.9%)
Age (Years)
≤24 years	62 (16.1%)	14 (3.6%)	0.014 *
25–34 years	211 (54.8%)	20 (5.2%)
35–44 years	33 (8.6%)	5 (1.3%)
45–54 years	14 (3.6%)	3 (0.8%)
55≤ years	16 (4.2%)	7 (1.8%)
Type of professional qualification
MBBS	189 (49.1%)	5 (1.3%)	<0.001 ***
MBBS-FCPS	62 (16.1%)	3 (0.8%)
MD	19 (4.9%)	5 (1.3%)
MD-FCPS	43 (11.2%)	9 (2.3%)
Other	23 (5.9%)	27 (7.1%)
Experience (Years)
˂5 years	192 (49.9%)	21 (5.5%)	0.045 *
5–10 years	83 (21.6%)	11 (2.9%)
11–20 years	34 (8.8%)	8 (2.1%)
>20 years	27 (7.0%)	9 (2.2%)
Type of healthcare facility
Public hospital	221 (57.4%)	8 (2.1%)	<0.001 ***
Private hospital—inpatient setting	79 (20.5%)	31 (8.1%)
Private hospital—outpatient setting	36 (9.4%)	10 (2.5%)
Patients seen/week
˂10 patients	66 (17.1%)	13 (3.4%)	0.666
10–30 patients	59 (15.3%)	7 (1.8%)
31–50 patients	60 (15.6%)	7 (1.8%)
>50 patients	151 (39.2%)	22 (5.8%)

MBBS: Bachelor of Medicine, Bachelor of Surgery; MBBS-FCPS: MBBS-Fellowship of the College of Physicians and Surgeons; MD: Doctor of General Medicine; MD-FCPS: MD-Fellowship of the College of Physicians and Surgeons; * p < 0.05; *** p < 0.001; p-values < 0.05 are denoted in boldface.

).

3.4. Practices, Relevant Sources of Information and Correlates Related to H. pylori-Associated Gastric Ulcers Among Physicians

The summary of the responses associated with the practices related to H. pylori-associated gastric ulcers among physicians is shown in

Table 6. Participants’ responses in the H. pylori-related practice-assessment domain of the questionnaire (N = 385).

Practice Question	Responses (n, %)
	Always	Most of the Time	Occasionally	Rarely	Never
(Q1) How frequently do you recommend H. pylori testing for patients with symptoms indicative of gastric ulcer?	120 (31.2%)	137 (35.6%)	70 (18.2%)	28 (7.3%)	30 (7.7%)
(Q2) How frequently do you discuss the risk factors associated with H. pylori-induced gastric ulcers with your patients?	152 (39.4%)	143 (37.1%)	48 (12.5%)	22 (5.7%)	20 (5.2%)
(Q3) How frequently do you recommend lifestyle modifications to patients with H. pylori-induced gastric ulcer?	160 (41.6%)	127 (32.9%)	30 (7.8%)	26 (6.8%)	40 (10.3%)
(Q4) How frequently do you prescribe triple therapy or quadruple therapy to manage the symptoms in patients with H. pylori-induced gastric ulcer	165 (42.9%)	127 (32.9%)	36 (9.4%)	31 (8.1%)	26 (6.8%)
(Q5) How often do you recommend follow-up testing to confirm H. pylori eradication following treatment?	142 (36.8%)	118 (30.6%)	52 (13.5%)	36 (9.4%)	37 (9.6%)

. Furthermore, 66.8% of respondents recommend H. pylori testing (Q1) in the majority of cases. No significant differences were noted for the recommendation of H. pylori testing, based on the participants’ sex (p = 0.123), age (p = 0.065), years of working experience (p = 0.075) and number of patients seen/week (p = 0.198); however, holders of MBBS degrees and those working in public institutions were more likely to do so (p < 0.001 in both cases). Moreover, 76.5% has made it routine to discuss the risk factors of H. pylori-induced gastric ulcers with their patients (Q2); no significant differences were noted for the recommendation of H. pylori testing, based on the participants’ sex (p = 0.339), age (p = 0.235), and number of patients seen/week (p = 0.798), while those having <5 years of working experience (p = 0.015), holders of MBBS degrees and those working in public institutions were more likely to do so (p < 0.001 in both cases). Additionally, 74.5% make it common practice to recommend lifestyle modifications to patients affected by H. pylori-induced gastric ulcers (Q3): male physicians (p = 0.011), holders of MBBS degrees (p < 0.001), having <5 years of working experience (p = 0.008) and those in public institutions were more likely to do so (p < 0.001); on the other hand, the respondents’ age (p = 0.103) and number of patients seen/week (p = 0.264) did not considerably affect the frequency of lifestyle counseling provided. A total of 75.8% found it critical to prescribe pharmacotherapy (triple therapy or quadruple therapy (Q4) during the management of H. pylori-induced gastric ulcers. In view of the relevant correlates, holders of MBBS degrees (p < 0.001), having <5 years of working experience (p = 0.02) and those in public institutions were more likely to do so (p < 0.001); in contrast, the respondents’ sex (p = 0.242), age (p = 0.135) and number of patients seen/week (p = 0.826) did not considerably affect the frequency of drugs prescribed. Finally, 67.4% highlighted the importance of follow-up testing to confirm the eradication of H. pylori following pharmacotherapy (Q5): holders of MBBS degrees (p < 0.001), having <5 years of working experience (p = 0.003) and those in public institutions were more likely to do so (p = 0.002). On the hand, the respondents’ sex (p = 0.904), age (p = 0.267) and number of patients seen/week (p = 0.578) did not considerably affect their response rates (Table 6).

Regarding their main sources of evidence-based information: 32.9% (n = 127) have noted medical journals and publications, followed by online medical/educational resources (27.0%; n = 104), conference and seminar lectures (17.9%; n = 69), professional networks and associations (10.9%; n = 42), and other healthcare professionals (10.9%; n = 42), respectively. Over half (50.9%; n = 196) of the surveyed physicians had encountered awareness campaigns or educational materials pertaining to H. pylori-induced gastric ulcers and their associated risks. Additionally, 79.7% (n = 307) expressed willingness to participate in more awareness campaigns if they were conducted in their scope or region.

3.5. Logistic Regression Analyses

Physicians’ responses were also subjected to analyses in logistic regression models, where the main outcome measures were the achievement of good knowledge and good attitude scores, respectively (

Table 7. Binary logistic regression analyses, corresponding to participants’ H. pylori-related knowledge and attitudes.

Correlates	Good Knowledge		Good Attitude
	cOR (95% CI)	aOR (95% CI)	cOR (95% CI)	aOR (95% CI)
Gender
Male	2.146 (0.974–4.732)	1.709 (0.558–5.233)	1.763 (0.925–3.359)	1.348 (0.610–2.981)
Female (Ref.)	1	1	1	1
Age (Years)
≤24 years	0.980 (0.286–3.362)	1.468 (0.257–8.397)	0.516 (0.179–1.491)	0.563 (0.135–2.348)
25–34 years	0.330 (0.100–1.094)	1.134 (0.211–6.084)	0.217 (0.080–0.589) **	0.467 (0.125–1.746)
35–44 years	0.264 (0.044–1.574)	0.307 (0.029–3.200)	0.346 (0.095–1.263)	0.503 (0.101–2.489)
45–54 years	0.209 (0.034–1.456)	0.245 (0.015–2.476)	0.490 (0.106–2.264)	0.808 (0.147–4.451)
55≤ years (Ref.)	1	1	1	1
Type of professional qualification
MBBS	0.005 (0.001–0.037) ***	0.013 (0.001–0.119) ***	0.023 (0.008–0.064) ***	0.050 (0.015–0.169) ***
MBBS-FCPS	0.029 (0.006–0.133) ***	0.087 (0.015–0.489) **	0.041 (0.011–0.149) *	0.062 (0.015–0.263) ***
MD	0.084 (0.018–0.395) **	0.193 (0.030–1.259)	0.224 (0.072–0.695) *	0.314 (0.081–1.220)
MD-FCPS	0.057 (0.016–0.206) ***	0.075 (0.017–0.335) **	0.178 (0.072–0.442) ***	0.173 (0.058–0.517) **
Other (Ref.)	1	1	1	1
Experience (Years)
˂5 years	0.359 (0.137–0.941) *	0.125 (0.035–10.390)	0.328 (0.136–0.790) *	1.888 (0.519–6.867)
5–10 years	0.333 (0.108–1.031)	0.178 (0.023–6.233)	0.398 (0.149–1.062)	1.572 (0.415–5.952)
11–20 years	0.319 (0.076–1.339)	0.365 (0.101–9.284)	0.706 (0.240–2.075)	1.708 (0.449–6.497)
>20 years (Ref.)	1	1	1	1
Type of healthcare facility
Public hospital	0.074 (0.018–0.298) ***	0.102 (0.015–0.677) *	0.130 (0.048–0.352) ***	0.303 (0.081–1.138)
Private hospital—inpatient setting	1.555 (0.618–3.913)	0.748 (0.187–2.996)	1.413 (0.626–3.190)	1.117 (0.400–3.116)
Private hospital—outpatient setting (Ref.)	1	1	1	1
Patients seen/week
˂10 patients	2.269 (1.036–4.967) *	1.590 (0.463–5.464)	1.352 (0.642–2.845)	1.091 (0.393–3.028)
10–30 patients	0.329 (0.073–1.481)	0.172 (0.026–1.144)	0.814 (0.330–2.007)	0.933 (0.302–2.880)
31–50 patients	0.494 (0.138–1.764)	0.471 (0.093–2.387)	0.801 (0.325–1.973)	0.925 (0.307–2.784)
>50 patients (Ref.)	1	1	1	1

MBBS: Bachelor of Medicine, Bachelor of Surgery; MBBS-FCPS: MBBS-Fellowship of the College of Physicians and Surgeons; MD: Doctor of General Medicine; MD-FCPS: MD-Fellowship of the College of Physicians and Surgeons; * p < 0.05; ** p < 0.01; *** p < 0.001; cOR = crude Odds Ratio; aOR = Adjusted Odds Ratio; CI = Confidence Interval; ORs and CIs associated with significant results are denoted in boldface.

). Males were more likely to have good knowledge than females, but this was not statistically significant (OR = 2.146). Physicians aged 25–34 exhibited a significantly lower likelihood of good knowledge (OR = 0.330) and a substantially reduced likelihood of positive attitudes (OR = 0.217, p < 0.01) compared to those aged 55 and above. Educational attainment emerged as a strong predictor of knowledge and attitudes. Physicians holding an MBBS degree were significantly less likely to possess good knowledge (OR = 0.005, p < 0.001) and positive attitudes (OR = 0.023, p < 0.001). This trend continued across other educational qualifications, indicating that those with advanced degrees, such as MD and FCPS, were more likely to demonstrate higher knowledge and better attitudes than those with lower qualifications. In terms of experience, physicians with less than 5 years of healthcare experience showed significantly lower odds of having good knowledge (OR = 0.359, p < 0.05) and positive attitudes (OR = 0.328, p < 0.05) compared to their counterparts with more than 20 years of experience. The type of healthcare facility also played a significant role. Physicians working in public hospitals were significantly less likely to have good knowledge (OR = 0.074, p < 0.001) and better attitudes (OR = 0.130, p < 0.001). Additionally, physicians seeing fewer than 10 patients weekly were more likely to possess good knowledge (OR = 2.269, p < 0.05), whereas no significant associations were found between patient load and attitudes (Table 7).

4. Discussion

There is a substantial lack of research on the knowledge of H. pylori diagnosis, prevention, and treatment among Pakistani physicians. In the present cross-sectional, questionnaire-based study, we aimed to assess the KAP of physicians in Pakistan regarding the screening, treatment, and follow-up of H. pylori–induced gastric ulcers. Unlike prior reports—which have primarily focused on the general-microbiological aspects of H. pylori infections [10] or peptic ulcer disease [8]—the present work specifically examines gastric ulcers as an early-stage manifestation, and their management practices. To the best of our knowledge, this is the first such study in the Pakistani context. Early detection and management of chronic H. pylori infections is critical for preventing progression to severe complications such as gastric cancer and MALT lymphoma [7]. By identifying gaps in physicians’ understanding and clinical practices, this study provides novel insights that are essential for developing targeted interventions to improve early management and prevent long-term complications. Overall, the majority of the respondents in our sample have demonstrated appropriate knowledge (>90%) and attitudes (>85%) in the respective domains, with participants recognizing the public health significance of H. pylori; however, there were also several important gaps in KAP, which were also underscored by our findings.

This contrasts with a study by Alajm et al., which reported that 42% of participants had an average knowledge level, 41% had excellent scores, and 17% had poor knowledge in this domain, respectively [40]. Even some general physicians—actively engaged in clinical settings—have insufficient knowledge of the diagnostic and therapeutic recommendations on H. pylori, as indicated by a study by Cano-Contreras et al. [45]. Although the overall knowledge scores among physicians were high, the fact that only 49.6% of respondents correctly identified H. pylori as a contagious agent highlights an important inconsistency within the knowledge domain. This discrepancy suggests that—while many physicians may be familiar with the clinical manifestations and management approaches of H. pylori-induced gastric ulcers—important gaps remain regarding the organism’s transmission dynamics and infectivity. Such knowledge gaps may have implications for patient counseling, preventive education, and infection prevention and control practices. Similarly, previous research in China indicated that physicians had low levels of knowledge pertaining to H. pylori infectivity, infection rates, and the latest consensus guidelines [26]. In contrast, numerous studies from other geographical regions reported that a higher percentage of physicians understood the dangers of H. pylori, with 83.9% recognizing its risks [27,35]. This is consistent with the current study’s finding that 96.4% of physicians were aware of the risk factors of H. pylori-induced gastric ulcers. Additionally, the current study also found that 45.7% of physicians recognized abdominal pain as a symptom. A study conducted in China emphasized the importance of all physicians being aware of the risks of H. pylori infections and associated complications to provide timely referrals to gastroenterologists [26]. Moreover, Alajmi et al. reported a gender difference in knowledge level, with males attaining higher knowledge scores than females [40].

The attitudes of physicians towards H. pylori-induced gastric ulcers may considerably affect their everyday practices, and subsequently influence the quality of life of patients and treatment outcomes. The attitudes towards H. pylori-induced gastric ulcers among physicians in the current study were generally positive, which contrasts with the findings from Riyadh, Saudi Arabia, where only 56.0% of participants had positive attitudes regarding H. pylori infections, prevention, and management [40]. Na’amnih et al. reported that 85.0% of primary care physicians referred patients with suspected gastric or duodenal ulcers to specialists for further evaluation and management, aligning with the current study’s findings where 78.2% of physicians referred patients with H. pylori-induced gastric ulcers to specialists [46]. These findings are also consistent with a study assessing Spanish primary care physicians, where 79.0% referred patients to gastroenterologists after the failure of a second-line treatment [47]. A study from Germany reported that 86.0% of family physicians referred their patients to gastroenterologists more often, while initiating eradication treatment less commonly (45.6%) [48]. However, attitudes varied significantly by socio-demographic factors, such as age and years of experience. Additionally, in the current study, younger physicians aged 25–34 (54.8%) exhibited poor attitudes compared to older age groups. This aligns with the study of Na’amnih et al., where younger physicians tend to follow recommendations and guidelines related to H. pylori-induced gastric ulcers more than older physicians [46].

Regarding participants’ practices, the findings of this study highlight that although a majority of participants recognized the public health significance of H. pylori, some where unfamiliar with the evidence-based guidelines such as the Maastricht VI or ACG recommendations, i.e., 66.8% had a clear opinion on recommending H. pylori testing if suspicious symptoms arise, 76.5% noted routinely discussing principal H. pylori-induced gastric ulcer risk factors and exposures with their patients, 74.5% highlighted the importance of providing lifestyle counseling, 75.8% underscored the importance of administering pharmacotherapy, while 67.4% emphasized the importance of follow-up testing after triple or quadruple combination therapy in our sample. The observed variability in physicians’ screening, treatment, and follow-up practices, together with the potential reliance on empirical therapeutic approaches, may contribute to inappropriate antibiotic utilization, and increasing antimicrobial resistance. This concern is particularly relevant in South Asia, where antibiotic misuse, over-the-counter antimicrobial availability, and inconsistent adherence to evidence-based treatment guidelines remain widespread challenges. Based on this, while our respondents showed notably high knowledge and attitudes, these do not necessarily translate to best practices in ~20–30% of respondents. The practices of physicians regarding H. pylori-induced gastric ulcer management exhibit some consistency with international studies. Our findings align with a study from the UK by Lim et al., who found that 25% of primary care physicians with an interest in gastroenterology used H. pylori serology as a screening test for young dyspeptic patients [49]. In the context of prescribing pharmacotherapy, our results correspond with findings from Tosetti et al., where general practitioners in Italy were found more frequently administering eradication therapy, instead of referring patients to gastroenterologists [50]. While a Spanish study of primary care physicians found 80.9% never prescribed treatment without initial confirmation of the infection [47]. Our results showed similar rates as earlier German [48] and Italian [50] studies, where 74.0% and 76.4% of primary care physicians always confirmed routine eradication therapy with a follow-up test; on the other hand, only 43.6% of primary care physicians confirmed the success of eradication therapy in Hungary [51]. These variations may be due to differences in healthcare systems, financing situations, including adherence to clinical guidelines, and the level of awareness and training among physicians in different regions.

In terms of sources of information, the current study found that physicians primarily relied on medical journals and online resources, similar to findings from Italy, where general physicians rely on printed or online journals (27.0%), and 15% on resources on the internet (15.0%) [50], whereas in a study from Israel, 50.0% of healthcare professional respondents reported primarily relying on professional guidelines [46]. These findings highlight the need for continuous professional development programs to address specific gaps in knowledge, attitudes, and practices regarding H. pylori-induced gastric ulcers. Regular workshops and seminars—particularly in high-patient-volume public hospitals—may provide practical training and peer-learning opportunities. The development of accessible online resources will also support flexible, self-directed learning, thereby improving overall physician competence in managing H. pylori-induced gastric ulcers more effectively.

While our results provide valuable insights in local contexts, several limitations of our report must be acknowledged. First, our study primarily focused on two hospitals in Lahore, which may not represent the broader population of physicians across Pakistan. Differences in healthcare infrastructure, patient demographics, institutional practices, and access to continuing medical education across regions may further limit the broader generalizability of the findings. Second, the study sample disproportionately consisted of physicians with MBBS qualifications, and those with less than five years of professional experience. This imbalance may have occurred because highly qualified and experienced physicians, including those with MBBS-FCPS, MD, and MD-FCPS degrees, were less willing to participate due to time constraints and heavy clinical workloads. Consequently, the findings may more strongly reflect the KAP of early-career physicians. Third, although participants were categorized according to qualifications and years of experience, respondents were not specifically stratified according to specialty designation, department, or level of clinical training (e.g., junior doctors, general physicians, or gastroenterologists), respectively. As physicians from different specialties may vary considerably in their exposure to patients, H. pylori management needs, and evidence-based gastroenterology practices, the absence of specialty-specific analyses may limit the interpretation of the findings. Fourth, the use of convenience sampling may have introduced selection bias. In addition, the study relied on self-reported responses, making social desirability and response bias possible, whereby participants may have overreported adherence to guideline-based management practices or ideal clinical behaviors rather than actual routine practices. Fifth, the adherence to international recommendations, including Maastricht VI and ACG guidelines, was evaluated based on self-reported practices, rather than objective clinical assessments. Moreover, the study did not include prescription audits, clinical audits, or medical record reviews to verify actual prescribing behavior or follow-up practices. Sixth, although the questionnaire demonstrated acceptable validity and internal consistency, questionnaire-based assessments may not fully capture the complexity of real-world clinical decision-making. Additionally, the ≥50% cut-off used to categorize “good” knowledge and attitude levels, while adopted from previously published KAP studies for methodological consistency, may represent a relatively lenient classification approach and could potentially overestimate adequate knowledge levels among participants. Furthermore, the study did not evaluate local antimicrobial resistance patterns or institutional eradication protocols, both of which may considerably influence physicians’ treatment choices and adherence to evidence-based recommendations.

Future nationwide multicenter studies involving physicians from diverse healthcare settings, specialties, and experience levels are warranted to provide a more representative assessment of H. pylori-related clinical practices in Pakistan. Future research should also incorporate objective methodologies, such as prescription audits, chart reviews, and clinical audits, to better assess actual compliance with international management guidelines. Additionally, incorporating qualitative methods, specialty-specific analyses, antimicrobial resistance surveillance data, and digital data collection tools may provide a more comprehensive understanding of physicians’ knowledge, attitudes, and practices regarding H. pylori management. Comparative, multi-national and multidisciplinary studies may further help to identify the strategies to improve evidence-based management and patient outcomes.

5. Conclusions

The current study—while it demonstrated high levels of knowledge and attitudes among physicians in Pakistan—highlights notable gaps in practices and variations in clinical practices regarding the diagnosis and management of H. pylori-induced gastric ulcers. Despite recognizing the public health relevance of gastric ulcers, there is a space for improvement in routinely recommending H. pylori screening, appropriate first-line therapeutic regimens, and follow-up testing. The reliance on medical journals and online resources for evidence-based information highlights the need for more accessible educational resources, tailored to local settings and constraints. These findings emphasize the importance of targeted educational programs to address knowledge gaps, standardize practices, and enhance the appropriate management of H. pylori-induced gastric ulcers among physicians in Pakistan.