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Abstract
Background This study aimed to investigate the knowledge, attitude and practice (KAP) of rosacea patients towards rosacea.
Objective The objective was to assess the KAP levels among rosacea patients to inform potential educational interventions.
Design A web-based cross-sectional study was conducted.
Participants/setting The study was conducted from November 2022 to October 2023 among rosacea patients attending the Dermatology Department of Southwest Hospital, Chongqing, using a self-administered questionnaire.
Intervention No specific intervention was applied; the focus was on understanding existing KAP.
Main outcome measures The primary outcome measures included KAP scores regarding rosacea.
Statistical analyses performed Multivariate logistic regression analysis and structural equation modelling were employed to analyse the associations between KAP scores and demographic factors.
Results A total of 514 valid questionnaires were collected, with 458 (89.11%) respondents being women. The mean KAP scores were 7.14±2.98 (possible range: 0–12) for knowledge, 52.57±7.07 (possible range: 13–65) for attitude and 62.77±13.24 (possible range: 18–90) for practice. Multivariate analysis indicated that knowledge, attitude, being male, aged 25–30 years and having health insurance were independently associated with proactive practice. Additionally, structural equation modelling revealed that knowledge directly influenced both attitude and practice, while attitude also directly impacted practice (all p<0.001).
Conclusions The study found that rosacea patients had inadequate knowledge, a positive attitude and suboptimal practices regarding their condition. It is recommended that comprehensive patient education and support programmes be developed to enhance knowledge, foster positive attitudes and improve practice behaviours among rosacea patients.
- Attitude
- Awareness
- Dermatology
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this published article (and its supplementary information files).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study effectively gathered a substantial sample size of 514 valid responses, allowing for robust statistical analysis of knowledge, attitude and practice among rosacea patients.
Multivariate logistic regression and structural equation modelling provided insightful relationships between knowledge, attitude and practice, highlighting key factors influencing proactive care among rosacea patients.
The study’s reliance on self-administered questionnaires may introduce response bias, as participants might over-report positive attitudes or practices related to rosacea management.
The cross-sectional design limits causal inferences about the relationships between knowledge, attitude and practice, making it challenging to determine long-term trends or effects.
Introduction
Rosacea, often referred to as acne rosacea, is a prevalent inflammatory skin condition that predominantly afflicts the central face.1 2 It is characterised by chronic inflammatory facial dermatosis, featuring symptoms such as transient or persistent erythema, flushing, dryness and skin burning, along with telangiectasia, vascular inflammation, inflammatory papules, pustules and red or watery eyes.3 Notably, it is more frequently observed in women than in men.4 Recent international studies have reported a rosacea prevalence of approximately 5.5%, with the condition affecting up to 3.48% of the Chinese population.5 6 Moreover, the accompanying subjective symptoms of rosacea, including sensations of burning, stinging and pruritus, can further diminish patients’ quality of life and disrupt their sleep patterns.7 8 Hence, understanding patients’ knowledge, attitudes and practices regarding rosacea is crucial for improving treatment outcomes and enhancing their quality of life.
The knowledge, attitude and practice (KAP) survey functions as a 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 moulds behaviours.9–11 Considering that patients’ self-management is crucial for the management and control of diseases, when patients actively engage and take appropriate measures to manage their conditions, it often leads to symptom alleviation, improved quality of life and reduced healthcare resource utilisation. It is noteworthy that there is currently a lack of KAP studies in this direction. Therefore, this study aimed to investigate the KAP of rosacea patients towards their condition.
Methods
Study design and participants
This cross-sectional study was conducted between November 2022 and October 2023 among rosacea patients at the Dermatology Department of Southwest Hospital, Chongqing. The inclusion criteria were as follows: (1) a diagnosis conforming to the 2021 Chinese Rosacea Diagnosis and Treatment Expert Consensus, which delineates persistent erythema and hypertrophic alterations in the central facial area as core diagnostic criteria. A rosacea diagnosis could be established with the presence of one or more of these defining features. Key characteristics of rosacea included intermittent flushing, papules and/or pustules, telangiectasia and specific ocular manifestations (such as eyelid telangiectasia, eyelid inflammation, keratitis, conjunctivitis and keratoconjunctivitis), with the presence of two or more of these primary features warranting a rosacea diagnosis; (2) individuals aged 18 or older, who possessed the capacity for independent thinking and responding to survey questions. Exclusion criteria encompassed the following: (1) patients concurrently afflicted with facial allergic or inflammatory conditions, such as allergic dermatitis, steroid-dependent dermatitis or common acne, as determined by the consensus of two or more experienced dermatologists in distinguishing these from similar facial dermatitis; (2) patients contending with severe comorbidities, including cardiovascular diseases, lupus erythematosus, endocrine system disorders, haematological disorders or confirmed tumours; (3) nursing or pregnant women; (4) individuals who declined to provide informed consent. This study has received ethical approval from the ethics committee of Southwest Hospital, Chongqing (approval no. KY2023027) and obtained informed consent from the research participants.
Questionnaire introduction
A questionnaire with four dimensions was developed based on the guidelines for rosacea management and the Chinese Rosacea Diagnosis and Treatment Guidelines (2021 edition) and the previous literature.12 13 A rigorous refinement process was executed, involving input from three dermatology experts, resulting in the elimination of redundant or overlapping questions and the clarification of items with unclear wording. Prior to the official survey, a preliminary pilot test was conducted involving 32 participants. A pilot study involving 30 valid questionnaires revealed an overall Cronbach’s α coefficient of 0.904. The Cronbach’s α coefficient for the knowledge dimension was 0.823, for the attitude dimension it was 0.833 and for the practice dimension it was 0.825.
The final questionnaire, written in Chinese, comprised four distinct sections: (1) demographic information, collecting participant details such as age, gender, residence, education, employment and income; (2) the knowledge dimension included 12 questions related to rosacea, where participants received 1 point for each correct answer and 0 for incorrect or uncertain responses; (3) the attitude dimension comprised 13 questions rated on a five-point Likert scale, gauging participants’ attitudes toward rosacea; (4) the practice dimension contained 18 questions also rated on a five-point Likert scale, evaluating participants’ rosacea management practices. Scores exceeding 70% of the maximum in each section indicate adequate knowledge, positive attitude and proactive practice.14
Questionnaire distribution and quality control
The questionnaire was administered in a paper-based format. Following the confirmation of a diagnosis in the outpatient department, based on meeting diagnostic criteria, validated by multiple doctors and supported from image analysis. Patients were encouraged to contemplate their responses independently, with any uncertainties addressed through conversational clarification rather than inducing specific answers. The patients themselves completed the questionnaire and ensured the quality and comprehensiveness of responses. All questionnaire items were made mandatory. A research team, consisting of three doctors trained as research assistants responsible for questionnaire promotion and distribution, diligently assessed all submissions for completeness, internal consistency and logical coherence. Submissions exhibiting logical errors, incomplete answers or uniform responses across all items were categorised as invalid.
Statistical analysis
The sample size was 5–10 times the number of questionnaire items.15 The number of independent variables in this questionnaire was 43. Therefore, the required sample size was at least 215. Considering an estimated rate of invalid questionnaires of 20%, at least 269 participants were required.
Data analysis was conducted using Stata V.17.0 (Stata Corporation, College Station, Texas, USA). Continuous variables were described as mean ± SD, and between-group comparisons were performed using t-tests or analysis of variance. Categorical variables were presented as n (%). Pearson correlation analysis was employed to assess the correlations between KAP scores. In multivariate analysis, a 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. Structural equation modelling (SEM) was employed to test the following hypotheses: (1) knowledge had impacts on attitude; (2) knowledge had impacts on practice; (3) attitude had impacts on practice. Two-sided p values <0.05 were regarded as statistically significant.
Patient and public involvement
Patients and/or the public were not involved in this study.
Results
Initially, a total of 518 questionnaires were collected, excluding one questionnaire with residence selected “D”, one questionnaire with outliers in education and two questionnaires with outliers in the knowledge section. The remaining valid questionnaires were 514, with a validity rate of 99.23%. Among them, 458 (89.11%) were women, 146 (28.40%) were in the age group of 31–40 years, 399 (77.63%) were residing in urban areas, 333 (64.79%) were educated with college/bachelor’s degree and above and 275 (53.50%) were employed with a mean duration of rosacea diagnosis of 27.07±32.28 months.
The mean KAP scores were 7.14±2.98 (possible range: 0–12), 52.57±7.07 (possible range: 13–65) and 62.77±13.24 (possible range: 18–90), respectively. The KAP scores varied from patients with different gender, age, residence, education, employment status, monthly per capita income and marital status (all of p<0.01). Additionally, the availability of health insurance is more likely to affect patients practice (p<0.001) (table 1).
The distribution of knowledge dimensions revealed that the three knowledge items with the highest correctness rates were as follows: ‘fluctuations in temperature, sun exposure, emotional changes or the consumption of spicy foods can swiftly trigger facial flushing in rosacea patients’ (K5) with 93.58%, ‘the primary clinical manifestations of rosacea include intermittent facial flushing, persistent erythema or papules, pustules and dilated capillaries’ (K1) with 87.16% and ‘the severity of rosacea is closely linked to post-diagnosis skincare practices, with excessive cleaning and improper skincare routines potentially exacerbating the condition’ (K7) with 79.38%. The three items with the lowest correctness rates were ‘rosacea is a chronic, recurring inflammatory skin condition and does not typically involve eye symptoms’ (K8) with 27.24%, ‘rosacea predominantly affects females aged 20–50, with children and the elderly being less susceptible to the condition’ (K4) with 28.40% and ‘rosacea is more commonly observed in individuals with darker skin tones compared with those with lighter skin tones’ (K3) with 33.27%. (online supplemental table 1).
Supplemental material
When it comes to patients’ attitudes towards rosacea, 79.57% consider the condition a major problem to varying degrees (A1). The vast majority (91.64%) reported that they would actively seek help from a doctor if the disease made them feel anxious (A2). 71.6% felt very low self-esteem or low self-esteem about their appearance caused by the disease (A3). The most strongly agreed risk factors to avoid were ultraviolet (UV) exposure (A4.1), inappropriate use of skincare products (A4.10) and extreme temperature fluctuations (A4.5), with 56.03%, 49.81% and 45.72%, respectively (online supplemental table 1).
Specific sunscreen practices showed that participants always protected themselves from the sun by using a sunshade umbrella (P1.1, 22.57%) and sun-protective mask (P1.4, 17.12%). Regarding facial cleansing habits, 30.74%, 37.35%, 36.58% and 35.80% avoided excessively hot or cold water (P2.1), the use of facecloths (P2.2), facial friction motions (P2.3) and excessive cleaning (P2.4), respectively. 52.14% always chose skincare products that were less irritating and suitable for them (P3.3). 45.72% reported that they were firm in their choice of formal medical treatment when necessary (4.1). It is worth noting that the largest proportion of people were not firm in reducing staying up late (P4.3), reducing the intake of spicy, sugary and oily food (P4.4) and exercising properly (P4.5), sometimes doing it but sometimes not, with 31.71%, 34.63% and 33.27%, respectively (online supplemental table 1).
Correlation analysis showed that significant positive correlations were found between knowledge and attitude (r=0.533, p<0.001), as well as practice (r=0.536, p<0.001). Meanwhile, there was also a correlation between attitude and practice (r=0.592, p<0.001) (online supplemental table 2).
Multivariate logistic regression analysis showed that being male (OR=0.311, 95% CI: 0.113 to 0.858, p=0.024), aged 31–40 years (OR=0.342, 95% CI: 0.144 to 0.810, p=0.015), aged 41 years and above (OR=0.295, 95% CI: 0.097 to 0.899, p=0.032), lived in rural areas (OR=2.354, 95% CI: 1.032 to 5.369, p=0.042), graduated from high school or technical school (OR=6.860, 95% CI: 1.357 to 34.688, p=0.020), educated to college/bachelor’s degree and above (OR=7.043, 95% CI: 1.641 to 5.761, p=0.017) and with monthly per capita income greater than 10 000 ¥ (OR=3.074, 95% CI: 1.641 to 5.761, p<0.001) were independently associated with good knowledge (table 2). Meanwhile, knowledge score (OR=1.384, 95% CI: 1.253 to 1.529, p<0.001), being male (OR=0.258, 95% CI: 0.122 to 0.545, p<0.001) and with monthly per capita income greater than 10 000 ¥ (OR=4.264, 95% CI: 1.925 to 9.443, p<0.001) were independently associated with positive attitude (table 3). Furthermore, knowledge score (OR=1.360, 95% CI: 1.209 to 1.529, p<0.001), attitude score (OR=1.132, 95% CI: 1.082 to 1.184, p<0.001), being male (OR=0.357, 95% CI: 0.136 to 0.943, p=0.038), aged 25–30 years (OR=0.482, 95% CI: 0.243 to 0.958, p=0.037) and having health insurance (OR=0.239, 95% CI: 0.094 to 0.608, p=0.003) were independently associated with proactive practice (table 4).
Baseline characteristics and knowledge, attitude and practice scores
Univariate and multivariate logistic regression analysis of good knowledge
Univariate and multivariate logistic regression analysis of positive attitude
Univariate and multivariate logistic regression analysis of proactive practice
The SEM demonstrates highly favourable model fit indices, suggesting a well-fitting model (online supplemental table 3) and showed that knowledge had direct effects on attitude (β=0.667, p<0.001) and practice (β=1.840, p<0.001). Moreover, attitude also has a direct impact on practice (β=1.689, p<0.001) (figure 1).
Structural equation modelling (SEM) for knowledge, attitude and practice.
Discussion
Patients had inadequate knowledge, positive attitude and suboptimal practice towards rosacea. Multivariate logistic regression analysis showed that knowledge score, attitude score, being male, aged 25–30 years and having health insurance were associated with proactive practice. SEM showed that knowledge had direct effects on attitude and practice, and attitude also had a direct impact on practice. This study may contribute in revealing the extent of patients’ understanding of their respective medical conditions, as well as their attitudes and practices regarding treatment and self-management.
This study underscores the need for targeted interventions to enhance clinical practice for rosacea patients. It is evident from the results that patients generally possess inadequate knowledge, exhibit a positive attitude and engage in suboptimal practices regarding their condition. The mean scores for KAP, with a wide range of possible values, reveal significant room for improvement across all three domains. These findings align with previous studies that have highlighted knowledge deficits among rosacea patients.16 Notably, the study identifies various demographic and socioeconomic factors that influence patients’ KAP scores. For instance, gender, age, residence, education level, employment status and monthly per capita income all play a role in shaping patient KAP. This mirrors the findings of similar research, which underscores the importance of tailoring interventions to specific patient profiles. Furthermore, the availability of health insurance emerged as a crucial factor influencing patient practice, emphasising the need for policy-level improvements to ensure affordable access to treatment and care. Multivariate logistic regression analysis reveals that male patients, those aged 31–40 and 41 years and above, residents of rural areas, individuals with higher education levels and those with higher incomes demonstrate a greater likelihood of possessing good knowledge about rosacea. Similarly, a positive attitude is more prevalent among those with higher knowledge scores, men and individuals with higher incomes. Importantly, both knowledge and attitude have a significant influence on proactive practice, suggesting that interventions aimed at enhancing knowledge and cultivating a positive attitude can lead to improved practice behaviours.9 17 In conclusion, this study’s findings provide valuable insights for tailoring interventions to address the specific needs and disparities within the rosacea patient population.18 19
The study’s assessment of rosacea patients’ knowledge highlights several areas of deficiency and misconceptions. While a substantial proportion of patients correctly identified the primary clinical manifestations of rosacea, including intermittent facial flushing and dilated capillaries. Additionally, misconceptions about the prevalence of rosacea in individuals with darker skin tones and the affected demographic, including children and the elderly, were evident. Patients also displayed limited awareness of the triggers for facial flushing and the possibility of effectively managing rosacea symptoms and recurrence. Furthermore, misconceptions were apparent regarding the involvement of eye symptoms. The study also identified a knowledge gap regarding the role of skin barrier function and the benefits of skin barrier repair in rosacea management. Moreover, there was limited awareness of the appropriateness of specific medications for mild and persistent erythema. Patients demonstrated partial knowledge about skincare products containing skin barrier repair ingredients and the potential benefits of complementary physical therapies. To address these deficiencies, clinical practice can benefit from tailored educational initiatives, effective trigger management and the range of treatment options, both pharmaceutical and physical therapies.20–22
The assessment of rosacea patients’ attitudes reveals significant variations in their perceptions and behaviours. While the majority of participants reported not considering rosacea a significant issue. Furthermore, a notable number of respondents expressed a lack of proactive help-seeking behaviour when experiencing anxiety due to their condition. These findings highlight the need for interventions aimed at fostering a better understanding of the psychosocial aspects of rosacea. A substantial proportion of participants acknowledged feeling self-conscious about their appearance due to rosacea, which is consistent with a previous study emphasising the psychosocial impact of the condition.23 Additionally, the study identified factors that patients consider important to avoid, such as exposure to UV radiation, emotional stress and inappropriate use of skincare products. These perceptions align with existing recommendations for rosacea management.12 13 To improve clinical practice, healthcare professionals should emphasise the psychosocial impact of rosacea and provide support for patients in coping with self-consciousness. Furthermore, patient education should emphasise the importance of avoiding trigger factors, aligning patient attitudes with established guidelines for rosacea management.24 25
The assessment of rosacea patients’ practice behaviours reveals a range of practices. While a considerable number of patients regularly employ sun-protective measures, such as using sunshade umbrellas, wearing sunglasses and applying sunscreen, there is room for improvement in promoting these practices more consistently, especially in patients who never use them. In terms of facial cleansing habits, patients exhibit a variety of behaviours, with opportunities for improvement in avoiding the use of excessively hot or cold water and minimising localised facial massages and friction, which are essential in rosacea management. Encouraging the avoidance of ‘three-no’ skincare products can be further emphasised to enhance patient practices.26 For daily lifestyle and treatment practices, promoting formal medical treatment when necessary, emotion management, regular daily routines, a balanced diet and appropriate physical exercise can be areas of focus for enhancing clinical practice.27 28 The selection of suitable skincare and cosmetic products and the importance of daily lifestyle choices and treatment adherence.29 30
The results of this study indicate a significant positive correlation between KAP among rosacea patients, affirming the interconnectedness of these aspects in managing the condition. The SEM further underscores the interdependence of these factors, demonstrating that knowledge has a direct and substantial impact on attitude and practice, while attitude itself directly influences practice behaviours. These findings suggest that interventions aiming to enhance patient knowledge can lead to more positive attitudes and, subsequently, improved practice behaviours. To improve clinical practice for rosacea patients, healthcare providers should focus on comprehensive educational programmes that address these three inter-related components, thereby promoting a holistic approach to rosacea management.31
While our findings highlight the need for comprehensive patient education and support programmes, we acknowledge the practical challenges in implementing these recommendations. The proposed interventions would require additional healthcare resources, including dedicated healthcare professionals for patient education, time allocation for psychological support and infrastructure for educational programme delivery. The financial implications would include costs for developing educational materials, training healthcare providers and potentially hiring additional staff. Given current healthcare resource constraints, a phased implementation approach could be considered. For instance, starting with cost-effective digital education platforms and gradually expanding to more resource-intensive interventions based on available funding and staffing. Healthcare facilities could also explore partnerships with patient advocacy groups and use existing resources to minimise additional financial burden. Future research should include cost-effectiveness analyses of these interventions to help healthcare providers and policymakers make informed decisions about resource allocation.
Strengths and limitations of the study
The study successfully gathered a substantial sample size of 514 valid responses, enabling robust statistical analysis of KAP among rosacea patients. The use of multivariate logistic regression and SEM provided valuable insights into the relationships between KAP, highlighting key factors influencing proactive care among rosacea patients. However, the study’s reliance on self-administered questionnaires may introduce response bias, as participants might over-report positive attitudes or practices related to rosacea management. The cross-sectional design limits the ability to make causal inferences about the relationships between KAP, making it challenging to determine long-term trends or effects. Additionally, the study was conducted in a single dermatology department in Chongqing, which may limit the generalisability of the findings to a broader population or different geographic regions. Despite these limitations, our findings provide valuable insights into the KAP of rosacea patients and highlight areas for targeted interventions.
Conclusion
In conclusion, patients had inadequate knowledge, positive attitude and suboptimal practice towards rosacea. Comprehensive patient education and support programmes should be considered to improve the management of rosacea, with a focus on increasing knowledge, fostering positive attitudes and enhancing practice behaviours among rosacea patients.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this published article (and its supplementary information files).
Ethics statements
Patient consent for publication
Ethics approval
All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. This study has been approved by the ethics committee of Southwest Hospital, Chongqing (Approval No. KY2023027) and obtained informed consent from the research participants. The study was carried out in accordance with the applicable guidelines and regulations. Participants gave informed consent to participate in the study before taking part.
Footnotes
Contributors YL and LG carried out the studies, participated in collecting data and drafted the manuscript. TH performed the statistical analysis and participated in its design. TH and LG participated in the acquisition, analysis or interpretation of data and drafted the manuscript. All authors read and approved the final manuscript. LG is the guarantor.
Funding Chongqing Science and Health Joint Medical Research project number 2023MSXM078
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.