Determinants of sepsis knowledge: a representative survey of the elderly population in Germany

Sepsis is the primary cause of death from infection and a medical emergency requiring early recognition and treatment [1]. Sepsis is responsible the death of over 6 million people per year worldwide [2]. In 2013, approximately 280,000 hospital patients were diagnosed and treated for sepsis in Germany. Approximately 70,000 of these patients died [3]. Delays in treatment are associated with increased risk of mortality [4]. Knowledge about early sepsis symptoms and the urge to seek emergency medical treatment are crucial to initiate early treatment, especially in major risk groups like the elderly or persons with comorbidities. To date, studies reveal substantial gaps in sepsis knowledge and perceptions in various countries [5‐7]. In 2009, an international survey including 6021 participants from Europe and the USA revealed that 88% of the participants had never heard the term sepsis before [5]. Compared to stroke and myocardial infarction, perception of sepsis severity was also low in a Korean survey [7]. Even high-risk groups are not aware that vaccination protects against sepsis [8]. National and international initiatives such as World Sepsis Day aim to increase awareness and knowledge about sepsis. Overall, a recent WHO resolution on sepsis [2, 9] demands “increased public awareness of the risk of progression to sepsis from infectious diseases through health education”.

In order to design optimal health education provisions, it is crucial to assess perceptions of elderly Germans as the major risk group for sepsis and identify the relevant knowledge gaps [10] and the determinants of knowledge. For this purpose, we conducted a representative telephone survey. Based on a literature review, we identified potentially important determinants of knowledge in two categories: sociodemographic variables [11] and health information sources [12, 13]. This study is part of a prospective, multimethod intervention study aiming to increase influenza and pneumococcal vaccination rates and knowledge about sepsis in individuals aged ≥ 60 years in a model region in Germany, the federal state of Thuringia [14]. In order to evaluate the intervention’s effect on sepsis knowledge, this study serves as a baseline prior to the intervention. Therefore, it is important to assess similarities and differences of the Thuringian elderly compared to the nationwide sample.

A total of 701 participants in the German sample and 700 participants in the Thuringian sample were interviewed. For the recruitment process, see Fig. 1. For demographics of the interviewees, see Table 1.

The survey presents the first comprehensive assessment of sepsis knowledge and its determinants in the German population aged 60 years and older, which comprises a major risk group for acquiring sepsis. In the federal state of Thuringia, recognition of the term “sepsis” was higher than in the nationwide sample and higher than in prior studies [5]. Nevertheless, profound comprehension as well as knowledge about the definition, symptoms and treatment of sepsis were low in both samples. The most prominent misbelief was that sepsis is characterized by a red line leading from a wound to the heart. Given that only a minority of participants knows that respiratory infections and influenza can lead to sepsis, it is not surprising that the interviewees were unaware that vaccinations may prevent sepsis. Beyond that, many important symptoms of sepsis were unknown, especially abrupt cognitive impairment and hypotension as early signals of sepsis. Even though the results revealed that this survey’s participants were aware that sepsis is an emergency, the majority of participants did not know the origins and signs of sepsis. They further underestimate the relative risk of dying from sepsis in comparison to other severe medical conditions. Thus, insufficient knowledge of sepsis symptoms and underestimation of disease severity may hamper timely presentation of patients in a healthcare facility, which can lead to a delay in medical treatment and increased mortality. Every delay in treatment is associated with an increase of mortality risk by 2% for the delay in antimicrobiological treatment and 1% for the delay in source control [4], therefore every hour in sepsis treatment is crucial. Younger age and higher education were determinants of increased sepsis knowledge. This suggests that providers and campaign designers should adapt the materials to older age groups and also present information for a less educated audience. Identifying important health information sources allows distributing education materials effectively, which is key to achieving the WHO resolution’s demand of increasing public awareness of sepsis [2].

The strength of this study is its representativeness regarding age, gender, education and living environment (urban/rural). The results contribute valuable knowledge regarding the design and content of education campaigns on sepsis [14]. Given the fact that more than 80% of sepsis cases are community acquired [21], education of the general public about seeking urgent medical treatment is critical in preventing avoidable deaths from sepsis. For other medical emergencies such as stroke or acute myocardial infarction, education campaigns have effectively increased awareness and reduced delay of initial treatment [22, 23]. National and international support by politicians, researchers and clinicians is crucial [9]. To achieve this goal, it is necessary to expand education of sepsis for healthcare professionals, who also have large gaps in knowledge about sepsis diagnosis and management [24, 25].

Sepsis awareness has considerably increased compared to results from the German Sepsis Foundation, which conducted surveys in 2013 and 2017 with 1014 participants, representative of the total population of Germany [26]. From 2013 to 2017, the survey found that within the population over 60 years of age the knowledge of the term sepsis increased by 9.7% to 64.7%. Apart from this lower estimation of sepsis awareness, other results are comparable. In this study, only a minority (20–30%) was aware of influenza and pneumonia as causes of sepsis and knew that vaccination can prevent sepsis. Similarly, several international studies record lower sepsis awareness [5‐7]: 21% of interviewees in Sweden [6], 55% in the USA [27] and 66% in UK had heard of the term sepsis before (75% in the age group > 75 years) [UK Sepsis Trust 2017: YouGov/Sepsis UK Survey Results, unpublished]. The US and the UK studies found that sepsis awareness was higher in older individuals, a fact that may contribute to the significantly higher sepsis awareness in our study. Beyond that, potential increases in knowledge about sepsis are probably due to high efforts in educating about sepsis. Especially in Thuringia, a higher awareness can be expected through the local presence of and efforts made by the Head Office of the Global Sepsis Alliance and the offices of the German Sepsis Foundation and German Sepsis Aid. Other reasons may lie in the following limitations of our study.

In order to reach the final sample of 700 participants, about 30,000 numbers had to be dialed for each survey. Fifty percent of the calls were unanswered or mismatched quotes (younger than 60 years of age) and 46.5% refused to take part, so the overall response rate for both studies is 2.2%. This may indicate an underrepresentation of people with lower education and/or aversion to talk about health-related topics. The weighting corrects for this bias, but especially in the regressions we cannot correct for these biases.

A very high number of participants were aware that when sepsis is suspected, immediate contact with a healthcare facility is required. Due to randomization of the questionnaire items and the possibility that the participant had answered several questions about the severity of sepsis before this question, this number may be artificially high due to anchoring effects [28]. Further, possible influences of other confounding factors to sepsis knowledge (e.g., career in the health sector or individual experiences with sepsis) cannot be excluded and remain the subject of future research.

In conclusion, our survey has shown that in the elderly – one of the major risk groups for sepsis – knowledge about sepsis, its origin and its prevention is limited. This is also true for the fact that sepsis follows a unique and time-critical clinical course, which in the early stages is highly amenable to treatment through early diagnosis and timely and appropriate clinical management. For these reasons, educational and awareness campaigns for the public are urgently needed. The results of this survey may help to design such campaigns in terms of content – the role of vaccination in prevention and early warning symptoms. The results also help clinicians to form expectations about their patients’ level of knowledge. Such campaigns are important elements to reduce the huge human and health economic burden of sepsis.