Knowledge, Attitude and Practices towards Hepatitis B Infection and Vaccination among Public Health Students in Ghana

Background: Hepatitis-B (Hep-B) infection is a global public health problem of great concern which affects more than 5% of the local population in Sub-Saharan Africa. This study assessed students’ knowledge, attitude and practices towards Hepatitis B infection and vaccination at the University of Health and Allied Sciences, Ghana. Methods: A cross-sectional quantitative descriptive survey was conducted among 262 Public Health students of the University of Health and Allied Science of the Volta region of Ghana, using a multi-stage sampling technique in selecting participants. A structured questionnaire was used to collect data from the participants. Data was analyzed using SPSS Version 20.1. Results: Study respondents were mostly males, forming 69.8% as against 30.2% respondents who were not vaccinated against Hep B infection, majority (50.9%) of them were not willing to be vaccinated even if it was offered to them at no cost. Conclusion: There was a significantly high level of knowledge on Hep-B infection and the availability of vaccine for Hep-B infection among students. However, the majority of the respondents felt they did not need to be protected from Hep-B infection. More education is needed on the importance of vaccination as an effective measure for controlling Hepatitis infection.


Introduction
Hepatitis-B (Hep-B) infection is a global public health problem of great concern.
The spectrum of the disease is highly variable ranging from mild disease to chronic liver diseases including hepatocellular carcinoma. There are approximately 350 million chronic Hepatitis-B surface antigen carriers in the world [1].
An estimated 257 million people are living with hepatitis B virus infection, in 2015 hepatitis B resulted in 887,000 deaths, mostly from complications including cirrhosis and hepatocellular carcinoma [2]. There is currently no permanent cure for Hepatitis Virus infection. Hence, prevention of the disease through vaccination is the only effective means to control the disease. Hepatis-B is caused by a DNA-virus, the Hepatitis-B Virus (HBV) [2]. The virus is highly contagious, 50 -100 times more infectious than Human Immunodeficiency Virus (HIV), and is transmitted between people through blood, semen, vaginal fluids and mucous membranes, hence the most common ways of transmission are by unprotected sex, unsafe blood transfusions, unsafe use of needles, from mother to child at birth, close household contact and between children in early childhood [3].
Seven types of hepatitis virus have been identified; hepatitis A to G and hepatitis B remains the most serious type with high risk of death from liver cirrhosis and cancer. HBV is unique compared to other sexually transmitted diseases, because it can be prevented with vaccines [3]. Hepatitis B, C and D are transmitted by parenteral contact with infected body fluids including blood, semen, saliva, sweat and tears, invasive medical procedures using contaminated equipment, vertical transmission and from family member to child whereas hepatitis A, E, G are typically caused by ingestion of contaminated food or water, there are more than two billion people worldwide, having evidence of recent or past HBV infection and 350 million are chronic carriers [4]. According to the World Health Organization (WHO), HBV infection affects more than 5% of the local population in Sub-Saharan Africa and more than 8% in West Africa, reaching up to 15% in some areas [5]. The transmission of the virus occurs early in life and is associated with a low rate of spontaneous viral clearance and a high risk of  [6]. Immunization for HBV has been available since 1982 and has been shown to be highly effective in reducing the prevalence of hepatitis B surface antigen (HBsAg) in children worldwide, moreover, national immunization programs have led to a substantial decrease in the burden of chronic liver disease and HCC in young adults born after 1984 [7].
HBV is an important occupational hazard for unvaccinated Healthcare workers (HCWs) including students, with an estimated 2 to 4 times higher incidence than the general population [8] [9]. Knowledge regarding the infection and its related safety precautions among HCWs is therefore essential to minimize the acquired infections in healthcare settings among this vulnerable population as they remain in direct contact with potentially infected persons, blood, and medical tools and instruments during the course of service delivery [10] [11]. Inadequate knowledge of HBV among HCWs however, may affect their behavioral pattern to vaccination and safety measures. In spite of the high burden of disease due to chronic Hepatitis B and the improvements and opportunities for care and treatment worldwide, the majority of people infected with HBV are unaware of their status and hence normally present with advanced stage of the disease [9].
In low-income countries, for instance, only about 5% of HBV infected persons know their infection status. This low uptake of HBV testing is a result of inadequate testing facilities or services, lack of effective policies and standards for testing, poor laboratory capacity and infrastructure, high cost and complex diagnostic assays and algorithms, and the use of substandard test kits and reagents [9].
The HBV vaccines (HBVc) have been in existence since 1992 and are available as monovalent formulations for birth doses or for vaccination of at-risk adult populations [12]. A standard three-dose vaccine regimen, with the second and third doses given 1 month and 6 months apart, respectively, from the initial dose, has been identified as very effective in conferring immunity against HBV [13]. Among HCWs and other healthy adults, HBV vaccination is known to be highly effective for prevention of the infection; hence HBV vaccination has been recommended by the WHO as a primary preventive strategy for the control of the infection among HCWs [14]. Many studies have estimated HBV knowledge and vaccination status among HCWs and medical students in many parts of the world [15]. Little evidence is however available in Ghana. This study therefore assessed students' knowledge, attitude and practices towards Hepatitis B infection and vaccination at the University of Health and Allied Sciences, Ghana. A multi-stage sampling method was used in this study. First, a stratified sampling technique was used to select the various public health programmes. A simple random sampling was then employed in selecting participants. A proportional allocation was made according to the population of students in each programme. The study was carried out using a structured pretested questionnaire.

Respondents' Knowledge on Hep-B Infection and Vaccination
All (262)

Discussion
In this study, we described the knowledge regarding Hepatitis B Virus (HBV) infection, its mode of transmission, and prevention among the Public Health undergraduate students. We also studied the students' HBV status and vaccination history of the students. The study found a significantly high level of Know- consistent with a study by [1], which asserted that more than half of the participants were aware that HBV can be transmitted via unprotected sex and conta- tus. This finding seems to be in contradiction with the finding of [18], which indicated that 36% of the respondents did not know their HBV status.
Even though, majority of the respondents felt they were at risk of Hep-B infection by virtue of the nature of their work, a significant proportion (56.9%) of the respondents felt they did not need to be protected against Hep-B infection.  [21], and the cost of vaccination were cited by most of these studies as the main reason for low uptake. Similarly, findings from [22] reported the cost of the vaccine, and the belief that vaccination is not an important preventive measure that to be taken as reasons for failure to be vaccinated. Surprisingly, the majority who were not vaccinated indicated that they will not be vaccinated even if it was offered for free. The fear of needle prick by most students might be the reason for the unwillingness to be vaccinated even if it was offered for free. This finding however contradicts the finding of [23] which affirmed that more than half of the unvaccinated nursing students were willing to be vaccinated if it was offered to them for free.

Limitation
The descriptive survey and the structured data collection instrument used in this study did not enable the participants to express themselves candidly, and thus limited the researchers' ability to probe. If qualitative aspects were included in this study, it could have been more efficient in exploring the respondents' view, deciphering other associated factors and to strengthen the findings of the quantitative study through in-depth interviews. Secondly, vaccination status was self-reported and not verified by vaccination records. So, recall bias could have led to over-or underestimation of coverage.

Ethical Consideration
Ethical approval for the study was obtained from the University of Health and Allied Science Ethical Review Board. However, local permission and approval for the study was required and obtained from the participants. Participation was voluntary and respondents could withdraw at any stage without any penalty. Open Journal of Preventive Medicine dents felt they did not need to be protected from Hep-B infection even though they believed they were at risk of contracting the infection. Surprisingly, most of the students who were not vaccinated against Hepatitis infection were not willing to be vaccinated even if it is offered for free. Cost of the vaccine was identified as a major reason for students not being vaccinated against Hep-B infection.

Recommendation
The Ministry of Health and the Health Training institutions must intensify education on the importance of vaccination as an effective measure for controlling Hepatitis infection. Secondly, the cost of Hepatitis B vaccination should be looked at and possibly made free for all health trainees to ensure a wider coverage of the vaccination amongst students. The researchers further recommend that vaccination against Hepatitis B should be made compulsory for all students in Health training institutions.