Background

Probiotics are defined as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host,” as established by the Food and Agriculture Organization of the United Nations and the World Health Organization (FAO/WHO)1. This concept of probiotics is further supported by the International Scientific Association for Probiotics and Prebiotics (ISAPP)2. These living microorganisms, often found in probiotics-containing yogurt, have gained popularity as health-promoting foods due to their beneficial effects on gastrointestinal health and inflammation3. Supplementation with probiotics has shown promise in bolstering both the immune and gastrointestinal systems4. As widely recognized nutraceuticals, probiotics are believed to contribute to the maintenance of gut health, improved immune function, and even the potential management of certain chronic diseases5.

The Knowledge, Attitude, and Practice (KAP) survey functions as a diagnostic research tool, illuminating a group’s comprehension, beliefs, and actions on a specific subject, particularly within the realm of health literacy, where it is based on the premise that knowledge positively influences attitudes, which in turn shape behaviors6,7,8. The safety of probiotics is a critical factor influencing the selection of probiotic strains and meeting consumer demand9. The evaluation of immunostimulatory effects of specific probiotic strains lies primarily with manufacturers and regulatory agencies. Transparent communication of this information is essential to guide consumers, especially those with chronic inflammation, in making informed choices10. The large diversity of probiotics that are available on the market, makes it difficult for healthcare professionals and consumers to decide which probiotics to choose11. Differences in the potential effects of probiotics may arise from various factors, including preparation methodologies, the specific strains used (e.g., bacterial or yeast strains), and the dosage of probiotics12. The general population’s knowledge of probiotics varies, influenced by factors like education and age. Attitudes toward probiotics range from positive beliefs in their health benefits to skepticism. Such skepticism may stem from a lack of clear understanding of their mechanisms of action, inconsistent evidence regarding their efficacy, and concerns over potential commercial bias in their promotion. Additionally, misconceptions about the differences between probiotics and prebiotics or doubts about the safety and appropriateness of certain probiotic strains may further contribute to public hesitancy. Practices differ, with some actively using probiotics and others rarely or never trying them due to factors like availability and economic conditions. Although studies have explored Chinese consumers’ perceptions of probiotics and functional foods, comprehensive, large-scale research specifically targeting the general population’s KAP toward probiotics remains limited. Therefore, this study aimed to investigate the KAP of probiotics among the general population in China.

Methods

Study design and participants

This multicenter cross-sectional study was conducted across three tertiary comprehensive hospitals situated in different regions: Hebei (Hebei General Hospital), Shanxi (Shanxi Provincial People’s Hospital), and Xinjiang (Urumqi International Hospital) between May and July 2023 and the general population were enrolled. Inclusion criteria encompassed individuals who were 18 years of age or older, and willing to voluntarily take part in the study. The study focused on health-related KAP, and personal preferences and ethno-regional biases were not explicitly considered. Consumer or business survey expertise was not involved, as the primary aim was to address public health perspectives. The study was ethically approved by the Medical Ethics Committee of the Hebei General Hospital and with the 1964 Helsinki declaration and informed consent was obtained from the study participants.

Questionnaire introduction

The questionnaire was designed with reference to previous literature13, and reliability was tested by randomly sampling 76 individuals, with a Cronbach’s α coefficient of 0.840, suggesting good internal consistency.

The final questionnaire encompasses four distinct dimensions: basic characteristics, knowledge, attitude, and practice (Supplement questionnaire). The basic characteristics section comprised 12 questions. The knowledge dimension consisted of 13 questions, each rated with scores of 2, 1, and 0 to indicate varying levels of knowledge (i.e., well known, heard of, and unaware of), resulting in a total possible score ranging from 0 to 26. The attitude dimension incorporated 17 questions employing a five-point Likert scale (ranging from 5 − 1, corresponding to strongly agree to strongly disagree), yielding a score range from 17 to 85. Similarly, the practice dimension consisted of 10 questions, where questions 1–6 employed a five-point Likert scale (ranging from always to never) with scores of 5 − 1, resulting in a score range of 6–30. Meanwhile, questions 7–10 were open-ended inquiries concerning probiotics and their preparations. For each dimension, adequate knowledge and a positive attitude were defined as scores exceeding 70% of the total score for that particular dimension14.

Distribution and quality control

The questionnaires were distributed to study participants through the WeChat platform. The survey questionnaire, hosted on the Wenjuanxing platform (https://www.wjx.cn/mobile/statnew.aspx), was shared with the WeChat workgroups of the medical examination centers within these hospitals. All individuals meeting the inclusion criteria were invited to participate in the survey, with participants having the option to complete and submit the questionnaire based on their individual circumstances and willingness. To ensure data quality and completeness, each IP address was restricted to one submission, and all questionnaire items were made mandatory. Participants were assured of anonymity while completing the questionnaires. The research team, including three doctors trained as research assistants responsible for promoting and distributing the questionnaires, meticulously reviewed all submissions for completeness, internal consistency, and reasonableness. Questionnaires completed in less than 90 s, those with logical errors, or those where all options were identical were considered invalid.

Statistical analysis

The sample size was determined based on the guideline of having 5–10 times the number of questionnaire items15. Given that the questionnaire contained 40 independent variables, the minimum required sample size was calculated to be 200 participants. To account for potential survey questionnaires that might be invalid (approximately 20%), the study aimed to recruit at least 250 participants. The null hypothesis in this study posited no significant associations between knowledge, attitude, and practice (KAP) scores regarding probiotics among the general population in China. The alternative hypothesis proposed significant relationships among these variables.

Statistical analysis was conducted using R 4.3.1. Continuous variables were described using mean ± standard deviation (SD). Comparisons between two groups were made using the independent samples t-test, while comparisons among three or more groups were performed using analysis of variance (ANOVA). Categorical variables were presented as n (%). Pearson correlation analysis was employed to assess the correlations between knowledge, attitude, and practice scores. In multivariate analysis, 70% score distribution of the total score was used as the cut-off value. Univariate variables with P < 0.05 were enrolled in multivariate regression. Hypotheses were validated using structural equation modeling (SEM). It was hypothesized that knowledge directly affects attitude and practice, while attitude directly affects practice. Two-sided P < 0.05 were considered statistically significant in this study.

Results

Initially, there were 1585 questionnaires collected in this study, which were excluded according to the following criteria: 17 questionnaires with a response time of less than 90 s; 11 questionnaires that did not agree to participate in the survey; 4 questionnaires in which the respondents were less than 18 years of age; 20 questionnaires in which the “Self-rating of healthy dietary status” was incorrectly filled out; 47 questionnaires that chose “Unaware of” for all knowledge dimension questions; 21 questionnaires that chose both no purchase and purchase at the same time for question P7; 13 questionnaires that chose both don’t care and other; remaining 1,452 questionnaires, with a validity rate of 91.61%. Among them, 931 (64.12%) were females, 543 (37.40%) were in the age group of 30–40 years, with mean self-rating of healthy dietary status of 7.40 ± 1.67. 1067 (73.48%) were living in urban, 751 (51.72%) had bachelor’s degree. 830 (57.16%) were working in non-medical related jobs, 343 (36.84%) had given natural birth, 751 (51.72%) had purchased probiotics and their preparations in pharmaceuticals or nutraceuticals, out of which 502 (66.84%) had purchased them from pharmacies, followed by online purchase 321 (42.74%) (Table 1).

Table 1 Baseline characteristics.
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The mean knowledge, attitude, and practice scores were 10.94 ± 2.97 (possible range: 0–26), 34.57 ± 3.15 (possible range: 17–85), and 22.57 ± 3.72 (possible range: 6–30), respectively. The knowledge score varied from participants with different age (P < 0.001) and marital status (P = 0.003). Attitude score varied across gender (P < 0.001) and monthly household income (P = 0.005). The differences of practice score were found among those with different age, monthly household income, and marital status (all P < 0.001). Moreover, those with different residence, education, job type, whether ever given birth, whether purchased probiotics and their preparations in pharmaceuticals or nutraceuticals were more likely have different knowledge, attitude, and practice scores (all P < 0.005) (Table 1 and Supplementary Table 2).

The analysis of the knowledge dimension revealed that participants were most familiar with the health benefits of probiotics, such as promoting intestinal motility, maintaining gut microbiota stability, and alleviating gastrointestinal issues. Participants also showed awareness of probiotics’ roles in weight management, immune regulation, and dietary sources such as yogurt and soy products. However, gaps in knowledge were identified, particularly regarding the differences between probiotics and prebiotics, appropriate probiotic use for infants, and potential dietary allergens. Detailed percentages and question-specific responses are provided in Supplementary Table 1.

Participants’ attitudes towards probiotics varied, with 38.63% having varying degrees of skepticism about the efficacy of probiotics (A1). 47.8% were aware that probiotics should not be taken casually (A3). In addition, 76.1% believed that probiotics are needed when suffering from certain diseases (e.g. diarrhoea, constipation), constipation (A6), while 60.26% believed that probiotics are necessary even in a healthy state (A7). It is noteworthy that 17.98% believe that doctors recommend probiotics and preparations to make money. Regarding the factors that hindered their choice of probiotics and their preparations, the three most reported factors were too many types to know how to choose (A11.4, 71.69%), high storage requirements, some requiring refrigeration (A11.6, 64.67%), and short shelf life (A11.7, 63.43%) (Supplementary Fig. 1).

Participants’ practices revealed that 63.36% would check the strain number, number of live bacteria and manufacturer when purchasing probiotics (P1). 72.46% would avoid taking probiotics together with antibiotics (P4). 69.01% would take probiotics directly after opening the package without sub-assembling (P6) (Supplementary Fig. 2). 58.54% learnt about probiotics through hospital or healthcare personnel popularization, followed by self-media (44.49%), and News & TV (39.67%) (Supplementary Fig. 3). When it comes to the preferred forms of probiotics, the most popular are yoghurt, cheese, dairy products (61.85%), powder, lyophilized powder (40.08%), and capsules (30.65%) (Supplementary Fig. 4 A). Furthermore, the most popular conditions to store probiotics is storage at room temperature (60.81%) and refrigerated (57.85%) (Supplementary Fig. 4B). Additionally, the effects and benefits that most encouraged participants to use probiotics were regulating gut flora (78.51%) and aiding digestion and absorption (77.27%) (Supplementary Fig. 4 C). Finally, 59.50% and 51.65% of participants preferred to purchase probiotics through pharmacies and hospital prescriptions, respectively, which were the two most widely available channels (Supplementary Fig. 4D).

Multivariate logistic regression showed that age (P < 0.05), medical-related jobs (OR = 1.632, 95% CI: 1.282–2.081, P < 0.001), self-rating of healthy dietary status (OR = 1.131, 95% CI: 1.060–1.209, P < 0.001), and purchasing probiotics and their preparations (OR = 1.437, 95% CI: 1.148–1.801, P = 0.002) were independently associated with good knowledge. Meanwhile, being female (OR = 1.436, 95% CI: 1.145–1.804, P = 0.002) and purchasing probiotics and their preparations (OR = 0.572, 95% CI: 0.459–0.712, P < 0.001) were independently associated with positive attitude. In addition, knowledge (OR = 1.193, 95% CI: 1.145–1.246, P < 0.001), living in an urban area (OR = 1.475, 95% CI: 1.119–1.945, P = 0.006), and having a monthly household income of 5,000–10,000 yuan (OR = 1. 365, 95% CI: 1.023–1.821, P = 0.034), and self-ratings of healthy dietary status (OR = 1.138, 95% CI: 1.063–1.219, P < 0.001) were independently associated with proactive practices (Table 2).

Table 2 Multivariate analysis for KAP.
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SEM path analysis revealed that knowledge had a direct negative effect on attitude (β = −0.36, 95%CI: −0.48-0.23, P < 0.001), and direct effect was found between attitude and practice (β = −1.00, 95%CI: −1.27-0.72, P < 0.001). However, knowledge demonstrated substantially direct effects (β = 0.60, 95%CI: 0.38–0.81, P < 0.001) and indirect effect on practice (β = 0.36, 95%CI: 0.25–0.47, P < 0.001) (Fig. 1).

Fig. 1
figure 1

SEM analysis.

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Discussion

Participants in the northern region of China demonstrated insufficient knowledge, negative attitudes, yet certain proactive practices related to probiotics, such as checking product labels and consulting healthcare professionals. These behaviors might reflect the coexistence of misconceptions and incomplete knowledge, which require further investigation and targeted interventions. The study underscores the need to enhance clinical practice in China regarding probiotics. Healthcare professionals should focus on education, while public health policies should promote probiotic-rich diets, tailored to specific subpopulations.

The study reveals significant gaps in the KAP of probiotics among the general population in China. Overall, participants exhibited insufficient knowledge, a negative attitude, and limited proactive practices. These findings align with conclusions from other studies, indicating that consumers frequently possess limited understanding of probiotics16,17,18. Variations in KAP scores were observed across different demographic factors, such as age, marital status, gender, and income. Multivariate logistic regression analysis identified several factors independently associated with KAP levels. Good knowledge was linked to factors such as age, medical-related occupations, self-perceived dietary health, and the purchase of probiotics and their preparations. On the other hand, a positive attitude was associated with being female and not purchasing probiotics. Proactive practices were influenced by factors including knowledge, urban residence, higher income, and self-rated dietary health. These results underscore the importance of developing targeted strategies to address the deficiencies in probiotics related KAP within the Chinese general population19. Comprehensive educational efforts, gender-specific initiatives, and interventions focused on enhancing dietary health perceptions should be prioritized to improve clinical practices related to probiotics20.

This study shed light on the distribution of knowledge within the general population regarding probiotics. It is evident that there are substantial knowledge gaps, with a significant proportion of participants being unaware of fundamental concepts, such as the distinction between probiotics and lactic acid bacteria or the benefits of probiotics. This lack of awareness is inconsistent with the conclusions obtained from previous research that underscores the importance of clear public knowledge about probiotics for improving clinical practice21. To address these deficiencies and enhance clinical practice, targeted initiatives are essential22. These initiatives should include comprehensive educational campaigns that emphasize the distinctions between probiotics and prebiotics, the sources of probiotics in daily diets, and the potential health benefits of probiotic supplementation. Furthermore, promoting the use of probiotic supplements and understanding their specific functions, storage recommendations, and potential benefits for newborns, especially in cases of cesarean section births, should be integral components of these initiatives23,24. Overall, improving the general population’s knowledge of probiotics is essential for fostering a better understanding of their potential health benefits and, subsequently, for promoting proactive clinical practices associated with probiotics25,26.

The study uncovers a spectrum of attitudes among participants towards probiotics, with a notable percentage expressing skepticism about their efficacy. However, it is encouraging to note that a substantial proportion of participants recognized the need for caution when considering probiotics, indicating a level of awareness about responsible use. Furthermore, the belief that probiotics are necessary for specific health conditions, such as diarrhea and constipation, aligns with other studies highlighting the potential health benefits of probiotics in managing such conditions27. Intriguingly, a significant portion of participants also acknowledged the relevance of probiotics in maintaining overall health, which underscores the potential for wider acceptance of probiotics as part of daily health practices. However, the study also identifies certain misconceptions, including the perception that doctors recommend probiotics solely for financial gain. To address these deficiencies and enhance clinical practice, there is a need for tailored interventions that foster a more informed and balanced perspective on probiotics, emphasizing the potential benefits in both specific health conditions and overall well-being28,29. Educational initiatives should strive to dispel misconceptions and provide clear guidance on how to choose probiotics while addressing common concerns, such as storage requirements and shelf life. Such initiatives should be guided by the recognition that attitudes play a crucial role in determining probiotic utilization, and therefore, efforts should be made to bridge the knowledge-attitude gap for better clinical practice30.

The study uncovers various practices among participants when it comes to probiotics, reflecting a degree of informed decision-making, especially concerning factors like checking strain numbers, live bacteria content, and manufacturers when purchasing probiotics. Additionally, many participants demonstrated a prudent approach by avoiding the simultaneous use of probiotics and antibiotics. The preference for direct consumption of probiotics after opening the package without sub-assembling is noteworthy, as it emphasizes ease of use. When considering the sources of probiotic information, the role of healthcare personnel in popularizing probiotics, and self-media as prominent information sources underscores the importance of healthcare providers in patient education and the potential impact of online resources. Furthermore, the popularity of various probiotic forms, such as yogurt, cheese, and capsules, indicates a diverse market that can cater to individual preferences. It is important to note that yogurt and cheese are not inherently probiotics; they can serve as carriers of probiotics only if live probiotic strains are specifically added during their production. The efficacy of these products depends on factors such as the strain viability, production methods, and storage conditions, which require further public awareness and education. Storage practices, such as room temperature and refrigeration reflecting an understanding of probiotic product preservation. The focus on benefits related to gut health and digestion underscores the recognition of probiotics’ potential advantages in promoting well-being. However, to further improve clinical practice, efforts should be directed at ensuring accurate, evidence-based information dissemination through healthcare personnel and reliable online sources31,32. Additionally, educational initiatives should emphasize proper probiotic usage in various forms and storage conditions, especially in the context of room temperature. The high preference for pharmacies and hospital prescriptions as channels for purchasing probiotics suggests the importance of ensuring the accessibility of reliable probiotic products through these avenues33. Overall, these findings provide a valuable insight into current probiotic practices and indicate that initiatives should focus on enhancing informed decision-making. While there is a lack of universally accepted guidelines for probiotics, initiatives should aim to promote adherence to general recommendations provided by healthcare authorities and manufacturers for the safe and effective use of probiotics.

It is evident that knowledge and practice, as well as attitude and practice, are positively correlated, which suggests that a better understanding of probiotics is associated with more proactive practices and a more positive attitude. However, the lack of a significant correlation between knowledge and attitude raises interesting questions and highlights the complexity of the KAP framework. The path analysis in the SEM further elucidates this intricate relationship. It indicates that knowledge exerts a direct positive effect on practice, reinforcing the importance of informed decision-making in clinical practice. Simultaneously, the SEM reveals a negative direct effect of knowledge on attitude, emphasizing the need to address misconceptions and foster a more balanced perspective. Similarly, attitude directly influences practice, underlining the pivotal role of positive attitudes in promoting proactive behaviors. To improve clinical practice, targeted interventions should focus on educating the general population and healthcare professionals about probiotics, addressing common misconceptions, and fostering a more accurate and supportive perspective on their use and benefits. Moreover, it is essential to recognize the interdependence of these factors within the KAP framework, as they collectively contribute to better probiotic-related clinical practice34.

This study has several limitations. First, its cross-sectional design does not allow for the establishment of causation. Second, the use of self-administered questionnaires may introduce response bias and could affect the accuracy of self-reported data, potentially not fully reflecting actual behaviors. Third, the study was conducted in a specific geographic region (Northern China), which may limit the generalization of the findings to other regions or populations. Finally, the relatively small sample size compared to the overall population and the lack of random sampling further restrict the broader applicability of the results.

Conclusions

In conclusion, general population in the north of China had inadequate knowledge, negative attitude and proactive practice towards probiotics. There is a clear imperative to enhance clinical practice regarding probiotics in China. Healthcare professionals should prioritize educational initiatives, dispelling misconceptions and emphasizing the health benefits of probiotics. Moreover, public health policies should promote the inclusion of probiotic-rich foods in daily diets, while tailoring these efforts to the specific needs of subpopulations with higher incomes, living in urban areas, or self-rating their dietary status as healthy.