Knowledge, screening practice and infection-related behaviors toward Helicobacter pylori among university students in East China-a cross-sectional study.

Introduction
Approximately half of the global population has been infected with Helicobacter pylori (HP)1. Most infected individuals are initially asymptomatic, but long-term infection can lead to diseases such as chronic gastritis and gastroduodenal ulcers, and is closely associated with extra-intestinal conditions like idiopathic thrombocytopenic purpura2. As a major cause of gastric cancer3, HP eradication is a cost-effective primary prevention strategy to reduce its incidence and mortality4. China bears a particularly high burden of gastric cancer, ranking among the highest globally in both incidence and mortality5. It is projected that by 2050, China will have 280,000 new gastric cancer cases, with approximately 40% to 62% attributable to HP infection6. While the overall global incidence of gastric cancer has been declining, the absolute incidence among young adults is rising7. This trend may be linked to the persistently high HP infection rates among adolescents8. Therefore, strengthening HP prevention, control, and screening among the general public is important for reducing the gastric cancer burden.
Multiple studies9–15 revealed low HP screening rates, insufficient knowledge, and poor adherence to preventive behaviors in the general population. A study of 1,031 residents in Bosnia and Herzegovina15 reported a screening rate of only 36.18%, with 83.41% admitting to at least one dietary habit associated with HP infection. Research on 1,042 Chinese community residents9 showed that while 68.9% had heard of HP, the screening rate was merely 27.3%; only 26.6% possessed a high level of HP knowledge, 40.5% never used serving chopsticks, and 44.1% never disinfected household tableware. These current conditions highlight the urgency and importance of improving public knowledge and behaviors related to HP.
Notably, even among the highly educated university students, their HP screening rates and knowledge levels exhibit a similar trend16,17. Among 334 Saudi university students16, only 18% reported a history of HP infection and merely 8.4% had a high knowledge level. Similarly, a study of 1,634 Chinese university students17 reported an HP screening rate of only 14.1%, with 34.6% having no prior knowledge of HP and only 5% demonstrating a high knowledge level. Studies indicated that earlier screening and intervention in young populations can significantly reduce cumulative incidence and offer high cost-effectiveness18–20. University students, with their relatively higher educational attainment and health literacy21, and their potential role as “digital mentors” within families22, represent a crucial target for HP health education, potentially amplifying the impact of prevention efforts. Currently, cross-sectional studies focusing on HP knowledge and related behaviors among university students remain limited. Existing research often focuses solely on knowledge assessment, with lifestyle evaluations primarily covering dietary preferences, while lacking comprehensive assessment of hygiene and dining-table habits. This study aimed to investigate the current status of HP-related knowledge and behaviors among university students in East China, providing a scientific basis and practical reference for more effectively integrating this new generation of intellectuals into the HP health education and promotion system.

Methods

Study design
From March to June 2025, university students were recruited as participants using a convenience sampling method from 3 universities in each of the 6 provinces/municipality: Shanghai, Jiangsu, Zhejiang, Shandong, Fujian, and Jiangxi, totaling 18 universities. The survey was conducted simultaneously offline and online. Uniformly trained investigators visited high-density areas in target campuses, such as libraries, teaching buildings, and cafeterias, to recruit students on-site, distribute paper questionnaires, and collect them upon completion. Prior to the survey, participants were informed of the study’s primary purpose and could voluntarily decide whether to participate. At the investigators’ own universities, electronic questionnaires were distributed via campus new media platforms. The first page of the electronic questionnaire contained detailed instructions, and participants voluntarily decided whether to join the study. The survey was automatically terminated if a participant declined. Inclusion criteria were: age ≥ 18 years; full-time enrolled university student; voluntary participation; ability to comprehend the questionnaire and complete it independently. Exclusion criteria were: non-degree-seeking students (e.g., short-term exchange students). The sample size was calculated using the epidemiological research formula23: N = Z2*p*(1-p)/δ2. For a 95% confidence level, Z = 1.96; the allowable error (δ) was set at 0.03. Based on a Meta-analysis24, the prevalence of HP infection among adults in mainland China in recent years was 42.6%, and p was set at 0.426. The calculated minimum sample size was 1043. Accounting for a potential 30% non-response rate, the final minimum sample size required was 1490.

Survey instrument
A self-administered questionnaire was developed for this survey. Based on a review of the literature2,4,9–11,13,16,20,25–27, a primary version of the questionnaire was drafted and subsequently revised after reviews from 2 clinical experts. A pilot test was conducted with 40 participants prior to the formal survey to assess the comprehensibility and clarity of the items and to identify any potential ambiguities. Based on the feedback received, the wording of certain items was revised accordingly. The final questionnaire consisted of 40 items across 4 sections: ①Demographic Characteristics (14 items): Including basic information such as gender, age, grade, major type, family geographic district, family residence region, number of generations in family, household’s per capita living area, parental education attainment, and parental occupation. It also assessed the presence of gastrointestinal discomfort in the last year and a family history (including deceased members within 3 generations) of gastrointestinal diseases (peptic ulcer, chronic gastritis, colorectal cancer, esophageal cancer, gastric cancer, and gastric mucosa-associated lymphoid tissue lymphoma). ②HP Knowledge Level (5 items): Item 1: "Have you heard of HP before this survey?" Answering “Yes” led to the continuation of the questionnaire; answering “No” led to skipping the remaining 4 items in section "HP Knowledge Level" and the all items in section "HP Screening and Treatment Practices", proceeding directly to section "HP Infection-Related Behaviors". Items 2–4 assessed knowledge regarding HP transmission routes, associated symptoms, complications, and prevention measures, respectively. All 4 items were multiple-choice. Adopting the method used by Wang et al.9, 1 point was awarded for each correctly selected option, with no points for “Unclear” or incorrect selections. The total possible score was 29. Based on the total score, knowledge levels were categorized as low (0–10 points), medium (11–19 points), or high (20–29 points). A pre-survey of 200 samples yielded a Cronbach’s alpha of 0.897. The results of the exploratory factor analysis indicated a Kaiser–Meyer–Olkin (KMO) measure of 0.76 and a Bartlett’s test of sphericity with p < 0.001. One common factor was extracted, accounting for 61.89% of the total variance. These results indicated that this section of the questionnaire had good internal consistency and validity. ③HP Screening and Treatment Practices (7 items): Including personal screening history, personal infection history, personal treatment history, personal re-examination history, history of re-eradication therapy, family screening history, and family treatment history. ④HP Infection-Related Behaviors (14 items): Including personal long-term (lasting > 1 year) habits (multiple-choice), personal dining habits, and sharing of household items (multiple-choice). Criteria for Excluding Inattentive Responses:①Clearly patterned responses; ②Selection of contradictory options in multiple-choice questions. For example, in the item "Which of the following complications are associated with HP infection?" which listed specific diseases and an “Unclear” option, simultaneous selection of specific complications and “Unclear” was considered an inattentive response.

Data analysis
Categorical variables, including demographic characteristics, HP knowledge level, HP testing and treatment history, HP infection-related behaviors, were described using frequencies (N) and percentages (%). Normally distributed continuous variables were presented as the mean ± standard deviation (Mean ± SD), while non-normally distributed continuous variables were presented as the median (interquartile range, IQR). Univariate ordinal logistic regression analysis was used to examine the associations of demographic characteristics and personal HP screening practice with HP knowledge level. Univariate binary logistic regression analysis was used to examine the associations between demographic characteristics and personal HP screening practice, and the associations between HP infection-related behaviors and HP infection. Variables that reached statistical significance (p < 0.05) in the univariate ordinal/ binary logistic regression analysis were subsequently included in multivariable ordinal/ binary logistic regression analysis to identify independent factors influencing university students’ HP knowledge level, screening practice, and infection status. The results of the regression analyses were presented as regression coefficients (β), standard errors (SE), odds ratios (OR), and their corresponding 95% confidence intervals (95%CI). A two-tailed p-value < 0.05 was considered statistically significant. Data from online and paper questionnaires were uniformly collated and coded in Microsoft Excel 2021. All statistical analyses were performed using IBM SPSS Statistics version 27.0.

Ethical considerations
This study was approved by the Ethics Review Committee of Jiangsu University (Approval No.: JSDX20250327001). All methods were performed in accordance with relevant guidelines/regulations and the Declaration of Helsinki. Participants of offline surveys signed a written informed consent before completing paper questionnaire. For online surveys, participants signed the informed consent displayed on the first page of the electronic questionnaire; only after signing it will they be redirected to the specific items of the questionnaire. All participants had the right to withdraw from the study at any time.

Results

Demographic characteristics
A total of 2,036 questionnaires were received. After excluding 11 inattentive responses, 2,025 valid questionnaires were included in the final analysis. The median age of participants was 20 (IQR = 2), with females constituting the majority (60.2%). Regarding major types, Engineering (33.4%) and Humanities (36.3%) were the most represented. A total of 33.7% of participants reported experiencing gastrointestinal discomfort in the last year, and 22.0% reported a family history of gastrointestinal diseases. Detailed data are presented in Table 1.

HP knowledge level
Among the participants, 234 had never heard of HP. Of the 1,791 participants who were aware of HP, the median total knowledge score was 15 (IQR = 11). The distribution of knowledge levels was as follows: 30.6% low, 42.9% medium, and 26.5% high. The median scores for individual knowledge dimensions were: transmission routes, 1 (IQR = 1); common symptoms, 3 (IQR = 4); complications, 2 (IQR = 2); and prevention measures, 9 (IQR = 7). Specific data are shown in Table 2.
Univariate ordinal logistic regression analysis (Table 3) identified the following factors associated with HP knowledge level (p < 0.05): gender, grade, major type, family geographic district, family residence region, household’s per capita living area, father’s education attainment, father’s occupation, mother’s occupation and family history of gastrointestinal diseases. These significant factors were subsequently entered into a multivariable ordinal logistic regression analysis (Table 3), which revealed that gender, major type, family geographic district, household’s per capita living area, father’s education attainment and family history of gastrointestinal diseases were independent influencing factors for HP knowledge level (p < 0.05). Specifically, female students, those whose fathers had a senior high school education, and those with a household’s per capita living area between 30–40 m2 tended to have higher HP knowledge. In contrast, students majoring in Humanities, those whose family geographic district was outside East China, and those without or unsure of a family history of gastrointestinal diseases were more likely to have lower HP knowledge.

Previous HP screening and treatment practices
Among the 1,791 participants aware of HP, only 22.9% had ever undergone HP screening, of whom 26.3% tested positive. Among those with a positive result, 76.0% completed a standard eradication therapy, 45.1% received follow-up testing after treatment, and 87.5% of those with a positive follow-up test underwent re-treatment. Regarding family members, 17.7% reported that family members had been screened for HP, and 76.3% of those family members received treatment. Detailed screening and treatment data are presented in Table 4.
Table 5 presents the factors associated with personal HP screening practice. The univariate binary logistic regression analysis showed that grade, major type, family residence region, father’s education attainment, mother’s education attainment, father’s occupation, mother’s occupation, gastrointestinal discomfort in the last year and family history of gastrointestinal diseases were related to personal HP screening. The multivariable binary logistic regression analysis identified grade, major type, father’s education attainment, mother’s education attainment, gastrointestinal discomfort in the past year and family history of gastrointestinal diseases as independent influencing factors for personal HP screening. Specifically, students whose fathers had a senior high school education or a university degree or above, and those whose mothers had a university degree or above were more likely to have been screened. Conversely, second-year students, those majoring in Humanities, those without gastrointestinal discomfort in the last year, and those without or unsure of a family history of gastrointestinal diseases were less likely to have undergone screening.

HP infection-related behaviors
Among the surveyed university students, 45.9% reported a habit of consuming coffee or milk tea, and 40.5% frequently consumed sweets or desserts. Only 28.5% took vegetables and fruits daily. Regarding dining practice, 54.6% did not practice individual dining at home, 37.5% shared tableware with family members, and 16.0% shared teacups. The utilization rates of serving chopsticks and spoons were low, with only 18.3% always using them. Among the 8.3% who never used them, the primary reasons were "Lack of usage habit" (61.5%) and "Dining venues don’t provide them" (38.5%). Specific data are detailed in Table 6.
Table 7 presents the behavioral factors associated with HP infection. Univariate binary logistic regression analysis indicated that smoking, consumption of coffee/milk tea, consumption of sweets/desserts, consumption of seafood, frequency of vegetable and fruit intake, habit of sharing straws or bottle openings with others, sharing tableware within the family and sharing mouthwash cups within the family were factors associated with HP infection (p < 0.05). When entered into a multivariable binary logistic regression analysis, consumption of coffee/milk tea, consumption of seafood, frequency of vegetable and fruit intake and sharing tableware within the family were identified as independent influencing factors for HP infection. Individuals who frequently consumed coffee/milk tea, frequently consumed seafood,  and had a lower frequency of vegetable and fruit intake exhibited lower rates of HP infection, whereas those who shared tableware within the family had a higher infection rate.

Discussion
This study aimed to investigate the current status of knowledge, screening and treatment practices, as well as related dietary preferences and hygiene habits regarding HP infection among university students in East China, providing a reference for enhancing future health education and promotion.
The findings indicated that university students in East China possessed a moderate overall level of HP knowledge. Among the different knowledge dimensions, awareness of HP complications was the weakest. This may be related to students’ perception of themselves as young and distant from disease, leading to a limited knowledge about complications. Another possible explanation is that most non-medical students were unfamiliar with the medical terminology associated with complications. Regarding transmission routes, recognition of oral-oral transmission was 77.3%, significantly higher than the 48.6% reported by Wang et al.9 and 31.1% by Shin et al.26. Recognition of fecal–oral transmission was 54.4%, higher than the 29.8% reported by Wu et al.11 and 26.0% by Teng et al.10. However, a high percentage (56.7%) incorrectly selected droplet transmission, slightly above the 53% reported by Bailey et al.12. Concerning common symptoms, nausea (59.2%) and epigastric pain (56.2%) had the highest recognition rates, exceeding those reported among university students by Hafiz et al.16. Notably, most HP infections are asymptomatic in early stages, yet only 7.7% of students correctly identified this, lower than the 29.0% reported by Hariri et al.14. This suggested a significant gap in students’ understanding of HP clinical symptoms and a widespread neglect of its concealed characteristics. For complications, recognition rates for extra-gastrointestinal diseases like Iron deficiency anemia were much lower than for gastrointestinal diseases, consistent with findings by Wang et al.9. Studies from Gansu, China28 and Sudan29 indicated that physicians also lack awareness of HP’s extra-gastric effects. Regarding gastrointestinal diseases, recognition rates for chronic gastritis and peptic ulcer were 64.7% and 51.3%, respectively, lower than those found by Gao et al.17. Surprisingly, only 29.5% correctly identified gastric cancer, lower than the 38.4% reported by Omari et al. 30 and 56.0% by Alajmi et al.31, potentially indicating an underestimation of HP as a major risk factor for gastric cancer among participants12,32. For preventive measures, over 75% recognized the effectiveness of using serving chopsticks /spoons and implementing individual dining. However, awareness of measures related to oral hygiene and medical screening was below 70%. Therefore, university healthcare professionals should recognize that students lack comprehensive knowledge of HP transmission routes, easily overlooked symptoms, complications, and preventive measures. It is essential to enhance students’ HP knowledge and protective awareness through health education, targeted campaigns, and regular screening interventions.
Multivariate ordinal regression analysis revealed that female university students had significantly higher HP knowledge levels than males. This aligns with studies in the general population reporting better HP knowledge among females15,25, which may be related to females’ greater tendency to actively seek health information online compared to males33. Medical students exhibited significantly higher knowledge levels than Humanities majors, consistent with findings that healthcare professionals30,34 and medical students17 possessed better HP knowledge, reflecting the positive role of medical education in knowledge acquisition. Students from families residing in East China had better HP knowledge, possibly because residents in economically developed regions generally pay more attention to health issues35. Ample living space was regarded as a protective factor against HP infection36,37. This study found that students with a household’s per capita living area of 30–40 m2 had significantly higher knowledge levels than those with less than 20 m2, the difference possibly related to family economic status. Parental educational background also significantly influences their children’s health knowledge38. In this study, students whose fathers had a senior high school education demonstrated significantly higher HP knowledge levels than those whose fathers had a junior high school education or below. Although maternal education usually has a stronger influence on children’s health knowledge38, no significant effect was observed in this study, which may be related to sample demographic differences. Students with a family history of gastrointestinal diseases showed higher HP knowledge levels. Prior studies indicated that individuals with a family history of HP infection tend to have higher knowledge scores12,34. Family medical history can serve as tangible health education material, with parents conveying related knowledge through descriptions of symptoms and treatment experiences to their children. Notably, prior experience with HP screening showed no statistical significance in the univariate model, contrasting with previous study indicating that screening history improved HP knowledge level39. This discrepancy may stem from insufficient explanation by physicians regarding the potential benefits of eradication therapy when prescribing tests or treatments26, leading to limited patient awareness. In future clinical practice, healthcare professionals can utilize large language models such as ChatGPT or create short science popularization videos to strengthen health education, clarifying the necessity of screening and eradication, thereby enhancing patients’ awareness and treatment adherence regarding HP.
This study found a low HP screening rate of 22.9% among university students, which aligns closely with previous studies on university students and the general population in various countries9,11,12,15–17,25,40. This may be attributed to the frequent absence of symptoms among participants and the fact that HP screening was not typically included in routine health check-ups15,25. Among the 108 individuals with a prior positive HP screening result, 91 underwent eradication therapy, with 9 admitting incomplete adherence to the prescription. The post-treatment re-examination rate was 45.1%, lower than the rates exceeding 70% reported in previous studies15,25, and the eradication success rate was only 36.3%. Although current guidelines41,42 do not recommend universal screening for HP in asymptomatic children and adolescents, targeted testing and eradication therapy are still advised for those with specific high-risk factors, such as gastrointestinal symptoms or a family history of gastric cancer41,42. Binary logistic regression analysis revealed that second-year students had a significantly lower screening rate than fourth-year students. This may be related to the timing of the study during graduation season, when graduating seniors often require physical examination for further education or employment, increasing opportunities for gastrointestinal testing. Additionally, the psychological stress and related unhealthy lifestyles among graduating seniors may lead to gastric discomfort43, prompting medical visits and higher screening rate. Medical students were screened approximately 1.7 times more often than Humanities majors, consistent with findings by Gao et al.17. Their theoretical and clinical training likely enhanced awareness of HP risks and screening benefits. Previous studies indicated that higher educational attainment44,45 was an independent protective factor against HP infection and was significantly associated with higher screening rate9. This study found that students with highly educated parents were more likely to undergo HP screening. This tendency may be related to various factors associated with higher family educational backgrounds, such as socioeconomic status38, lifestyle37,38, health literacy46, disease prevention awareness46, and accessibility of medical resources38,46. Furthermore, students without gastrointestinal discomfort in the last year, or those without or unsure of a family history of gastrointestinal diseases, had significantly lower screening rate. Upper gastrointestinal symptoms36,37,47 and a family history of gastric diseases47,48 were recognized risk factors for HP infection. Individuals with family members suffering from gastrointestinal diseases tend to hold more positive attitudes towards HP eradication34. This study speculated that a family history may increase students’ vigilance about their gastrointestinal health, prompting proactive screening, whereas the onset of gastrointestinal symptoms may directly motivate healthcare-seeking and screening9. Given that gastrointestinal symptoms and a family history of gastrointestinal diseases are key drivers for HP screening, university health centers could consider offering targeted HP counseling and testing during entrance physical examinations to students with such symptoms or a family history of gastric cancer, thereby enabling early detection and intervention.
This study found that individuals with a higher frequency of vegetable and fruit intake were more susceptible to HP infection, which contradicts previous epidemiological findings47,49. While polyphenols in vegetables and fruits exhibit significant anti-HP activity50 and positively impact HP colonization status51 , inflammation alleviation51, and delaying antibiotic resistance51, the consumption of raw produce may increase infection risk due to surface contamination from irrigation with polluted water52. Future health education should emphasize the thermolabile nature of HP53 and promote safe food handling practices, such as avoiding raw consumption. Students who did not consume seafood were more susceptible to HP infection. Although contaminated seafood can act as a transmission vector in the food chain54, and long-term seafood consumption may be associated with aggravated HP symptoms15, previous researches suggested that fucoidan from sea cucumber55 and astaxanthin from shrimp56 possessed anti-HP potential through mechanisms such as direct antibacterial action55, adhesion inhibition55, and immunomodulation56. Therefore, the association between seafood and HP infection requires further mechanistic investigation, distinguishing between the effects of raw and cooked consumption. Individuals without the habit of consuming coffee or milk tea (a tea-based drink popular among youth) were more susceptible to HP infection. The literature on the relationship between coffee/tea intake and HP infection presents inconsistent findings. Some studies suggested that drinking coffee57 or tea48,57 reduced HP infection rates, while others identified coffee45,58 or tea27 consumption as significant risk factors. Additionally, coffee may induce59 or perpetuate25 upper gastrointestinal symptoms in patients with HP infection. Future research should incorporate detailed data on the types, quantities and serving temperatures of coffee/tea, and whether participants have intentionally altered their intake for any reason.
This study identified that long-term sharing of tableware with family members significantly increased the risk of HP infection. The high HP prevalence in Asian countries is largely attributed to traditional communal dining practices60, whereas individual dining or using serving chopsticks/spoons can effectively reduce infection risk37,44,48. However, the personal dining practices among the surveyed university students were suboptimal: household adoption of individual dining was below 50%, and consistent use of serving chopsticks/spoons was under 20%. Among those who never used serving chopsticks/spoons, "Lack of usage habit" was the primary reason. Huang et al.61 suggested that individuals accustomed to shared meals struggle to change their behavior spontaneously without intervention. The communal dining tradition in China is often perceived as a symbol of equality and intimacy, while using serving utensils can be misinterpreted as distancing or unwillingness to share62. Such cultural perceptions may weaken individuals’ self-efficacy in using serving utensils and their perception of health risks62. "Dining venues don’t provide them" was another major reason. Using serving chopsticks/spoons and individual dining are collective health behaviors62,63, and social norms significantly influence individual acceptance61. The catering industry should proactively provide and encourage the use of serving chopsticks/spoons to create collective momentum. Chen et al.64 found that actively urging others to use serving utensils was often perceived as impolite, which may explain why only 19.1% of students consistently reminded family or peers to do so. Yang et al.63 suggested that advertising campaigns highlighting collective efficacy were more effective in boosting willingness than those focusing solely on self-efficacy. Therefore, collective-level interventions can enhance people’s willingness to adopt serving chopsticks/spoons. It is recommended to organize campus activities promoting the use of serving chopsticks/spoons, and use digital platforms such as short videos and large language models to amplify the impact of health education.

Limitations
This study had several limitations. First, as a cross-sectional study, it cannot infer causal relationships among HP knowledge, screening practice, and infection-related behaviors. Longitudinal studies are needed to clarify these causal pathways. Second, the sample was derived from universities in East China using convenience sampling and voluntary participation, which limits representativeness and may introduce selection bias. Future research should employ probability-based sampling in nationwide large-sample studies for validation. Third, data were collected via a mix of online and offline questionnaires. Although measures such as uniform instructions and data screening were implemented to control bias, information bias arising from different survey modes cannot be completely ruled out. All data were self-reported and thus susceptible to recall bias.

Conclusions
This cross-sectional survey assessed the knowledge level, screening and treatment practices, and related behaviors concerning HP among university students in East China. The results indicated that the overall HP knowledge level in this population was moderate, while the screening rate remained low. Multivariate regression analysis further revealed that knowledge level was independently influenced by multiple factors, including gender, major type, certain family background, and family history of gastrointestinal diseases. Screening practice was closely associated with grade, certain family background, gastrointestinal discomfort, family history of gastrointestinal diseases. Regarding lifestyle habits, specific dietary behaviors (e.g., consumption of coffee/milk tea, seafood) and sharing tableware within the family were significantly linked to HP infection. Future research should employ more representative sampling designs, longitudinal follow-up, and incorporation of objective detection indicators to further verify the causal pathways of relevant factors. Such efforts will provide more robust evidence to support the development of family-based HP prevention and control strategies that leverage university students as a key entry point.

Supplementary Information