Assessment of Knowledge and Practice on Hepatitis B Infection Prevention and Associated Factors among Health Science Students in Woldia University, Northeast Ethiopia

Background Hepatitis B virus is a global problem, with 66% of all the world population living in areas where there are high levels of infection. HBV is the leading risk factor for HCC globally and accounts for at least 50% of cases of HCC. Medical and health science students, being part of the health-care system, are exposed to the infection as a risk as other health-care workers when they come in contact with patients and contaminated instruments. Objective The main aim of this study was to assess the knowledge and practice of hepatitis B virus infection prevention and its associated factors among health science students in Woldia University. Methods Institutional-based cross-sectional study was conducted from January 30 to May 30, 2019, among health science students of Woldia University who had previous clinical attachments. Two hundred students were selected by the systematic random sampling method. Association of dependent and independent variables was computed using a bivariable and multivariable logistic regression model. P<0.05 was considered as significantly associated. Result The study revealed that, out of 200 participants, 96 (48%) have poor knowledge, whereas 104 (52%) showed good knowledge about HBV. Regarding the practice of participants, 79 (39.5%) of the students have good practice to prevent HBV, whereas 121 (59.5%) had poor practice towards HBV infection prevention. Conclusion Based on the current study, greater than half of the students who participated in the study have good knowledge of hepatitis B infection prevention and most of the students have poor practice about infection prevention of hepatitis B virus.


Introduction
Hepatitis is an inflammation of the liver mainly caused by the hepatitis B virus. Hepatitis B virus is a global problem, with 66% of all the world population living in areas where there are high levels of infection. Hepatitis B virus is a very important public health problem affecting almost 10% of the world population [1]. e viral hepatitis pandemic takes a heavy charge on lives, communities, and health systems. It is responsible for an estimated 1.4 million deaths per year from acute infection and hepatitis-related liver cancer and cirrhosis-a toll comparable to that of HIV and tuberculosis.
Of those deaths, approximately 47% are attributable to hepatitis B virus. Worldwide, approximately 240 million people have chronic hepatitis B virus infection and 130-150 million have chronic hepatitis C virus infection. Without an expanded and accelerated response, the number of people living with the hepatitis B virus is projected to remain at the current, high levels for the next 40-50 years, with a cumulative 20 million deaths occurring between 2015 and 2030 [2].
HBV is contagious and easy to be transmitted from one infected individual to another by blood contact, mother to child, unprotected sexual intercourse, sharing of eating utensils, and other barbershop and beauty salon equipment [3]. Hepatitis B is mainly transmitted through prenatal infection, skin, and mucous membrane infections caused by contaminated blood or body, sexual contacts, and injection drug abusers. Also, tattooing, ear piercing, acupuncture, and dialysis are procedures that increase the risk of infection. HBV is the leading risk factor for HCC globally and accounts for at least 50% of cases of HCC. Chronic liver disease due to hepatitis B virus (HBV) accounts for the majority of HCC cases and thus highly amenable to preventive measures [4,5]. Hepatitis B infection mainly affects the liver that interrupts the liver's ability to perform vital functions and cause both acute and chronic diseases. Hepatitis virus has an insidious effect elsewhere in the body or has an extrahepatic effect. e prevalence of hepatitis B virus infection is higher in those persons exposed to blood products [6,7].
Hepatitis B infection is common due to the gap in the sterilization technique of instruments or due to the improper hospital waste management as 10% to 20% health-care waste is regarded hazardous and it may create a variety of health risks. Among the health-care personnel, HBV is transmitted by the prick of infected, contaminated needles and syringes in the skin, or through accidental inoculation of the minute quantities of blood during surgical and dental procedures. Knowledge regarding the hepatitis B virus and safety precautions is needed to minimize the health-care settings acquired infections among health personnel [8]. e overall number of health-care workers per annum exposed to sharp injuries contaminated with HBV was estimated to reach 2.1 million [9,10]. It can reduce the transmission of viral hepatitis to both users of health-care services as well as health-care workers through the rigorous application of universal precautions for all invasive medical interventions, consistent implementation of infection control practices, including safe injection measures in health-care and community settings. But it still occurs because of the absence or poor quality of screening in blood transfusion services [2].
Medical and health science students, being part of the health-care delivery system, are exposed to the infection as a risk as other health-care workers when they come in contact with patients and contaminated instruments. ey are the first level of contact between patients and medical care. ey are expected to undertake activities related to patient care at the beginning of their clinical years. Since medical and health science students are at increased risk of acquiring needle stick injury, and exposed to blood and blood products in their professional practice, conducting a study regarding the knowledge and practice level of students is very crucial for intervention to reduce the transmission of the virus.
is study assessed the knowledge and practice of students towards HBV infection prevention among health students in Woldia University. e result of this study will assist the stakeholders to be aware of the knowledge and practice level of students to prevent the burden of HBV infection.

Sample Size Determination.
e sample size for this study was determined by using the single population proportion formula by considering the following assumptions: e proportion of knowledge and practice on hepatitis B infection prevention was taken from the result of a previous similar study conducted among Wollo University Medical College students; from this study, the student who had good knowledge and good practice about hepatitis B infection prevention was 81.1% and 59.8%, respectively. By taking the prevalence which gives the highest sample value population proportion, 59.8% (p � 0.598), level of significance 5% (α � 0.05), Z α/2 � 1.96, and margin of error 5% (d � 0.05). Finally, a 10% nonresponse rate was added, and then, the total sample size required for this study appeared to be 200 [11].

Sampling Technique.
e study participants were selected from each department by proportion based on the total number of students in each department. e study participants were selected from each department among 3 rd (n = 22) and 4 th (n = 23) year Public Health and 3 rd (n = 19) and 4 th (n = 27) year Nursing students, then 2 nd (n = 18), 3 rd (n = 20), and 4 th (n = 31) year Midwifery, and 2 nd (n = 25) and 3 rd (n = 15) year Medical Laboratory students of Woldia University. A systematic random sampling method was used to select specific students from the classroom by using their checklist.
en the first student was selected by lottery method and the next student was selected in the interval according to their order in the list. In the case of absent students, the next student was taken as a respondent and the interval continue as in the previous.

Data Collection Method and Procedure.
Data were collected by using a structured questionnaire and pretest before starting the actual data collection was conducted. e questionnaire was containing written consents, socio-demographic variables, knowledge, and practice questions towards hepatitis B infection prevention which were developed by adapting from different peer-reviewed literature. en, after getting permission letter from Woldia University College of Health Science Department of Nursing, the participants were selected from each department student checklist by the systematic random sampling method.
2.6. Eligibility Criteria. Regular health science students who had previous clinical exposure were included in this study, whereas critically ill students at the time of data collection were excluded from the study.

Operational Definitions
Good knowledge: Study participants who answer more than half of the knowledge questions correctly.
Poor knowledge: Study participants who answer less or equal to half of the knowledge questions correctly. Good practice: Study participants who were able to answer more than half of practice item questions correctly.
Poor practice: Participants who were unable to answer less or equal to half of the practice item questions correctly [12].

Data Quality Control.
For ensuring data quality, training was given for data collectors and supervisors. After this, pretest of the questionnaire was conducted on 5% of students in Wollo University Health Science students a week before the actual survey, and necessary modification was done according to the gap identified. Data collection from the participant was carried out in their class room. e data collection process was strictly followed day to day by the supervisor and principal investigators and the collected data was checked its completeness and consistency every day by the supervisor and principal investigators. explaining the purpose of the study. ey were informed to withdraw from the study at any time and/or to refrain from responding to questions if they were not interested to participate by any reason. Finally, data were collected in the way in which we were not inflicted right, culture, norms, and ethical issues of participants.

Results
A total of 200 students from four different departments were participated in the study making a response rate of 100%. e majority of the participants (85%) were with in the age group of 20-24, and 115 (57.5%) of the respondents were males. e majority (182 (91%)) of the study participants were single in marital status, and more than half (56%) of the respondents came from urban areas.

Knowledge of Hepatitis B Transmission and Prevention.
Out of the 200 participants, 96 (48%) have poor knowledge, whereas 104 (52%) showed good knowledge about HBV.
irty-two percent of 65 (32.5%) of the study participants did not know about hepatitis B postexposure prophylaxis (Table 1).

Practices of Respondents on Hepatitis B Infection
Prevention. Out of 200 participants, 79 (39.5%) of students have good practice, whereas 121 (59.5%) had poor practice towards HBV infection prevention. 149 (74.5%) of the respondents were never screened for HBV, and 16 (8%) of the students were vaccinated against HBV. Among the vaccinated group, 2 (12.5%) completed all 3 doses of the vaccination schedule, and the remaining 4 (25.4%) and 10 (62.5%) students took only first and second dose, respectively ( Table 2).

Factors Associated with Knowledge and Practice of
Students. In this study, academic year and field of study of the respondents were significantly associated with knowledge of participants. Being 4 th and 3 rd year are 14 and 8 times more knowledgeable about HBV than being 2 ndyear student, respectively (P < 0.001). An infield of study, being nurse is less likely knowledgeable towards infection prevention and transmission of HBV than medical laboratory students (AOR � 0.071, P < 0.001). Being a health officer and midwifery student also less likely knowledgeable towards infection prevention of HBV than medical laboratory students (AOR � 0.130 and 0.129, respectively) ( Table 3).
In the current study, 137 (68.5%) of the respondents reported that the reason for not vaccinated against the hepatitis B virus is due to lack of resources; also 21 (10.5%) of the respondents reported lack of resource is the reason for not using personal protective equipment. Likewise 86 (43%) of respondents respond the reason for not screening for the hepatitis B virus is due to lack of resources followed by 43 (21.5%) feeling of low-risk status [ Table 4].

Discussion
In the current study, 52% of participants had good knowledge of hepatitis B virus infection prevention. is result was in line with the study conducted in Pakistan in which the knowledge level reported among medical students of seven medical colleges of Karachi was 57.1%, a study conducted in Saudi Arabia in which 50% of medical students in the University of Dammam, the study conducted among medical students of Tanta University, Egypt, which was 57.85%, and a study conducted in Haramaya University, 56.5% of students were knowledgeable regarding hepatitis B virus infection prevention [13][14][15][16]. But the current finding was lower than the study conducted among students at Cacodyl University, Ivory Coast, revealed that 69.4% of the students were knowledgeable [17], the study conducted among medical students of the University of Yaoundé I, Cameroon, reported that 83.2% [18], and the study conducted at Wollo University Medical College students revealed 81.1% have good knowledge on hepatitis B infection prevention [11]. e higher knowledge in other studies may be due to most of the study participants were in-service students from different health-care settings compared to fresh regular students in this study.
In the current study, academic year and field of study were significantly associated with knowledge of participants. Being 4 th and 3 rd year (AOR � 14.00 and 8.00, respectively, P < 0.001) are more knowledgeable than 2 nd -year students. is may be due to, as year of study increases, increasing in practical experience and theoretical knowledge by the students. Regarding field of study, being a nurse is less likely knowledgeable towards infection prevention towards HBV than medical laboratory students (AOR � 0.071, P < 0.001).
Being health officer and midwifery (AOR � 0.130 and 0.129) also less likely knowledgeable towards infection prevention of HBV than medical laboratory students, respectively. is may be due to medical laboratory students have better exposure to infection prevention during different sample collection procedures for their day to day activity. is study is in line with the study conducted at Haramaya University, which is a statistically significant association between the field of study and knowledge of HBV was observed among medical science students, but the year of study was not significantly associated with knowledge of the students [15]. A similar study conducted at Gondar University among health science students revealed the field of study was significantly associated with knowledge of HBV infection prevention [19]. is study revealed that out of 200 participants, 39% of them have a good practice on hepatitis B infection prevention.
is finding was lower compared to the study conducted on Wollo University medical college students, which showed that 50.0% of students have a good practice on hepatitis B infection prevention, and the study conducted among medical students of Tanta University, Egypt, in which the students who have good practice were 68.1% [11,16]. is may be due to the difference in resource allocation, knowledge, and perception of students in the area.  In the current study, lack of resource/resource limitation was the main reason for not screening for hepatitis B virus (43%) and not vaccinated for hepatitis B virus (68.5%). is study was comparable with similar study done at Sudan; unawareness of vaccine, expensiveness of the vaccine, fear or perceived high risk of HBV infection through occupational exposures, fear of contracting hepatitis from the vaccine, doubt of the efficacy of the vaccine, and absence postexposure prophylaxis were the reason of not being vaccinated [20].

Conclusion
Based on the current study, greater than half of the students have good knowledge of hepatitis B infection prevention; however, most of the students have poor practice about infection prevention on HBV. Study department and field of studies are factors for knowledge of the students towards infection prevention of HBV, whereas lack of resource, lowrisk status, and doubt of vaccine efficacy were the main reason not to be screened and vaccinated for hepatitis B virus.

Recommendations
Woldia University College of Health Science should give special emphasis on HBV infection prevention training for health science students before they start their clinical attachment.
It is also recommended that the university should allocate resources for complete vaccination of all health science students before they start clinical attachment despite their profession.

Data Availability
e datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical Approval
Ethical clearance was obtained from Woldia University College of health science, Research and Community Service Office. Permission letter was obtained from Woldia University College of Health Science Department of Nursing. e purpose and objective of the study were explained to the respondents.

Consent
Verbal consent was taken from each participant after clearly explaining the purpose of the study. ey were informed to withdraw from a study at any time and/or to refrain from responding to questions if they were not interested to participate by any reason. Finally, data were collected in the way in which the authors were not inflicted right, culture, norms, and ethical issues of participants.

Conflicts of Interest
e authors declare that there are no conflicts of interest regarding the publication of this paper.

Authors' Contributions
Teshome Gebremeskel, Tirfe Beshah, and Mulugeta Tesfaye participated in designing the study and were involved in the write up of methodology of the proposal, research work, and statistical analysis. Biruk beletew, Ayelign Mengesha, and Addisu Getie participated in drafting the paper and contributed to the designing of methodology and write up of the proposal and the manuscript. All authors read and approved the final paper.