Knowledge, Attitudes and Practice of Otitis media with effusion: A Cross-Sectional Study Among the General Chinese Population

doi:10.21203/rs.3.rs-4878004/v1

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Knowledge, Attitudes and Practice of Otitis media with effusion: A Cross-Sectional Study Among the General Chinese Population

https://doi.org/10.21203/rs.3.rs-4878004/v1

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Background

Otitis media with effusion (OME) is a prevalent ear condition imposing a notable public health burden yet remains inadequately addressed. Understanding the community's comprehension and attitudes toward OME is pivotal for public health strategies. This study aimed to evaluate the current knowledge, attitudes, and practices (KAP) concerning OME among the Chinese populace and gauge the educational demand for OME information.

Methods

A cross-sectional study was conducted on 973 participants in China. All participants were interviewed using an online questionnaire which was consisted of 34 questions, and tested their knowledge, attitude and practices on OME. Based on estimated knowledge scores, the general public was divided into low, moderate, and high knowledge levels. Descriptive statistics, chi-square tests and logistic regression analysis were used to analyse the data.

Results

Results from 973 valid responses revealed that most participants lacked sufficient knowledge (68.0%) but held positive attitudes (83.8%) and displayed good care-seeking practices (80.2%) toward OME. The mean knowledge score was 23.64 ± 9.87 out of 58 points, with gender, age, and marital status influencing knowledge levels (P < 0.05), favoring women and those aged 25–35. Nearly eight out of ten respondents indicated positive medical practices when experiencing OME symptoms. A significant 83.8% expressed a desire for health education, with most concerned about OME prevention.

Conclusion

This study found that the general population in China lacks sufficient knowledge about OME, underscoring the importance of health education. However, most individuals still exhibited positive attitudes toward and practices regarding OME. Emphasizing the importance of healthcare education and promoting the benefits of active medical practice models in OME is crucial.

otitis media with effusion

secretory otitis media

KAP

knowledge

attitude

practice

Otitis media with effusion (OME), also known as secretory otitis media (SOM), is a common cause of hearing impairment in both children and adults. It is characterized by inflammation in the middle ear and the accumulation of fluid. This lesion is regarded as a public health issue globally due to its relatively high incidence, with approximately 4% of children being affected by OME during childhood[1]. The reported prevalence of OME varies across countries. In the United States, 50–90% of children under the age of 5 are affected by OME[2]. A review of the disease burden of otitis media in the Asia-Pacific region revealed that the incidence of OME ranged from 1.14% in Thailand to 13.8% in Malaysia[3]. In urban areas of Xi’an, China, the overall prevalence of OME was 4.3%[4]. These findings indicate that OME remains a significant public health concern on a global scale.

OME is typically self-limiting, with approximately 50% of patients recovering within three months and up to 92% recovering within 6 months[5]. Additionally, the symptoms of OME are relatively insidious. The effects are mostly short-term, but in children experiencing recurrent episodes, some effects on behavior and cognition, such as dyslexia, delayed reactions, word restriction, and attention deficit, can be observed. It may impair interpersonal skills, hinder education, and have a significant impact on the physical and mental health of both children and parents[6]. Furthermore, chronic OME can lead to middle ear adhesion, sclerosis, and possibly cholesterol granulomas. The economic burden of OME is estimated to range between $3 billion and $5 billion annually. However, due to significant indirect costs, the actual economic impact of otitis media is likely greater and challenging to quantify[2].

A study by Alsuhaibani et al.[7] reported that more than half of 703 Saudi parents reported having suboptimal knowledge of OME, and 56% of them had positive attitudes. Furthermore, similar articles also demonstrate that parents have a low level of knowledge about otitis media, yet they have a positive attitude toward it[6–9]. Li et al.[10] reported that 7.09%~36.6% of Chinese parents had good caregiving knowledge about OME, and more than half of them required education. Unfortunately, Li’s[10] study focused solely on parental caregiving knowledge, as there has been no research conducted to explore OME among the Chinese general population. Previous studies have shown that OME knowledge and attitudes can facilitate early detection and intervention. To our knowledge, no studies have focused primarily on the general population’s knowledge of OME in China. Therefore, the current research aimed to assess the general population's knowledge, attitudes and care management practices regarding OME to assist in developing effective health education programs.

A cross-sectional study was conducted in China between August and December 2022 to investigate Chinese knowledge, attitudes, and practices related to OME. The Ethics Committee of West China Hospital of Sichuan University approved this study (approval number: 2022416).

2.1 Questionnaire design

The initial Chinese version of the questionnaire was developed by a research team after conducting a thorough literature review of comparable studies and international guidelines [2, 8, 10] involving otolaryngologists, medical sociologists, and statisticians. Before data collection, three otolaryngologists with at least five years of practice and research experience were invited to independently review the draft questionnaire. The questionnaire items were revised according to the reviewers’ feedback and suggestions. In addition, the researchers randomly approached 20 participants from the general population in person and asked them to complete the questionnaire online as a pilot test. Feedback was gathered regarding the clarity of the questions and response options. Subsequently, four experts in the field of otolaryngology and survey studies reviewed the responses and each item of the survey, confirming the final version.

2.2 Patient and Public Involvement

The sample size was calculated according to a previous article, with the required sample size calculated based on an estimated absolute error of 5% and a 95% confidence interval (CI), resulting in a minimum required sample size of 384 using n = z2pq\d2[7]. Considering the missing and nonresponsive patients, we expanded the sample size by 10%, yielding a predicted minimum sample size of 422.

The inclusion criteria and exclusion criteria were assessed in the same way for online and hospital-based participants. The inclusion criteria were participants who were willing to participate, were over the age of 16, were conscious and had independent thinking ability, and were able to read Chinese and use a smartphone to operate the electronic questionnaire system. Individuals under the age of 18 completed the questionnaire with parental accompaniment. The exclusion criteria were participants who were not willing to answer this questionnaire and who were younger than 16 years.

In terms of participant preferences, it was suggested that older participants, those with a history of OME, and participants recruited from hospitals may possess a greater level of knowledge about OME. Recruitment methods could include online platforms such as WeChat, QQ, Douban, etc., as well as researcher-led recruitment of participants at hospitals. After the participants completed the questionnaire, they could access the correct answers regarding OME-related knowledge at the end of the questionnaire.

Data collection and analysis

The QR code was distributed via a questionnaire using popular Chinese social media by researchers to obtain access to the general population as much as possible, informed consent was obtained by answering the first question, and the purpose, time and requirements of this study were explained in detail. Notably, this study was anonymous and confidential.

Then, the questionnaire was passed through the electronic questionnaire system "Wenjuanxing" (https://www.wjx.cn). In the online survey, the QR code and link of the questionnaire were sent to popular Chinese social media (including WeChat groups, WeChat moments, Douban and QQ groups) as much as possible to obtain access to the general population. In the offline survey, three researchers conducted face-to-face invitations to individuals in various public settings, such as hospitals and universities, asking them to scan the QR code for the survey. The self-administered questionnaire included 34 items designed to assess participants' knowledge, attitudes toward, and practices related to OME (see Appendix 1). This test consisted of closed-ended and multiple-choice questions divided into four main sections: socioeconomic characteristics of participants (14 items), knowledge (11 items), attitudes toward OME (5 items), and medical practice (4 items).

The total score for knowledge of OME was 58. If participants answered "yes" to a single-choice question or selected the correct choices for multiple-choice questions, they received one point. Choosing the wrong option resulted in a score of 0 points. Participants who scored ≥ 50% (29 points) were considered knowledgeable about OME. Participants who would seek medical care were considered to have good practices. Participants who were willing to receive education on OME knowledge were deemed to have a positive attitude.

IBM SPSS Statistics 23 was used to perform the statistical analyses. Categorical data were analyzed with frequencies and percentages, and quantitative data were analyzed with mean values, standard deviations, medians and interquartile intervals. Fisher’s exact test, chi-square test, and analysis of variance (ANOVA) were used for group comparisons. To assess the differences in the mean knowledge scores and attitudes, ANOVA was used. A t test was used to analyze the differences based on sex. For all the statistical analyses, P ≤ 0.05 was considered to indicate statistical significance.

A total of 1025 questionnaires were returned, 52 of which were discarded because of insufficient time for questions, disagreements and inconsistencies. The inconsistencies included conflicts between participants’ marital status and age and between participants’ child age and participants’ age. Finally, data analysis was conducted on 973 questionnaires, and the effective rate was 81.6%.

3.1. Sociodemographic data

The sociodemographic information of the participants is presented in Table 1. Of the 973 participants, 54.9% were female, and participants aged 26–35 accounted for 37.7%. The majority of participants (75.7%) resided in urban areas, and 56.2% were married. Additionally, among all participants, 47.9% reported having children, with the majority being mothers (55.1%). Moreover, 74.0% of the participants reported no history of OME. Notably, 75.8% of parents denied that their children had OME, while 6.8% were unsure about their children’s OME status.

Table 1

Sociodemographic characteristics of participants in China (N = 973)
	Frequency (n)	Percentage (%)
Gender
Male	439	45.1
Female	534	54.9
Age (in years)
16–25	329	33.8
26–35	367	37.7
36–45	166	17.1
> 45	111	11.4
Marital status
Married	547	56.2
Unmarried	426	43.8
Monthly household income(yuan)
< 5000	243	25.0
5000–10000	424	43.6
> 10000	306	31.4
Residential zone
Urban	737	75.7
Rural	236	24.3
Have the participants ever suffered from OME?
Yes	253	26.0
No	720	74.0
Were the participants parents?
Yes	466	47.9
No	507	52.1
The relationship with the child*
Father	205	44.0
Mother	257	55.1
Others	4	0.9
Have participants’ child ever suffered from OME?*
Yes	81	17.4
No	353	75.8
I do not know	32	6.8
* This percentage was calculated based on 466 respondents who answered "yes" to the question "Were the participants parents?"

3.2. Knowledge about OME

For knowledge, the average score was 23.64 ± 9.87 points. A total of 662 (68.0%) participants scored 0–28, and 311 (32.0%) participants scored 29–58. Merely 48.4% of participants were knowledgeable about the greater prevalence of OME in children than in adults. Among them, 43.3% lacked awareness regarding the potential improvement of OME within three months. Moreover, 69.1% of the participants acknowledged the impact of OME on hearing.

The participants reported that the most prevalent cause of OME was upper respiratory tract infection (43.3%), followed by allergic rhinitis (42.7%) and nasopharyngeal carcinoma (16.1%) (Fig. 1A). Figure 2A displays the participants’ responses regarding factors potentially associated with OME. The most frequently and accurately identified factors included infections (66.2%), an immature immune system (54.7%), and exposure to passive smoking (44.0%). Conversely, the least frequently and most accurately selected factors were early formula feeding (17.6%) and cleft palate (16.5%). Additionally, participants identified wetting of the ear during a shower or swimming (62.9%), having an intraauricular foreign body (61.8%), and cerumen impaction (51.6%) as factors linked to OME.

Over 60% of participants recognized hearing loss (67.9%), auricular stuffiness (64.9%), and otalgia (62.0%) as symptoms of OME. However, only 24.8% of participants were aware that walking unsteadily was also associated with OME. Additionally, the participants reported that intraauricular pus (46.2%) was a symptom of OME (Fig. 1B).

The majority of participants were aware of the detrimental effects of OME on children, with 75.5% recognizing that OME could lead to hearing loss. However, 7.3% were unaware of the harmful nature of OME, and 6.2% reported that OME had no impact (Fig. 1C). Regarding hearing loss, more than half of the participants were aware of being insensitive to sound (67.6%), a common symptom of hearing loss. Only 26.6% of participants recognized that a limited vocabulary in children is also a common indicator of hearing loss (Fig. 1D).

In terms of OME, otoendoscopy (65.1%) and hearing assessments (65.0%) were the two most commonly chosen options (Fig. 1E). Figure 2B subsequently illustrates the participants’ responses concerning OME treatment approaches. The most commonly selected option was observation and follow-up (61.0%). Systemic antibiotics were chosen by 42.1% of participants, whereas only 32.4% were aware of adenoidectomy as a treatment for OME.

3.3. Attitudes about OME

The majority of participants replied that they would rely on medical-related official accounts or video platform (54.8%, n = 533), healthcare professionals (49.7%, n = 484) and traditional media (36.5%, n = 355) as sources of information. Most participants (83.8%, n = 815) had a positive attitude toward learning about OME. The majority replied that they were willing to receive OME-related knowledge and would like to rely on new media (74.0%, n = 603), medical staff (61.7%, n = 503), and hospital health manuals (56.3%, n = 459) as sources of information. Among those who would receive knowledge, prevention (78.3%), causes (68.6%), and consequences (66.7%) were the most common.

3.4. Practice of OME

The participants showed a positive attitude toward seeking medical care, with 80.2% (n = 780) opting for treatment. Fewer than a quarter of the participants chose not to seek treatment if they had OME (19.8%, n = 193). Among those who rejected treatment, the reasons included tolerable discomfort from OME (51.3%, n = 99), the disease would heal on its own (46.1%, n = 89), the perception that OME cannot be completely cured (43.0%, n = 83), and a lack of time to therapy (42.5%, n = 82). Similarly, the parents of participants also had a positive approach toward seeking medical care (88.4%, n = 412). The majority of parents opted to take their child to the hospital when they had OME, with the department of otorhinolaryngology being the preferred choice (82.8%, n = 341). Some parents chose a watchful waiting approach (11.6%, n = 54) because they thought OME could self-heal (64.8%, n = 35). When surgery was necessary for the children with OME, 86.3% of the parents agreed to the procedure, while 13.7% refused due to concerns about the risks involved (75.0%, n = 48).

3.5 Correlations between knowledge, practice, and attitudes toward otitis media and sociodemographic parameters

The correlations between sociodemographic characteristics and knowledge, attitudes, and practices were measured. This study indicated that there were no significant differences in the attitudes and practices of participants based on gender, age, marital status, or attitude (P < 0.05) (refer to Appendix 1).

There was a statistically significant correlation between gender, age, marital status and knowledge level (Table 2). According to the bivariate analysis, women and unmarried participants were more knowledgeable about OME (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.06–1.84, P = 0.017; OR = 1.33, 95% CI = 1.01–1.74, P = 0.040, respectively); however, according to the multivariate analysis, the difference was not statistically significant. Multivariate analysis revealed that the difference between knowledge level and age was statistically significant. Participants aged 26–35 years, 36–45 years and > 45 years were more knowledgeable about OME than participants aged 16–25 years were (OR = 2.20, 95% CI = 1.13–4.27, P < 0.05; OR = 2.18, 95% CI = 1.25–3.80, P < 0.01; OR = 1.96, 95% CI = 1.08–3.53, P < 0.05, respectively).

Table 2

Binary regressions of knowledge
Characteristic	Unadjusted OR (95% CI)	P value	Adjusted OR (95% CI)	P value#
Gender
Male	1.00		1.00
Female	1.40(1.06–1.84)	0.017*	1.28(0.96–1.70)	0.094
Age (in years)
16–25	1.00		1.00
26–35	2.48(1.45–4.23)	0.001**	2.20(1.13–4.27)	0.020*
36–45	2.24(1.32–3.81)	0.003**	2.18(1.25–3.80)	0.006**
> 45	2.19(1.23–3.93)	0.008**	1.96(1.08–3.53)	0.026*
Marital status
Married	1.00		1.000
Unmarried	1.33(1.01–1.74)	0.040*	1.37(0.87–2.15)	0.179
Monthly family income(yuan)
< 5000	1.00		1.00
5000–10000	0.70(0.48-1.00)	0.051	0.72(0.48–1.06)	0.094
> 10000	0.79(0.58–1.07)	0.128	0.80(0.58–1.10)	0.165
Residential zone
Urban	1.00		1.00
Rural	0.89(0.65–1.23)	0.477	0.98(0.69–1.38)	0.894
With or without child
With	1.00		1.00
Without	1.14(0.87–1.50)	0.339	0.79(0.50–1.25)	0.311
Have you ever suffered from OME
Yes	1.00		1.00
No	1.32(0.96–1.80)	0.089	1.21(0.87–1.68)	0.266

*Correlation is significant at the 0.05 level, **Correlation is significant at the 0.01 level.

OME is a common cause of hearing loss in children and adults and is a worldwide public health problem. A previous domestic survey showed that the awareness rate of parents with disease caregiving knowledge of OME was 7.09%-36.6%, and the health education needs of parents with OME were more than 50%[10]. However, this study did not conduct KAP research on OME knowledge for parents. Therefore, this study aimed to investigate and analyze the Chinese public's understanding of OME-related knowledge, attitudes and practices, understand the domestic public's demand for knowledge about the disease, and provide direction for better knowledge popularization to treat OME early.

In this cross-sectional survey of online electronic questionnaires, the knowledge, attitudes, practices related to OME and its influencing factors were observed, and the preferred sources and forms of relevant knowledge among participants of different regions, ages, genders and occupations in the Chinese mainland were collected. This study revealed that the public has a low level of knowledge, positive attitudes and positive practices toward OME, which is consistent with previous studies[7, 10].

In terms of assessing the risk factors for OME, this study revealed that infection and immature immune system status were common risk factors for OME, while early attending day care and early formula feeding were not high risk factors. Daycare, smoking exposure, and excessive use of pacifiers are also risk factors for OME, in addition to supine bottle feeding[2, 5]. Among the causes of OME, upper respiratory tract infection and allergic rhinitis were the most common. However, only 16.5% of participants chose cleft lip and/or palate (CL/P), which indicates that the participants had insufficient knowledge of CL/P as a high risk factor for OME. Soeselo et al[11] indicated that inaccurate information and education provided by medical professionals leads to insufficient awareness of CL/P among participants. Therefore, improving the public's awareness of CL/P may help reduce the prevalence of OME caused by CL/P and prevent subsequent adverse outcomes.

Although the incidence rate of OME in adults is lower than that in children, OME is also a common disease in adults, and its common causes include nasopharyngeal carcinoma (NPC) and eustachian tube dysfunction[12]. NPC is common in people in southern China, and symptoms of a lump or mass in the neck can lead patients to see a doctor. NPC can cause mechanical or functional eustachian tube obstruction, which is associated with OME. OME also presents as a complication of irradiation treatment for NPC. However, in this study, NPC and eustachian tube dysfunction (16.2% and 22.7%, respectively) were the two least common combined diseases of OME.

The symptoms of OME vary, and hearing loss is a common symptom in children with OME. The participants’ main cognition of hearing loss in children was direct performance, such as loud TV watching, and the degree of recognition of the long-term effects of hearing loss was low, such as vocabulary limitation and asking children to repeat sentences in conversation. This finding is similar to that of Parmar et al.[13] This may be related to the relatively poor long-term performance caused by hearing loss, which is not easy to detect.

For patients with OME that lasts longer than three months, tympanostomy tube insertion is the primary surgical intervention[2]. To allow the middle ear cavity to be ventilated, the tube was inserted through the tympanic membrane. The procedure is generally well accepted, with relatively rare complications such as perforation of the eardrum[5]. If surgery was indicated, 13.73% of the parents did not accept it. The top three reasons were worry about the risk of surgery, the effect of surgery, and recurrence after surgery. Therefore, it is necessary for professionals to perform surgery carefully. Chando et al.[6] reported that when clinicians respected parents’ autonomy in making decisions about the child’s treatment when appropriate, they felt respected. Gkiousias et al. [14] also emphasized that thorough communication of information to parents by clinicians during treatment consultations can impact parents’ decision-making, enhancing shared decision-making and improving clinical care.

In addition to the formulation of treatment plans, Vlastos et al.[14] reported that the disease knowledge provided by doctors is not necessarily what patients want. Parents preferred knowledge of the incidence rate, risk factors, causes, examinations, treatment and consequences; however, doctors thought that the definition, pathogenesis and surgical procedure of OME are important. This research revealed that most participants had a positive attitude toward OME, and the public wanted to obtain OME-related knowledge, focusing on the causes, hazards, diagnosis and preventive measures of OME, among which most participants chose preventive measures (76.75%). This suggests that the public aims to lower the prevalence of this disease through a better understanding of OME, which is also similar to the findings of previous studies[9, 10]. Therefore, in future education activities, medical workers should pay attention to OME preventive measures.

Similar to Meherali et al.[9] and Gkiousias et al.[15], patients' knowledge mainly comes from doctors, relatives and friends. In addition, with the popularization and development of the internet, an increasing number of participants tend to acquire knowledge quickly and conveniently through the internet, including disease knowledge[16]. Whether it is the main source of knowledge or the way to obtain knowledge in the future, the majority of participants choose new media. According to Li et al.[10], medical consultation and publicity via popular science books, the internet and other media were the preferred methods for parents of children to obtain relevant knowledge, which is consistent with the findings of this study. Gkiousias et al.[15] reported that the public is worried about the authenticity and accuracy of online information, which may be related to mixed information on the internet. It is difficult for the public without basic medical knowledge to identify the authenticity of online information. Therefore, it is important to establish a professional and reliable platform for knowledge popularization.

There was a significant difference in knowledge scores between men and women in this study, and women scored higher, which was similar to the findings of Di Berardino F et al.[17] and Alharbi et al.[18]. Alharb MM et al.[18] reported a positive relationship between education status and OME knowledge level and health-seeking behavior, but there was no significant relationship with attitude, which is different from our findings. In this study, there was a negative relationship between OME knowledge scores and attitudes, but there was no significant relationship between OME knowledge scores and health care-seeking behavior. This may be because participants with high scores have mastered OME disease knowledge to a certain extent; therefore, the education demand for disease knowledge is relatively reduced.

Like all survey-based studies, this study has limitations. There may be selection bias among participants due to nonrandomization, limited objective conditions, and the use of a questionnaire sample mostly composed of urban residents, which may not fully represent the knowledge level of the entire Chinese population. The study only included participants who could read and use smartphones, excluding those who were illiterate or did not use smart devices (primarily elderly individuals), which is not representative enough. Further assessment is needed to understand the knowledge, attitudes, and practices of otitis media with effusion (OME) among rural and illiterate participants, as well as those who do not use smartphones.

Most of the participants had good attitudes and practices toward OME, but they had insufficient knowledge of OME. Gender, age, and marital status can significantly affect people’s knowledge of OME. The majority of individuals showed a strong interest in receiving healthcare education on OME, indicating a need for popular science information. The use of new multimedia methods to quickly disseminate this information could greatly enhance medical practice related to OME for the general population.

CL/P Cleft lips and/or palate

KAP Knowledge, attitudes and practices

NPC Nasopharyngeal carcinoma

OME Otitis media with effusion

OR Odds ratio

95% CI 95% Confidence interval

Acknowledgments: We are thankful to the Fundamental Research Funds for the Central Universities.

Ethics approval and consent to participate:

This study was approved by the research council and ethics committee of West China Hospital of Sichuan University. We confirm that all methods were carried out in accordance with relevant guidelines and regulations. Additionally, we confirmed that informed consent was obtained from participants by answering the first question of the questionnaire.

Availability of data and materials:

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Consent for publication:

Not applicable

Competing interests:

The authors declare that they have no competing interests

Funding:

Not applicable

Authors’ contributions:

Qianghan Zeng and Dan Lu contributed to the study conception and design. Qianghan Zeng, Zhongjing Pan, Tianpei Ma, Jianrong Zuo, Ting Xu, and Dan Lu contributed to the data collection, statistical analysis and manuscript drafting. Dan Lu supervised the study. Qianghan Zeng, Zhongjing Pan and Dan Lu approved the final version of the manuscript.

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Knowledge, Attitudes and Practice of Otitis media with effusion: A Cross-Sectional Study Among the General Chinese Population

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Abstract

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1. Introduction

2. Method

2.1 Questionnaire design

2.2 Patient and Public Involvement

3. Results

3.1. Sociodemographic data

3.2. Knowledge about OME

3.3. Attitudes about OME

3.4. Practice of OME

3.5 Correlations between knowledge, practice, and attitudes toward otitis media and sociodemographic parameters

4. Discussion

5. Limitations

6. Conclusion

Abbreviations

Declarations

References

Appendix

Additional Declarations

Supplementary Files

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