Knowledge and practice of pregnant women and health care workers on hepatitis B prevention in the Limbe and Muyuka health districts of the south west region of Cameroon

Introduction Hepatitis B virus (HBV) infection is a major health problem worldwide owing to its high prevalence and significant morbidity and mortality. There are about 2 billion people living with HBV worldwide and over 360 million chronic carriers. The purpose of this study was to assess the knowledge and practices of pregnant women and health care workers in the ANC and maternity units on HBV infection and its transmission. Methods About 270 women attending ANC and 31 health care workers were selected by convenience sampling. They were evaluated using a structured questionnaire to assess their knowledge and practices on HBV prevention and transmission. Results Pregnant women in the Limbe Health District demonstrated good knowledge but adopted poor practices whereas in the Muyuka Health District, pregnant women demonstrated poor knowledge and adopted poor practices regarding the mode of transmission and prevention of HBV infection. Health care workers in both the Limbe and Muyuka Health Districts however, demonstrated good knowledge and adopted good practices. Conclusion There was a significant relationship between the knowledge and practice of pregnant women and health care workers on Hepatitis B prevention in the Muyuka Health District (P = 0.0006).


Introduction
Hepatitis B Virus (HBV) is a small enveloped DNA virus known to infect humans and belongs to the hepadnaviridae family. HBV infection is a major health problem worldwide owing to its high prevalence and significant morbidity and mortality. There are about 2 billion people living with HBV worldwide and about 360 million chronic carriers [1].
The total number of deaths attributable to HBV was 786,000 according to the Global Burden of Disease (GBD), 2010. Of these number, 132,200 (17%) were estimated to be caused by acute hepatitis B, 341,400 (43%) were caused by liver cancer and 312,400 (40%) were caused by cirrhosis [2]. As a result, the GBD 2010 estimates HBV to be the 15 th ranked caused of human death [2]. It is transmitted through sexual intercourse, by exchange of saliva during kissing and also from infected mothers to their babies: during childbirth, breastfeeding and through the placenta [3]. Unlike Human Immunodeficiency Virus (HIV), the hepatitis B virus can survive outside the body for at least seven days [4]. During this time, the virus can still cause infection if it enters the body of someone who is not protected by the vaccine. The burden of HBV is highest in Africa where approximately 65 million chronically infected individuals live, with prevalence rates ranging from less than 7% to more than 20% in some countries [5]. Recent studies in Cameroon show that the prevalence of HBV ranges from 6-16% [6,7]. Fouelifack [8], Noubiap [7] report the prevalence of HBV as high as 10.1% and 12% among blood donors in hospital blood banks in Cameroon respectively.
Pregnant women are considered vulnerable and even at a higher risk of transmitting the virus to their newborns if not early diagnosed. As far as the burden of HBV in health care workers is concerned, numerous studies have shown that they are at higher risk of acquiring HBV than the general population. Clinicians with direct patient contact, such as physicians, dentists, nurses, and dialysis workers, laboratory workers have higher risk of exposure to HBV than other health care workers [9]. A review of studies done in the USA has shown a high prevalence rate of HBV ranging from 13 to 18% in some groups of health care workers such as surgeons, [10]. In sub-Saharan Africa too, exposure to HBV remains a serious risk to health care workers. It has been estimated that 6,200 HBV infections occur each year among health care workers in sub-Saharan African [11]. This study was therefore designed to assess the knowledge and practice of pregnant

Methods
Study area: Limbe is the capital of Fako Division. It has a total population of 72,106 inhabitants as of 2015 [12]. It is located on latitude 40'46.008" N, longitude 913'13.008" E and about 15 km from Buea, the headquarters of the south west region of Cameroon.
Muyuka is a small town in Fako Division of the south west region of among pregnant women with an error margin (d) of 0.05.
Where: z = the standard normal deviation at 1.96 (which corresponds to a 95% confidence interval), p = the prevalence of hepatitis B in the general Cameroonian population, q = 1 -p; d = the degree of precision expected to be 0.05. Therefore, N= 1.96²*0.097 (1-0.097)/0.05²; N = 135. Therefore, sample size for questionnaire administration to pregnant women was 135 questionnaires per health district giving a total of 270 questionnaires. The sample size for questionnaire administered to health care workers was exhaustive, that is, all health care workers at the ANC and maternity unit of the study sites who consented to respond to the questionnaires were included.

Administration of questionnaires to pregnant women and health care workers
All participants who consented were interviewed using a structured questionnaire adapted from questionnaire formulated by Mohammed [13]. Prior to its use in this study, a total of 20 questionnaires were pretested at the Regional Hospital Buea among pregnant women attending ANC and health care workers at the ANC and maternity unit with the aim of revising poorly structured questions, estimate the average time required to fill the questionnaire.
Two hundred and seventy questionnaires were administered to pregnant women attending ANC and 31 questionnaires were administered to health care workers at the ANC and maternity in all the hospitals under study for a period of 2 months (July-August) to assess their knowledge and practices on hepatitis B prevention and transmission.
Knowledge on HBV infection consisted of 12 questions and each correct response was scored as 1 and 0 for a wrong response. The knowledge scores for an individual was calculated and summed up to give a total knowledge score on 12. A score between 0-4 was classified as poor, 5-8 as good and 9-12 as excellent adapted from a study conducted by Abongwa [14]. Practices of pregnant women and health care workers on HBV infection were assessed on a scale of 6 because there were 6 questions on practices regarding HBV infection. A score of 0-3 was classified as poor practice while a score of 4-6 was classified as good practice. Demographic information of the participant was also obtained through administration of questionnaires.

Data entry and analyses
Data from the questionnaires were entered into a template in Excel version 10. The data was verified for completion, cleaned and exported into SPSS v 20.0 for analyses. Descriptive analysis was carried out by calculating the mean, median, standard deviation and frequencies of different variables using the SPSS v 20.0.

Ethical considerations
Ethical clearance was obtained from the Institutional Review Board of the Faculty of Health Science, University of Buea. Administrative clearance was obtained from the regional delegation of public health for south west region Cameroon and written approval from the head of every hospital under study. Participants had the study protocol carefully explained to them and participation was voluntary. Written informed consent was obtained from all participants. Study participants, data confidentiality and integrity were maintained by restricting access of the information and primary data to the principal investigator.

Limbe and Muyuka health districts
The characteristics of the 270 pregnant women who responded to the questionnaires in the Limbe and Muyuka health districts are summarized on Table 1. The ages of these women ranged from 16 to 46 years with a mean ± SD age of 22.6 ± 5.6 years, with the  Table 2. The ages of these health care workers ranged from 20 to 48 years with a mean ± SD age of 22.6 ± 5.6 years, with the predominant age group being health care workers of < 25 years.

Risk factors associated to HBV infection
Out of the 270 women who responded to the questionnaires, 257 (95.2%) had a history of ear piercing, 51 (18.9%) had a history of dental procedure, 20 (7.4%) had a history of blood transfusion and 52 (19.3%) had a history of surgical procedure meanwhile only 1 (0.4%) had a history of unsafe injection (Table 3).  Table 4 and Table 5. There was a significant relationship between the knowledge and practice of pregnant women and health care workers on HBV infection in the Muyuka Health District with a P value of 0.0006 (Table 5). This is similar to the observation of Abongwa [14] and Frambo [6] where pregnant women demonstrated poor knowledge and adopted workers in our study is similar to studies in Egypt [15] and Japan [16] but however contradict those reported by Yonatan [17] in Ethiopia and Kabir [18] in Iran. Good knowledge and practice of health care workers can be explained by the fact that they are medical personnel and their level of education is above primary and secondary school levels.