Poor practices of medical and health sciences students for the prevention of hepatitis B viral infections in Ethiopia

Corresponding Author Belay tafa Postal Address: P.O.Box 19; Ambo, Ethiopia E-mail address: belaytf@gmail.com Abstract Hepatitis B virus (HBV) is a serious global public health problem and health professionals, especially medical and health sciences students, are at risk of acquiring infection through occupational exposure. Hence, this study was aimed at assessing medical and health sciences students’ knowledge, attitudes and practices towards HBV transmission and prevention.


Introduction
In general, there are six common known types of hepatitis viruses, namely hepatitis A, B, C, D, E and G; all cause hepatitis, the inflammation of the liver.Amongst all, hepatitis B and C viruses are the common causes of chronic liver disease and permanent liver damage.Hepatitis A, E and g are typically transmitted primarily through ingestion of contaminated food and water while hepatitis B, C, and D are primarily transmitted via the mucocutaneous route, unprotected sex, infected blood transfusion, and use of nonsterilized needles and syringes (injection drug use, tattooing, scarification and nosocomial transmission). 1 Hepatitis B virus (HBV) causes serious public health problems worldwide affecting the liver.According to the geographic areas, the global prevalence of chronic HBV infection can be classified into high, intermediate and low endemicity areas.Forty five percent of the world population lives in highly endemic areas, 43% live in areas of intermediate endemicity and 12% live in areas of low endemicity. 2 As in the 2009 WHO report, about 2 billon people are affected with HBV worldwide, more than 350 million suffer from chronic lifelong infection with chronic HBV and more than one million of individuals die because of chronic hepatitis, cirrhosis and hepatocellular carcinoma.Among the chronically infected, 65 million of them reside in Africa.thus, Africa carries 15-18% of the global burden of HBV infection.the prevalence of HBV in Africa was estimated to be 8% in West Africa, 5 -7% in Central, Eastern, and Southern Africa 3 showing that the burden of viral hepatitis was significantly high in Africa as compared to developed countries.the occupational risk for HBV acquisition varies according to the workplace in the healthcare setting and time of exposure to the agent such as blood, serum and wound exudates which have high risk; semen, vaginal fluid and saliva have moderate risk and urine, feces, sweat, tears and breast milk have low risk. 4e WHO estimated that out of the 35 million healthcare workers (HCWs) worldwide, three million experience percutaneous exposures to blood pathogens each year, of these two million are exposed to HBV, 0.9 million to hepatitis C virus (HCV) and 170,000 to human immunodeficiency virus (HIV).5 Different studies conducted among HCWs showed that they are at risk of acquiring blood borne disease including HBV, HCV and HIV compared to any other occupational group due to occupational exposure.In line with this, a study done among HCWs and non HCWs in Southern Oromia, Ethiopia, showed HBV was detected in 7.3% of HCWs and 0.9% of non HCWs.6 A study conducted among HCWs and medical students in University of gondar Hospital revealed that the overall lifetime and one year prevalence of occupational exposure to blood and body fluids (BBFs) were 70.2% and 62.9%, respectively.the exposure rate of BBFs was highest among interns, 90.6%, followed by HCWs, 63.3% and lowest among housekeeping staff, 45.2%; 7 this shows that students are also at high risk for infection and transmission of HBV to other individuals.
Different research showed that probably the disease has a long history in our country.Studies in Jimma University Hospital, 8 Amhara and tigray regional states, 9 Bahir Dar Felege Hiwot referral Hospital 1 and Dire Dawa City 10 among blood donors showed that the prevalence rate of hepatitis B surface antigen (HBsAg) among students was 12.5%, 13.5%, 3.1%, 20% and 3.4%, respectively.Despite the long history of the disease in the country, there have not been any bold and pragmatic measures put in place to curb it except the introduction of hepatitis B vaccine into national immunization schedules by March 2007, particularly for newly born infants, aged 6-14 weeks. 11udies conducted in United Arab Emirates and Côted'Ivoire showed books, media, school and HCWs as the most important information sources for the university students for prevention of infection of HBV. 12 On the other hand, in Ethiopia, media publicity on this disease is not substantial as compared to other infectious diseases.therefore, health sciences students and even HCWs do not have any source to obtain information out of school curricula about this deadly disease.In Ethiopia, medical and health sciences students practice in all clinical settings where healthcare services are delivered.Hence, medical and health sciences students, being part of the healthcare delivery system, are exposed to the same risk as HCWs while coming in contact with patients and contaminated instruments.As one study revealed, because of lack of awareness about the disease transmission, most medical students do not practice universal precautions on a routine basis. 13ot for citation purposes Poor Practices for the Prevention of HBV Infections Fiseha et al.
A press report published on March, 28, 2013 claimed that over 10 million Ethiopians are infected with HBV and the majority of the infected population is unaware of their disease status. 14In Ethiopia, the limited knowledge on hepatitis prevalence as well as the minimal awareness about the disease can increase the risk of infections and transmission from patients to medical and health sciences students or healthcare workers and vice versa during healthcare delivery to the patients.therefore, this study was aimed at assessing medical and health sciences students' knowledge, attitudes and practices towards HBV transmission and prevention in Dire Dawa University.Source and study population the source population for the study was all medical and health science students of Dire Dawa University.the study populations for this study were selected 3 rd , 4 th , 5 th and 6 th year medical students as well as 2 nd , 3 rd and 4 th year midwifery and anesthesia students of the University.Medical and health sciences students attending second year and above who had taken infectious diseases related courses and started clinical attachment were included in the study.

Study Design, Period and Setting
Students not yet started a clinical attachment, those having mental illness or serious illness as well as those who have not taken infectious diseases related courses were excluded from the study.

Sample Size Estimation
the sample size was determined using a single population proportion formula.A prevalence rate of 50% knowledgeable students, 5% margin of error and a 95% confidence interval of certainty (= 0.05) were used to calculate the sample size.Based on these assumptions, sample size was computed as follows.

Sampling Technique
Study participants were selected using a systematic sampling technique.First, we stratified students based on year of study and department.Next, the sample size was distributed proportionally to each year of study based on the student population.Finally, using Where n = sample size of population for N>10,000

Data Collection
Data were collected using structured and selfadministered closed-ended questions. the questionnaire was prepared in English language consisting of four sections.The first section contained socio-demographic characteristics of the respondent.the second section was designed to assess the knowledge about mode of transmission, sequelae and prevention of HBV. the third and fourth sections contained questions related to participants' perception toward the risk of acquiring HBV infection and practice of precautions to prevent themselves from contracting the disease.

Data Quality Control
To ascertain completeness and clarification before implementing data collection, the questionnaire was pretested on 5% of medical and health sciences students of Haramaya University and Jijiga University who were on clinical attachment at Dil Chora Hospital, and the necessary modifications were made.

Operational Definition
Assessment: the process of measuring the level of knowledge, attitudes and practices of medical and health sciences students regarding HBV infections using a structured, self-administered questionnaire.
Knowledge: 18 major questions were prepared to each participant to assess knowledge about route of transmission, sign, symptoms, sequelae, and prevention of HBV infection.Each response was scored as 'yes' or 'no'.Each correct answer was given a score of '1' while a wrong answer was given a score of '0'.Students' knowledge was classified into two levels according to the total score obtained; a total score of ≤ 8 (correctly answered <50%) was regarded as having poor knowledge, and 9 or more (correctly answered ≥ 50%) was considered as having good knowledge.
Attitude: Seven major questions were prepared to assess attitudes of participants toward HBV infection.Each response scored as 'yes' or 'no'.the scoring range of the questionnaire was 7 (largest) to 0 (smallest).those who have answered yes to more than 50% (≥ 4) of questions were considered as having good attitudes toward HBV infection and prevention, not for citation purposes Poor Practices for the Prevention of HBV Infections Fiseha et al.
whereas below 50% percent (<4 questions) was considered as having bad attitudes.
Practice: four major questions were prepared to assess practice of participants toward the prevention of HBV infection.Each response was scored as 'yes' or 'no'.Each correct answer was given a score of '1' while a wrong answer was given a score of '0'.Each question was labelled as good or poor practice.

Variables in the study
Knowledge, attitude, and practice of the study participants towards HBV transmission and prevention were considered as dependent variables; and sex, age, residence areas, marital status, religion, year of study and departments of the study population were considered as the independent variables.risk factors for HBV infection such as history of blood transfusion, history of medical and surgical procedures, exposure to blood or other body fluids, needle sticks and sharp objects exposure and source of information on HBV were also considered as independent variables.

Data Entry and Analysis
Data were checked for completeness and consistency.Coded data were entered and cleaned using Epi Data software (the EpiData Association, Odense, Denmark) and analyzed using SPSS version 20.0 (IBM, Armonk NY).Descriptive statistics such as frequencies and proportions were used to summarize the data.Bivariate and multivariate analyses were carried out using logistic regression to examine the relationship between the outcome variables and selected sociodemographic factors.Adjusted and unadjusted odds ratios (OR) and their 95% confidence intervals (CIs) were used as indicators of the strength of association.A p-value of less than 0.05 was considered statistically significant.involved in similar study conducted at Haramaya University which showed that only 181 (56.2%) of them had good knowledge. 16the present study also showed higher level of participants' knowledge than the result obtained from the study conducted in Iraq, which showed that only 14% of the participants had good knowledge. 17A report from Egypt also showed that only negligible (1%) number of the participants had good knowledge about HBV. 18Even though similar criteria were used to select the participants (those students starting clinical attachment) and the same study type was used as our study, the source population and status of previous experience might resulted in the difference in terms of knowledge.

Socio-Demographic Characteristics of the
In  and health students.On the other hand, the result of this study is in line with a study conducted in India which reported a high proportion of medical students (86.7%) having good knowledge about HBV. 13 this might be due to the fact that participants in India were selected only from medical students which parallels the knowledge of medical students in this study.
regarding routes of transmission, the result from this study showed that participants' knowledge ranges from 76.3% to 100%; 76.3% (for absence of transmission by sharing foods with infected individuals), 91.1% (awareness about non inheritability of HBV from the family) and 100% (awareness of transmission through contaminated blood and blood products).this is higher than the knowledge status obtained from the study conducted among Vietnamese university students that showed only 55.4% of the respondents knew the route of HBV transmission and 52.8% of them misunderstood that HBV can be heritable. 19this might be due to the fact that participants in Vietnamese university study had been selected from first year nursing and medical technician students who had not started clinical attachment and lack previous occupational exposure.
In contrast, in our study, majority of the participants were particularly medical students who come from different health background with long exposure in working areas and have a higher educational level, and study participants were selected only from those who had started clinical attachments and this might contribute for the greater level of knowledge.
Concerning knowledge assessment on the availability of vaccine against HBV, 169 (88.9%) of the study participants had information about its existence.this is higher than the proportion of knowledgeable participants obtained from similar studies conducted in Egypt, ghana and Côte-d'Ivoire which were 42%, 59% and 35.7%, respectively. 20,21 his might be due to the fact that medical students participated in our study have different health backgrounds and being employed and had exposure in professional jobs.
In our study, 140 participants (73.7%) had good attitudes towards HBV where the remaining 50 (26.3%)had poor attitudes.this showed that participants with poor attitude is higher in our study when compared to the result from the study conducted in Egypt which showed only 14% of the participants had poor attitudes. 18garding hepatitis B vaccine requirement, the majority (78.4%) of our respondents believe that HBV vaccine is required for healthy individual protection.this is lower than the result from similar study conducted among Vietnamese university students which showed 97.9% of students believed healthy people need vaccination against HBV. 19regarding not for citation purposes Poor Practices for the Prevention of HBV Infections Fiseha et al.
the attitudes towards standard precautions, all the 190 (100%) of the respondents believed that it is the most important means to reduce the risk of transmission of infections.this is similar with the study conducted in Addis Ababa University that showed 94.9% of the respondents strongly agreed or agreed that standard precautions are important in controlling hospital acquired infections. 22ming to important practices to reduce the spread of HBV from another individual to self and from one person to another, the overall result of this study showed poor practice.In the present study, only 26 (13.7%) were screened for hepatitis B and took three dose of vaccine against HBV whereas the majority (164, 86.3%) of the respondents were never screened for hepatitis B and had not been vaccinated against HBV.This finding is consistent with a study conducted in Haramaya University that showed 85.7% of them were never screened for hepatitis B and only 13.4% of participants were vaccinated against HBV. 16On the other hand, the vaccination coverage against HBV of respondents reported in our study was lower than the result reported in a similar study from Addis Ababa University (22.7%), 22 India (63%), 13 Pakistan (62%) 23 and Iraq (45%). 17the difference might be due to socioeconomic differences as can be seen from the major reason for not receiving vaccine is being costly.
Concerning practice towards standard precautions, despite all 190 (100%) respondents having good knowledge and good attitude, only 79 (41.6%) of the respondents used personal protective devices while caring for their patients.However, this is better than a result obtained from study conducted in Addis Ababa University that showed only 6.9% of respondents have good practicing of standard precautions. 22this might be due to previous experience obtained from occupation by our study participants.

Conclusion and Recommendations
In conclusion, the results from the present study revealed that the study participants among the medical and health sciences students in Dire Dawa University had good knowledge and attitudes towards the hazards, mode of transmission and means of prevention of HBV in general.However, it was observed that their practices were poor towards the prevention of HBV infections.
Based on the results of this study, it is recommended that healthcare professionals must utilize personal protective devices consistently to protect themselves and the nation at large from HBV infections.Furthermore, the Ethiopian government in general and Ethiopian Ministry of Health in particular should ensure availability of vaccine against HBV for medical and health sciences students to suppress the spread of the virus.
A cross-sectional study was conducted at College of Medicine and Health Sciences of Dire Dawa University from February to March 2017.Dire Dawa University is one of the public educational institutions found in 2006/07 academic year.However, the School of Medicine was begun with the birth of the New Innovative Medical Education Initiative (NIMEI) in 2011 having an objective of alleviating the scarcity of physicians in Ethiopia.Besides the medical program, anesthesia and midwifery departments were opened in the 2013/2014 academic year, and the college was named as College of Medicine and Health Sciences in 2015/16.

P
= assumed percentage of knowledgeable students d = marginal of error 5% (0.05) = the reliability coefficient of 95% i.e. 1.96 the calculated sample size was 384.Since the source population was 373 (which is less than 10,000), we used a correction formula 15 to determine the corrected sample size, n o.Where n o = the sample size for a population <10000 n = the sample size for a population had it been >10000 N = the size of the entire population The final sample size for this study was 190. not for citation purposes Poor Practices for the Prevention of HBV Infections Fiseha et al.

Table II . Socio-demographic characteristics of the study participants
Study ParticipantsA total of 190 students were included from three different departments in the study with a response rate of 100%.themajority of the students, 107 (56.3%), was within the age group of 20-24, and 145 (76.3%) of the respondents were males.Of the study participants, 171 (90%), were single in marital status, and 124 (65.3%) came from urban area (tableII).Attitudes toward HBV infection and preventionOf the 190 participants, only 11(5.8%) had bad attitudes towards HBV infection and prevention.Concerning their jobs, the majority of the participants (181, 95.3%), believed that their jobs increased the risk of HBV not for citation purposes vaccine requirement for complete protection.Out of 190 respondents, 110 (57.9%) believed that all patients should be tested for HBV before receiving health care.Concerning care giving to HBV infected patients, 109 (57.4%) of respondents did not give the same standard of care for patients with HBV as they did for others.183(96.3%) of respondents believed that education is effective in improving knowledge on hepatitis B. the data revealed that all the study participants had good attitudes towards standard precautions important to control hospital acquired infections.themeanscore related to attitude was 5.05±0.99(tableIV).

Table VI . Bivariate analysis for knowledge among medical and health sciences students of College of Medicine and Health Sciences, Dire Dawa University
(COR= 0.300; 95% CI [0.096, 0.937]) and (COR= 0.286; 95% CI [0.090, 0.911]) respectively.However, fourth and third year students have five and four times

Table VII . Bivariate analysis for attitude among medical and health sciences students of College of Medicine and Health Sciences, Dire Dawa University
Concerning practices, only the department of the respondents was significantly associated with mean practices (table VIII).respondents from Medicine and Midwifery Departments have four and three not for citation purposes

Table VIII . Bivariate analysis for practice among medical and health sciences students of College of Medicine and Health Sciences, Dire Dawa University
variables were included in multiple logistic regression models.In multiple logistic regression analysis, it was identified that only department and year of study were associated with knowledge of the respondents (tableIX).Medicine Department respondents were nearly not for citation purposes