Article Text

Original research
Knowledge, attitudes and practices towards the diagnosis and management of paediatric sepsis among paediatric physicians and nurses: a cross-sectional study of 21 hospitals in Hubei Province, China
  1. Jing Yue1,
  2. Hui Zhao1,
  3. Jie Li1,
  4. Jiannan Wu1,
  5. Ronghao Zheng2
  1. 1Department of Emergence, Hubei Province Women and Children Hospital, Wuhan, Hubei, China
  2. 2Department of Pediatric Nephrology, Rheumatology, and Immunology, Maternal and Child Health Hospital of Hubei Province, Wuhan, Hubei, China
  1. Correspondence to Ms Hui Zhao; zhaohui20230504{at}sina.com

Abstract

Objectives To evaluate the knowledge, attitudes and practices towards diagnosing and managing paediatric sepsis among paediatric physicians and nurses.

Design A cross-sectional, questionnaire-based study.

Setting 21 hospitals in Hubei Province between February 2023 and March 2023.

Participants Paediatric physicians and nurses.

Interventions None.

Primary and secondary outcome measures The questionnaire contained 35 items across four dimensions (demographic information, knowledge, attitude and practice).

Results The study included 295 participants (173 women). The average knowledge, attitude and practice scores were 10.93±2.61 points (possible range, 0–20 points), 32.22±2.65 points (possible range, 7–35 points) and 36.54±5.24 points (possible range, 9–45 points), respectively. Knowledge had a direct influence on both attitude (β=0.240, 95% CI 0.136 to 0.365, p=0.009) and practice (β=0.278, 95% CI 0.084 to 0.513, p=0.010), which also indirectly influenced practice through attitude (β=0.162, 95% CI 0.078 to 0.290, p=0.007). Attitude directly influenced practice (β=0.677, 95% CI 0.384 to 0.902, p=0.025). A higher attitude score was associated with good practice (OR=1.392; 95% CI 1.231 to 1.576; p<0.001), while not working in a tertiary hospital reduced the odds of good practice (OR=0.443; 95% CI 0.2390.821; p=0.010).

Conclusions The knowledge regarding paediatric sepsis, especially knowledge about sepsis management, is poor among paediatric physicians and nurses in Hubei Province. The findings of this study may facilitate the development and implementation of training programmes to improve the diagnosis and management of paediatric sepsis.

  • Surveys and Questionnaires
  • Paediatric intensive & critical care
  • PAEDIATRICS

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The study was conducted across multiple hospitals in Hubei Province, potentially enhancing the generalisability of the findings to a broader population of healthcare professionals.

  • Using statistical analyses, such as regression models, allowed for exploring associations and causal pathways between knowledge, attitudes and practices.

  • The cross-sectional design only captures data at a single point in time, limiting the ability to establish causal relationships or observe changes over time.

  • Despite its comprehensiveness, the questionnaire might not capture all nuances of participants’ knowledge, attitudes and practices, potentially omitting important aspects.

Introduction

Sepsis is a leading cause of morbidity and mortality in children, with recent estimates suggesting that 3.0 million neonates and 1.2 million children worldwide develop sepsis each year.1 The global incidence of sepsis in children <5 years and children and adolescents 5–19 years were 4.9 million and 23.7 million in 2017.2 Sepsis is also an important cause of healthcare utilisation, with 2.9%–8.2% of children in intensive care units (ICUs) having this life-threatening condition.3 4 Sepsis in children is associated with a high mortality rate, which ranges from 1% to 5% in children with sepsis, 9% to 20% in children with severe sepsis and 11% to 19% for neonatal sepsis. Therefore, paediatric sepsis must be diagnosed and treated promptly.

The diagnosis of paediatric sepsis is complex due to the varied and often non-specific presentation of this syndrome in neonates and children and is based on the history, clinical examination and investigations, including blood tests and urinalysis.5–7 The management of sepsis involves initial resuscitation, ventilatory and circulatory support, maintenance of oxygen delivery, antimicrobial therapy and management of end-organ dysfunction.8 Although there are published guidelines for the diagnosis and management of paediatric sepsis, several studies have revealed suboptimal adherence to these guidelines.9–11 However, it is important to note that relevant data for China are lacking. Identifying deficiencies in knowledge and practice among paediatric clinicians and nurses in China would facilitate the development and implementation of training programmes to enhance the quality of care given to children and neonates with sepsis.

Knowledge, attitude and practice (KAP) surveys provide useful information about people’s baseline knowledge, attitudes, beliefs, misconceptions and behaviours towards a health-related topic.12 The insights yielded by KAP surveys can also help inform the development and implementation of education/training programmes to overcome issues and barriers that impair disease prevention. However, KAP studies relating to paediatric sepsis are rare. Therefore, this study aimed to evaluate the KAP toward diagnosing and managing paediatric sepsis among paediatric physicians and nurses in Hubei Province, China.

Methods

Study design and participants

This study is reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) reporting guideline.13 This cross-sectional, questionnaire-based survey enrolled paediatric medical and nursing staff at 21 hospitals (online supplemental table S1) in Hubei Province between February 2023 and March 2023. The inclusion criteria were (1) paediatric physician or nurse; (2) aged ≥21 and (3) at least 1 year of professional experience working in paediatrics. Physicians or nurses who refused to participate in the study were excluded. The study was approved by the Medical Ethics Committee of the Maternal and Child Health Hospital of Hubei Province (ethics approval number [2023] IEC [007]), and informed consent was obtained from all study participants. The questionnaire was responded to anonymously, and there were no means to connect a questionnaire with its respondents’ identities.

Questionnaire design and distribution

The questionnaire was designed with reference to the relevant guidelines and literature.5 8 14 15 The draft version of the questionnaire was modified according to the comments of a panel of expert reviewers, which consisted of two emergency physicians, one ICU physician one nursing educator and two senior emergency nurses. A pretest was administered to 100 paediatric physicians and nurses, and the Cronbach’s alpha value was 0.783, indicating good reliability (ie, good internal consistency).

The final version of the questionnaire (online supplemental materials) was in Chinese and included four dimensions (demographic information, knowledge, attitude, and practice; one screen for each dimension) containing 35 questions. The demographic information dimension consisted of seven items that obtained the following data: gender, age, education level, type of hospital at which employed, occupation, level of seniority and years of work experience. The knowledge dimension contained 10 items, each of which was scored 2 points for a correct response and 0 points for an incorrect or unclear answer, except for K2, K3 and K7. For K2 and K3, familiarity, fairly familiarity and unfamiliarity were scored as 2, 1 and 0, respectively. K7 scores 1 point for each correct answer. The total score of the knowledge dimension ranged from 0 to 20 points. The attitude dimension consisted of seven items, which were scored using a 5-point Likert scale (‘strongly agree’=5 points, ‘agree=4 points, ‘neutral=3 points, ‘disagree’=2 points and ‘strongly disagree=1 point). The total score of the attitude dimension ranged from 7 to 35 points. The practice dimension consisted of 10 questions. Nine of the questions in the practice dimension had multiple responses and were scored using a 5-point Likert scale. The total score for the practice dimension was based on these nine items and ranged from 9 to 45 points. The P1 in the practice dimension was not scored and was evaluated using a descriptive analysis.

An online version of the questionnaire, which included a description of the aims and relevance of the survey, was designed using the Wenjuanxing web platform. Recruitment was conducted through WeChat academic groups (ie, closed survey) and interactions with individuals via WeChat, and unique third-party methods were used to confirm account uniqueness and authenticity, thus ensuring that each response was from a legitimate respondent. The participants were exclusively recruited through WeChat, a widely used electronic social networking software commonly used for work or academic communication in China. This study enlisted participants from the official WeChat groups of two professional associations, consisting of paediatric physicians and nurses affiliated with 21 hospitals in Hubei Province. The official WeChat group of the Pediatric Branch of the Maternal and Child Health Alliance of Hubei Province consisted of 498 members, while the official WeChat group of the Wuhan Medical Association had 149 members. Respondents with IP addresses not corresponding to the target cities were prohibited from taking the survey. Additionally, demographic information provided during registration was cross-checked with the survey responses, and any discrepancies resulted in exclusion from the study. Links to the questionnaire were distributed via WeChat. The survey platform limited respondent participation to once per IP address and device (including computers and phones), and multiple accounts were removed. All items were mandatory for questionnaire submission. There were no incentives for participation. The questionnaire items were not randomised. A review of the answers before submission was not allowed to increase the spontaneity of the responses. Cookies were not used.

In China, the physicians in public hospitals have at least an undergraduate degree, and the nurses need at least a college degree. An educational background is necessary to become a member of an official association. Therefore, in the present study, there were three options for education: ‘college or undergraduate’, ‘master’ and ‘PhD’. The result showed 24, 187 and 84 participants for the three options. Therefore, ‘college or undergraduate’ and ‘master’ were pooled into ‘master’s degree and below’ for analysis.

Statistical methods

Quantitative variables are described as the mean±SD and were compared between groups using analysis of variance. Categorical variables are described as frequency (percentage) and compared by Fisher’s exact test. Correlations between the KAP scores were evaluated using Pathway analysis. Univariate and multivariate logistic regression analyses were used to identify factors associated with good practice, defined as a practice score exceeding 38 points (85% of the highest possible score). Variables with p<0.05 in the univariate analysis were entered into the multivariate analysis, and ORs and 95% CIs were calculated. A two-sided p value less than 0.05 was considered to be statistically significant. SPSS V.26.0 (IBM, Armonk, New York) was used for the analysis.

Patient and public involvement

No patient is involved.

Results

Demographic characteristics of the study participants

Sixteen of the 311 submitted questionnaires were excluded (incorrect responses about education level, n=8; refusal to participate in the study, n=5; and <1 year of work experience in paediatrics, n=3). Therefore, 295 valid questionnaires were included in the final analysis. Based on the number of members in the two WeChat groups, the rudimentary response rate was 45.60% (295/647).

The baseline characteristics of the 295 study participants (173 females, 58.64%) are summarised in table 1. Just over half the respondents (53.56%) were aged <40 years old. Most of the participants were educated to a master’s degree level or below (71.53%), employed as a physician (87.80%), and working in a public tertiary hospital (64.75%). Approximately one-quarter of the respondents (25.08%) had a vice-senior or higher title, and nearly two-thirds of the participants (65.76%) had more than 10 years of work experience.

Table 1

Questionnaire dimension scores stratified according to baseline characteristics

Knowledge scores

The average knowledge score was 10.93±2.61 points (possible range, 0–20 points), indicating that the physicians and nurses had only a moderate level of knowledge about paediatric sepsis. The distribution of the responses to each of the nine questions in the knowledge dimension is shown in online supplemental table S2 and figure 1A. Almost all the respondents recognised that systematic screening of children with acute onset of disease is required in clinical practice (96.27%) and that blood samples for culture should be collected before administering antibiotics in children with suspected sepsis (97.63%). Additionally, the majority of participants were aware of the indications for adrenocorticosteroid use (78.31%), the importance of dynamic monitoring of blood lactate indicators in children with sepsis (84.41%) and the correct timing for the initiation of empiric antimicrobial therapy in children with septic shock (81.02%). However, only a minority of respondents were knowledgeable about the correct timing for the initiation of empiric antimicrobial therapy in children with sepsis-related organ dysfunction but without shock (13.56%), the recommended solutions for fluid resuscitation and subsequent volume replacement therapy (39.32%), the maximum recommended volume of fluids to be given within the first hour in a child with sepsis and hypotension (24.07%), and the role of vasoactive drugs in the management of paediatric sepsis (11.19%).

Figure 1

Distribution of responses to some of the statements in the practice dimension. (A) K2: In addition to blood lactate, C reactive protein and procalcitonin, biomarkers that aid in the early identification of sepsis in children also include soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and soluble leucocyte differentiation antigen 14 subtype (sCD14-ST). K3: The clinical tools commonly used in sepsis screening are the Systemic Inflammatory Response Syndrome (SIRS) criteria, Sequential Organ Failure Assessment (SOFA) criteria, Quick Sequential Organ Failure Assessment (qSOFA) and Modified Pediatric Early Warning Score (PEWS) for children. (B) What is the main method you use to acquire knowledge related to sepsis in children?

Subgroup analyses (table 1) revealed significantly higher knowledge scores for healthcare workers who had a PhD degree (p=0.007 vs master’s degree or below) or who worked in a public tertiary hospital (p=0.040 vs other). However, the knowledge score was comparable between subgroups stratified according to the other baseline characteristics (table 1).

Attitude scores

The average attitude score was 32.22±2.65 points (possible range, 7–35 points), implying that the surveyed physicians and nurses had good attitudes towards diagnosing and managing paediatric sepsis. Most respondents (96.61%–99.32%) strongly agreed or agreed with 5 of the 7 items in the attitude dimension (online supplemental table S3). Additionally, 83.39% of participants indicated they were confident that they could recognise sepsis or the early stage of systemic inflammatory response syndrome (SIRS), while 77.62% of the healthcare workers stated that they were confident about correctly managing paediatric sepsis. In subgroup analyses, the attitude score did not differ significantly between subgroups (table 1). Based on the confidence response, four knowledge questions with the lowest correct rate were analysed. There were no significant differences in the correct rates of the knowledge questions among subjects with varying self-reported confidence levels (online supplemental table S4).

Practice scores

The practice score for the respondents averaged 36.54±5.24 points (possible range, 9–45 points). The responses to the items in the practice dimension are shown in online supplemental table S5 and figure 1B. Most respondents (65.76%–76.61%) stated that blood lactate testing, blood sampling for culture and antimicrobial therapy were carried out within 1 hour of the diagnosis of sepsis. Most of the participants reported always/often performing urinalysis for patients with sepsis/suspected sepsis (70.51%), always/often using ceftriaxone or other broad-spectrum antibiotics to treat patients with sepsis (73.22%), always/often using plasma procalcitonin to aid in the diagnosis of sepsis (85.76%) and always/often performing fluid resuscitation with crystalloids (87.12%). However, only 51.53% of the healthcare workers stated that they always/often monitored blood pressure when performing fluid resuscitation in patients with sepsis, and only 37.97% of the respondents used echocardiography to assist in treating sepsis. Approximately two-thirds of the surveyed physicians and nurses (66.44%) were familiar or fairly familiar with the commonly used tools for sepsis screening, whereas only around one-third of the respondents (33.56%) were familiar or fairly familiar with the use of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and soluble leucocyte differentiation antigen 14 subtype (sCD14-ST) as biomarkers for sepsis in children. The main approaches to learning about sepsis were reading published guidelines and literature (37.63%), department-based learning (24.07%), attendance of lectures (18.64%) and relevant training (16.95%).

Subgroup analyses demonstrated that a significantly higher practice score was observed for participants who had a PhD degree (p<0.001 vs master’s degree or below), worked in a public tertiary hospital (p<0.001 vs other), were physicians (p<0.001 vs. nurses) and had ≤5 years of work experience (p=0.022).

Pathway analysis of KAP

Knowledge had a direct influence on both attitude (β=0.240, 95% CI 0.136 to 0.365, p=0.009) and practice (β=0.278, 95% CI 0.084 to 0.513, p=0.010), which also indirectly influenced practice through attitude (β=0.162, 95% CI 0.078 to 0.290, p=0.007) (figure 2). Attitude directly influenced practice (β=0.677, 95% CI 0.384 to 0.902, p=0.025).

Figure 2

Pathway analysis of knowledge attitude and practice.

Logistic regression analysis of factors associated with good practice

The univariate analysis indicated that a higher knowledge score (p=0.001), higher attitude score (p<0.001), higher level of education (p=0.018) and working in a public tertiary hospital (p=0.002) were associated with good practice (ie, practice score >38 points). The multivariate analysis revealed that a higher attitude score (OR=1.392; 95% CI 1.231 to 1.576; p<0.001) was independently associated with good practice, whereas the odds of good practice were lower for physicians and nurses who did not work in a tertiary hospital (OR=0.443; 95% CI 0.239 to 0.821; p=0.010) (table 2).

Table 2

Univariate and multivariate logistic regression analysis of factors associated with good practice (practice score>38 points)

Discussion

The present study found that paediatric physicians and nurses in Hubei Province had moderate knowledge, good attitudes and reasonably good practices regarding diagnosing and managing sepsis in children. Notably, specific deficits in knowledge and practices were identified. The KAP scores were positively correlated. In addition, good practices were associated with a higher attitude score and working in a tertiary hospital. This research provides new insights that could guide the design and implementation of targeted education and training interventions to increase awareness about sepsis among paediatric medical and nursing staff.

The physicians and nurses in the present study had only a moderate level of knowledge about sepsis. Specific deficiencies in knowledge included the correct timing for the initiation of empiric antimicrobial therapy in children with sepsis-related organ dysfunction but without shock, the recommended solutions for fluid resuscitation/volume replacement therapy, the maximum volume of fluids that should be administered within the first hour in a child with sepsis and hypotension and the role of vasoactive drugs in the management of paediatric sepsis. There were important differences in the success rates of the knowledge questions. The differences could be due to differences in the difficulty of the questions, specific actions performed by physicians or nurses and weak points in the training curriculum of the physicians and nurses in Hubei Province. These findings highlight specific areas that should be targeted by training interventions to improve knowledge. Jeffery et al also identified knowledge gaps among paediatric nurses, specifically in SIRS/sepsis recognition: the correct response rate was only 60.8%±7.4%, with the nurses easily recognising septic shock but experiencing difficulty recognising earlier stages of sepsis.16 However, further direct comparisons of our data with those of other studies are limited by the lack of KAP studies among paediatric healthcare workers. Nevertheless, our findings broadly agree with previous studies in the non-paediatric setting. For example, Rahman et al found that emergency department personnel in Malaysia had a moderate level of knowledge about the identification and management of sepsis/SIRS,17 while Salameh et al concluded that emergency department nurses and physicians in Palestine had a poor-to-moderate level of knowledge about the definition, early detection, diagnosis, monitoring and management of sepsis.18 Roye-Green et al reported that 69.3% of surveyed healthcare workers in Jamaica could define sepsis, and the signs of sepsis (as defined by Quick Sequential Organ Failure Assessment) were correctly identified by 60.6%–76.4% of the respondents.19 Furthermore, a study in the USA found that less than 20% of resident physicians correctly identified the diagnostic criteria for sepsis despite considering themselves to have excellent or good training in diagnosing and managing sepsis.20 Low awareness of sepsis and its management among healthcare workers in Gabon has also been reported.21

Overall, the physicians and nurses in the present study had good attitudes towards diagnosing and managing paediatric sepsis, with 83.39% of participants stating they were confident of recognising sepsis or early-stage SIRS and 77.62% of respondents being confident about correctly managing paediatric sepsis. Some previous studies have also described very positive attitudes towards sepsis management in the non-paediatric setting,18 19 although other research has suggested more neutral attitudes.17 Thus, it appears that attitudes to sepsis management are good even when gaps in knowledge are evident. Besides, there were no significant differences in the correct rates of the sepsis management knowledge questions among subjects with varying self-reported confidence levels. These results suggest that while many participants express confidence in their sepsis management skills, there is no clear correlation with their actual performance on the knowledge questions.

Despite good attitudes, the nurses and physicians in this study exhibited some deficiencies in their practices, especially with regards to blood pressure monitoring during fluid resuscitation, the use of echocardiography to assist in the treatment of sepsis and the relevance of sTREM-1 and sCD14-ST as biomarkers for sepsis in children. Nevertheless, the overall practice score was quite high. Studies in non-paediatric settings have reported moderate-to-good levels of practice,18 although suboptimal practices have been identified regarding the measurement of lactate levels, interval for antimicrobial therapy after a presumptive sepsis diagnosis, use of crystalloids for fluid resuscitation and indications for blood culture.19 Additionally, there is evidence of insufficient compliance with sepsis guidelines in hospitals in Poland22 and China.23

The observed variance between moderate knowledge of sepsis and positive attitudes, alongside proficient practices, may stem from various factors. It is plausible that some participants executed certain actions based on experience or routine, rather than comprehensive understanding. Additionally, the disparity could partly arise from differences in the specific topics covered by the knowledge assessment and the practical scenarios, introducing a potential source of bias. Moreover, the influence of social desirability bias cannot be overlooked, as participants may have been inclined to respond in a manner aligned with perceived norms rather than their actual behaviours.24 25 These factors underscore the complexity underlying the relationship between KAP in clinical settings, warranting further investigation in future studies. A deeper understanding of these discrepancies is crucial for refining educational initiatives aimed at healthcare professionals, facilitating the development of more effective curricula tailored to address existing gaps.

Similarly, the lack of correlation between self-evaluation and objective knowledge could also be attributed to the influence of social desirability bias, wherein respondents may overestimate their competencies to align with societal expectations. Moreover, the Dunning-Kruger effect suggests that individuals with limited knowledge in a subject may paradoxically exhibit higher levels of confidence,26 further complicating the correlation between self-evaluation and objective knowledge. Addressing these discrepancies through tailored educational programmes is essential for mitigating overconfidence and enhancing the accuracy of self-assessment among healthcare providers. By acknowledging and addressing these cognitive biases, educational interventions can be restructured to target existing deficits more effectively, thereby improving overall clinical competence and patient outcomes.

Our analysis revealed that having a PhD degree, working in a public tertiary hospital, and working as a physician rather than a nurse were associated with higher knowledge and/or practice scores, although no factors were found to influence attitude. Furthermore, working in a public tertiary hospital was independently associated with good practice in the logistic regression analysis. Tertiary hospitals often act as medical hubs for multiple regions and provide more comprehensive medical care, education programmes and research activities than primary or secondary hospitals, so it might be expected that tertiary hospitals would have a higher level of expertise regarding paediatric sepsis. In agreement with our findings, previous reports have concluded that postgraduate training, working as a doctor rather than a nurse, and specialisation in critical care/emergency medicine are associated with greater knowledge and better practices.17–19

The KAP scores were significantly positively correlated, in agreement with published results.17 18 Furthermore, the multivariate logistic regression analysis identified higher attitude scores as an independent predictor of good practice. Taken together, these findings imply that interventions to enhance awareness and attitudes would positively impact the practices of healthcare workers in paediatric departments. The main methods used by the study participants to learn about sepsis were reading published guidelines and literature, department-based learning, attending lectures and relevant training. A survey in Germany suggested that physicians were more accustomed to self-directed learning, whereas nurses usually attended practical courses.27 Notably, the physicians and nurses in the above study reported a high need for training in basic procedures and emergency algorithms.27 There is good evidence that implementing sepsis training can enhance healthcare workers’ KAP.19 28–31 Furthermore, simulation training has been demonstrated to improve the care given to paediatric patients with severe sepsis/septic shock.32 Therefore, we suggest that providing training that focuses on diagnosing and managing paediatric sepsis would help enhance knowledge and improve practices. Nevertheless, it should be emphasised that, in addition to knowledge gaps, other barriers to optimal management of sepsis have been identified, including lack of resources such as monitoring equipment, staff shortages and emergency department overcrowding.18 33–35 Furthermore, a recent investigation identified six drivers of change in neonatal ICUs: availability of new knowledge or technology, externally derived guidelines, standardisation of practices, participation in research, occurrence of adverse events and desire to improve care.36 Therefore, the management of paediatric sepsis can also be improved by measures other than education and training, such as implementing protocols based on international guidelines and introducing new technologies.

This study has some limitations. First, the sample size was quite small, so the analysis may have had insufficient power to detect some real differences between groups. Second, although this was a multicentre study, it was restricted to hospitals in Hubei Province; hence, the generalisability of the results remains unknown. In addition, only the members of the two professional associations were approached for participation, resulting in a sample with higher levels of education, work experience and professional titles, probably introducing bias that overestimated or underestimated the KAP levels. Third, although the questionnaire was developed based on published guidelines and literature, it may have had limitations regarding its ability to evaluate perceptions of paediatric sepsis. Fourth, this study did not investigate whether training programmes would enhance the questionnaire scores. Finally, KAP studies are at risk of the social desirability bias, which entails that participants can answer what they know should be done instead of what they are doing.24 25

In conclusion, this study provides new insights into physicians’ and nurses’ KAP regarding paediatric sepsis in Hubei Province. We anticipate that the results may help guide the development and implementation of targeted education programmes to improve the diagnosis and management of paediatric sepsis in China. Such education programmes could be incorporated into the training curriculum of physicians and nurses, included in continuing education activities and/or disseminated through non-traditional media (ie, online continuing education programmes).

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

The study was approved by the Medical Ethics Committee of the Maternal and Child Health Hospital of Hubei Province (ethics approval number [2023] IEC [007]). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We are grateful to all the patients who participated in this study.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Contributors JY and JL carried out the studies, participated in collecting data and drafted the manuscript. JY and HZ performed the statistical analysis and participated in its design. JNW and RZ participated in the acquisition, analysis or interpretation of data and drafted the manuscript. All authors read and approved the final manuscript.And the guarantor of the article is HZ.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or 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.