Knowledge, attitude and practices towards Hepatitis B infection among Medical, Dental and Nursing Interns: A comparative study

https://doi.org/10.33698/NRF0206 – Romi Jain

Abstract : This study was undertaken to determine the knowledge, attitudes and practises regarding hepatitis B infection among dental, medical and nursing interns. A cross sectional questionnaire based study was undertaken among dental, medical and nursing interns from Terna Dental College, Navi Mumbai. Questionnaire consisted of demographic information, questions related to knowledge, attitude and practices about hepatitis B. Data was analysed using SPSS software. Results revealed that the mean age of the respondents was 22.31+3.40, 23.31±1.10 and 21.10±0.83 years for Dental, Medical and Nursing interns respectively. Immunization rate was highest among Dental interns (81.10%) whereas 71.40 % Medical interns and 68.30% Nursing interns were immunized. Knowledge about various modes of Hepatitis B virus (HBV) transmission was highest among the medical interns (80.6%). Merely 32.1% Medical interns, 18.0% Dental and 3.5% Nursing interns knew about post exposure prophylaxis. Conclusion: Overall there is a need to provide formal and obligatory education about Hepatitis B infection, its transmission, prevention along with update on infection control practices for health care providers.

Keywords

Hepatitis B infection, Survey, Vaccination, Post exposure prophylaxis

Introduction

High morbidity and mortality due to hepatitis B virus (HBV) infection has been reported  worldwide.1-3    In  India,  HBV  surface

Correspondence at

 Dr. Romi Jain

Senior Lecturer

Department of Public Health Dentistry Terna Dental College

Nerul, Navi Mumbai – 400 706

antigen prevalence among general population ranges from 2 to 8% which places India in an intermediate HBV endemicity zone and it has second largest global pool of chronic HBV infections. With the global rise in the number of people infected with hepatitis B virus, cross infection has become a paramount concern for the health care professionals and their patients.1

All health care professionals including Dental, Medical and Nursing are said to be at a risk of infections caused by various micro- organisms including M. tuberculosis, hepatitis B, hepatitis C viruses, HIV, mumps etc1-3.  In  a  dental  office,  infections  can  be expedited through several routes, including direct contact with blood, oral fluids or other secretions; indirect contact with contaminated instruments, operatory equipment or environmental surroundings; or contact with airborne contaminants present in either droplet splatter or aerosols of oral and respiratory fluids4 There have been several reports of HBV transmission to patients from surgeons despite the development of the universal precautions.4,5      However,   the   awareness among these professionals about the hazards of Hepatitis B is still limited 5

To minimize the risk of cross infection, specific recommendations have been issued by professional health agencies. These recommendations include routine use of barrier techniques (gloves, masks), sterilization of instruments, vaccination and the universal precautions.6

The compliance with these recommendations and infection control programs has been recently studied in different parts of the world 5-8.These studies indicate that there are gaps in knowledge regarding modes of transmission, the risk of infection from needle stick injuries, and awareness about general measures which protect against HBV transmission among health care professionals. Similarly, the vaccination status of these professionals who are constantly at risk is reported to be low.8 Health care providers should be familiar not only with treatment but also with epidemiological aspects of diseases such as transmission, prevention and control. General knowledge about viral hepatitis and its transmission and prevention can stop the spread of this disease in hospitals and in society.

Hepatitis is a preventable disease and the health professionals have an effective role in its prevention. Hence this study was undertaken to determine the knowledge, attitudes and practices regarding hepatitis B virus among, medical, dental and nursing interns from Terna dental college, Navi Mumbai.

Materials and Methods

A cross-sectional questionnaire study was conducted to determine the knowledge attitudes and practices regarding hepatitis B infection among dental, medical and nursing interns from Terna dental college, Navi Mumbai.

Ethical clearance was obtained from the ethical committee of the institution. The necessary permission to carry out the study was obtained from the respective authorities of colleges and informed consent was taken from all the participants. Prior to the commencement of the main study, a pilot study was conducted among 50 students to assess the feasibility and validity of the proforma. All the medical, dental and nursing interns who were present on the day of study and willing to participate were included in the study. Thus total 95 dental, 98 medical and 92 nursing interns participated in the study. A standardized structured proforma was developed to collect the data, which consisted of two parts. The first part consisted of general information like the age, sex, CDE/CME attended, immunization status etc. The second part consisted of 30 questions related to knowledge, attitude and practices towards hepatitis B infection. Out of 30 closed ended questions, 18 questions were related to knowledge, 7 questions were related to attitude and 05 were related to practices regarding Hepatitis B infection. For Knowledge 4 or 5 options were given and each correct answer was given one point to calculate mean knowledge score. Attitude questions were based on 3 point Likert scale(Agree, Uncertain, Disagree).

The questionnaire was constructed with reference to relevant literature. Content validity and face validity of questionnaire was ascertained with the help of expert opinion. The questionnaire forms were distributed to the interns during their duty hours. The questionnaire generally took an average of fifteen minutes to complete and forms were collected immediately after the survey.The data was analyzed using Statistical Package for Social Science (SPSS) version 17.0. The p-value was taken as significant when less than 0.05 (with confidence interval of 95%) and the student t test was used to obtain the results.

Results

The mean age of dental interns was 22.31+3.4, for medical interns was 23.31±1.10 and for nursing interns was 21.10±0.83 years. In the present study more than 90% of dental, medical and nursing interns had not attended any CDE/CME/CNE program on hepatitis B. Immunization rate was highest among dental interns with 81.10% being immunized against hepatitis B and lowest among nursing interns (68.30%) (Table 1).

Table-1: Profile of subjects

Sl no Variables Dental Medical Nursing
1. Gender      
  Male 23(24.20) 35(35.70) 11(12.20)
  Female 77(75.80) 65(63.30) 81(87.80)
2. CDE/ CME on Hepatitis B attended 2(2.10) 90(9.20) 9(9.80)
3. Current immunization status Immunized 77(81.10) 70(71.40) 63(68.30)

 

Knowledge Score of respondants

Mean knowledge score of medical interns (9.8)

were higher to nursing (8.6) and dental interns(9.1). (Fig -1)

Knowledge

Although around 75% of medical and Dental interns knew correctly that HBV is widespread and more infectious virus than HIV, Nursing interns showed deficiency about it (34%). Study participants showed poor knowledge about incubation period as less than 15% gave the correct answer. More than 50% of dental and medical interns knew that there are no prominent symptoms in most of the HBV infection cases whereas none of the nursing interns gave the correct answers.

In the present study, knowledge about various modes of HBV transmission was highest among medical interns (80.6%) followed by nursing (70.7%) and dental interns (69.7%). Although more than 90% interns knew that there is a vaccine available to protect people from hepatitis B but less than half of the Dental interns (49%), 65% of medical and 85% of nursing interns knew about the immunization schedule. All the participants showed gross deficiency regarding post exposure prophylaxis as more than 80% didn’t know about it. (Table 2)

Table 2: Knowledge of respondent towards Hepatitis B infection

Sl

no

 Question No. of subject responded correct
Dental Medical Nursing
1 Incubation period of HBV is 1 – 6 weeks 57(60.0) 77(78.6) 49(53.7)
2. There are no prominent symptoms of hepatitis B in 95% of cases 55(57.9) 66(67.3) 0(0.00)
3 HBV infection is transmitted by Parenteral, sexual and Perinatal route 66(69.5) 79(80.6) 65(70.7)
4. A vaccine is available to protect people from hepatitis B 92(96.8) 94(95.9) 83(90.2)
5. The immunization doses are taken at intervals of 0, 1, 6 months 47(49.5) 64(65.3) 79(85.4)
6. Hepatitis B carrier rate in India is 2-7% (intermediate endemicity zone) 47(49.5) 46(46.9) 58(63.4)
7. HBV is highly infectious and as widely transmitted as HIV infection 70(73.7) 82(83.7) 31(34.1)
8. Post exposure prophylaxis for HBV infection 17(18.0) 31(32.1) 3(3.5)
9. An infected mother may transmit hepatitis B to her newborn baby through breast milk 61(64.2) 65(66.3) 61(65.9)
10. Hepatitis B virus may be transmitted by needles used for piercing ears 81(85.3) 94(95.9) 65(70.7)

 

Attitude and behaviour towards HBV infection

All the three groups (Dental, Medical and Nursing) showed positive attitude and agreed that they have a professional as well as moral duty to treat hepatitis B infected patients (more than 80%) and will work willingly in the same environment as a person infected with. Table 3: Attitude of respondent towards Hepatitis B infection hepatitis B (more than 60%). Although misconception noted like hepatitis infected patients should be treated separately in clinics (more than 70%) and they should not be allowed to work in restaurants or cafeterias. Majority of the Medical and Dental interns showed strong personal worry about the risk of being infected by Hepatitis B (78.2%) while Nursing interns rated it as moderate. (Table 3)

Table-3: Attitude and behaviour towards HBV infection

Sl no Question Dental Medical Nursing
1. Would you willingly work in the same environment as a person      
  infected with hepatitis B?      
  A) Agree 59(62.1) 71(72.4) 63(68.3)
  B) Disagree 4(4.2) 14(14.3) 29(31.7)
  C) I Do Not Know 32(33.7) 13(13.3) 0(0.00)
2. People with hepatitis B should not be allowed to work in      
  restaurants or cafeterias      
  A) Agree 55(57.9) 70(70.4) 56(61.0)
  B) Disagree 9(4.2) 28(29.6) 36(39.0)
  C) I Do Not Know 36(37.9) 0(0.00) 0(0.00)
3. Dentists have a professional and moral duty to treat hepatitis B      
  infected patients      
  A) Agree 81(85.3) 90(90.8) 79(85.4)
  B) Disagree 2(2.1) 8(9.2) 11(12.2)
  C) I Do Not Know 12(12.6) 0(0.00) 4(2.4)
4. Hepatitis patients should be treated separately in clinics?      
  A) Agree 80(84.2) 86(87.8) 67(73.2)
  B) Disagree 1(1.1) 12(12.2) 25(26.8)
  C) I Do Not Know 14(14.7) 0(0.00) 0(0.00)
5. How strong is your personal worry about the risk of being      
  infected by Hepatitis B?      
  A) Strong 76(80.0) 69(70.4) 40(43.9)
  B) Moderate 0(0.00) 25(25.5) 43(46.3)
  C) Low 19(20.0) 4(4.1) 9(9.8)

 In the present study majority of the interns were following good infection control practices as about 90% of the interns reported the use of gloves and facemask during working on patients although usage was highest among Dental followed by Medical and Nursing interns. (Table 4)

Table 4: Behaviour of respondent towards Hepatitis B infection

Sl no Questions Dental Medical Nursing
1. In our daily clinical practice we always use gloves? 91(95.8) 92(93.9) 83(90.2)
2. We change gloves in between patients? 85(89.5) 94(95.9) 74(80.5)
3. In our daily clinical practice we always use facemasks? 86(90.5) 90(91.8) 74(80.5)
4. The mode of sterilization or disinfection used routinely in our practice is?

A)   Dry heat sterilization

B)   Steam under pressure (autoclave)

C)  Quaternary ammonium compounds

D)  Gluteraldehyde

  

 

5(5.3)

82(86.3)

 

8(8.5)

  

 

3(3.1)

91(92.9)

4(4.1)

  

 

20(22.0)

56(61.0)

 

16(17.1)

 

Factors affecting knowledge about Hepatitis B infection

Mean knowledge score was highest in medical interns (9.82±2.37) followed by dental (9.10±1.23) and nursing interns (8.62±2.89). This difference between the three groups was statistically significant. (p<0.05) (Figure 1)

Present study revealed that overall mean knowledge score was higher in females (9.29±2.37) compared to males (8.90±2.40). Also score was higher among the respondent who had attended CDE/CME program on Hepatitis B (9.80±1.23) as well as the responded that were immunized against HBV (10.02±2.2). All these differences were found to be statistically significant (p<0.05) (Table5)

 

Table 5: Factors affecting mean knowledge score

  Variables Knowledge scores (mean±SD) P value t value Df
1. Gender        
  Male 8.90±2.40 0.004 1.218 290
  Female 9.29±2.37      
2. CDE/CME attended        
  Yes 9.80±1.23 0.0001 6.463 290
  No 8.26±2.22      
3. Immunization status        
  Immunised 10.02±2.2 0.0001 7.023 290
  Not immunised 8.19±1.4      

Student t test was used to compare the mean knowledge score

Discussion

Hepatitis B infection is a serious blood- borne disease, caused by the hepatitis B virus (HBV) which attacks the liver and although in acute cases rarely results in liver failure and death, the main public health problem is that this can lead to lifelong chronic HBV infection, which may be followed by cirrhosis and/or liver cancer. Chronically infected HBV carriers are able to transmit HBV through contact with their body fluids, which includes occupational exposure to their blood and secretions, sexual intercourse. People at risk include health care workers (HCWs) in contact with blood and human secretions, haemodialysis staff, oncology and chemotherapy nurses, all personnel at risk of needle stick/sharps injuries, which includes those working in operating rooms and clinical laboratories, respiratory therapists, surgeons, doctors, dentists, as well as medical, dental and nursing students.9,10 Scientific knowledge regarding HBV transmission is essential for any healthcare professionals since they have to take the proper protection during their clinical practice. The risk of transmission of hepatitis B virus infection in health care worker is 6% to 30%. WHO guidelines state that all high risk groups should be vaccinated against Timely and suitable prophylaxis following the exposure to HBV can prevent the infection and subsequent development of the chronic infection or the liver disease. The professionals should be aware of post exposure prophylaxis regimen in case of any accidental exposure to HBV. Immediate treatment following the percutaneous injury includes washing the exposure site with soap and water; mucous membrane and eyes should to be flushed with water only (Singhal,  V  et  al.  2009).19    Present  study revealed a significant lack of knowledge among all medical, dental and nursing interns about post exposure prophylaxis as merely 32% knew the correct answer.hepatitis B.11 In the present study there was As recommended by centres for deficiency, about 18% of dental, 28% medical and 31% nursing interns were not vaccinated. The proportion of immunized dental and medical participants in the present study (79.6%) was lower as compared to study by T Paul et al (1999)12  among dental staff of Riyadh Military Hospital in whom it was 85.7%, medical students in Karachi private medical college in study by Qudsia Anjum et al (2005)13  where it was 81% and also lower than dental interns in Pondicherry (93.9%) in a study done by P. Tirounilacandin et al (2009)14  and by Ali Kabir et al (2010)15 wherein all the dentists were immunized for HBV (100%).

Only half of the interns found to be aware that there are no prominent clinical features of HBV in most of the cases. This was in line with the study done by Ganesh R et al (2011)16. In the present study more than 90% of dental, medical and nursing interns were aware of HBV vaccine. Although awareness was comparatively lower among nursing interns. This was similar to the other studies.13,16,17,18 disease control and prevention (CDC), post exposure prophylaxis includes hepatitis B immunoglobulin (HBIG) and/or hepatitis B vaccine series which should be initiated within 24hrs to latest 1 week from the time of exposure after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person (Centres for Disease Control and Prevention, 2001).20 The international guidelines on infection control state that standardize your disinfection and sterilization practices and treat each case as if infected. Few studies reported discriminatory practices by general practitioners, nurses, dentists and other health care workers while treating HBV positive patients20   and similar was noted in the present study where majority (more than 80%) agreed that infected patients should be treated separately in a clinical practice.

In the present study around more than two third of dental, medical and nursing interns agreed to work in the same environment as a person infected with HBV which was in line with the study of Omani medical interns (58%) by Ali A Al-Jabri et al (2004).21  A majority of the dental (80%) and medical (70.4%) interns showed a strong personal worry about the risk of being infected by Hepatitis B whereas merely 43% nursing interns were strongly worried. This difference might be attributed to the low knowledge about various routes of HBV transmission among nursing interns. It was comparable with a study conducted by S Naidoo (1997)22 amongst dental practitioners (85%) in South Africa and in dental interns (81.4%) as assessed by Mohamed Abdullah Jaber (2011)17 It is alarming that about 15- 20% of the respondents were not in practice of using gloves and face mask routinely or they do not change them after every patient. The usage of protective barriers was least among the nursing interns. Similar results were reported by Porter et al.23 But in another study conducted among general dental practitioners revealed that 38% of the respondents were not using gloves during surgery24  which is higher than that reported in the present study.

Present study showed that mean knowledge score was significantly higher among females compared to males. These finding may indicates differences in the views towards the risk of HBV between the two gender. Mean knowledge score was significantly higher among the respondents who had attended CDE/CME program on HBV. This indicates the effectiveness of CDE/CME program in increasing awareness. This suggests the need to organize more number of CDE/CME programmes for the health care professionals as it has a significant impact in improving their knowledge regarding HBV and its prevention. The mean knowledge score was higher among all those who were immunized against HBV compared to the unimmunized counterparts. This could be due to the fact that all those who had knowledge regarding HBV transmission got themselves immunized against the same. Although, these three groups have to work in the same settings and will be exposed more or less to same occupational hazards in their careers, they have a vast difference in knowledge regarding one of the serious health problems that they will be at risk while delivering healthcare. The nursing staff in the hospital is more in direct contact with the patients and therefore at greater risk of acquiring hepatitis B infection but this study indicated lack of adequate knowledge.

We found that different studies around the globe have reported different results for the various parameters. It is because of the differences in the general awareness of the people in those regions about hepatitis B and also the differences in the study subjects involved in these reported studies. Overall, medical interns scored better than the dental and nursing interns which are on expected lines. All the healthcare professionals should get themselves vaccinated as they get admission into such courses as well as by taking booster doses at proper intervals, without which they become more vulnerable for infection.

As we have seen varying results in different studies reported globally on this topic, it is recommended that these type of studies should to be conducted in different areas and bigger samples so that relevant strategies can be made for target population. Hepatitis B is a highly infectious disease, and it shares many of its routes of transmission akin to those of HIV/AIDS. Making the healthcare team aware of its correct knowledge will go a long way in prevention of both these infections.

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