Knowledge and Willingness to Utilize Hepatitis B Preventive Measures among Pregnant Women in Ado-Ekiti, Southwest, Nigeria

Introduction Mother-to-child transmission remains an important mode of transmission of hepatitis B infection particularly in endemic areas. The knowledge and practices of pregnant women about mother-to-child transmission (MTCT) of hepatitis B virus (HBV) may influence the uptake of strategies to reduce mother-to-child transmission of infection. Objectives This study assessed the knowledge and willingness to uptake hepatitis B virus infection preventive services among pregnant women in Ado-Ekiti, Nigeria. Methods This was a cross-sectional study that involved 373 pregnant women at the Ekiti State University Teaching Hospital (EKSUTH) and Maternal Child Specialist Clinics, Ado-Ekiti, Nigeria. A structured questionnaire was used to assess their knowledge, practices, and perceptions about MTCT of hepatitis B infection. Results Only 52.5% (196) of the respondents had good knowledge, although the majority 290 (77.7%) had heard of hepatitis B infection prior to the survey. Only 147 (39.4%) of the respondents had ever had hepatitis B screening. More persons with professional jobs had good knowledge about hepatitis B infection compared with other occupations (p < 0.001). However, more respondents aged 30–34 years had poor knowledge about hepatitis B infection compared with other age groups (p = 0.045). Respondents with good knowledge about hepatitis B infection were willing to uptake hepatitis B infection prevention services (p < 0.001) Conclusion This study showed that respondents with professional jobs had good knowledge about hepatitis B infection and those who had good knowledge about the infection were willing to utilize hepatitis B preventive measures. Awareness of MTCT of HBV did not translate into good practice as only few respondents had screened for hepatitis B. There is a need to intensify education about modes of transmission of hepatitis B infection with an emphasis on promoting good preventive practices.


Introduction
Chronic hepatitis B virus (HBV) infection is a major public health problem.As at 2019, about 296 million persons worldwide were infected and about 1.5 million people acquire the infection annually.Tese persons mostly reside in low and middle-income countries [1,2].Te prevalence of HBV infection varies throughout the world, and it is highly endemic in developing countries: South East Asia, China, sub-Saharan Africa, and the Amazon Basin where at least 8% of the population are chronic carriers of hepatitis B virus [3].Nigeria also has a signifcant burden of HBV infection; for instance, a systematic analysis done by Ajuwon et al. showed the pooled prevalence of HBV infection in Nigeria to be 9.5% [4].
Te impact of HBV infection is devastating for individuals, families, communities, and the world at large.HBV infection was responsible for 820,000 deaths worldwide in 2019 [1].Chronic HBV infection is also an important and major risk factor for liver cirrhosis and hepatocellular carcinoma [1,14].
Hepatitis B virus (HBV) is mostly transmitted through contact with infected body fuids, and the predominant mode of transmission is believed to be related to the endemicity of HBV infection in the particular area [3].Nigeria, being an area with high hepatitis B virus endemicity, a major mode of transmission, is mother to child transmission of the virus [1].Other modes of transmission are sexual and parenteral/percutaneous transmission [3].Terefore, reducing mother to child transmission of hepatitis B virus may reduce the global and local prevalence of chronic hepatitis B infections.It is also well known that mother to child transmission causes the highest chronic carrier rate of greater than 85% [1,15], and this risk is reduced by 90% with HBV vaccine and hepatitis B immunoglobulin administration within 12-24 hours of birth [15].
Hence, to achieve the World Health Organization's target of reducing HBV infection to 0.1% by 2030 [16], one of the main areas of focus should be prevention of mother to child transmission of hepatitis B virus.Available strategies to prevent or reduce mother to child transmission of HBV include hepatitis B vaccination, administration of hepatitis B immunoglobulin (HBIG) to newborn at birth, and use of antiviral prophylaxis in pregnancy.Hepatitis B vaccination is freely available for newborn and infants as it is incorporated into the routine immunization schedule of the National Programme on Immunization.HBIG and antivirals are readily available in the country for a fee.Currently, in Nigeria, the coverage for many of the HBV preventive strategies is suboptimal; for example, hepatitis B vaccination coverage among children is low; according to the 2018 National Demographic Health Survey, only 52% of children aged 12-23 months received hepatitis B vaccine at birth [17].
Having information on the knowledge and practices of pregnant women about HBV infection particularly motherto-child transmission will identify gaps which stakeholders and policy makers could address towards achieving the desired goal of reducing/eliminating HBV infection [18].Reports from previous studies conducted in Nigeria and outside on evaluation of the level of knowledge of and practices of pregnant women about HBV infection have been inconsistent [19][20][21][22][23]. Te authors are not aware of any study that assessed knowledge particularly of prevention of mother to child transmission of hepatitis B virus among pregnant women in Ekiti State, Nigeria.Terefore, this study aimed to assess knowledge and willingness to uptake HBV infection preventive services among pregnant women in Ado-Ekiti, Nigeria.

Sample Size Determination.
Te sample size was calculated using online software Raosoft sample size calculator (https://www.raosoft.com/samplesize.html)using the following assumptions; 5% margin of error, confdence level of 95%, response distribution of 50%, and estimated total population of pregnant women in Ado-Ekiti of 20,000.Te sample size obtained was 377, and a 5% (19) attrition rate was added to the sample size giving a sum of 396.A total of 400 questionnaires were administered.

Sampling Method.
A convenience sampling was used: all consecutive attendees of the antenatal clinics of the two health facilities who gave consent to participate in the study were recruited.

Inclusion Criterion.
Te inclusion criterion was every pregnant woman attending the ante-natal clinics who gives consent to be a part of the study.

Exclusion Criteria.
Exclusion criteria were pregnant women who have not registered or undergone booking clinic experience and women who were acutely ill and unable to respond to the interview.

Results
Out of 400 questionnaires that were distributed, 384 questionnaires were returned giving a response rate of 96.0%.Eleven questionnaires had incomplete information, hence removed from the analysis.Terefore, a total of 373 questionnaires were analyzed.1).About two-third (66.2%) of the respondents were willing to have the hepatitis B screening test.Majority 243 (65.1%) of the respondents were willing to provide hepatitis B immunoglobulin for their newborn if there is a need.Two hundred and sixty-six (71.3%) respondents were willing to allow their babies to take hepatitis B vaccine (Figure 2).Interdisciplinary Perspectives on Infectious Diseases 3

Respondents' Perceptions about Modes of Transmission and Prevention of Mother to Child Transmission of Hepatitis B
Virus.Slightly more than one-half (59.8% and 56.6%) of the respondents agreed that hepatitis B virus can be transmitted through unprotected sexual intercourse, and there is an increased risk of contracting hepatitis B infection from unsafe injections, respectively.Majority 270 (72.4%) of the respondents agreed that hepatitis B virus can be transmitted through transfusion of infected blood.Nearly one-half (49.3%) of the respondents neither agreed nor disagreed to the statement that hepatitis B virus can be transmitted from animals to humans.Also, majority 249 (66.7%) of the respondents agreed that hepatitis B exposed babies require hepatitis B vaccine to prevent them from being infected.One hundred and forty-fve (38.9%) of the respondents neither agreed nor disagreed to whether hepatitis B vaccine was free for all babies and 204 (54.7%) did not know whether hepatitis B immunoglobulin is free or not (Table 2).

Association between Socio-Demographic Characteristics of
Respondents and Level of Knowledge about Hepatitis B Infection.Tere was statistically signifcant association between the level of knowledge about hepatitis B infection and age of respondents; more respondents aged 30-34 years had poor knowledge when compared with the other age brackets (p � 0.045).However, more respondents who were professionals had good knowledge about hepatitis B infection compared with other occupations (p < 0.001).Tere was no signifcant association between the level of knowledge about hepatitis B infection and other sociodemographic characteristics (tribe, religion, marital status, and the highest level of education) (Table 3)

Association between Respondents' Level of Knowledge and Willingness to Uptake Hepatitis B Infection Preventive
Services.Tere was signifcant association between the level of knowledge about hepatitis B infection and willingness to uptake preventive services.More respondents who had good knowledge were willing to have HBV screening, allow their babies to have HBV vaccine, and provide hepatitis B immunoglobulin for their child (p < 0.001) (Table 4).

Discussion
Pregnant women remain major stakeholders in achieving the WHO goal of eliminating hepatitis by year 2030 as mother to child transmission of HBV is a major route of transmission particularly in hepatitis B infection endemic countries like Nigeria.Tis study assessed the knowledge of practices and perceptions about hepatitis B among pregnant women in Ado-Ekiti, Nigeria.It also assessed the willingness of pregnant women to utilize hepatitis B infection  prevention services.In all, barely one-half of the respondents had overall good knowledge about hepatitis B infection although majority of them were aware of hepatitis B virus and modes of preventing transmission from mother to child and were willing to uptake prevention services.However, as high as 40% of respondents did not know some important ways by which hepatitis B infection could be contracted and only few of them had ever screened for hepatitis B.
Tat barely one-half (52.5%) of our respondents had overall good knowledge about mother to child transmission (vertical transmission) of hepatitis B infection, and its modes of prevention are disturbing because pregnant women are major stakeholders in combating the burden of this infection considering the fact that vertical transmission is an important route of transmission of this infection which also causes the most chronic carrier [1].Chronic carriage of hepatitis B virus (chronic hepatitis) is associated with an increased risk of developing liver cirrhosis and liver carcinoma [24,25].
In this study, although there was a high level of awareness about hepatitis B infection amongst the respondents as majority (78%) of them were aware of the infection, only about one-half of them had overall good knowledge, and this may suggest a need to intensify education about hepatitis B infection and put structures in place that will encourage routine screening of pregnant women and vaccination as and when due.Having majority of our respondents aware of hepatitis B infection is comparable to 64.4% reported by Odelola et al. from a similar study conducted in Sagamu, Ogun State Nigeria [21].However, a similar study by Idowu et al. in Oyo State, Nigeria, observed that a lower proportion (51.8%) of their respondents were aware of hepatitis B virus infection [22].Idowu et al.
conducted their study among pregnant women at a primary health care centre and ours was at a tertiary hospital and a private facility where more of our respondents had tertiary education (90.9% versus 54.8%).
In this study, about 7 out of 10 respondents knew that an infected mother could infect her new-born with the virus.Tis fnding is in consonance with the report of a study conducted in Ghana [23].Our fnding that about 70% of our respondents were aware of mother-to-child transmission of the virus may explain why majority (>60%) of them were willing to uptake hepatitis B infection prevention services (hepatitis B screening, hepatitis B immunoglobulin, hepatitis B vaccine).Tis emboldens the need to make hepatitis B prevention services readily accessible and afordable to pregnant women by policy makers and health care providers.However, a similar study from Ogun State, Nigeria, found that only 47.4% of their respondents knew about mother-to-child transmission of hepatitis B infection and only about one-third of their respondents were willing to uptake hepatitis B prevention services [21].Tis diference between our study and the study from Ogun State, Nigeria, may be due to the educational status of our study participants.Majority (90.9%) of our respondents had tertiary education, while only 30% of theirs had tertiary education.It is well known that the level of formal education may have infuence on health seeking behaviour.
In this study, we observed that more than 40% of our respondents did not know that hepatitis B virus could be transmitted through sexual intercourse and unsafe injections.Tis is a cause for concern as engagements in these risky behaviours due to ignorance may continue to fuel transmission of the infection and stall/impede eforts   [28].At variance with our fnding is a report from Vietnam which stated that 62.4% of the pregnant women in their study had hepatitis B screening during their recent pregnancy [29].Our study fnding that only about two-ffth of the respondents ever had hepatitis B screening is   [30].Tis observation raises the need for studies focused on reasons or barriers to uptake of hepatitis B screening services during the ante-natal period among women in Nigeria.Te diference in the hepatitis B screening rate reported in our study and the Vietnamese study is probably due to high attention on hepatitis B infection in Vietnam occasioned by its high prevalence and burden in the country [31].

Interdisciplinary Perspectives on Infectious Diseases
It is worrisome that only 2 (0.54%) of out of all our respondents had hepatitis B screening outside the current pregnancy period.Tis could refect accessibility and availability of hepatitis B screening services outside the antenatal care services.It could also be due to suboptimal knowledge of hepatitis B infection and its complications [32,33].
In this study, there was signifcant association between the level of knowledge about hepatitis B infection and age of respondents; more of those aged 30-34 years had poor knowledge compared to other age groups.Tis fnding is a cause for worry because majority of our study participants were in this age group, and it is expected that most of these pregnant women at this age would have had previous pregnancy experience and thus should have had access to this information from ante-natal care services.Also, we observed signifcant association between the level of knowledge and occupation.More professionals had good knowledge about hepatitis B infection.It may imply that they are more exposed to sources of information about hepatitis B infection.A similar study conducted in Ghana reported a similar observation that majority of pregnant women who had excellent knowledge about hepatitis B infection worked in the formal sector [34].
Tis study showed no association between the level of knowledge about hepatitis B infection and respondents' highest level of education, and this contradicts previous reports among similar population [19,21,34].Te reason for this is not clear.Tis study observed the suboptimal level of knowledge about hepatitis B infection in spite of the high level of awareness of the infection among pregnant women.Although majority of the pregnant women were aware of the infection, it did not translate into good practice.However, most of them were willing to uptake hepatitis B infection preventive services, and this is commendable.

Study Limitations.
Being a questionnaire-based study, there is possibility of some bias associated with selfreporting.However, to minimize this, the participant's information section stated the purpose of the study (academic) and requested for honest answers.Also, the questionnaire had no name or any means of identifcation.We acknowledge that some important questions were omitted; we did not ask questions on the respondents' source of information about hepatitis B infection, we did not ask for parity, and we did not ask for reasons why those that have not had hepatitis B screening have not had it.Also, the convenience sampling method used may also have excluded some participants who presented when the researchers were not available at the clinics.Despite these limitations, this study provided information on the level of awareness/ knowledge of hepatitis B infection, practice of hepatitis B screening, and willingness to uptake hepatitis B preventive services among pregnant women in the study locality.

Conclusion
Tis study showed that respondents who were professionals had good knowledge about hepatitis B infection and those who had good knowledge about the infection were willing to utilize hepatitis B preventive measures.Ensuring that women attain high socioeconomic status may be a measure in addressing the burden of hepatitis B transmission.Te study also observed that despite the high level of awareness about hepatitis B infection and the fact that majority (73%) were aware of mother to child transmission of HBV, it did not translate into good practice as only a few (39.4%) of the respondents had hepatitis B screening.Hence, there is a need to intensify education about hepatitis B infection with an emphasis on the mode of transmission at various fora and media of communication.Furthermore, measures should be instituted to encourage good practices related to prevention of mother to child transmission of hepatitis B infection which include ensuring national policy on hepatitis B screening for all pregnant women as part of ante-natal care and subsidizing or providing ante-natal care services free of cost.

Figure 1 :
Figure 1: Awareness of hepatitis B and practice of HBV screening among respondents.

Figure 2 :
Figure 2: Respondents' willingness to uptake hepatitis B preventive services.
2.1.Study Design and Setting.A cross-sectional study conducted at the Antenatal Care Clinics of the Ekiti State University Teaching Hospital (EKSUTH) and Maternal Child Specialist Clinics.Both health facilities are located in Ado-Ekiti, the capital city of Ekiti State, Nigeria.Te Ekiti State University Teaching Hospital was established in 2008 and serves as a referral centre for 3 specialist hospitals, 18 secondary health facilities, and over 150 primary health care facilities owned by the Ekiti State Government.Te Obstetrics and Gynaecology Department operates the Antenatal Clinic four days a week (Mondays, Wednesdays, Tursdays, and Fridays) with an average of 400 pregnant women attending monthly.Te Maternal Child Specialist Clinics (MCSC) is a private-owned health facility.It is one of the high-volume hospitals in Ado-Ekiti and conducts antenatal clinic once weekly (Tuesdays) with an average of 100 pregnant women attending the clinic monthly.Te two health facilities have separate booking clinic days that are not part of the antenatal clinic days.Te study was conducted from August to October 2019.

Table 2 :
Respondents' perceptions about modes of transmission and prevention of mother to child transmission of hepatitis B virus.Manyprevious studies have reported a similar observation.Tese include 14.1% by Gebrecherkos et al. in northwest Ethiopia [20], 41.7% by Nsiah et al. in Kumasi, Ghana [19], and 8.3% by Katamba et al. in northern Uganda

Table 3 :
Association between socio-demographic characteristics of respondents and knowledge about hepatitis B infection.

Table 4 :
Association between respondents' level of knowledge and willingness to uptake hepatitis B prevention services.