Observational Study Open Access
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 21, 2023; 29(43): 5818-5833
Published online Nov 21, 2023. doi: 10.3748/wjg.v29.i43.5818
Knowledge, attitude, and practice of patients living with inflammatory bowel disease: A cross-sectional study
Xiao-Xiao Shao, Lu-Yan Fang, Xu-Ri Guo, Dao-Po Lin, Department of Gastroenterology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang Province, China
Wei-Zhong Wang, Rui-Xin Shi, The Second Clinical Medical College, Wenzhou Medical University, Wenzhou 325035, Zhejiang Province, China
ORCID number: Dao-Po Lin (0000-0003-0785-7675).
Author contributions: Fang LY and Guo XR carried out the study and participated in collecting data; Shao XX drafted the manuscript; Wang WZ and Shi RX performed the statistical analysis and participated in its design; Lin DP participated in the acquisition, analysis, and interpretation of data; and all authors read and approved the final manuscript.
Supported by Wenzhou Science and Technology Bureau, No. Y20220031.
Institutional review board statement: Our study was approved by the ethics committee of the same hospital (Approval No. 2022-K-184-02).
Informed consent statement: Each patient provided written informed consent before completing the survey.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Dao-Po Lin, MD, Department of Gastroenterology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, No. 109 Xueyuan Western Road, Wenzhou 325027, Zhejiang Province, China. wmuldp@163.com
Received: August 14, 2023
Peer-review started: August 14, 2023
First decision: October 8, 2023
Revised: October 20, 2023
Accepted: November 14, 2023
Article in press: November 14, 2023
Published online: November 21, 2023
Processing time: 98 Days and 0.4 Hours

Abstract
BACKGROUND

Patients with inflammatory bowel diseases (IBDs) generally have poor knowledge, attitude, and practice of their disease, while the data from China are lacking.

AIM

To address this knowledge disparity among Chinese patients with IBD.

METHODS

This web-based, cross-sectional study was conducted on a cohort of IBD patients who visited the Second Affiliated Hospital of Wenzhou Medical University between December 2022 and February 2023. Their socio-demographic information and the knowledge, attitude, and practice scores were collected and estimated using a self-designed questionnaire. Pearson’s correlation analysis was used to determine the pairwise correlations among knowledge, attitude, and practice scores. A multivariate logistic regression analysis was further performed to determine the independent factors associated with their knowledge, attitude, and practice scores.

RESULTS

A total of 353 patients (224 males) with IBD completed the questionnaires. The mean knowledge, attitude, and practice scores were 10.05 ± 3.46 (possible range: 0-14), 41.58 ± 5.23 (possible range: 0-56), 44.20 ± 7.39 (possible range: 0-56), respectively, indicating good knowledge, positive attitude, and proactive practice toward IBD. Pearson’s correlation analysis showed that the knowledge score had significant positive correlations with the attitude score (r = 0.371, P < 0.001) and practice score (r = 0.100, P < 0.001). The attitude score had a significant positive correlation with the practice score (r = 0.452, P < 0.001). Moreover, multivariate logistic regression analysis showed that aged 30-40 years [odds ratio (OR) = 4.06, 95% confidence interval (CI): 1.04-15.82, P = 0.043], middle school education (OR = 3.98, 95%CI: 1.29-12.33, P = 0.017), high school/technical secondary school education (OR = 14.06, 95%CI: 3.92-50.38, P < 0.001), and junior college/bachelor’s degree and above education (OR = 15.20, 95%CI: 4.15-55.650, P < 0.001) were independently associated with good knowledge. The higher knowledge score was independently associated with a positive attitude (OR = 1.23, 95%CI: 1.11-1.36, P < 0.001). The higher attitude score was independently associated with proactive practice (OR = 1.20, 95%CI: 1.11-1.30, P < 0.001).

CONCLUSION

Chinese patients with IBD might have good knowledge, a positive attitude, and proactive practice toward their disease. However, a small number of specific items require education.

Key Words: Attitude, Cross-sectional study, Inflammatory bowel disease, Knowledge, Practice, Questionnaire

Core Tip: To address this knowledge disparity among Chinese patients with inflammatory bowel disease (IBD), a web-based, cross-sectional study was conducted on 353 IBD patients (224 males). Their mean knowledge, attitude, and practice scores were 10.05 ± 3.46 (range: 0-14), 41.58 ± 5.23 (range: 0-56), and 44.20 ± 7.39 (range: 0-56), respectively. Multivariate logistic regression analysis showed that age and education were independently associated with knowledge. Knowledge was independently associated with attitude. The attitude was independently associated with the practice. In conclusion, patients with IBD in China might have good knowledge, a positive attitude, and proactive practice toward their disease. However, some specific items require education.



INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic, non-specific inflammation of the gastrointestinal tract, including ulcerative colitis and Crohn’s disease. The IBD usually develops before age 30[1-3]. Moreover, IBD is associated with a poor quality of life and may increase colorectal cancer risk[2-4]. The individual management strategy of IBD is tailored to each patient according to diagnosis, disease activity grade, disease lesion, and personal prognostic factors[1,3-7]. Despite this, IBD continues to be difficult to manage, as treatment adverse effects and repeated exacerbation/recurrence episodes can eventually necessitate costly second-line therapies or even surgery[8-11].

Maintaining proper lifestyle habits is necessary and complementary to medical treatments in patients with IBD[12,13]. Fundamental to patient self-management is knowing which foods and situations to avoid and what can be done to alleviate symptoms[12,13]. To implement adequate self-management, a thorough understanding of IBD causes, risk factors for exacerbation/recurrence, disease mechanisms, and treatments is essential, and this knowledge needs to be translated into more effective (but not infallible) self-management. In addition, since there is no cure for IBD, self-management is essential to its treatment[1,5,14]. Indeed, since the management of IBD necessitates the adoption of healthy lifestyle habits, IBD patients are the first to be accountable for their health[12,13], which requires proper knowledge, attitudes, and practice (KAP) of the specific lifestyle routines to implement. The appropriate KAP about IBD can reduce medical acceleration in patients with IBD[15]. Since the 1990s, however, some studies have revealed that patients with IBD have misconceptions and limited knowledge of their disease[16-21]. Such studies are important to identify the gaps in knowledge that represent barriers to the proper management of IBD. Identifying these obstacles could also aid in designing interventions to enhance or rectify knowledge[22,23]. Owing to significant differences in culture, economy, health literacy, healthcare systems, and government policies, KAP data are usually very specific to a given population. Of note, data about the KAP toward IBD in Chinese patients with IBD are lacking.

The KAP methodology provides quantitative and qualitative data on the misconceptions that could represent obstacles to a specific task/subject in a specific population[22,23]. Hence, this study aimed to investigate the KAP of patients with IBD toward their disease in Zhejiang Province, China. The results could help healthcare providers to improve the patient’s self-management of IBD.

MATERIALS AND METHODS
Study design and participants

It was a cross-sectional study conducted on patients with IBD at the Second Affiliated Hospital of Wenzhou Medical University using convenience sampling. Our study was approved by the ethics committee of the same hospital (approval No. 2022-K-184-02). Each patient provided written informed consent before completing the survey.

Procedures

The questionnaire was designed with reference to the World Gastroenterology Organization Practice Guidelines for the Diagnosis and Management of IBD in 2010[24] and the clinical nutrition guideline for IBD by the European Society for Clinical Nutrition and Metabolism in 2016[25]. Then, the questionnaire was submitted to 5 experts for review. After the modifications based on their comments, a small-scale validation was performed (33 copies), showing a Cronbach’s α of 0.854.

The final questionnaire was in Chinese patients with IBD and included four dimensions with 62 items. Among them, the socio-demographic information dimension consisted of 20 items. The knowledge, attitude, and practice dimensions consisted of 14 items each. The items in the knowledge dimension were scored 1 point for a correct answer and 0 points for a wrong or unclear answer (total score of 0-14). The options from positive to negative (e.g., 4 to 0) were assigned for the attitude and practice dimension. The total scores were 0-56 for the attitude dimension and 0-56 for the practice dimension. The threshold for good knowledge, positive attitude, and proactive practice was ≥ 70.0%.

The questionnaires were administered to the participants through WeChat on the SoJump platform (https://www.wjx.cn/app/survey.aspx). A given IP address could be used to submit a questionnaire only once. All items must be answered before the submission of the questionnaire. Questionnaires that took less than 2 min to complete or with obvious filling patterns were excluded.

Statistics analysis

All analyses were performed using Stata 17.0 (Stata Corporation, College Station, TX, United States). The normal distribution of continuous data was checked using the Kolmogorov-Smirnov test. Those continuous data conforming to the normal distribution were presented as means ± SD and analyzed using Student’s t-test (two groups) or ANOVA (more than two groups). Otherwise, they were presented as medians (ranges) and analyzed using the Wilcoxon-Mann-Whitney U-test (two groups) or the Kruskal-Wallis analysis of variance (more than two groups). Categorical data were displayed as numbers (percent). Pearson’s correlation analysis was used to determine the pairwise correlations among KAP scores. A multivariate logistic regression analysis was performed to determine the independent factors relevant to the KAP score. Variables with P-values less than 0.20 in the univariate analysis were included in the multivariate logistic analysis. Two-sided P-values below 0.05 were regarded as statistically significant.

RESULTS

The present study included a total of 353 valid questionnaires. Most of the participants were male (63.5%), aged 20-30 (32.9%) years. The other social-demographic data are presented in Table 1. The mean knowledge, attitude, and practice scores were 10.05 ± 3.46 (possible range: 0-14), 41.58 ± 5.23(possible range: 0-56), and 44.20 ± 7.39 (possible range: 0-56), respectively, indicating good knowledge, positive attitude, and proactive practice toward IBD (Table 1).

Table 1 Characteristics of the participants.
Variablesn (%)Knowledge
Attitude
Practice
mean ± SD
P value
mean ± SD
P value
mean ± SD
P value
Total35310.05 ± 3.4641.58 ± 5.2344.20 ± 7.39
Gender0.4680.8300.077
    Male224 (63.5)9.95 ± 3.5741.62 ± 5.0244.72 ± 7.35
    Female129 (36.5)10.2 ± 3.2841.50 ± 5.5943.28 ± 7.40
Age, yr (10 cases missing)< 0.0010.1420.886
    ≤ 2041 (11.6)9.46 ± 3.8740.95 ± 5.1344.00 ± 8.15
    20-30116 (32.9)10.87 ± 2.9442.41 ± 5.2544.37 ± 7.40
    30-4085 (24.1)10.56 ± 3.0341.81 ± 5.2443.89 ± 6.92
    > 40101 (28.6)9.02 ± 3.9140.88 ± 5.2144.70 ± 7.27
Ethnicity (1 case missing)0.0110.0280.609
    Han341 (96.6)10.13 ± 3.3941.69 ± 5.1644.25 ± 7.41
    Minorities11 (3.1)7.45 ± 4.8938.18 ± 6.5143.09 ± 6.85
Residence0.0060.0590.002
    Rural149 (42.2)9.38 ± 3.7244.18 ± 5.1943.76 ± 7.76
    City122 (34.6)10.66 ± 3.0542.48 ± 5.0545.97 ± 6.73
    Suburb/urban-rural combination82 (23.2)10.35 ± 3.8540.95 ± 5.4542.35 ± 7.13
Education< 0.0010.0030.089
    Primary school and below25 (7.1)6.92 ± 3.5340.00 ± 4.9742.88 ± 7.21
    Middle school67 (19.0)7.99 ± 4.1739.99 ± 5.8242.40 ± 8.01
    High school/technical secondary school84 (23.8)10.25 ± 2.8841.42 ± 4.8344.55 ± 6.98
    Junior college/bachelor’s degree and above177 (50.1)11.18 ± 2.7542.47 ± 5.0544.89 ± 7.29
Work status< 0.0010.0020.012
    Employed185 (52.4)10.79 ± 2.9642.39 ± 4.9045.13 ± 6.83
    Other168 (47.6)9.23 ± 3.7840.68 ± 5.4443.17 ± 7.85
Monthly per capita income< 0.0010.0030.074
    < 5000173 (49.0)9.32 ± 3.8740.61 ± 5.2043.29 ± 7.95
    5000-10000104 (29.5)10.88 ± 2.5242.37 ± 4.9645.21 ± 6.59
    > 1000076 (21.5)10.55 ± 3.2742.68 ± 5.3244.87 ± 6.93
Marital status0.0290.9390.201
    Unmarried or other157 (44.5)10.50 ± 3.2141.60 ± 5.2544.76 ± 7.40
    Married196 (55.5)9.69 ± 3.6241.56 ± 5.2343.74 ± 7.37
Smoking habit0.1630.3860.202
    No (no smoking)282 (79.9)10.18 ± 3.3341.45 ± 5.1343.94 ± 7.18
    Yes (smoking or used to smoke)71 (20.1)9.54 ± 3.9242.06 ± 5.6345.20 ± 8.14
Drinking habit0.4610.7440.372
    No (no drinking)240 (68.0)10.14 ± 3.4041.51 ± 5.2743.95 ± 7.36
    Yes (drinking or used to drink)113 (32.0)9.85 ± 3.5941.71 ± 5.1644.71 ± 7.47
Medical insurance type (multiple choices)
    Basic medical insurance for urban employees187 (53.0)10.68 ± 3.06< 0.00143.62 ± 4.98< 0.00144.79 ± 7.140.108
    New cooperative medical insurance112 (31.7)9.16 ± 4.020.00154.18 ± 5.450.00143.34 ± 7.880.138
    Basic medical insurance for urban residents62 (17.6)9.18 ± 3.770.02955.13 ± 4.870.46044.56 ± 6.710.666
    Commercial insurance23 (6.5)10.74 ± 3.370.32356.30 ± 4.760.49045.61 ± 7.240.343
    No insurance3 (0.8)12.33 ± 1.150.25252.00 ± 4.580.23534.67 ± 9.290.025
Which IBD< 0.0010.0050.553
    Ulcerative colitis133 (37.7)9.16 ± 3.6954.57 ± 5.0643.89 ± 7.55
    Crohn’s disease220 (62.3)10.59 ± 3.2156.18 ± 5.2544.38 ± 7.30
Duration of IBD0.9950.9480.248
    < 1 yr239 (67.7)10.05 ± 3.4655.58 ± 5.1744.65 ± 7.36
    1-2 yr59 (16.7)10.08 ± 3.4355.41 ± 5.3043.17 ± 7.72
    > 2 yr55 (15.6)10.02 ± 3.5655.73 ± 5.5943.33 ± 7.09
Ostomy0.0140.0880.621
    Yes27 (7.6)8.48 ± 4.3753.93 ± 5.9543.52 ± 10.05
    No326 (92.4)10.18 ± 3.5355.71 ± 5.1544.25 ± 7.14
Comorbidities0.4630.0640.004
    Yes59 (16.7)9.75 ± 3.7254.42 ± 5.1141.71 ± 7.32
    No294 (83.3)10.11 ± 3.4155.81 ± 5.2344.64 ± 7.28
Family history of IBD0.5880.9910.392
    Yes9 (2.5)10.67 ± 4.2155.56 ± 4.9842.11 ± 6.43
    No344 (97.5)10.03 ± 3.4555.58 ± 5.2444.25 ± 7.41
Surgical history0.3400.4870.894
    Yes165 (46.7)10.24 ± 3.3955.78 ± 5.1044.14 ± 7.47
    No188 (53.3)9.88 ± 3.5355.39 ± 5.3544.24 ± 7.34
History of drug allergy0.1100.1200.890
    Yes48 (13.6)10.79 ± 2.7356.67 ± 5.1544.33 ± 7.36
    No305 (86.4)9.93 ± 3.5555.40 ± 5.2344.17 ± 7.41
What kind of treatment is being received?0.0400.0040.276
5-aminosalicylic acid drugs (e.g., mesalazine)19 (5.4)8.63 ± 3.4455.00 ± 4.9945.32 ± 8.87
Glucocorticoids1 (0.3)12.0057.0050.00
Immunosuppressants (e.g., azathioprine, tacrolimus, cyclosporine, etc.)6 (1.7)6.50 ± 3.2751.33 ± 6.3837.83 ± 9.99
Biological agents (e.g., infliximab, vedolizumab, ustekinumab)301 (85.3)10.16 ± 3.4955.97 ± 5.1344.33 ± 7.26
Biological agents + immunosuppressants14 (4.0)9.93 ± 3.3451.36 ± 5.5843.57 ± 6.73
Biological agents + 5-aminosalicylic acid drugs12 (3.4)11.25 ± 1.4853.42 ± 4.3642.50 ± 6.99

The knowledge items with the lowest score were K2 (21.0%, “At present, and many factors such as heredity, immunity, environment, and microorganisms are involved in the pathogenesis of the disease”), K11 (42.2%, “There are no side effects under the therapy of glucocorticoids, etc.”), K4 (60.1%, “Extraintestinal manifestations of IBD include oral ulcers, joint injury, skin injury, eye lesions, hepatobiliary diseases, etc.”), and K13 (65.7%, “All patients with IBD cannot normally absorb the nutrients they intake”) (Table 2). The attitude item with the lowest score was A8 (“I think that treatment can be stopped when the colonoscopy shows mucosal healing i.e., complete healing of colonic erosions and ulcers”) (Table 3). The practice item with the lowest score was P11 (“I will use a diet diary to identify foods that may cause discomforts such as abdominal pain or diarrhea and try to avoid them in my future diet”). In addition, 98.0% of the participants were willing to stop smoking and drinking (Table 4).

Table 2 Knowledge dimension, n (%).
Knowledge
Correct
Wrong
Unclear
IBD is a group of chronic, non-specific recurrent intestinal inflammatory diseases, including UC and CD316 (89.5)2 (0.6)35 (9.9)
At present, many factors, such as heredity, immunity, environment, and microorganisms, are involved in the pathogenesis of the disease74 (21.0)185 (52.4)94 (26.6)
Symptoms of IBD can include abdominal pain, diarrhea, bloody stool, anemia, fever, joint swelling, pain, etc.293 (83.0)13 (3.7)47 (13.3)
Extraintestinal manifestations of IBD include oral ulcers, joint injury, skin injury, eye lesions, hepatobiliary diseases, etc.212 (60.1)32 (9.1)109 (30.9)
IBD often occurs in young adults and is more common between the ages of 20-50 yr267 (75.6)16 (4.5)70 (19.8)
IBD is a lifelong disease, and the patient’s condition is prolonged and repeated. At present, there is no specific and effective medicine or method to cure the disease293 (83.0)11 (3.1)49 (13.9)
Colonoscopy and mucosal biopsy are the best methods to establish the diagnosis and assess the disease’s severity in patients with IBD285 (80.7)6 (1.7)62 (17.6)
Generally, medical treatment is the main treatment for IBD, but surgical treatment is needed when intestinal obstruction, intestinal perforation, and canceration occur275 (77.9)5 (1.4)73 (20.7)
The treatment of patients with IBD varies widely among individuals, with different classifications and severity of the disease leading to different treatment outcomes and efficacy299 (84.7)1 (0.3)53 (15.0)
Drugs for treating IBD include hormones, aminosalicylic acid drugs, immunosuppressants (azathioprine, methotrexate, etc.), and biological agents274 (77.6)5 (1.4)74 (21.0)
There are no side effects after treatment with glucocorticoids, etc.149 (42.2)39 (11.0)165 (46.7)
Currently, the biological agents approved for treating IBD in China include infliximab, vidrizumab, and ustekinumab292 (82.7)6 (1.7)55 (15.6)
All patients with IBD can’t normally absorb the nutrients they intake232 (65.7)60 (17.0)61 (17.3)
Emotion, smoking, drinking, and other behaviors will not affect IBD286 (81.0)36 (10.2)31 (8.8)
Table 3 Attitude dimension, n (%).
Attitude
Strongly agreeAgreeNeutralDisagreeStrongly disagree
I am confident in the treatment of IBD158 (44.8)134 (38.0)58 (16.4)3 (0.8)0
I think patients with IBD need to avoid certain foods186 (52.7)144 (40.8)22 (6.2)1 (0.3)0
I think that patients with IBD combined with malnutrition need to use a combination of intestinal and extra-intestinal nutrition support according to the disease situation if necessary171 (48.4)151 (42.8)29 (8.2)1 (0.3)1 (0.3)
I think scientific dietary guidance and management are key to managing IBD193 (54.7)141 (39.9)18 (5.1)1 (0.3)0
I think developing a specific treatment plan for IBD needs to be tailored to the individual’s situation and developed jointly by the IBD medical specialist and the patient208 (58.9)129 (36.5)15 (4.2)1 (0.3)0
I think the adjustment of IBD medication needs to be carried out under the guidance of specialists, and patients should not adjust their own medication228 (64.6)112 (31.7)13 (3.7)00
I believe that during IBD medication, patients need to monitor the side effects of their medication and provide timely feedback to their specialists216 (61.2)128 (36.3)9 (2.5)00
I think treatment can be stopped when the colonoscopy shows mucosal healing (i.e., complete healing of colonic erosions and ulcers)37 (10.5)47 (13.3)92 (26.1)134 (38.0)43 (12.2)
I think the early application of biologics, in conjunction with specialist advice, will allow early control of disease activity to change the course of the disease and minimize complications and disability in the bowel171 (48.4)147 (41.6)30 (8.5)3 (0.8)2 (0.6)
I think patients with IBD should reduce their intake of saturated fatty acids (animal oil, cream, fatty meats, meat soups, etc.)137 (38.8)156 (44.2)52 (14.7)7 (2.0)1 (0.3)
I think that IBD patients should try to drink plain hot water and freshly squeezed juices and need to avoid strong tea, sugary drinks, coffee, alcohol, etc.177 (50.1)148 (41.9)24 (6.8)2 (0.6)2 (0.6)
I think the IBD disease has obviously increased the family’s financial burden172 (48.7)133 (37.7)42 (11.9)5 (1.4)1 (0.3)
I think I can get married, get pregnant, and give birth normally if my IBD disease is controlled125 (35.4)166 (47.0)52 (14.7)8 (2.3)2 (0.6)
I think IBD has affected my normal work, study, and social interaction98 (27.8)134 (38.0)86 (24.4)30 (8.5)5 (1.4)
Table 4 Practice dimension, n (%).
Practice
Always
Often
Sometimes
Seldom
Never
I will actively cooperate with the medical staff for my treatment and nursing244 (69.1)93 (26.3)15 (4.2)1 (0.3)0
I will communicate with specialists regularly and follow up regularly166 (47.0)116 (32.9)62 (17.6)9 (2.5)0
I will vent my bad emotions correctly, such as through exercise relaxation, music relaxation, and implied adjustment, to relieve mental stress106 (30.0)125 (35.4)92 (26.1)25 (7.1)5 (1.4)
I will communicate with family members, close friends, and patients and gain encouragement and emotional support94 (26.6)117 (33.1)92 (26.1)41 (11.6)9 (2.5)
Yes, n (%)No, n (%)
I will take care to quit smoking and drinking346 (98.0)7 (2.0)
I will take care to avoid staying up late and overworking120 (34.0)119 (33.7)87 (24.6)23 (6.5)4 (1.1)
I will take care to choose appropriate physical exercise according to my physical condition96 (27.2)95 (26.9)105 (29.7)50 (14.2)7 (2.0)
If there is an ostomy, I will go to an IBD specialist for standard treatment336 (95.2)17 (4.8)000
If I am treated with biological agents, I will pay attention to monitoring the related side effects179 (50.7)107 (30.3)52 (14.7)11 (3.1)4 (1.1)
If a food allergy is identified, I will take care to avoid it in my daily diet210 (59.5)105 (29.7)30 (8.5)5 (1.4)3 (0.8)
I will use a “diet diary” to identify foods that may cause discomfort, such as abdominal pain or diarrhea, and try to avoid them in my future diet106 (30.0)94 (26.6)67 (19.0)42 (11.9)44 (12.5)
I will improve my understanding of diseases and treatment through WeChat groups, networks, and popular science lectures100 (28.3)85 (24.1)104 (29.5)52 (14.7)12 (3.4)
I will insist on taking medicine or receiving infusion treatment of biological agents as prescribed by my physician247 (70.0)86 (24.4)16 (4.5)3 (0.8)1 (0.3)
I will encourage and help other people with IBD as much as I can135 (38.2)78 (22.1)93 (26.3)37 (10.5)10 (2.8)

The knowledge score was found to be related to the attitude score (r = 0.371, P < 0.001) and practice (r = 0.100, P < 0.001) score, respectively. The attitude score was related to the practice score (r = 0.452, P < 0.001) (Table 5). Moreover, multivariate logistic regression analysis suggested that aged 30-40 years [odds ratio (OR) = 4.06, 95% confidence interval (CI): 1.04-15.82, P = 0.043], middle school education (OR = 3.98, 95%CI: 1.29-12.33, P = 0.017), high school/technical secondary school education (OR = 14.06, 95%CI: 3.92-50.38, P < 0.001), and junior college/bachelor’s degree and above education (OR = 15.20, 95%CI: 4.15-55.650, P < 0.001) were independently linked with the knowledge score (Table 6). The knowledge score (OR = 1.23, 95%CI: 1.11-1.36, P < 0.001) was independently associated with the attitude score (Table 7). In addition, the attitude score (OR = 1.20, 95%CI: 1.11-1.30, P < 0.001) had an independent effect on the practice score (Table 8).

Table 5 Correlation analysis.

Knowledge dimension
Attitude
Practice
Knowledge dimension1
Attitude0.371 (P < 0.001)1
Practice0.100 (P < 0.001)0.452 (P < 0.001)1
Table 6 Univariate and multivariate analysis of knowledge.
VariablesUnivariate analysis
Multivariate analysis
OR (95%CI)
P value
OR (95%CI)
P value
Gender
    Male1.09 (0.62-1.92)0.751
    FemaleRef
Age
    ≤ 20RefRef
    20-302.80 (1.10-7.09)0.0303.01 (0.97-9.38)0.057
    30-402.17 (0.84-5.63)0.1114.06 (1.04-15.82)0.043
    > 400.76 (0.33-1.75)
Ethnicity
    Han3.83 (1.13-12.94)0.0313.70 (0.80-16.97)0.093
    MinoritiesRefRef
Residence
    RuralRefRef
    City3.08 (1.56-6.07)0.0011.69 (0.74-3.84)0.213
    Suburb/urban-rural combination1.95 (0.97-3.90)0.0601.33 (0.58-3.03)0.496
Education
    Primary school and belowRef
    Middle school2.99 (1.15-7.76)0.0253.98 (1.29-12.33)0.017
    High school/technical secondary school11.80 (4.20-33.17)< 0.00114.06 (3.92-50.38)< 0.001
    Junior college/bachelor’s degree and above20.70 (7.75-55.28)< 0.00115.20 (4.15-55.65)< 0.001
Work status
    Employed4.07 (2.23-7.41)< 0.0011.34 (0.63-2.85)0.444
    OtherRefRef
Monthly per capita income
    < 5000RefRef
    5000-100003.94 (1.84-8.43)< 0.0012.04 (0.81-5.18)0.133
    > 100002.46 (1.17-5.18)0.0180.90 (0.34-2.36)0.823
Marital status
    Unmarried or otherRefRef
    Married0.61 (0.35-1.07)0.0830.85 (0.33-2.16)0.734
Smoking habit
    No (no smoking)Ref
    Yes (smoking or used to smoke)0.60 (0.33-1.12)0.10
Drinking habit
    No (no drinking)Ref
    Yes (drinking or used to drink)0.85 (0.49-1.50)0.584
What kind of IBD is being diagnosed
    Ulcerative colitis0.50 (0.29-0.85)0.0110.57 (0.28-1.18)0.132
    Crohn’s diseaseRefRef
Duration of IBD
    < 1 yr1.14 (0.54-2.39)0.729
    1-2 yr0.98 (0.39-2.45)0.964
    > 2 yrRef
Ostomy?
    Yes0.51 (0.21-1.23)0.135
    NoRef
Comorbidities
    Yes0.62 (0.32-1.19)0.149
    NoneRef
Family history of IBD
    Yes1.86 (0.23-15.16)0.560
    NoRef
Surgical history
    Yes1.15 (0.67-1.97)0.613
    NoRef
History of drug allergy
    Yes1.40 (0.60-3.29)0.433
    NoRef
What kind of treatment is being received?
5-aminosalicylic acid drugs (e.g., mesalazine)Ref
Glucocorticoids--
Immunosuppressants (e.g., azathioprine, tacrolimus, cyclosporine, etc.)0.46 (0.07-2.99)0.418
Biological agents (e.g., infliximab, vedolizumab, ustekinumab)2.11 (0.77-5.80)0.148
Biological agents + immunosuppressants1.69 (0.34-8.40)0.520
Biological agents + 5-aminosalicylic acid drugs--
Table 7 Univariate and multivariate analysis of attitude.
VariablesUnivariate analysis
Multivariate analysis
OR (95%CI)
P value
OR (95%CI)
P value
Knowledge score (as continuous variables)1.24 (1.14-1.34)< 0.0011.23 (1.11-1.36)< 0.001
Gender
    Male1.42 (0.73-2.74)0.300
    FemaleRef
Age
    ≤ 20Ref
    20-301.49 (0.52-4.25)0.461
    30-401.29 (0.43-3.82)0.651
    > 401.27 (0.44-3.65)0.656
Ethnicity
    Han4.69 (1.31-16.80)0.0173.21 (0.66-15.59)0.149
    MinoritiesRefRef
Residence
    RuralRefRef
    City2.47 (1.06-5.76)0.0371.63 (0.61 4.32)0.329
    Suburb/urban-rural combination1.12 (0.51-2.44)0.7790.98 (0.39-2.47)0.968
Education
    Primary school and belowRefRef
    Middle school0.95 (0.30-2.97)0.9250.85 (0.23-3.08)0.803
    High school/technical secondary school2.37 (0.70-8.05)0.1650.87 (0.22-3.49)0.841
    Junior college/bachelor’s degree and above2.91 (0.95-8.94)0.0620.82 (0.20-3.26)0.774
Work status
    Employed2.65 (1.32-5.30)0.0061.54 (0.64-3.70)0.338
    OtherRefRef
Monthly per capita income
    < 5000RefRef
    5000-100002.22 (0.97-5.09)0.0601.10 (0.42-2.89)0.850
    > 100002.16 (0.85-5.46)0.1051.06 (0.35-3.17)0.924
Marital status
    Unmarried or otherRef
    Married0.97 (0.51-1.88)0.937
Smoking habit
    No (no smoking)Ref
    Yes (smoking or used to smoke)0.88 (0.40-1.94)0.755
Drinking habit
    No (no drinking)Ref
    Yes (drinking or used to drink)1.16 (0.57-2.36)0.689
What kind of IBD is being diagnosed
    Ulcerative colitis0.75 (0.39-1.44)0.383
    Crohn’s diseaseRef
Duration of IBD
    < 1 yr0.92 (0.36-2.35)0.866
    1-2 yr0.91 (0.29-2.90)0.873
    > 2 yrRef
Ostomy?
    Yes0.55 (0.19-1.53)0.250
    NoRef
Comorbidities
    Yes0.68 (0.31-1.51)0.341
    NoneRef
Family history of IBD
    Yes1.05 (0.13-8.64)0.962
    NoRef
Surgical history
    Yes1.14 (0.59-2.19)0.698
    NoRef
History of drug allergy
    Yes1.52 (0.52-4.47)0.448
    NoRef
What kind of treatment is being received?
5-aminosalicylic acid drugs (e.g., mesalazine)RefRef
Glucocorticoids----
Immunosuppressants (e.g., azathioprine, tacrolimus, cyclosporine, etc.)0.24 (0.02-2.22)0.2060.38 (0.03-4.43)0.438
Biological agents (e.g., infliximab, vedolizumab, ustekinumab)1.10 (0.24-5.02)0.8990.88 (0.17-4.53)0.878
Biological agents + immunosuppressants0.21 (0.03-1.32)0.0960.16 (0.02-1.17)0.070
Biological agents + 5-aminosalicylic acid drugs0.35 (0.05-2.51)0.2980.17 (0.02-1.51)0.113
Table 8 Univariate and multivariate analysis of practice.
VariablesUnivariate analysis
Multivariate analysis
OR (95%CI)
P value
OR (95%CI)
P value
Knowledge score (as continuous variables)1.10 (1.02-1.19)0.0200.96 (0.87-1.06)0.412
Attitude score (as continuous variables)1.21 (1.13-1.30)< 0.0011.20 (1.11-1.30)< 0.001
Gender
    Male1.62 (0.86-3.04)0.134
    FemaleRef
Age
    ≤ 20Ref
    20-301.25 (0.45-3.50)0.672
    30-401.65 (0.53-5.11)0.386
    > 401.16 (0.41-3.30)0.780
Ethnicity
    Han0.65 (0.14-3.11)0.589
    MinoritiesRef
Residence
    RuralRefRef
    City2.41 (1.08-5.40)0.0332.01 (0.80-5.04)0.139
    Suburb/urban-rural combination1.12 (0.53-2.38)0.7681.12 (0.49-2.58)0.788
Education
    Primary school and belowRef
    Middle school0.66 (0.20-2.22)0.503
    High school/technical secondary school2.10 (0.56-7.84)0.272
    Junior college/bachelor’s degree and above1.58 (0.49-5.11)0.441
Work status
    Employed2.76 (1.41-5.40)0.0031.93 (0.88-4.21)0.099
    OtherRefRef
Monthly per capita income
    < 5000RefRef
    5000-100002.42 (1.06-5.51)0.0361.31 (0.51-3.33)0.578
    > 100001.71 (0.74-3.94)0.2070.86 (0.32-2.28)0.755
Marital status
    Unmarried or otherRef
    Married0.65 (0.34-1.25)0.200
Smoking habit
    No (no smoking)Ref
    Yes (smoking or used to smoke)0.86 (0.41-1.84)0.706
Drinking habit
    No (no drinking)Ref
    Yes (drinking or used to drink)1.18 (0.60-2.35)0.631
What kind of IBD is being diagnosed
    Ulcerative colitis0.80 (0.43-1.52)0.501
    Crohn’s diseaseRef
Duration of IBD
    < 1 yr1.39 (0.59-3.27)0.445
    1-2 yr0.74 (0.27-2.01)0.558
    > 2 yrRef
Ostomy
    Yes0.62 (0.22-1.72)0.354
    NoRef
Comorbidities
    Yes0.43 (0.21-0.88)0.0220.50 (0.23-1.09)0.082
    NoneRefRef
Family history of IBD
    Yes--
    NoRef
Surgical history
    Yes1.11 (0.59-2.09)0.741
    NoRef
History of drug allergy
    Yes0.83 (0.35-1.99)0.682
    NoRef
What kind of treatment is being received?
5-aminosalicylic acid drugs (e.g., mesalazine)Ref
Glucocorticoids--
Immunosuppressants (e.g., azathioprine, tacrolimus, cyclosporine, etc.)0.19 (0.02-1.41)0.104
Biological agents (e.g., infliximab, vedolizumab, ustekinumab)1.38 (0.38-4.97)0.622
Biological agents + immunosuppressants2.44 (0.23-26.30)0.463
Biological agents + 5-aminosalicylic acid drugs0.94 (0.13-6.63)0.948
DISCUSSION

The findings of our study suggested that Chinese patients with IBD had good knowledge, positive attitudes, and proactive practice toward their disease. Nevertheless, some specific items warranting more education were identified. These outcomes may be useful for the management and self-management of IBD patients in clinical practice.

Several studies revealed misconceptions and relatively poor knowledge in patients with IBD about their disease[16-21]. A study from England published 30 years ago already acknowledged that patients with IBD had poor knowledge regarding their disease but were willing to acquire information[16]. More contemporary data indicated little progress since then, i.e., that the knowledge of patients with IBD toward their disease was poor[17-21], including in New Zealand[17], Canada[18], Israel[19], Poland[20], and South Korea[21]. Surprisingly, in the present study, the patients with IBD showed good KAP toward IBD, but it could be noted that most participants had a junior college/bachelor’s degree and above education and were receiving expensive biological agents, thereby suggesting a higher socioeconomic status that could influence the results.

The present investigation also demonstrated that age and educational attainment were independently associated with knowledge scores. Specific knowledge items that need improvement include the etiology of IBDs, the possible extraintestinal manifestations of IBDs, the side effects of glucocorticoids, and nutrient absorption. Even though the other knowledge items had high scores, none scored above 90%, indicating they would benefit from additional instruction. Furthermore, knowledge was the only factor independently associated with the attitude score, and attitude was the only factor independently connected with the practice score. Hence, improving the knowledge of patient about IBDs should enhance their KAP. Since a proper KAP of IBDs has been associated with better IBD outcomes[15], improving the KAP can improve patient outcomes, given that self-management is at the core of IBD management[12,13].

Still, patients obtain knowledge primarily from available resources (books, the internet, newspapers, etc.), their social network, and healthcare professionals. A study highlighted variable access to high-quality information on IBD-related nutrition[26], and nutrition is a major factor influencing the intestinal microflora and the outcomes of IBDs[27-29]. Furthermore, a study in New Zealand showed that the KAP of IBD in the general population was also low[30,31], suggesting that patient education is deficient or ineffective since the patients with IBD have poor KAP. Healthcare providers are the primary source of reliable patient information, but studies unveiled that the KAP of IBD among healthcare providers was also low[32,33]. Having limited knowledge about a disease can impede the spread of accurate information. Therefore, previous studies suggest that priority should be placed on educating patients, healthcare professionals, and the general public.

There are some limitations in this study. It was conducted at a single institution, limiting its applicability to other hospitals in China. The questionnaire was designed by local investigators and was probably influenced by local policies and guidelines, further restricting the exportability of the questionnaire. The study has local scope, and the results cannot be extrapolated to other populations, which makes similar studies necessary in other locations. The study population shows high education and use of biological products, which suggests a selection bias. KAP surveys represent the situation of a specific population at a precise time point. Therefore, studies in other populations and time might be necessary to examine the actual KAP situation in China and the effect of education. Finally, all KAP surveys were susceptible to social desirability bias, in which participants may have been more likely to provide the expected response than the actual answer[34].

CONCLUSION

In conclusion, this study suggests that Chinese patients with IBD have good knowledge, positive attitudes, and active practice toward their disease. Nevertheless, some specific items warranting more education were identified, especially regarding the etiology and contributing factors to the disease, extraintestinal manifestations, glucocorticoid side effects, and nutrient absorption.

ARTICLE HIGHLIGHTS
Research background

The management of inflammatory bowel disease (IBD) necessitates the adoption of healthy lifestyle habits, which requires proper knowledge, attitudes, and practice of the specific lifestyle routines to implement. However, patients with IBD generally have poor knowledge, attitude, and practice (KAP) of their disease, while the data from China are lacking.

Research motivation

The motivation of this study is to help healthcare providers to improve the patient’s self-management of IBD.

Research objectives

The object of this study is to investigate the KAP of patients with IBD toward their disease in Zhejiang Province, China.

Research methods

Self-designed questionnaires were administered to the participants through WeChat on the SoJump platform (https://www.wjx.cn/app/survey.aspx). Pearson’s correlation analysis was used to determine the pairwise correlations among KAP scores. A multivariate logistic regression analysis was further performed to determine the independent factors associated with their KAP scores.

Research results

A total of 353 patients (224 males) with IBD completed the questionnaires. Their mean KAP scores were 10.05 ± 3.46 (possible range: 0-14), 41.58 ± 5.23 (possible range: 0-56), 44.20 ± 7.39 (possible range: 0-56), respectively, indicating good knowledge, positive attitude, and proactive practice toward IBD. Age and education were independently associated with their KAP.

Research conclusions

Chinese patients with IBD might have good knowledge, a positive attitude, and proactive practice toward their disease. Nevertheless, some specific items warranting more education were identified, especially regarding the etiology and contributing factors to the disease, extraintestinal manifestations, glucocorticoid side effects, and nutrient absorption.

Research perspectives

The findings of this study may be useful for the management and self-management of IBD patients in clinical practice.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: China

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C, C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Rodrigues AT, Brazil; Triantafillidis J, Greece S-Editor: Wang JJ L-Editor: A P-Editor: Wang JJ

References
1.  Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019;114:384-413.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 870]  [Cited by in F6Publishing: 810]  [Article Influence: 162.0]  [Reference Citation Analysis (0)]
2.  Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017;389:1756-1770.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1542]  [Cited by in F6Publishing: 1989]  [Article Influence: 284.1]  [Reference Citation Analysis (1)]
3.  Torres J, Mehandru S, Colombel JF, Peyrin-Biroulet L. Crohn's disease. Lancet. 2017;389:1741-1755.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1121]  [Cited by in F6Publishing: 1432]  [Article Influence: 204.6]  [Reference Citation Analysis (4)]
4.  Kalla R, Ventham NT, Satsangi J, Arnott ID. Crohn's disease. BMJ. 2014;349:g6670.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 60]  [Cited by in F6Publishing: 56]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
5.  Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018;113:481-517.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 612]  [Cited by in F6Publishing: 744]  [Article Influence: 124.0]  [Reference Citation Analysis (0)]
6.  Terdiman JP, Gruss CB, Heidelbaugh JJ, Sultan S, Falck-Ytter YT; AGA Institute Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn's disease. Gastroenterology. 2013;145:1459-1463.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 180]  [Cited by in F6Publishing: 175]  [Article Influence: 15.9]  [Reference Citation Analysis (0)]
7.  Sandborn WJ. Crohn's disease evaluation and treatment: clinical decision tool. Gastroenterology. 2014;147:702-705.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 67]  [Article Influence: 6.7]  [Reference Citation Analysis (0)]
8.  Fukuda T, Naganuma M, Kanai T. Current new challenges in the management of ulcerative colitis. Intest Res. 2019;17:36-44.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 29]  [Cited by in F6Publishing: 37]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
9.  Popov J, Farbod Y, Chauhan U, Kalantar M, Hill L, Armstrong D, Halder S, Marshall JK, Moayyedi P, Kaasalainen S. Patients' Experiences and Challenges in Living with Inflammatory Bowel Disease: A Qualitative Approach. Clin Exp Gastroenterol. 2021;14:123-131.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Reference Citation Analysis (0)]
10.  Gravina AG, Pellegrino R, Zingone F. Editorial: Challenges in Inflammatory Bowel Disease: Current, Future and Unmet Needs. Front Med (Lausanne). 2022;9:979535.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
11.  Gearry RB, McCombie AM, Vatn M, Rubin DT, Steinwurz F, Loftus EV, Kruis W, Tysk C, Colombel JF, Ng SC, Van Assche G, Bernstein CN. What Are the Most Challenging Aspects of Inflammatory Bowel Disease? An International Survey of Gastroenterologists Comparing Developed and Developing Countries. Inflamm Intest Dis. 2021;6:78-86.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
12.  Plevinsky JM, Greenley RN, Fishman LN. Self-management in patients with inflammatory bowel disease: strategies, outcomes, and integration into clinical care. Clin Exp Gastroenterol. 2016;9:259-267.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 56]  [Article Influence: 7.0]  [Reference Citation Analysis (0)]
13.  Squires SI, Boal AJ, Lamont S, Naismith GD. Implementing a self-management strategy in inflammatory bowel disease (IBD): patient perceptions, clinical outcomes and the impact on service. Frontline Gastroenterol. 2017;8:272-278.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 11]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
14.  Ko CW, Singh S, Feuerstein JD, Falck-Ytter C, Falck-Ytter Y, Cross RK; American Gastroenterological Association Institute Clinical Guidelines Committee. AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis. Gastroenterology. 2019;156:748-764.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 164]  [Cited by in F6Publishing: 171]  [Article Influence: 34.2]  [Reference Citation Analysis (0)]
15.  Park J, Yoon H, Shin CM, Park YS, Kim N, Lee DH. Higher levels of disease-related knowledge reduce medical acceleration in patients with inflammatory bowel disease. PLoS One. 2020;15:e0233654.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 11]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
16.  Jones SC, Gallacher B, Lobo AJ, Axon AT. A patient knowledge questionnaire in inflammatory bowel disease. J Clin Gastroenterol. 1993;17:21-24.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 41]  [Cited by in F6Publishing: 40]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
17.  Buerkle KS, Vernon-Roberts A, Ho C, Schultz M, Day AS. A Short Knowledge Assessment Tool Is Valid and Acceptable for Adults with Inflammatory Bowel Disease. Dig Dis Sci. 2022;67:2049-2058.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 5]  [Reference Citation Analysis (0)]
18.  Benchimol EI, Walters TD, Kaufman M, Frost K, Fiedler K, Chinea Z, Zachos M. Assessment of knowledge in adolescents with inflammatory bowel disease using a novel transition tool. Inflamm Bowel Dis. 2011;17:1131-1137.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 76]  [Cited by in F6Publishing: 79]  [Article Influence: 6.1]  [Reference Citation Analysis (0)]
19.  Krauthammer A, Harel T, Zevit N, Shouval DS, Shamir R, Weiss B. Knowledge of disease and self-management of adolescents with inflammatory bowel diseases. Acta Paediatr. 2020;109:2119-2124.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
20.  Breuker G, Boucher B, Kroon P. On "Supervised exercises compared with radial extracorporeal shock-wave therapy..." Engebretsen K, Grotle M, Bautz-Holter E, et al. Phys Ther. 2011;91:37-47. Phys Ther. 2011;91:826; author reply 826-826; author reply 827.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
21.  Kim JY, Yoon H, Hwang JS, Yang SK, Park SH, Loftus EV Jr. Comparison of Disease-related Knowledge of Patients With Inflammatory Bowel Disease Between the West and the East Using an Updated Questionnaire (IBD-KNOW). J Clin Gastroenterol. 2020;54:720-724.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 10]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
22.  Andrade C, Menon V, Ameen S, Kumar Praharaj S. Designing and Conducting Knowledge, Attitude, and Practice Surveys in Psychiatry: Practical Guidance. Indian J Psychol Med. 2020;42:478-481.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 104]  [Article Influence: 26.0]  [Reference Citation Analysis (0)]
23.  Dayrit M, Taylor A, Yan J, Braichet JM, Zurn P, Shainblum E. WHO code of practice on the international recruitment of health personnel. Bull World Health Organ. 2008;86:739.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 13]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
24.  Bernstein CN, Fried M, Krabshuis JH, Cohen H, Eliakim R, Fedail S, Gearry R, Goh KL, Hamid S, Khan AG, LeMair AW, Malfertheiner P, Ouyang Q, Rey JF, Sood A, Steinwurz F, Thomsen OO, Thomson A, Watermeyer G. World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis. 2010;16:112-124.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 319]  [Cited by in F6Publishing: 340]  [Article Influence: 24.3]  [Reference Citation Analysis (1)]
25.  Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr. 2017;36:321-347.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 342]  [Cited by in F6Publishing: 378]  [Article Influence: 47.3]  [Reference Citation Analysis (0)]
26.  Prince AC, Moosa A, Lomer MC, Reidlinger DP, Whelan K. Variable access to quality nutrition information regarding inflammatory bowel disease: a survey of patients and health professionals and objective examination of written information. Health Expect. 2015;18:2501-2512.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 15]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
27.  Zheng L, Wen XL. Gut microbiota and inflammatory bowel disease: The current status and perspectives. World J Clin Cases. 2021;9:321-333.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 21]  [Cited by in F6Publishing: 24]  [Article Influence: 8.0]  [Reference Citation Analysis (0)]
28.  Qiu P, Ishimoto T, Fu L, Zhang J, Zhang Z, Liu Y. The Gut Microbiota in Inflammatory Bowel Disease. Front Cell Infect Microbiol. 2022;12:733992.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 109]  [Article Influence: 54.5]  [Reference Citation Analysis (0)]
29.  Fernandes D, Andreyev J. The Role of the Human Gut Microbiome in Inflammatory Bowel Disease and Radiation Enteropathy. Microorganisms. 2022;10.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
30.  Vernon-Roberts A, Gearry RB, Day AS. The Level of Public Knowledge about Inflammatory Bowel Disease in Christchurch, New Zealand. Inflamm Intest Dis. 2020;5:205-211.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 10]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
31.  Groshek J, Basil M, Guo L, Parker Ward S, Farraye FA, Reich J. Media Consumption and Creation in Attitudes Toward and Knowledge of Inflammatory Bowel Disease: Web-Based Survey. J Med Internet Res. 2017;19:e403.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 16]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
32.  Umar S, Kapetanos A. Knowledge, Attitude and Practices of Preventive Health Care Measures in Inflammatory Bowel Disease Patients Among Primary Care Physicians: A Pilot Project. Am J Gastroenterol. 2017;112:S328-S329.  [PubMed]  [DOI]  [Cited in This Article: ]
33.  Benson MJ, Abelev SV, Corte CJ, Connor SJ, McGregor IS. Attitudes and Knowledge of Australian Gastroenterologists Around the Use of Medicinal Cannabis for Inflammatory Bowel Disease. Crohns Colitis 360. 2020;2:otaa045.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
34.  Bergen N, Labonté R. "Everything Is Perfect, and We Have No Problems": Detecting and Limiting Social Desirability Bias in Qualitative Research. Qual Health Res. 2020;30:783-792.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 290]  [Cited by in F6Publishing: 321]  [Article Influence: 80.3]  [Reference Citation Analysis (0)]