Knowledge, attitudes, and practices (KAPs) regarding tick-borne rickettsial disease among medical staff in endemic areas of China

Introduction

Tick-borne rickettsial disease (TBRD) refers to rickettsial diseases caused by tick transmission. Rickettsial is divided into the Rickettsiaceae and Anaplasma families, and Rickettsiaceae is further divided into four categories, namely, the spotted fever group rickettsial (SFGR), typhus group rickettsial, ancestral group rickettsial, and transitional group rickettsial (Merhej et al., 2014). The disease is transmitted via saliva through a tick bite (Nicholson et al., 2019; Walker & Ismail, 2008). More than 20 causative agents have been identified (Kernif et al., 2016). Infections are often similar to many other acute febrile illnesses characterized by fever, chills, and headache, with maculopapular rash at the site of the vector bites similar to many other infections (Adem, 2019; Biggs et al., 2016). Some patients may present with erythema nodosa in the early stage (Peregrina-Rivas et al., 2022), which can be used as a reference for early identification. In a small number of individuals, there have been reported cases of concurrent infections with two types of SFGR, occasionally accompanied by severe sequelae such as encephalitis (Mendes et al., 2021; Rudakov et al., 2019).

In recent years, studies have revealed that missed diagnosis and misdiagnosis of TBRD are prevalent and have a significant impact on the prognosis of patients (Biggs et al., 2016; Igolkina et al., 2022). One of the most important factors in the misdiagnosis of TBRD is the lack of awareness among primary care staff and emergency department physicians when encountering undifferentiated acute febrile disease during the tick season (Walker et al., 2022). According to the investigation, many patients do not exhibit rash during diagnosis and treatment (Igolkina et al., 2022; Kinoshita et al., 2021). A rash’s delay in appearance or absence can also make a TBRD diagnosis challenging. Literature reviews have shown that many cases of delayed disease diagnosis were caused by a lack of knowledge among medical staff (Bégué, 2023; Li & Liu, 2021). Early recognition in the clinical course is critical because this is the most effective period of antibacterial therapy (Biggs et al., 2016). Medical staff play an important role in detecting and controlling infectious diseases. They are also an important source of information to help raise public awareness among high-risk people (Eleftheriou et al., 2023). The Knowledge, Attitudes, and Practices (KAPs) theory is the most widely utilized framework for explaining how individual knowledge and beliefs influence change in health practices. Therefore, gaining a comprehensive understanding of the KAPs of medical personnel towards TBRD is imperative.

China is a country with a vast territory and lush forests. With the intensification of globalization, climate change, and expansion of human activities, the incidence of TBRD in China has gradually increased, and the incidence range has continued to expand (Fang et al., 2015). Lu’an City in Anhui Province is an endemic area in China. Lu’an City is located in the Ta-pieh Mountain area. This city is rich in forest vegetation and suitable for tick breeding. As early as 2006, tick-borne diseases appeared in Anhui Province (Zhang, Ni & Feng, 2010), and in 2013, it was confirmed that SFGR was transmitted in Lu’an City (Hu et al., 2022; Lyu et al., 2021). Follow-up investigations by the local Centers for Disease Control and Prevention showed that there was a natural foci of TBRD in Lu’an City, ehrlichiosis, as the TBRD also has been found to exist in Lu’an and hundreds of cases of TBRD are diagnosed annually in Lu’an (Lu et al., 2023).

Increasing awareness among professionals in the field is paramount for establishing effective control measures against pathogens. Assessing the knowledge of medical staff could provide useful information on the levels of interventions required to adapt government-related measures to meet the demands of a changing world. Nevertheless, to our knowledge, there are no KAP data for specific occupational high-risk populations in China. The survey on KAPs in China mainly covers the general population in endemic areas (Lyu et al., 2017). Therefore, this study aimed to assess the basic knowledge of medical staff in endemic areas of China. This approach will be essential for building core competencies regarding TBRD and suggesting additional adjustment measures.

Materials and Methods

Metrics

Results

Discussion

TBRD is a regional disease whose geographical distribution is synchronized with the seasonal activities of ticks as vectors (Romer et al., 2020). In recent years, TBRD and the discovery of new pathogens have been reported in more and more countries, making it a public health issue of worldwide concern (Faccini-Martinez et al., 2018; Leon de la Fuente & Sanchez, 2018; Sevestre et al., 2021; Silva-Ramos et al., 2022). Improving the medical staff’s understanding of TBRD is conducive to improving the disease’s early diagnosis rate and enhancing patients’ recovery levels (Walker et al., 2022). This study provides new insights into TBRD awareness among healthcare workers in endemic areas of China, as well as new practices for preventing tick bites and controlling tick transmission.

The results showed that the medical staff was poor in awareness of TBRD. This could be attributed to the scarcity of health education initiatives. As a newly emerging infectious disease, TBRD has not yet been fully managed in China (Lyu et al., 2021). Compared to the results of this survey, other studies have found that the knowledge, attitudes, and practices of medical staff were significantly different. In a survey on tick-borne diseases in endemic areas of the United States, the attitudes and practices levels of the local population were low, reflected in the low participation rate in personal prevention practices (Beck et al., 2022). A study in Finland showed that tick prevention practices in the region is still in its infancy (Zöldi et al., 2017). In contrast, many Czech students used targeted preventive measures regarding tick-borne diseases before going out (Butler et al., 2016).

Further analysis of our results showed that gender, age, professional title, department, and training affected the TBRD knowledge score, mainly reflected in the higher scores of male participants, infectious department personnel, having postgraduate or higher education, and trained medical staff. The infectious department is a common department for TBRD patients, so relevant medical staff are expected to know more about the disease. At the same time, as the job titles of medical staff increase, so do their scores. Senior medical staff in China have greater professional knowledge and rich experience, so their scores are higher than those of lower-ranking medical staff. It can be seen from a survey of students in Egypt (Khamassi Khbou et al., 2020) that after training in a specific course, students gained a higher level of knowledge, which is consistent with our findings. Training on TBRD in endemic areas of China is increasing, which is a good sign. Notably, men’s TBRD knowledge scores were higher than women’s. The reasons behind this are worth further reflection.

Some unexpected results are also worth highlighting. First, when analyzing the attitudes and practices of medical workers with rickettsial disease, we found that age, education level, and training were the most common factors influencing attitudes and practices scores. As age decreased and education increased, the score of medical personnel was higher. As education level increased, knowledge level increased. Compared with the results of a study on tick-borne diseases and German foresters (San Martin Rodriguez et al., 2020), the education level of medical personnel in endemic areas in China did not affect the knowledge score but played an important role in the attitudes and practices scores. In Germany, education did not affect the practices of those surveyed. However, surveys in prevalent areas of the United States showed that education was associated with better practices (Beck et al., 2022). In addition, the younger age group showed better attitudes and practices than the older age group, suggesting that more attention should be paid to the practices of the older group in daily work. Finally, the notably higher scores obtained by trained medical staff further highlighted the importance of relevant training.

When analyzing TBRD health education groups, we found that 35.24% of the people fell into the first quadrant, and 88.71% of the first quadrant had a positive attitude toward TBRD. This part of the population is a successful product of TBRD health education (Brockmann & Brezinski, 2015; Ercis & Unalan, 2015). TBRD education must continue to be highlighted in future efforts to educate medical professionals. A total of 15.34% of the population fell into the second quadrant, with poor knowledge but superior practice levels. This part of the population under-performed in TBRD health education, and in-depth analysis is needed to analyze the causes. A total of 18.33% of the population fell into the third quadrant, with poor knowledge and practices. A total of 31.09% of the population fell into the fourth quadrant, indicating that while they showed good level of knowledge, they had no corresponding practice ability, suggesting that their knowledge did not produce an effect.

There were some limitations to this study. We selected Lu’an City in Anhui Province as an endemic area in China to conduct a cross-sectional survey. The survey site needs to be further expanded to be more representative of the population. At the same time, this study was conducted as a field survey, and the options about attitudes and practices were graded, which could easily lead to the medical staff choosing inconsistent options to obtain higher scores.

Conclusion

Overall, this KAPs study provides information on the knowledge and practice of TBRD among healthcare workers in endemic areas of China and analyzes its influences. Given the low knowledge scores of medical personnel, further intervention and education programs are needed to reduce the misdiagnosis rate of TBRD further. Further epidemiological studies also need to be performed increase the number of medical professionals in the first quadrant while also strengthening the health intervention of the population in the third quadrant to promote the virtuous circle of knowledge, belief, and practice of medical staff.

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