Knowledge,attitude and practice towards hepatitis B infection among high school students in Asante Mampong,Ghana

Abstract

BACKGROUND:

Hepatitis B virus (HBV) infection is a serious global public health problem, with significant morbidity and mortality from acute and chronic complications. Increasing awareness and improving knowledge of HBV helps reduce the risk of the disease. Although many studies have been conducted on HBV in Ghana, few have focused on examining knowledge, attitude and preventive practices among adolescents towards the disease.

OBJECTIVE:

The objective of this study was to assess HBV knowledge, attitude and practice (KAP) among adolescents in high schools in the Asante Mampong Municipality in the Ashanti Region of Ghana.

METHODS:

A descriptive cross-sectional study was conducted among 398 adolescents from six senior high schools within the Asante Mampong Municipality. Data was collected using a 30-item structured questionnaire. Each item had two response options: “Yes” and “No”. A scoring system was generated and respondents were given a score on each item answered. A positive response to an item was scored 1 point and a negative response was scored 0. Scores were then summed up and averaged to give the mean knowledge, attitude and practice scores.

RESULTS:

The majority of the respondents were male (60%), between 15 and 17 years (45%), Christian (93%) and in their first year of study. The adolescents had basic knowledge, positive attitude, and poor practices towards HBV. There was no significant relationship between the demographic variables of the respondents and KAP mean scores.

CONCLUSION:

There is the need to introduce health education and awareness programs in schools within the Asante Mampong Municipality to improve students’ level of knowledge of HBV. Countrywide studies examining KAP towards HBV infection among adolescents are also warranted.

Keywords

Hepatitis B infection adolescents KAP scores senior high school Ghana HBV

1. Introduction

Hepatitis B virus (HBV) infection is a serious global public health problem, with significant morbidity and mortality from acute and chronic complications [1]. The World Health Organization (WHO) estimates that in 2015, 257 million people were living with chronic HBV globally, with 887 000 dying from the condition [2]. The burden of HBV infection is even higher in Sub-Sahara African and Southeast Asian countries [3].

HBV is a virus that attacks the liver and may be acquired through contact with infected blood or other body fluids [4]. Though hepatitis B is most commonly passed from person to person through sexual contact [5], it can also be passed through exposure to contaminated needles, including tattoo and body-piercing tools [6]. Thus, persons with a history of sexually transmitted diseases (STDs), multiple sex partners, as well as those who inject drugs are at greater risk of contracting hepatitis B. It begins as an acute self-limiting infection which may be either subclinical or symptomatic [7] and can cause chronic infection, resulting in cirrhosis of the liver, liver cancer, liver failure, and death [8]. However, unlike other sexually transmitted diseases, HBV can be prevented with a vaccine [9].

Adolescents have poor perception, low capacity and develop disinterest in seeking protective health care against HBV [10]. Additionally, in low and middle-income countries, such as Ghana, adolescents tend to have compromised knowledge on safer sexual practices, leading to the contraction of sexually transmitted infections including HIV/AIDS and hepatitis [11,12]. For instance, a recent systematic review by Aberg et al. estimated that HBV prevalence was higher (14.3%) in the Ghanaian adolescent population compared to adults (8.36%) and children under five years (0.55%) [13].

Increasing awareness and improving knowledge of HBV helps reduce the risk of the disease among adolescents [14]. A comprehensive study by the Centers for Disease Control and Prevention (CDC), USA indicates that incidence of HBV infection can be reduced when there is adequate knowledge and positive attitude which influence the general population to observe better health seeking behaviors [6].

Although many studies have been conducted on HBV in Ghana, few have focused on examining knowledge, attitude and preventive practices among adolescents towards the disease [15–17]. Recently, Adam and Fusheini assessed HBV knowledge, risk of infection and vaccination status of high school students in two rural districts of the Northern Region of Ghana. The authors classified HBV knowledge scores into poor, basic and good; and found the students’ overall knowledge to be basic, with a mean score of 11.8 ± 1.98 (3–16) [15] . Similarly, Amedonu et al. surveyed 244 high school students in the Hohoe Municipality in the Volta Region of Ghana and reported moderate knowledge (positive answers ranged from 4 to 8 out of 10 questions presented) of HBV among the majority (89.2%) of the respondents [16]. Also, in a descriptive cross-sectional study of 358 student nurses in the Volta Region of Ghana, Aniaku et al. found knowledge of participants to be satisfactory (average), with 59.5% having the right knowledge about hepatitis B transmission routes and prevention. The authors categorized the students’ knowledge scores as good, satisfactory/average, and poor. The overall mean knowledge score found was 29.6 (SD ± 6.98) [17].

The present study adds to the above studies by assessing HBV knowledge, attitude and practice among adolescents in high schools in the Asante Mampong Municipality in the Ashanti Region of Ghana. Findings from the study will be useful for health awareness and promotion programs aimed at improving the level of knowledge, attitude and practice towards HBV infection in the country.

In this study, the Knowledge, Attitude, Practice (KAP) theory was chosen as the theoretical framework. KAP is a health behavior change theory, proposed by western scholars in the 1960s in which the changes of human behavior are divided into three successive processes: the acquisition of knowledge, the generation of attitudes and the formation of behavior [18]. KAP of community members is crucial in order to design prevention programs in the community [19]. By knowing facts, having proper awareness and attitudes, the menace of infectious diseases can be prevented to a great extent [20]. KAP research has been the primary educational intervention strategy for Hepatitis B control worldwide [21]. Studies have shown that the level of KAP in individuals is linked to efficient management of illness, response to medical treatment, and promotion of one’s own health [22–25]. Lower KAP level has been one of the main indicators of poor health, inefficient health care use, and maladaptive disease preventive behavior [26,27].

2. Materials and methods

2.1. Study design and setting

A descriptive cross-sectional study was conducted among adolescents (aged 12–19 years) from 6 senior high schools within the Asante Mampong Municipality. The Municipality is one of the 260 Metropolitan, Municipal and District Assemblies (MMDAs) in Ghana, and forms part of the 43 MMDAs in the Ashanti Region. With a population of 103 761, the Municipality has 85 primary schools, 58 junior high schools, 6 senior high schools and one vocational school. There are also 2 teacher-training colleges, 1 midwifery and nursing training school, and a campus of one public university (University of Education, Winneba, Mampong Campus). The Municipality has 18 health facilities comprising 12 public, 5 private and 1 belonging to the Christian Health Association of Ghana (CHAG).

2.2. Sample size and sampling procedure

The minimum sample size used to collect the required data for the study was calculated using the Cochran formula [28]: $\begin{eqnarray}\displaystyle N={\displaystyle \frac{z^{2}pq}{d^{2}}}. & & \displaystyle \nonumber\end{eqnarray}$ N = sample size to be determined; z = statistical certainty of 1.96 at a confident level of 95%; p = assumed proportion of knowledge of HBV among adolescents in Ghana of 62% (based on an average knowledge of HBV computed from previous similar studies) [15–17]; q = proportion of those with no knowledge of HBV (1 − p = 0.38); and d = margin of error of 5% (0.05).

Substituting the above figures: $\begin{eqnarray}\displaystyle N=\frac{(1.96)^{2}(0.62)(0.38)}{(0.05)^{2}}=362. & & \displaystyle \nonumber\end{eqnarray}$ Non-response rate of 10% was added to give a sample size of 398.

We employed proportional sampling method to draw the 398 students from the 6 schools (Table 1) to participate in the study. Proportional sampling, as defined by Salkind [29], is a sampling method where a researcher divides a finite population into subpopulations and then applies random sampling techniques to each subpopulation. Each school’s population was treated as independent subpopulation. School sample size was determined by dividing the school’s total population by the total population of the study and then multiplying it by the total sample size.

Table 1
Sample size for each of the six participating schools

Name of school Population Proportion (%) Sample size

Amaniampong SHS 1,523 23 91

St. Joseph’s SHS 1,456 22 87

St. Monica’s SHS 1,828 27.5 109

Kofiase SDA SHS 1,206 18.2 76

Opoku Agyemang SHS 506 7.6 29

Oduko Boatemaa SHS 112 1.7 6

Total 6,631 100% 398

Name of school	Population	Proportion (%)	Sample size
Amaniampong SHS	1,523	23	91
St. Joseph’s SHS	1,456	22	87
St. Monica’s SHS	1,828	27.5	109
Kofiase SDA SHS	1,206	18.2	76
Opoku Agyemang SHS	506	7.6	29
Oduko Boatemaa SHS	112	1.7	6
Total	6,631	100%	398

SHS = Senior High School.

After determining the sample size for each of the participating schools, a simple random sampling technique was applied to select the required study participants. This was done by writing “Yes” and “No” on pieces of papers, folded and put in a box and thoroughly mixed for some time in a lottery system. Students were asked to pick from the box. Students who picked “Yes” per the school sample size were sampled to take part in the study. Those who picked “No” exited the study.

2.3. Questionnaire and data collection

A 30-item structured questionnaire, developed using information from previous studies [15,16,29], was implemented to analyze KAP levels of adolescents towards HBV infection (Supplementary Appendix). The questionnaire was divided into 4 sections: demographic information, consisting of 4 items; knowledge of HBV, comprising 12 items; attitude towards HBV, making up of 8 items; and preventive practices towards HBV, consisting of 6 items. Each item had 2 response options: “Yes” and “No”.

The questionnaire was pretested on 30 senior high school adolescents, selected conveniently, from a local church within the Mampong Municipality. These adolescents were students of the 6 senior high schools selected for this study. Data collected during the pretesting was used to modify the original questionnaire for acceptability, consistency and comprehension. Data from the pretesting was not included in the final analysis.

Data collection was done between February and March, 2019 through on-site questionnaire administration. The questionnaires were handed out to the students on the premises of each of the participating schools to complete. It took an average of 15 to 20 min to complete each questionnaire. Two research assistants were recruited to assist in the data collection.

2.4. Data analysis

The collected data was entered into Epi Info 7.0 and analysed using Statistical Package for Social Sciences (SPSS) software version 20 (IBM Corporation, Armonk, NY, USA). A scoring system was generated and respondents were given a score on each item answered. A positive response to an item was scored 1 point and a negative response was scored 0. Scores were then summed up and averaged to give the mean knowledge, attitude and practice scores. The knowledge-based items were scored from 0 (minimum) to 12 (maximum), with a mean score <5 indicating poor knowledge, between 5 and 8 indicating basic knowledge and >8 demonstrating adequate knowledge. The attitude-based questions were scored from 0 to 8, with a mean score ≤5 being negative attitude and >5 indicating positive attitude. Finally, scoring for the practice-based items ranged from 0 to 6, with a mean score ≤3 denoting bad practice and >3 demonstrating good practice.

Descriptive statistics were used to present the demographic data of the respondents. A Chi-square test was conducted to determine the relationship between the outcome variables (knowledge, attitude and practice) and the socio-demographic characteristics of the respondents. A p-value <0.05 was considered statistically significant.

2.5. Ethical approval

Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee (protocol number GHS-ERC084/10/19). A letter of introduction was sent to the Municipal Health Directorate, Municipal Education Directorate and heads of the participating schools for the study’s recognition and approval. Consent forms were given to the participants to sign. For those below 18 years, the forms were read and explained to their parents/guardians to sign on their behalf. Participants were assured of confidentiality of information taken from them.

3. Results

3.1. Demographic characteristics of the respondents

A total of 398 questionnaires were administered and 372 were received, giving a response rate of 93.5%. The majority of the respondents were male (60%), between 15 and 17 years (45%), Christian (93%) and in their first year of study (47%) (Table 2).

Table 2
Demographic characteristics of the respondents (N = 372)

Variables Frequency Percentage (%)

Gender

Male 224 60

Female 148 40

Age (years)

12–14 68 18

15–17 169 45

18 and above 135 37

Religion

Christian 348 93

Islam 21 6

Traditional 3 1

Year of study

First year 173 47

Second year 117 31

Third year 82 22

Variables	Frequency	Percentage (%)
Gender
Male	224	60
Female	148	40
Age (years)
12–14	68	18
15–17	169	45
18 and above	135	37
Religion
Christian	348	93
Islam	21	6
Traditional	3	1
Year of study
First year	173	47
Second year	117	31
Third year	82	22

3.2. Level of knowledge about HBV infection

The respondents’ level of knowledge regarding HBV infection is summarized in Table 3. The mean (SD) knowledge score was 5.90 ± 1.8 (range, 0–12), indicating basic knowledge of HBV among the study cohort. Although the majority (84%) of the respondents indicated that they had heard of hepatitis B, more than half (56%) could not answer correctly that HBV is a viral disease. Regarding modes of transmission, only 28%, 35%, 37% and 42% of the students responded correctly that HBV could be transmitted through the use of unsterilized equipment, from mother to child, through blood transfusion and through unprotected sexual intercourse respectively. Also, while 69% of the respondents knew of the existence of hepatitis B vaccine, the majority (76%) reported that the disease could be cured.

Table 3
Responses to hepatitis B knowledge items

Item Yes No

I have heard of a disease called hepatitis B 313 (84%) 59 (16%)

Hepatitis B is a viral disease 164 (44%) 208 (56%)

Hepatitis B can affect any age group 279 (75%) 93 (25%)

Hepatitis B can cause liver cancer 112 (30%) 260 (70%)

Healthy-looking hepatitis B positive persons can spread the disease 248 (67%) 124 (33%)

Hepatitis B can be transmitted through the use of unsterilized syringes, needles and surgical instruments 105 (28%) 267 (72%)

Hepatitis B can be transmitted through blood transfusion 138 (37%) 233 (63%)

Hepatitis B can be transmitted through unprotected sexual intercourse 156 (42%) 216 (58%)

Hepatitis B can be transmitted by shaking hands 167 (45%) 205 (55%)

Hepatitis B can be transmitted from mother to child 131 (35%) 241 (65%)

There is a vaccine for hepatitis B 256 (69%) 116 (31%)

Hepatitis B can be cured 284 (76%) 88 (24%)

Item	Yes	No
I have heard of a disease called hepatitis B	313 (84%)	59 (16%)
Hepatitis B is a viral disease	164 (44%)	208 (56%)
Hepatitis B can affect any age group	279 (75%)	93 (25%)
Hepatitis B can cause liver cancer	112 (30%)	260 (70%)
Healthy-looking hepatitis B positive persons can spread the disease	248 (67%)	124 (33%)
Hepatitis B can be transmitted through the use of unsterilized syringes, needles and surgical instruments	105 (28%)	267 (72%)
Hepatitis B can be transmitted through blood transfusion	138 (37%)	233 (63%)
Hepatitis B can be transmitted through unprotected sexual intercourse	156 (42%)	216 (58%)
Hepatitis B can be transmitted by shaking hands	167 (45%)	205 (55%)
Hepatitis B can be transmitted from mother to child	131 (35%)	241 (65%)
There is a vaccine for hepatitis B	256 (69%)	116 (31%)
Hepatitis B can be cured	284 (76%)	88 (24%)

Mean knowledge score = 5.90 ± 1.8 (0–12).

3.3. Attitude towards HBV

The respondents had a positive attitude towards HBV infection with a mean score of 5.47 ± 1.3 on a 0–8 scale. Although the mean score achieved is close to the established threshold (i.e. ≤5 being negative attitude and >5 indicating positive attitude), the majority of the respondents scored above average (50%) on all of the attitude-based questions. For instance, the majority of them indicated that hepatitis B infected persons should not be isolated (68%), it is safe to visit hepatitis B infected relative (65%), they would continue friendship with a person infected with hepatitis B (71%), and that they would not have any concern being in the same class with someone infected with hepatitis B (74%) (Table 4).

Table 4
Respondents' attitude towards HBV infection

Item Yes No

Do you think you could be infected with hepatitis B? 334 (90%) 38 (10%)

Should hepatitis B-infected persons be isolated to prevent further infections? 118 (32%) 254 (68%)

Is it safe to visit a hepatitis B-infected friend or relative? 243 (65%) 129 (35%)

Is it safe to sit close to a hepatitis B-infected person? 198 (53%) 174 (47%)

Would you continue friendship with a person who has hepatitis B? 266 (71%) 106 (29%)

Would you have any concern eating with a hepatitis B patient? 156 (42%) 216 (58%)

Would you have any concern if you are in the same class with someone infected with hepatitis B? 98 (26%) 274 (74%)

Is the hepatitis B vaccine safe and effective? 250 (67%) 122 (33%)

Item	Yes	No
Do you think you could be infected with hepatitis B?	334 (90%)	38 (10%)
Should hepatitis B-infected persons be isolated to prevent further infections?	118 (32%)	254 (68%)
Is it safe to visit a hepatitis B-infected friend or relative?	243 (65%)	129 (35%)
Is it safe to sit close to a hepatitis B-infected person?	198 (53%)	174 (47%)
Would you continue friendship with a person who has hepatitis B?	266 (71%)	106 (29%)
Would you have any concern eating with a hepatitis B patient?	156 (42%)	216 (58%)
Would you have any concern if you are in the same class with someone infected with hepatitis B?	98 (26%)	274 (74%)
Is the hepatitis B vaccine safe and effective?	250 (67%)	122 (33%)

Mean attitude score = 5.47 ± 1.3 (0–8).

3.4. Practices towards HBV

Regarding the students’ practices towards HBV, about 74% indicated that they were willing to be tested for the disease, more than average (60%) answered that they would ask for a new syringe from a medical staff, 56% said they would ask for screening of blood before transfusion, while 65% responded that they would always ask their barber for a new blade (Table 5). However, the majority of the respondents indicated that they had neither screened for (84%) nor vaccinated against (89%) HBV infection. Overall, the students’ mean score for HBV related practices was 2.81 ± 1.1 (0–6), thus demonstrating poor practices.

Table 5
Respondents' practices towards HBV infection

Item Yes No

Were you ever screened for hepatitis B? 61 (16%) 311 (84)

Would you be willing to be tested for hepatitis B? 274 (74%) 98 (26%)

Have you ever vaccinated against hepatitis B? 41 (11%) 331 (89%)

Would you ask for a new syringe from medical staff? 222(60%) 150 (40%)

Would you ask for screening of blood before transfusion? 208 (56%) 164 (44%)

Do you always ask your barber for a new blade? 240 (65%) 132 (35%)

Item	Yes	No
Were you ever screened for hepatitis B?	61 (16%)	311 (84)
Would you be willing to be tested for hepatitis B?	274 (74%)	98 (26%)
Have you ever vaccinated against hepatitis B?	41 (11%)	331 (89%)
Would you ask for a new syringe from medical staff?	222(60%)	150 (40%)
Would you ask for screening of blood before transfusion?	208 (56%)	164 (44%)
Do you always ask your barber for a new blade?	240 (65%)	132 (35%)

Mean practice score = 2.81 ± 1.1 (0–6).

3.5. Association between demographic characteristics and KAP

Table 6 shows the relationship between demographic characteristics and KAP among the respondents. None of the 4 demographic variables was significantly associated with KAP scores (P > 0.05).

Table 6
Association between demographic variables and KAP

Outcome variable Demographic variable Chi-square (X ²) P-value

Knowledge of HBV

Gender 2.94 0.58

Age 5.62 0.12

Religion 4.39 0.32

Year of study 5.84 0.98

Attitude towards HBV

Gender 6.13 0.18

Age 3.85 0.51

Religion 2.75 0.55

Year of study 3.97 0.33

Practice towards HBV

Gender 1.92 0.66

Age 1.13 0.83

Religion 3.72 0.11

Year of study 7.14 0.24

Outcome variable	Demographic variable	Chi-square (X ²)	P-value
Knowledge of HBV
	Gender	2.94	0.58
	Age	5.62	0.12
	Religion	4.39	0.32
	Year of study	5.84	0.98
Attitude towards HBV
	Gender	6.13	0.18
	Age	3.85	0.51
	Religion	2.75	0.55
	Year of study	3.97	0.33
Practice towards HBV
	Gender	1.92	0.66
	Age	1.13	0.83
	Religion	3.72	0.11
	Year of study	7.14	0.24

4. Discussion

It has been suggested that prompt and early care could be sought if a patient has knowledge about the signs and symptoms of HBV. Similarly, a person’s knowledge on HBV treatment can help people to take measures to protect themselves and others from contracting the disease [30]. This study assessed KAP towards HBV infection among senior high school adolescents in the Asante Mampong Municipality of the Ashanti Region of Ghana. The results showed that the adolescents had basic knowledge, positive attitude, and poor practices towards HBV. Also, there was no significant relationship between the demographic variables of the respondents and KAP mean scores.

The finding of basic knowledge of HBV among the adolescents in this study is consistent with the findings of similar studies conducted among senior high school students in the Northern [15] and the Volta [16] Regions of Ghana. Moderate knowledge was also found among tertiary students (Nursing training) in the Ho municipality of the Volta Region [17]. The finding also concurs with similar other studies conducted among adult population both in Ghana and in other Sub-Saharan African countries. For instance, Mkandawire et al. found basic knowledge of HBV among healthcare workers at Suntreso Government Hospital in the Ashanti Region of Ghana [31]. Also, Adoba et al. observed that 90.5% of barbers in Obuasi in the Ashanti Region lacked knowledge about HBV [32]. In northeast Ethiopia, about 21% of medical students responded incorrectly that HBV could be transmitted through the fecal-oral route, while almost a quarter of them believed the disease could not be transmitted through unprotected sex [33]. Further, Mursy and Mohammed observed average (58.2%) level of knowledge of HBV among nurses and midwives at two maternity hospitals in Khartoum state of Sudan [34]. These findings are a clear indication of an existence of a knowledge gap regarding HBV and its mode of transmission.

Contrary to the assertion in the literature that positive attitude leads to good practices [18,35], it was observed in this study that the respondents’ attitude towards HBV was positive, but their preventive practices were poor. The positive attitude demonstrated by the students could be the impact of the various educational campaigns being embarked on by Ghana Health Service and some civil society organizations to reduce other sexually transmitted infections (STIs) such as HIV/AIDS-related stigma and discrimination in the country, as almost all of the attitude-based questions used in this study were stigma-related.

KAP scores were not significantly associated with the adolescents’ demographic characteristics, such as age, gender, religion and year of study. This finding supports earlier finding by Amedonu and colleagues where the authors observed no association between the study respondents’ sociodemographic characteristics and KAP, except year of study which was significantly associated with the students’ attitude and practice scores [16].

4.1. Limitations

The study was conducted in only one out of the 260 Metropolitan, Municipal and District Assemblies (MMDAs) in Ghana. Thus, the findings are not representative of the entire adolescent population in the country. To this end, countrywide studies examining KAP towards HBV infection among adolescents are warranted.

5. Conclusions

The results of this study have shown that adolescents in high schools in the Asante Mampong Municipality of the Ashanti Region of Ghana have basic knowledge of HBV infection. There is therefore the need to introduce and intensify health education and awareness programs in schools within the Municipality to improve students’ level of knowledge of the disease. The Municipal Health Directorate and the Ghana Education Service in the Municipality should collaborate to organize a comprehensive HBV infection prevention campaign which focuses on vaccination and screening to increase vaccination uptake among senior high school students in the Municipality. Adequate knowledge will lead to positive attitude, which will eventually result in better and more effective preventive practices. Future studies on this topic should consider examining the relationship between high school students’ HBV KAP scores and their field of study. Such information will be useful for HBV educational campaigns.

Footnotes

Acknowledgements

The authors are grateful to the research assistants who assisted in collecting the data for this study. They are also grateful to the students who agreed to take part in this important study as well the Municipal Health and Education Directorates, and all the heads or principals of the included schools for allowing the study to be conducted in the Municipality and the schools.

Conflict of interest

None to report.

Supplementary material

The administered questionnaire is available from .

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