The Effectiveness of an Educational Intervention on Helicobacter pylori for University Students: A Quasi-Experimental Study

Introduction

Helicobacter pylori (H. pylori) is a gram-negative bacterium present in the gastric environment in approximately 4.4 billion individuals, making it the most widespread infection worldwide.¹ The primary reservoir is the stomach, and the principal mode of transmission is person-to-person contact. Many studies have reported that the prevalence of H. pylori is influenced by many factors, including educational level, geographical area, age, socioeconomic status, and living conditions.² Globally, a study showed that the infection rate in low and middle-income countries was 44.3% and 50.8%, respectively, while in the developed countries, it was 34.7%. This variation might be due to poor sanitation, crowded living conditions, lack of awareness, and poor water supply in less-developed countries.³ However, although Saudi Arabia is a developed country, one study showed H. pylori prevalence of 50–80% among symptomatic patients with abdominal pain, dyspepsia, and patients who underwent endoscopic procedures.⁴ The majority of those who have the organism are asymptomatic (85%), and less than 15% develop complications.⁵ Since most of them remain asymptomatic, long-term colonization of the gastric mucosa with H. pylori might lead to several complications, including peptic ulcer, chronic gastritis, gastric cancer, and mucosa-associated lymphoid tissue lymphoma.

Moreover, H. pylori infection is both pervasive and harmful, making its eradication a major public health concern. Unfortunately, general knowledge and awareness regarding H. pylori infection are relatively poor.^6–9 Education is an important approach for enhancing patients’ understanding, promoting patient-doctor communication, and raising self-cognition and management.^10,11 A study conducted by Zha et al (2022) that aimed to determine the impact of an enhanced patient education (EPE) program for H. pylori infection concluded that EPE could improve eradication rates and patient compliance to some extent, which constitutes a promising addition to clinical treatment regimens.¹²

The first phase of our study,¹³ which compared the knowledge of health science and non-health science undergraduate students about H. pylori infection, found the overall knowledge level to be relatively low. Educational interventions are needed to improve public awareness.^11,14 Hence, the implementation of an educational program for H. pylori infection that includes modes of transmission, complications, and prevention is imperative. Based on the findings of a low level of knowledge in the first phase of the study, the researchers felt that the need for developing an educational intervention for H. pylori was fundamentally important. The second phase of the study was conducted to assess the effectiveness of an educational intervention aimed at increasing university students’ awareness. To our knowledge, this study is the first to examine the effectiveness of an educational intervention on H. pylori infection among university students in Saudi Arabia.

Materials and Methods

Study Design, Setting, and Participants

This study used a quasi-experimental one-group pre- and post-test design to evaluate the effectiveness of an educational program regarding H. pylori infection and its prevention. This research was conducted at King Saud University, which includes undergraduate students from four colleges: two health colleges (College of Applied Medical Sciences and College of Nursing) and two non-health colleges (College of Science and College of Computer Science). Second-year (levels III and IV) and third-year (levels V and VI) undergraduate students participated in the study. These levels describe the semesters in the yearly program. A nonprobability convenience sampling technique was used. A total of 108 students who consented to participate in this study were selected. The inclusion criteria were as follows: i) full-time students registered in an undergraduate program and ii) willing to participate in the study. Students enrolled in the preparatory year were excluded from this study.

Development and Description of the Educational Package on H. pylori

Before establishing the content of the educational package on H. pylori (EPHP) and methods to be used for delivering the sessions, an extensive review of the literature on H. pylori was conducted. The educational package consisted of four parts: i) the EPHP objectives, ii) the content: the topics specified in the development section of the knowledge questionnaire, iii) the teaching method: lecture and discussion, and iv) audio-visual aids: PowerPoint slides and a video developed by the authors. The draft EPHP was developed based on a literature review. Furthermore, it was submitted to five experts from the fields of community nursing and medicine for content validation, who agreed on the relevance and appropriateness of the content. All aspects of the EPHP had over 80% agreement among the experts. Therefore, no further modifications were made. The total duration of the EPHP was 1 h, which predominantly had lecture discussions as the teaching method.

Data Collection

The data were collected in October 2021 using a two-part questionnaire; the first section assessed the socio-demographic factors, and the second section measured knowledge regarding H. pylori through 14 single-response multiple-choice items. The content areas of the survey were “meaning/perception of H. pylori infection and complications” (three items; items 1, 13, and 14), “signs and symptoms and risk factors” (four items; items 2–5), “mode of spread and prevention” (two items; items 6 and 8), and “diagnosis, treatment, and self-care” (five items; items 7, 9–12). A correct response was scored one, and an incorrect answer was zero. A score ranging from 0–14 was converted into a percentage score and classified into three levels: good (> 75%), fair (50–75%), and poor (< 50%). The instrument was developed by the researchers in the first phase of the study. This instrument is valid and reliable. The instrument’s psychometric properties were described in a previous publication.¹³ A pilot study conducted on a sample of students who were not part of the main study (n = 10) demonstrated that the study was feasible.

After explaining the purpose and procedure for data collection, participants who fulfilled the inclusion criteria and consented to participate were invited by each of the course’s faculty coordinators. On Day 1, participants completed the demographic and knowledge questionnaire (pre-test) through an online Google Forms survey, which was sent to their registered emails. After the students responded to the questionnaire, the educational intervention was conducted online through the Zoom platform. The educational session lasted 1 h in total, with a lecture and discussion session lasting 55 min and a video lasting 5 min. On Day 8, the post-test was conducted using the same structured knowledge questionnaire as used for the pre-test. The post-test was completed by all 108 students who took the pre-test.

Ethical Considerations

This study was conducted in accordance with the guidelines of the Declaration of Helsinki and ethical approval was granted by the Institutional Review Board of King Saud University (approval of Research Project No. E-19-4102). Implied informed consent at the beginning of the questionnaire was obtained from all participants. The confidentiality of the data collected was ensured, and its usage was solely intended for the researchers.

Statistical Analyses

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0 (Armonk, NY: IBM Corp). Frequencies and percentages were used to describe the sociodemographic data and knowledge of H. pylori infection among the students. The range (minimum and maximum), mean, standard deviation (SD), and median were calculated. To determine the normality of the distribution of pre-test and post-test data, the Kolmogorov–Smirnov test was used. The significance of the obtained results was determined at the 5% level. The Wilcoxon signed-rank test was used to analyze the effectiveness of the educational program.

Results

Socio-Demographic Characteristics of the Respondents

The socio-demographic characteristics of the respondents were analyzed (Table 1). The respondents were mostly in the 20 to 30-year age group (76.9%) and male individuals (61.1%). The university level of the respondents was higher in Year III (63.9%) than in Year II (36.1%). Two-thirds of the respondents had 4–7 siblings, and the majority (56.5%) claimed to have a monthly family income of more than 10,000 Saudi riyals (1 USD = 3.76 SR). Regarding their habits, most of them (95.4%) drank coffee or tea, and 60.2% drank < 2 cups per day. Interestingly, more than half of the respondents reported that their families consumed both bottled and tap water, and only 5.6% of respondents stated that their families used only tap water. About half of the respondents had heard about H. pylori infection, and their source of knowledge was similarly distributed between mass media (34%), reading articles (32.1%), and family (30.2%). Only 6.5% of the respondents had a history of H. pylori infection, and 57.1% of them received treatment.

Table 1 Socio-Demographic Characteristics of the Respondents (n = 108)

Comparison of Knowledge Before and After the Educational Intervention

The level of knowledge of H. pylori infection was measured among the participants before and after the introduction of the educational intervention. As shown in Figure 1 the overall knowledge of H. pylori infection increased after the educational intervention. Before the educational intervention, less than a tenth (9.3%) of the participants had good knowledge, which increased to 55.6% after the intervention. Moreover, approximately two-thirds of the participants had poor knowledge (62.0%) before the intervention. After the intervention, this figure reduced to 2.8%, and the groups with fair knowledge increased from 28.7% to 41.7%.

Figure 1 Distribution of the respondents regarding knowledge about H. pylori Infection. Knowledge scores were classified into three levels based on the percentage of scores achieved by the participants: good (>75%), fair (50–75%), and poor (< 50%). Pre-test (Questionnaire administered before the educational intervention); Post-test (Questionnaire administered after the educational intervention).

The overall and domain-wise knowledge of the respondents was analyzed to determine whether the educational intervention was effective in improving their knowledge. Thus, the hypothesis “there will be a significant increase in the mean post-test knowledge score of the students compared with their mean pre-test knowledge score” was tested at a 0.05 level of significance. The findings showed a significant increase in the mean from 43.5 to 76.8 (p < 0.001), indicating that the educational intervention was effective in improving the knowledge of students about H. pylori infection (Figure 2). The comparison of the percentage of respondents who answered each of the items correctly in the pre-test and post-test showed a significant increase in all except two items, with one denoting the meaning of H. pylori (“Helicobacter Pylori (H. pylori), commonly found in the stomach, is a bacterium” (p = 0.176) and the other related to the signs and symptoms (“A person suffering from H. pylori infection will experience which of the following?” (p = 0.784) (Table 2).

Table 2 Distribution of the Respondents Regarding Knowledge About H. pylori Infection

Figure 2 Descriptive Analysis of the Respondents According to Knowledge Domain about H. pylori Infection. Error bars represent the standard deviation, ***p = 0.001. Pre-test (Questionnaire administered before the educational intervention); Post-test (Questionnaire administered after the educational intervention).

Factors Associated with H. pylori Knowledge Among Respondents in the Pre-test

The socio-demographic characteristics of the respondents were analyzed to assess their association with pre-test knowledge. As shown in Table 3, respondents’ knowledge of H. pylori was independent of all except one variable; whether or not they had heard about H. pylori infection (χ2 = 8.666, p = 0.013).

Table 3 Relationship Between the Socio-Demographic Characteristics and Knowledge About H. pylori Infection (Pre-Test) (N = 108)

Discussion

Education is a critical component in the prevention and control of infections.^11,14 Therefore, developing and utilizing educational programs to raise awareness regarding the prevention and spread of infections, particularly H. pylori infection, is of fundamental importance. The educational intervention in our study was effective in improving knowledge of H. pylori infection among university students. The findings of this study will be particularly useful for health educators to raise awareness of H. pylori, specifically, as research has shown low awareness about H. pylori, not only in the general population^10,15 but also among university students.¹³ Furthermore, the low awareness in a recent survey among undergraduate university students in Saudi Arabia, conducted as the first phase of this study and published elsewhere, formed the basis of the current study.¹³ Interestingly, the study showed low awareness among both health and non-health science university students, indicating the need for educational programs to enhance students’ awareness of H. pylori infection, which is a public health concern.

Our finding of a significant increase in overall and domain-wise knowledge of H. pylori infection after the educational intervention is comparable to the findings of Ibrahiem and Saad (2021), who evaluated a health awareness package for H. pylori among family members in a hospital in terms of knowledge and hygienic practices in Egypt.¹⁶ Although their findings are comparable to our study’s, there are some differences. For instance, their sample involved family members, and they used face-to-face small-group education with a booklet. In contrast, our sample comprised university students registered in a baccalaureate program. Furthermore, we used online teaching that lacked face-to-face interaction. Although the specific characteristics of the individuals and teaching methods influenced the learning process, the educational intervention effectively improved learners’ knowledge. Although these studies have shown the effectiveness of educational interventions, findings have been reported among patients and family members. In addition to enhancing awareness, there are other benefits of educating patients. For instance, a systematic review and meta-analysis conducted by Zha et al (2022) on the effects of enhanced education for patients with H. pylori infection showed benefits in terms of improvements in eradication rates and patient compliance.¹² Although our educational intervention on H. pylori infection was aimed at improving the knowledge of university students, the students may benefit in the long term by utilizing this information to prevent H. pylori infection in the future. Further research is essential to determine its long-term benefits.

There is a paucity of research on educational interventions for H. pylori among university students. Therefore, we compared our findings with those of studies conducted on students in other knowledge domains, such as infection control precautions and hand hygiene. Similar to our findings, previous research reporting the effectiveness of educational interventions has been shown to improve students’ knowledge of hand hygiene,¹⁷ tuberculosis infection control,¹⁸ and infection control prevention.^19–22 For instance, Jordan’s nursing schools tested the educational program’s effectiveness in promoting students’ knowledge of infection prevention precautions and observed that after participating in the infection prevention educational program, participants in the experimental group demonstrated significantly better knowledge than those in the control group.²⁰ In another study that compared the effects of two educational programs for infection control, a simulation using standardized patients and a peer role-play for the experimental group and lectures, skills training, and peer tutoring practices for the control group, the results showed that both groups had statistically significant increase in knowledge, awareness of standard precautions, and infection control performance after the intervention.²¹ These studies further highlight the effectiveness of educational interventions in improving student knowledge using various methods. Similarly, our study found that online teaching was effective in improving students’ knowledge.

Contrary to our expectations, two items on the questionnaire did not show a significant increase in knowledge after the intervention: “Helicobacter Pylori (H. pylori), commonly found in the stomach, is a bacterium”, and “A person suffering from H. pylori infection will experience nausea.” This finding suggests that future educational programs should place greater emphasis on this content. Concerning the association between socio-demographic factors and pre-test knowledge of H. pylori, all except two factors, university level and having heard about H. pylori infection, were independent of the level of knowledge. The finding of a significant association between the knowledge level of H. pylori and university level of the students was similar to that of a previous report.¹³ In our study, a larger proportion of students in levels V and VI/ (third year) had fair knowledge than those in levels III and IV (second year). It seems possible that these results are due to the upward curricular movement of the students, suggesting that they acquired better information about H. pylori in their curricular advancement. Further studies with larger sample sizes are required to understand the relationship between these variables.

The strength of this study is that, to the best of our knowledge, this is the first study to develop and evaluate an educational intervention for H. pylori knowledge among Saudi university students. The respondents were recruited by convenience sampling from one university. Thus the findings may not be generalizable to all university students in Saudi Arabia. As this study used a small-sized convenience samples, selection bias is possible. Using a self-reported questionnaire rendered it difficult to avoid response bias. Furthermore, the quasi-experimental design with one group can affect internal validity. Future studies with control groups will be beneficial. This study did not assess the long term effects of the educational intervention, such as retention of knowledge and implementation of preventive measures of H. pylori infection. Future research efforts should not only use larger sample of schools, adolescents, and other vulnerable groups, but also examine the intervention effects on preventing H. pylori infection. Despite these limitations, the study was effective in improving university students’ knowledge. The implication of this finding is that educational intervention can be used as an adjunct to the regular education of students to enhance their knowledge of H. pylori. Moreover, a program such as this might boost adherence to H. pylori infection control practices and, as a result, reduce the prevalence and complications of H. pylori infection.