Background: Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease. It is the world’s most common serious liver infection. Two billion people have been infected with the hepatitis B virus. Approximately 1.5 million people are chronically infected. An estimated 820,000 people die each year from hepatitis B and related complications such as liver cancer.
Objective: The aim of this study is to assess the Knowledge, attitude, and vaccination status of clinical year students against hepatitis B infection at the University of Gondar, Gondar, Ethiopia, 2023.
Methodology: An institution-based cross-sectional study design was conducted at the University of Gondar. A convenience sampling technique was used to select the study samples of participants. A structured self-administered questionnaire was used to collect data. After data collection, data cleaning was done in order to avoid misleading data. The collected data were entered and analyzed using SPSS (version 20) software.
Results: This study aims to assess knowledge, attitude, and practice towards Hepatitis B and associated factors in clinical year students in the University of Gondar College of Medicine and Health Science. From a total of 465 students, 443 students had responded to the question. According to our study, 3.6% of participants had received the full dose of the hepatitis B vaccine.
Conclusion: Our study revealed that 3.6% of study participants received full-dose vaccination against HBV. We would like to recommend that all students in the healthcare profession be vaccinated before they start clinical attachments, provide training for students on infection prevention mechanisms, and universal precautions, particularly on HBV.

Hepatitis B virus, Vaccination, Clinical year, Health professionals, Knowledge, Attitude, Practice. 

Background: Hepatitis B, caused by the hepatitis B virus (HBV), is a liver infection that can be acute or chronic.[1] Chronic hepatitis B virus (HBV) infection continues to be a major public health issue worldwide.[2-5] Despite advances in hepatitis B prevention and treatment, hepatitis B remains a public health problem with high morbidity and mortality worldwide. According to the World Health Organization (WHO), approximately 296 million individuals globally were living with hepatitis B infection in 2019. Asia and sub-Saharan Africa bear most of the burden of chronic hepatitis B, with a large proportion of countries being endemic with an estimated HBV prevalence of >8%.[6] In Ethiopia, HBV prevalence ranges from 5.4% to 12.7%.[7] HBV spreads through exposure to infected blood or body fluids, including semen, vaginal secretions, and saliva. In endemic areas, transmission often occurs from mother to child during birth or between children under five, with chronic infection being common in infants infected early. Other transmission routes include needle sticks, tattooing, piercing, and drug use.[1] Healthcare workers and medical students are four times more likely to contract HBV than the general population due to occupational exposure to bloodborne pathogens. HBV is 40-100 times more contagious than HIV and can survive on surfaces for up to seven days, posing a significant risk to healthcare providers. The HBV vaccine, the first anticancer vaccine, is highly effective and safe, preventing 95% of chronic infections in both children and adults.[8]

Statement of the problem: Hepatitis B is a major public health threat and a leading cause of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. It is transmitted through percutaneous or mucosal exposure to infected blood or bodily fluids, including perinatal, sexual, needle-sharing, and healthcare-related routes. In 2019, an estimated 296 million people were living with chronic HBV infection, with 1.5 million new infections annually and 820,000 deaths, primarily from cirrhosis and liver cancer. Despite the availability of safe and effective vaccines, HBV remains a significant global burden.[1] The highest HBV burden is in the WHO Western Pacific and African regions, with 116 million and 81 million chronic infections, respectively. Other regions, including the Eastern Mediterranean, Southeast Asia, Europe, and the Americas, also report millions of cases.[9,10] Healthcare workers (HCWs) and health science students are at heightened risk due to frequent exposure to blood and bodily fluids. WHO reports that HCWs have a 10-fold higher HBV prevalence than the general population, with 66,000 infections annually. Lack of awareness and inadequate precautions further exacerbate this risk. Health science students face similar or higher risks due to inexperience, insufficient training, and workload.[1,11,12] Although a highly effective HBV vaccine has been available for over 20 years, offering 98-100% protection, vaccine coverage remains low in developing countries. Barriers include cost, accessibility, and late integration into national immunization programs. In Africa, only 18% of HCWs are vaccinated, highlighting the need for improved implementation in resource-limited settings.[10,13] The pooled prevalence of full-dose hepatitis B virus vaccination coverage among health care workers in Ethiopia was 20.04%.[14] This number is expected to be significantly lower among clinical year students since students often take the vaccination after they start working as health care professionals.

Justification of the study: The purpose of this study is to evaluate the knowledge, attitude, and practice towards hepatitis B vaccine among clinical year students in the University of Gondar College of Medicine and Health Science. We try to evaluate the attitude of clinical year students towards the efficacy of the HBV vaccine. Our aim is to identify how many clinical year students have practiced taking the HBV vaccine and to identify the reason why the rest didn’t take the vaccine.

Literature review: Despite the effective implementation of vaccination programs, a large number of Asia and African countries are still classified as areas of high endemicity for HBV. Studies in Ethiopia indicate that all types of viral hepatitis are endemic, and the overall pooled prevalence of 6% HBV infection among the community. Low vaccination coverage among adults aged 18 years or older (25.9%) in developing countries was indicated as the main risk factor for high endemicity. Medical trainees, especially in developing countries, have a very high risk of getting HBV infection during their training owing to the low HBV vaccine uptake rate and high rate of accidental exposure to body fluids. Reports in Africa indicate HBV infection rate among medical students reaches up to 31.5%. A study in Northwest Ethiopia indicated up to 4.2% of HBV infection among medicine and health trainees.[15]

Knowledge, attitude, and practice towards HBV vaccination: According to a study in Vietnam, out of 2000 students who participated, a majority of the study participants (88.4%) were aware that Chronic Hepatitis B(CHB) can cause liver cirrhosis, liver failure, liver cancer, or premature death, and most of the participants (97.5%) recognized hepatitis B vaccination could prevent HBV infection. Regarding attitude, reported that 61% being confident that the hepatitis B vaccine is safe. Regarding practice, only 24.9% responded that they sought to receive Hepatitis B testing, and 20.1% sought to receive the hepatitis B vaccine before entering practicum experiences at teaching hospitals.[16]

According to a study of Cameroonian medical students, it was reported that 83% of participants had adequate knowledge of HBV infection and vaccine. Regarding attitude, most medical students reported a positive attitude towards the HBV vaccine. The main negative attitudes towards the vaccine were worries about the adverse effects (48.99%) and being afraid of infection from the vaccine (39.31%). Regarding practice, it was reported that out of 714 participants, 186 (26.05%) had been vaccinated at least once against HBV. Of these, 28 (3.92%) had been administered only the 1st dose, 38 (5.32%) had received two doses, and 120 (16.81%) had received all three doses.[8]

According to a study at Hawassa University College of Medicine and Health Sciences, out of 396 study participants, more than half (240, 60.6%, 95% CI (0.556–0.654)) reported having good knowledge of hepatitis B virus prevention. Regarding attitude, 222 (56.1%) (95% CI (0.51–0.61)) of the respondents had a favorable attitude, while 174 (43.9%) of the respondents had an unfavorable attitude towards hepatitis B virus infection prevention. Practice towards Hepatitis B Virus Infection Prevention reported that about half of 199 (50.3%), 95% CI (0.452–553) had good practice towards hepatitis B virus infection prevention. Nearly three-fourths 296, 74.7%) of the respondents had been vaccinated against the hepatitis B virus. Regarding the doses of HBV vaccine taken by the study participants, 172 (43.4%) of the study respondents reported that they had taken three doses of HBV vaccine, but 99 (25%) and 25 (6.3%) of the participants responded that they had taken only two and one doses of HBV vaccine, respectively.[17]

According to a study at Wolkite University, out of 417 medical and health science students who participated, the majority of the study participants, 307(73.6%), had good knowledge about HBV infection, its mode of transmission, and prevention. Regarding knowledge on vaccination, it was reported that 349(83.7%) participants were aware of the HBV vaccine and its protection against HBV infection. Regarding attitude, 151(36.2%) reported a positive attitude towards HBV infection and risk perceptions. About 313(75.1%) study participants agreed that following infection control guidelines would protect them from being infected at work, and 286(68.6%) were aware that the HBV vaccine is safe and effective against HBV infection. Regarding practice, out of the 417 study participants, 161(38.5%) had screened for HBV, and 107(25.5%) had been vaccinated against HBV. However, out of the vaccinated participant, 24(5.4%) had completed the recommended three doses.[18]

According to a study in DebreBirhan, among 355 students of medicine and health science in DebreBirhan University, 276 (77.75%; 95%CI = (64.43 -91.82)) are reported to have knowledge regarding HBV, its mode of transmission, and prevention.[19]

Factors associated with vaccination status: From a study among medical science students in Iraq, lack of vaccination programs was the major reason for not receiving a vaccination (62%) among non-vaccinated respondents.[20] A study in a Nigerian University, among the 16.8% of the participants who never received the vaccine, a vast majority of them (94.7%) cited their busy schedule as the sole reason or one of the reasons for their failure to receive the vaccine. Another 5.3% believed that the vaccine was unavailable.[21]

In a study conducted among health science students in Mogadishu, Somalia, the most common reasons cited for not taking the vaccine were the unavailability of the vaccine (46.2%), high cost of vaccination (26.2%), lack of knowledge about the vaccine (21.4%), and fear of side effects of the vaccine (6.2%).[22] In a study conducted among Medicine and Health science students in Wolkite University, Southwest Ethiopia, Unavailability and high cost of the vaccine were frequently mentioned reasons for not being vaccinated against HBV. Being male gender, rural residence, positive attitude, good practice, and the medicine department were significantly associated factors with full-dose vaccination status.[18]

According to a study conducted among Medical and Health science students in Haramaya University, Harar, Ethiopia, reasons for not getting vaccinated were lack of information in 20.8% students, no need was felt by 2.8% students, 4.7% was afraid of injection, and 14% ignorance.[23]

Conceptual framework

Figure 1: Conceptual Framework to assess Vaccination status against hepatitis B infection and associated factors among students of medicine and health science in college of medicine and health science, University of Gondar, northwest, Ethiopia, 2023

Objectives:
General objectives: To assess the knowledge, attitude, and awareness towards hepatitis B vaccine among clinical year students of the University of Gondar, specialized and referral hospital, Northwest Ethiopia, in 2023.

Specific objectives:

• To assess the knowledge of clinical year students towards the hepatitis B vaccine in the UOG specialized and referral hospital, Northwest Ethiopia, in 2023.
• To identify the attitude of clinical year students towards the Hepatitis B vaccine in the UOG specialized and referral hospital, Northwest Ethiopia, in 2023.
• To determine awareness of clinical year students at the hepatitis B vaccine in the UOG specialized and referral hospital, Northwest Ethiopia, in 2023.

Operational definition:

• Knowledge: the information, understanding, and skills that you gained through education or experience.
  • “Good knowledge” if the respondents were able to answer 70% or more of the knowledge questions correctly.[19]
  • “Poor knowledge” if the respondents answered fewer than 70% of the knowledge items questions correctly.[19]

• Attitude: the way you think, feel, and behave towards things (feelings of clinical year students towards hepatitis B vaccine
  • Positive attitude: if the respondents were able to give the correct answer for 70% or more of the attitude items.[16]
  • Negative attitude: if the respondents answered fewer than 70% of the attitude items.[16]

• Practice: Overt behavioral habit of clinical year students towards hepatitis B vaccine
  • Good practice: score greater than or equal to 70% of the overall practice question .[19]
  • Malpractice: score less than 70% of the overall practice question.[19]

Study area and study period: This study was conducted at the college of Medicine and health science in which 2541 students are learning, found around 3000 meters from the main campus of UOG. It has 13 departments and was established with a mission to be committed in providing societal needs tailored education, problem-based research and relevant community services.

University of Gondar College of Medicine and Health Sciences (CMHS) is tertiary level teaching and referral hospital in Ethiopia, which is one of the biggest and oldest medical schools in Ethiopia established as the Public Health College in 1954. It provides health services such as surgery, internal medicine, pathology, TB/HIV, dermatology, antenatal care, delivery, postnatal care, laboratory, pharmacy, maternal and neonatal care, and other services. The study was conducted in Gondar University College of medicine and health science from December 5, 2023 to December 30, 2023.

Study design: Institutional based cross sectional study was conducted to assess the knowledge, attitude and awareness of HBV vaccination among clinical year students.

Source population: All students at college of medicine and health sciences in 2023

Study population: Clinical year students (Medicine, Anesthesia, Public Health) who are attending their education at CMHS in 2023

Sample size determination: Since our source population is small, the sample was determined by a convenience sampling method where all 465 clinical year students were taken.

95% confidence interval and 5% non-response rate was taken.

Table 1: Proportional allocation of sample size

Sampling procedure: A convenient sampling technique was implemented involving all clinical year students. Our study population is our sample size.

Study variables:
Dependent variables:

• Knowledge of clinical year students about HBV vaccine
• Attitude of clinical year students about HBV vaccine
• Practice of HBV vaccine among clinical year students

Independent variables:

• Age
• sex,
• Marital status
• Department
• Religion
• Background residence

Data collection tools and procedures:
Data collection tool: A structural questionnaire was prepared in kobo-tool box website and imported to kobo-tool collector application in English regarding knowledge, attitude and practice of clinical year students about HBV vaccine.

Data collection procedures: Structured questionnaire using kobo-tool collector application was used self-administered to collect relevant information to the stated research objectives.

Quality assurance of the study: Study participants was consented to give the truth through by explaining the purpose and importance of the study and assuring the confidentiality of data they provide.

Data processing and analysis: Data collected using kobo-tool collector application was downloaded in excel form and imported to spss(version 20) to analyze the data. Summary statistic is presented using frequency tables and graphs.

Ethical consideration: Permission was obtained from Gondar University College of Medicine and Health Sciences School of medicine to the interview. Respondents were asked for permission before the questionnaire was started and assured about confidentiality.

Inclusion criteria: Clinical year students of Gondar University College of Medicine and Health Sciences, 2023.

Exclusion criteria: All other students at Gondar University College of Medicine and Health Science, 2023.

Socio-demographic characteristics: A total of 443 medical and health science students belonging to three departments were enrolled in the study. Among the study participants, we got only a response rate of 95.27%. The mean age of the study participants was 23.97+2.23 years, that ranges from 20 to 28 years. Most of the study participants, 56.2%, were in the age groups less than 25 years. Two hundred seventy-one (61.2%) of respondents were male. Among 443 respondents, 88% were in the department of medicine. Almost all of the study participants 98.2% were single. Among 443 study participants, the majority 319(72.2%) were from Urban areas and 80.6% were following orthodox religion.

Table 2: Socio-demographic and other related characteristics of study participants at the university of Gondar, Northwest Ethiopia, 2023 (n=443)

Knowledge level of the study participants on HBV:
The majority of the study participants (99.3%) had good knowledge about HBV infection mode of transmission by blood and blood products. Among the study participants, 394(88.9%) found that HBV infection causes liver cancer. The majority of the study participants 433(97.7%) knew that HBV had laboratory tests. Regarding knowledge on vaccination, 428(96.6%) participants were aware of the HBV vaccine, and it provides protection against HBV infection, and also 287(64.8%) of participants knew that there is post-exposure prophylaxis for HBV (table 2).

Table 3: Knowledge level of study participants at the university of Gondar, Northwest Ethiopia, 2023 (n=443)

Attitudes of study participants towards HBV infection and its vaccination: The majority of (66.6%) study participants had a positive attitude towards HBV infection and vaccination. Among the study participants, 416 (93.9%) believed that they were at risk of HBV infection, 14(3.2%) were not sure, but 13 (2.9%) disagreed with it. About 382(86.2%) of the study participants believed in the safety and effectiveness of the Hepatitis B vaccine in protecting against HBV infection, 49(11.1%) were uncertain; however, 12 (2.7%) didn’t believe it. Additionally, 436 (98.4%) of the study participants agreed that medical and health science students should receive the Hepatitis B vaccine, while 7(1.6%) were not sure about it. 320(72.2%) agreed that all patients should be tested for HBV before they receive health care, 58(13.1%) were not sure, but 65(14.7%) didn’t agree with it. Furthermore, 108(24.4%) felt comfortable treating people infected with HBV, 71(16%) were uncertain, while 264 (59.6%) didn’t agree with it (Table 4).

Table 4: Attitudes of study participants at University of Gondar, College of Medicine and Health Sciences, Gondar, Northwest, Ethiopia, 2023 (n=443)

Practice of HBV Vaccination
Vaccination status of the study participants: Out of the 443 study participants, 3.6% (95% C. I 2.1 -5.4) received a full dose of the HBV vaccine in this study. The majority of the study participants, 78.1% have never received the hepatitis B vaccine, and only 54(12.2%) received one dose. Among the total study participants, only 19.4% were screened for hepatitis B infection. This shows that there is malpractice of Hepatitis B vaccination in our study participants.

Figure 2: Vaccination status of study participants

Reasons for not being vaccinated: Out of 346 unvaccinated respondents, the most frequently mentioned reasons for not being vaccinated against HBV were unavailability of the vaccine, 38.1%, and cost of the vaccine, 28.4%.

Figure 3: Reason for not being vaccinated against HBV

Screening status of study participants: Among the total study participants only 19.4% were screened for hepatitis b infection (figure 4).

Figure 4: Screening status of study participants

Needle stick injury among the study participants: Among the total study participants, 14.0% had a needle stick injury, and none of them took post-needle stick injury prophylaxis for hepatitis B infection.

Figure 5: Status of study participants for needle stick injury and post-needle stick injury prophylaxis

Among the total study participants, 308(68.85%) had good knowledge about the transmission, vaccine, number of doses, and complications of hepatitis B virus infection. 295(66.59%) had a positive attitude about the risk, safety of the vaccine, and 2.26% had good practice of being screened, being vaccinated, and taking the full dose of the hepatitis B vaccine (figure 6).

Figure 6: Good KAP about hepatitis B

This study showed that the vaccination status against HBV was 3.6% (95% C.I 2.1-5.4), which was found to be fully vaccinated. World Health Organization estimated 18-39% coverage of HBV vaccine among healthcare providers in developing countries and 67-79% in developed countries. Therefore, our study findings are lower than the WHO estimation in developing countries.

In our study, the finding was that those who received at least one dose were 21.9% which is lower than similar studies reported in eastern Ethiopia, 48.4% in which the study participants had received at least one dose of HBV vaccine.[9] Northern Tanzania (67.4%), Kenya (80%), Malaysia (95.9%), and Pakistan (73.42%), but found to be higher than in Cameroon (11.4%).[18-23] The variation in the vaccination rates might be due to differences in socioeconomic status, sample sizes, cost of the vaccination, and unavailability of the vaccine. This warrants the need to focus on the vaccination status of medical and health science students before enrolling in clinical practices, and to vaccinate them before starting the clinical attachments.

The 3.6% (95% CI 2.1-5.4) full-dose vaccination rate among our respondents was low, given their increased risk of contracting HBV. In this study, the most reported reason for not receiving a full course of vaccination among the study participants was the lack of availability of the vaccine (38.1%).

Limitations:

• The cross-sectional nature of the study makes it difficult to obtain a cause-and-effect relationship.
• The non-probability nature of the sampling technique made the sampling method difficult.
• The presence of non-respondents due to different reasons, such as unwillingness, unavailability, etc.
• Not all clinical year students were included due to their current absence from the university.

Recommendations: Our findings showed that students are at a very high risk of contracting HBV infection during their clinical training owing to the low HBV vaccine uptake rate. Thus, we recommend to the University of Gondar College of Medicine and Health Science and the University of Gondar General Specialized Hospital that:

• To provide HBV vaccine for all students who are going to start clinical year attachment, so that all students in the health care profession should be vaccinated before they enter clinical attachments.
• To provide training for students on infection prevention mechanisms and universal precautions, particularly on HBV.
• Health education is needed to create awareness of the attitudes and practices of students towards HBV and to enhance uptake of the vaccine.
• Facilitates measures that are required to put policies in place that encourage the vaccination of medical and health science students.

Our study revealed that 3.6% (95% CI 2.1-5.4) of study participants received full-dose vaccination against HBV. Lack of availability and cost of the HBV vaccine were frequently mentioned reasons among study participants for not being vaccinated against HBV.

First, we would like to thank the School of Medicine, CMHS, for giving us the opportunity to conduct this study. The authors gratefully acknowledge the dedication and tireless efforts of all team members from the development of the proposal to the final stage of this work. We also extend our sincere appreciation to the students who willingly participated in this study, demonstrated great enthusiasm, and provided their consent for the publication of the results.

This research received no funding or grant support.

Corresponding Author:
Wondwosen Mengist Dereje
University of Gondar, College of Medicine and Health Sciences, Ethiopia
Email: wondwosenmengist4@gmail.com

Co-Authors:
Tinsaye Demeke, Tsigereda Asfaw, Wondimu Gelaye, Wondwossen Tilahun Mengiste, Seyoum Mengesha, Desyibelew Chanie
University of Gondar, College of Medicine and Health Sciences, Ethiopia

Michael A. Negussie
School of Medicine, College of Health Sciences
Addis Ababa University, Addis Ababa, Ethiopia

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

The work of this research is approved by ethical review board of the School of Medicine, CMHS, University of Gondar under the declaration of 863/10/2023. This study was conducted in accordance with the fundamental principles of the declaration of Helsinki. Written informed consent was obtained from the participants of the study for publication.

The authors declare no conflict of interest.

None

https://doi.org/10.63096/medtigo30622468

Wondwosen MD, Tinsaye D, Tsigereda A, et al. Knowledge, Attitude, and Practice Towards Hepatitis B Vaccine Among Clinical Year Students in University of Gondar College of Medicine and Health Sciences, Northwest, Ethiopia: An Institution-based Cross-sectional Study. medtigo J Med. 2024;2(4):e30622468. doi:10.63096/medtigo30622468 Crossref